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Measles-Mumps-Rubella

Measles

Measles disease picture

Measles is a highly contagious acute viral respiratory illness caused by a single-stranded, enveloped RNA virus with 1 serotype. Humans are the only natural hosts of measles virus.

Transmission of the measles virus is through direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area.

Clinical features include a prodrome marked by high fever followed by the onset of cough, runny nose, and red, watery eyes (conjunctivitis). Koplik spots may be seen on mucous membranes in the mouth; these lesions present as blue and white spots on bright red background and appear a few days before and after the measles rash. The characteristic measles rash appears as maculopapular lesions that start on the head and gradually proceed down the body over 5-6 days.

Complications develop in approximately 30% of measles cases, which are most common in children younger than 5 years and adults 20 years and older. Complications include ear infections, diarrhea, pneumonia, or encephalitis (brain inflammation), and rarely death.

There is no cure for measles. Treatment is symptomatic and supportive.

Mumps

Mumps disease picture

Mumps is an acute viral illness caused by an enveloped RNA virus that belongs to the genus Rubulavirus, in the family Paramyxoviridae.  Humans are the only natural hosts for mumps virus, which is usually spread by respiratory droplets, saliva, or contact with contaminated fomites. The incubation period of mumps averages 16–18 days, with a range of about 2–4 weeks.

Mumps infection may present with primarily respiratory symptoms or may be asymptomatic. However, clinical features of mumps usually include unilateral or bilateral, parotitis, with single or multiple salivary glands affected. Parotitis occurs within the first 2 days and may first be noted as earache and tenderness on palpation of the angle of the jaw. Symptoms tend to decrease after 1 week and usually resolve after 10 days. Nonspecific prodromal symptoms may precede parotitis by several days, including low-grade fever which may last three to four days, myalgia, anorexia, malaise, and headache.

Complications of mump infections are more likely to be serious when adults are infected. Complications of mumps can include meningitis (in up to 15% of cases), orchitis, and deafness. Very rarely, mumps can cause encephalitis and permanent neurological damage.

Rubella

Rubella disease pictureRubella, also called German measles, is a contagious viral infection caused by rubella virus.  Humans are the only natural hosts of rubella virus, which is transmitted through person-to-person contact or droplets shed from the respiratory secretions of infected people. People may shed virus from 7 days before the onset of the rash to approximately 5–7 days after rash onset. Transmission from mother to fetus can also occur, with the highest risk of congenital rubella syndrome (CRS) if infection occurs in the first trimester. Infants with CRS can transmit virus for up to 1 year after birth. 

Symptoms of rubella are often mild, and up to 50% of infections may be subclinical or inapparent.  Rubella usually presents as a nonspecific, maculopapular, generalized rash that lasts ≤3 days with generalized lymphadenopathy. Rash may be preceded by low-grade fever, malaise, anorexia, mild conjunctivitis, runny nose, and sore throat. Adolescents and adults, especially women, can also present with transient arthritis. Infection during early pregnancy can lead to miscarriage, fetal death, or the fetus can develop Congenital Rubella Syndrome (CRS), which can affect virtually all organ systems, with deafness being the most common outcome. Up to 85% of infants are affected if infection occurs during the first trimester of pregnancy.

Complications of rubella are not common, and generally occur more often in adults than in children.  Arthralgia or arthritis may occur in up to 70% of adult women who contract rubella, and tend to occur about the same time or shortly after appearance of the rash, lasting for up to 1 month.  Additional complications that can occur are encephalitis, orchitis, neuritis, and a late syndrome of progressive panencephalitis. Complications that do occur more often in children than adults are hemorrhagic manifestations (approximately one per 3,000 cases) that may be secondary to low platelets and vascular damage, with thrombocytopenic purpura being the most common manifestation. Gastrointestinal, cerebral, or intrarenal hemorrhage may occur. Effects may last from days to months, and most patients recover.

M-M-R®II is a live-virus vaccine which includes antigens for measles, mumps, and rubella, licensed for persons 12 months and older. Two doses of MMR vaccine are routinely recommended for children, starting with the first dose at age 12 through 15 months and the second dose at age 4 through 6 years before school entry. Children can receive the second dose earlier as long as it is at least 28 days after the first dose.

Teens and adults should also be up to date on MMR vaccinations. MMR vaccination is especially important for:

  • Students at post-high school educational institutions
  • International travelers
  • Healthcare professionals
  • Women of childbearing age who are not pregnant
  • People who care for or are around immunocompromised people
  • People living with HIV without evidence of severe immunosuppression

After vaccination, it is not necessary to test patients for antibodies to confirm immunity.

