Should adults get a measles vaccine?

Measles Disease

Measles is an acute viral illness caused by a virus in the family paramyxovirus.^1-3 Measles is usually a mild or a moderately severe illness, but in some cases it can lead to serious complications and even death. Measles typically begins with a prodromal period of fever, cough, coryza, conjunctivitis, and malaise, followed by a characteristic maculopapular rash that begins on the head and face and spreads to the trunk and then to the upper and lower extremities.

The most common serious complication of measles is pneumonia, which occurs in approximately 6% of cases. It is the most common cause of measles-related death.^3,4 Another serious complication of measles is encephalitis, which occurs in 1 out of every 1,000 to 2,000 cases of measles. Other uncommon complications of measles include hepatitis, pericarditis, myocarditis, and keratitis which can lead to blindness.⁴ In pregnant women, measles may be associated with miscarriage and prematurity. A rare, but devastating, long-term complication of measles is subacute sclerosing panencephalitis (SSPE).^1,2,4,5 SSPE is a neurological condition that can appear seven to ten years after recovery from measles and leads to progressive mental and motor deterioration, seizures, coma, and eventually death. The death rate from measles varies greatly depending on the population studied. In developing countries, mortality rates can range from 2% to as high as 25%.^3,4 In the US during the years 1987 to 1992, the death rate was two to three deaths for every 1000 reported cases of measles.⁶

Measles is highly contagious.^3,4 Approximately 90% of susceptible people exposed to measles will become infected. It is spread from person to person through respiratory droplets and also by aerosolized particles that can remain in the air for up to two hours in an enclosed space. The disease can be transmitted for about four days prior to the onset of rash and four days after.  

Measles Vaccine

Before the introduction of the first measles vaccine in 1963, an estimated three to four million Americans contracted measles each year.³ In the years that followed vaccine introduction, the number of cases dropped by 95%. It is estimated that the currently available vaccine provides effective immunity to approximately 93 – 95% of people after one dose (if the dose is given after the age of 12 months) and to at least 97 – 99% of people after two doses.^3,4,7 Sporadic outbreaks of measles continue to occur in the US despite widespread vaccination.^1,3 Many of these outbreaks have occurred after an unvaccinated person travelled to an endemic country, contracted measles, returned to the US, and spread the virus to others. Most of these cases occur among people who have not been vaccinated.

In its 2013 report, the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommends that all eligible persons aged 12 months or older receive measles vaccination.⁵ There are two licensed and available vaccines for the prevention of measles, both of which are combined vaccines providing vaccination against other viral diseases in addition to measles: trivalent measles-mumps-rubella (MMR) vaccine and quadrivalent measles-mumps-rubella-varicella (MMRV) vaccine. The MMRV vaccine is approved for use only in children 12 months to 12 years of age. There is no vaccine available that contains the measles vaccine alone.

ACIP Recommendations for Measles Vaccination: ⁵

1. Adults born in 1957 or later: Adults who have documented evidence of immunity to measles*, either through documentation of prior adequate immunization, laboratory evidence of immunity, or laboratory evidence of disease, do not need any additional measles vaccine. Adults who do not have adequate evidence of immunity should receive at least one dose of the MMR vaccine. Two doses of MMR vaccine are recommended for adults without adequate evidence of immunity who are in the following higher risk groups:
   1. Persons entering college or any other post-high school educational institutions
   2. International travelers
   3. Healthcare personnel
   4. Close contacts of immunocompromised individuals
   5. Persons with HIV infection, without severe immunosuppression (should receive MMR, but not MMRV. See 2013 ACIP guidelines for further details regarding persons with HIV infection.)

2. Adults born before 1957: Adults born before 1957 are considered to have presumptive immunity to measles and do not require vaccination. However, these adults can choose to be vaccinated with one or two doses of MMR as long as there are no contraindications. Healthcare facilities should consider vaccination of healthcare personnel in this age-group who do not have other evidence of immunity.

*Adequate evidence of immunity for adults means having at least one of the following:⁵

• Written documentation of prior vaccination with a live measles virus-containing vaccine:
  1. One dose of vaccine (given at 12 months of age or later) for adults not at high risk
  2. Two doses of vaccine (given at 12 months of age or later, and given at least 28 days apart) for adults at higher risk (see list of high risk groups above).
• Laboratory evidence of immunity
• Laboratory evidence of disease
• Birth before 1957

It is important to note that a killed measles vaccine was on the market from 1963 to 1967. This vaccine was ineffective. Persons who were vaccinated with the killed measles vaccine are not considered to have adequate evidence of immunity and should receive vaccination with the MMR vaccine.

It is also important to note that self-report or parental report of prior vaccination or prior disease is not considered adequate evidence of immunity.

The ACIP does not recommend serologic screening for measles immunity if a person has other acceptable evidence of immunity (e.g., written documentation of adequate prior vaccination). The ACIP also does not recommend serologic testing after vaccination to verify immune response. The ACIP considers written documentation of adequate prior vaccination to supersede the results of subsequent serologic testing. If a person has a negative measles titer result, but has a documented history of two doses of measles vaccine, the ACIP does not recommend re-vaccination.