ProQuad® (MMRV) is a live-virus combination vaccine which includes antigens for measles, mumps, rubella, and varicella. ProQuad® is licensed for children 12 months through 12 years of age. If MMRV vaccine is used, at least 3 months should elapse between doses of varicella-containing vaccine.

Frequently Asked Questions

Answers to frequently asked questions (FAQs) related to measles outbreaks

Q1:

Is the U.S. military affected by recent measles outbreaks

A:

As part of the U.S. and global community, military members and their families share concerns about increased rates of measles.  Measles in military service members is very rare because of strong vaccine requirements.  Measles is a greater risk for family members, especially those who are less-than-fully vaccinated because of young age, medical conditions, or other reasons.

Q2:

What are the military's policies regarding measles vaccine

A:

Like all US healthcare, US military medicine follows the recommendations of the US Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices (CDC/ACIP).  The overarching reference for measles protection best practice is:  CDC. Prevention of measles, rubella, congenital rubella syndrome, and mumps. MMWR 2013:62(4):1-40.

Q3:

Should adults get extra vaccines because of measles outbreaks

A:

Adults should not get “extra” vaccines during measles outbreaks.  However, all adults should maintain evidence of measles immunity.  CDC/ACIP define evidence of measles immunity as: (a) documentation of adequate vaccination, OR (b) laboratory evidence of immunity or past disease, OR (c) birth before 1957.

Q4:

Should children get extra vaccines because of measles outbreaks

A:

Children older than 12 months of age should not get “extra” vaccines during measles outbreaks.  However, all children should maintain evidence of measles immunity.  CDC/ACIP define evidence of measles immunity in children as: (a) documentation of two doses of MMR (or MMRV) vaccine after 12 months of age, OR (b) laboratory evidence of immunity or past disease.

Q5:

Should infants get extra vaccines because of measles outbreaks

A:

Routine administration of measles vaccines (MMR or MMRV) should not begin before 12 months of age.  However, children younger than 12 months of age require special consideration for measles protection.  Children ages 6-12 months who travel internationally should receive one dose of MMR vaccine; they should subsequently receive two doses of MMR (or MMRV) after age 12 months and before school entry.  During measles outbreaks in the US, recommendations may also be made to give one dose of MMR to children ages 6-12 months.  Such recommendations are made by the cognizant public health authority who will define the time and location parameters of an outbreak; this was done in NY in April 2019.  The US military will support such recommendations for military families in affected areas.

Q6:

Why is a “3rd dose of MMR” recommended during mumps outbreaks, but not during measles outbreaks

A:

MMR vaccines are highly effective at providing lifetime protection against measles.  In contrast, MMR vaccines are less consistently effective against mumps, and mumps immunity may wane over time.  CDC/ACIP therefore recommend extra MMR vaccination during mumps outbreaks, at the discretion of public health authorities who define the time and location parameters of a mumps outbreak.  When extra MMR doses are recommended, CDC/ACIP advise that no one should receive more than three lifetime doses.

Q7:

What is “documentation of adequate vaccination” against measles

A:

Written documentation of vaccination includes vaccine type, date, administration details, and clinic stamp; documentation may be in a medical record of an official immunization record (e.g., “yellow shot card”).  Children should have two documented doses of MMR (or MMRV) administered after age 12 months, and separated by at least 28 days.  Adults should have at least one documented lifetime dose of a live-measles vaccine (like MMR or MMRV).  Adults should have two documented lifetime doses of live-measles vaccine if they are international travelers, students, healthcare workers, household contacts of immune-compromised people, or otherwise considered at higher risk of measles exposure.

Q8:

What is “laboratory evidence of immunity” against measles

A:

When people cannot provide documentation of adequate vaccination against measles, a blood test may demonstrate the presence of measles antibodies in sera.  This serologic test is often called a “titer” test.  If any serologic test in a person’s life ever demonstrates measles antibodies, CDC/ACIP consider this evidence of measles immunity.

Q9:

Should people get extra serologic testing for immunity because of measles outbreaks

A:

No.  After evidence of measles immunity has been established by either documented vaccination or laboratory testing, serologic testing should not be performed.  If serologic testing is performed after evidence of immunity has been established, results of serologic testing should be ignored.  CDC/ACIP make this recommendation because, after measles immunity has been established, it is possible for measles antibodies to become undetectable in sera even though immunity is maintained.  In these cases, an immune anamnestic (memory) response should occur after actual viral exposure and the person will still be protected from measles.

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