Recommendations by Other Organizations

State or local departments of health and other international organizations may provide slightly different recommendations than the ACIP. For instance, the New York City Department of Health recommends that all adults receive two doses of the MMR vaccine.⁷

Contraindications to Measles Vaccination:⁵

1. Pregnancy: Women should not receive MMR or MMRV vaccination while pregnant or while attempting to become pregnant. Women should avoid becoming pregnant for 28 days after vaccination. Non-pregnant women of childbearing age, however, should receive the MMR or MMRV vaccination, if indicated.
2. Immunosuppression: The following immunosuppressed groups should not receive MMR or MMRV:
   1. Persons with AIDS or severe immunosuppression associated with HIV infection (this does not apply to persons with HIV without severe immunosuppression. See 2013 ACIP guidelines for further details.)
   2. Persons with cellular immunodeficiencies, hypogammaglobulinemia, or dysgammaglobulinemia
   3. Persons with leukemia, lymphoma, blood dyscrasias, or other malignant neoplasms affecting the bone marrow or lymphatic system
   4. Persons who have a first-degree relative with congenital or hereditary immunodeficiency, unless the vaccine recipient has been determined to have a competent immune system based on clinical or laboratory evaluation
   5. Persons taking systemic immunosuppressants, including corticosteroids (equivalent to at least 20 mg/day of prednisone for at least two weeks)
3. History of anaphylactic reaction to neomycin: MMR and MMRV contain trace amounts of neomycin.
4. History of severe allergic reaction to any component of the vaccine
   1. Note: Allergy to egg is NOT a contraindication to vaccination.

There are several additional precautions to consider when administering MMR and MMRV vaccines. These include a number of conditions that may necessitate a delay in vaccination, including recent receipt of antibody-containing blood product or current moderate or severe illness. Precautions should be taken with recent administration of tuberculin skin testing (TST) due to potential interference with the performance of the TST. Precautions also should be taken with persons who have a history of thrombocytopenia or thrombocytopenic purpura. Healthcare providers should consult the vaccine package insert for further details.

Recommendations during Measles Outbreaks⁵

During measles outbreaks, the ACIP vaccination recommendations for adults change in the following ways:

• If the outbreak affects adults, a second dose of MMR vaccine should be considered for all adults who have received only one dose.
• If an outbreak occurs in a healthcare facility, birth before 1957 should no longer be considered adequate evidence of immunity for healthcare personnel. All unvaccinated healthcare personnel without laboratory evidence of measles immunity or confirmation of disease should be vaccinated.

Safety of Third Dose of MMR Vaccination

The ACIP does not routinely recommend a third dose of MMR vaccine for protection against measles. There is evidence, however, that a third dose is safe. This is important because some people who do not have documentation of their prior vaccinations may end up receiving a third dose of MMR vaccine to ensure they have adequate protection against measles. The evidence of the safety of a third dose of MMR comes from studies done during mumps outbreaks, when the ACIP did recommend a third dose of MMR in order to protect high risk individuals from infection with mumps. ^8-11 The ACIP has reported data on the short-term safety of a third dose of MMR vaccine during two mumps outbreaks in 2009 to 2010, collected among 2130 persons aged 9 to 21 years old, who received a third dose of MMR.⁵ Only a few adverse events were observed with the administration of a third dose of MMR vaccine, 7% in Orange County, New York and 6% in Guam. These adverse events included swelling, pain, and redness at the injection site (2 – 4%), muscle or joint aches (2 – 3%), and dizziness or lightheadedness (2%). Neither study found any serious adverse events. Taking into account these few reported occurrences of mostly non-systemic adverse events, a study of the 2009 to 2010 mumps outbreak in New York concluded that the administration of a third dose of MMR vaccine appears to be as safe as the first or the second dose.¹⁰

^References

1. Gastanaduy PA, Redd SB, Clemmons NS, et al. Manual for the Surveillance of Vaccine-Preventable Diseases. Chapter 7: Measles. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html. Published March 6, 2018. Accessed May 2, 2019.
2. Moss WJ, Griffin DE. Measles. Lancet. 2012;379(9811):153-164.
3. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th ed, second printing, Atkinson W, Wolfe C, Hamborsky J (Eds), Public Health Foundation, Washington, DC 2012.
4. Strebel P, Papania MJ, Gastanaduy PA, Goodson JL. Measles vaccine. In: Plotkin SA, Orenstein WA, Offit PA, editors. Vaccines. 7th ed. Philadelphia, PA: WB Saunders; 2017. p. 579–618.
5. Centers for Disease Control and Prevention. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013;62(RR04);1-34.
6. Gindler J, Tinker S, Markowitz L, Atkinson W, Dales L, Papania MJ. Acute measles mortality in the United States, 1987–2002. J Infect Dis. 2004;189 (Suppl 1):S69–77.
7. New York City Department of Health and Mental Hygiene. Measles: General information for health care providers. 2019.
8. Nelson GE, Aguon A, Valencia E, et al. Epidemiology of a mumps outbreak in a highly vaccinated island population and use of a third dose of measles-mumps-rubella vaccine for outbreak control--Guam 2009 to 2010. Pediatr Infect Dis J. 2013;32(4):374-380.
9. Aasheim ET, Inns T, Trindall A, et al. Outbreak of mumps in a school setting, United Kingdom, 2013. Hum Vaccin Immunother. 2014;10(8):2446-2449.
10. Abedi GR, Mutuc JD, Lawler J, et al. Adverse events following a third dose of measles, mumps, and rubella vaccine in a mumps outbreak. Vaccine. 2012;30(49):7052-7058.
11. Albertson JP, Clegg WJ, Reid HD, et al. Mumps outbreak at a university and recommendation for a third dose of measles-mumps-rubella vaccine — Illinois, 2015–2016. MMWR Morb Mortal Wkly Rep 2016;65:731–734. DOI: http://dx.doi.org/10.15585/mmwr.mm6529a2External.