Measles
Information about measles disease, vaccines and recommendations for vaccination from the Australian Immunisation Handbook.
Recently added
This page was added on 06 June 2018.
Updates made
This page was updated on 23 October 2023. View history of updates
Vaccination for certain groups of people is funded under the National Immunisation Program and by states and territories.
Overview
What
Measles is a highly infectious viral illness that is transmitted by respiratory aerosols.
Who
Measles-containing vaccine is recommended for:
- children ≥12 months of age
- adolescents and adults born during or since 1966 who have not received 2 doses of measles-containing vaccine, particularly
- healthcare workers
- childhood educators and carers
- people who work in long-term care facilities
- people who work in correctional facilities
- travellers
How
Measles-containing vaccine is recommended for children at 12 months of age as MMR (measles-mumps-rubella) vaccine, and at 18 months of age as MMRV (measles-mumps-rubella-varicella) vaccine.
All adolescents and adults born during or since 1966 should have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
Why
About 10% of measles cases involve complications. The World Health Organization is overseeing efforts to eliminate measles worldwide through immunisation and surveillance strategies.
Recommendations
Children
All children aged ≥12 months are recommended to receive 2 doses of measles-containing vaccine.
The vaccines usually received at each schedule point are:
- 12 months of age — MMR
- 18 months of age — MMRV
Measles-containing vaccine is funded through the NIP for children aged ≥12 months. For details see the National Immunisation Program schedule.
Age at 1st dose
Age at 1st dose
Measles-containing vaccines are not routinely recommended for infants <12 months of age. This is because maternal antibodies to measles persist in many infants after birth, declining progressively over the first year of life. These may interfere with active immunisation before 12 months of age.1
There is some evidence that a dose provided at ≥11 months (but before 12 months) of age is sufficiently immunogenic. This means that doses given in this time frame may not need to be repeated in all cases. See also Table. Minimum acceptable age for the 1st dose of scheduled vaccines in infants in special circumstances in Catch-up vaccination.
Children as young as 6 months of age can receive MMR vaccine in certain circumstances, including travel to highly endemic areas and during outbreaks. See Travellers. If an infant receives MMR vaccine at <11 months of age, they still need to also receive the 2 recommended vaccine doses at ≥12 months of age, at 12 and 18 months.
Age at 2nd dose
Age at 2nd dose
Children >12 months of age who have received 1 dose of measles-containing vaccine can receive the 2nd dose of measles-containing vaccine early (if at least 4 weeks after the 1st dose has elapsed) if they are at risk of coming in contact with measles.2 See Public health management.
MMRV as 1st dose is not recommended
MMRV as 1st dose is not recommended
MMRV vaccine is not recommended as the 1st dose of measles-containing vaccine in children <4 years of age. This is due to a small but increased risk of fever and febrile seizures when MMRV vaccine is given as the 1st dose of measles-containing vaccine in this age group. (See Adverse events).
If MMRV vaccine is inadvertently given as dose 1 of measles-containing vaccine, the dose does not need to be repeated (providing it was given at ≥12 months of age). The scheduled 18-month dose of MMRV should still be given at the usual time. See Table. Minimum acceptable age for the 1st dose of scheduled vaccines in infants in special circumstances in Catch-up vaccination. Advise parents and carers about the small but increased risk of fever and febrile seizures (compared with that expected after MMR vaccine).
For more details about MMRV vaccine to prevent varicella disease, see Varicella.
Catch-up vaccination for measles
Catch-up vaccination for measles
Children who have not received measles-containing vaccine at the recommended schedule points may need an alternative schedule.
See Catch-up vaccination for more details, including minimum intervals between doses.
Adolescents and adults
All adolescents and adults born during or since 1966 should have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given at ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
Adolescents and adults who have been incompletely vaccinated or do not have evidence of immunity to measles are recommended to receive measles-containing vaccine. See Catch-up vaccination for more details, including minimum intervals between doses. As measles is highly contagious, it is important to maintain a high level of measles immunity in the adult population, to reduce the risk of outbreaks and maintain elimination of measles in Australia.
People born before 1966 do not usually need to receive measles-containing vaccine (unless serological evidence indicates that they are not immune). This is because circulating measles virus and disease were very prevalent before 1966, so most people would have acquired immunity from natural infection.
However, confirmed cases of measles have occurred in people born before 1966.3 If in doubt about a person’s immunity, it may be faster and easier to vaccinate the person rather than conduct serological testing. See Serological testing for immunity to measles.
Review vaccination records for all adolescents and young adults to ensure that they have received 2 doses of measles-containing vaccine. See Epidemiology.
Measles-containing vaccine is funded through the NIP for adolescents and adults aged <20 years who have been incompletely vaccinated or do not have evidence of immunity to measles. For details see the National Immunisation Program schedule.
People aged ≥14 years are not recommended to receive MMRV vaccine
People aged ≥14 years are not recommended to receive MMRV vaccine
MMRV vaccine is not recommended for use in people ≥14 years of age. No data are available on safety, immunogenicity or efficacy in this age group.
If a person ≥14 years of age is inadvertently given a dose of MMRV vaccine, this dose does not need to be repeated.
Occupational groups
Healthcare workers are recommended to have received 2 doses of measles- containing vaccine. Measles can be transmitted in healthcare settings and infect staff and patients.4-7
Healthcare workers do not need to receive measles-containing vaccine if they have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given at ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
See Serological testing for immunity to measles, and Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsChildhood educators and carers are recommended to have received 2 doses of measles-containing vaccine given at least 4 weeks apart.
People who work in childhood education and care do not need to receive measles-containing vaccine if they have either:
- documented evidence of 2 doses of measles-containing vaccine with doses given at least 4 weeks apart and with both doses given ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
See Serological testing for immunity to measles, and Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsPeople who work in long-term care facilities are recommended to have received 2 doses of measles-containing vaccine given at least 4 weeks apart.
People who work in long-term care facilities do not need to receive measles-containing vaccine if they have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given at ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
See Serological testing for immunity to measles, and Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsPeople who work in correctional facilities are recommended to have received 2 doses of measles-containing vaccine given at least 4 weeks apart. Measles can be transmitted in correctional facilities and cause outbreaks.8,9
People who work in correctional facilities do not need to receive measles-containing vaccine if they have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given at ≥12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
See Serological testing for immunity to measles, and Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsTravellers
Travellers born during or since 1966 are recommended to have received 2 doses of measles-containing vaccine. Measles importation after international travel is the most significant source of measles cases in Australia.10-13
People born before 1966 do not need to receive measles-containing vaccine (unless serological evidence indicates that they are not immune). This is because circulating measles virus and disease were prevalent before 1966, so most people would have acquired immunity from natural infection.
However, confirmed cases of measles have occurred in people born before 1966.3 If in doubt about a person’s immunity, it may be faster and easier to vaccinate the person than conduct serological testing. See Serological testing for immunity to measles.
People born during or since 1966 who are travelling overseas are recommended to have either:
- documented evidence of 2 doses of measles-containing vaccine given at least 4 weeks apart and with both doses given at ≥ 12 months of age, or
- serological evidence of immunity to measles, mumps and rubella
See Serological testing for immunity to measles.
Travellers aged <12 months
Travellers aged <12 months
Infants travelling to countries where measles is endemic, or where measles outbreaks are occurring, may receive MMR vaccine from as young as 6 months of age, after an individual risk assessment.
However, this dose needs to be repeated, meaning that these infants need 2 further doses of measles-containing vaccine. They should receive the next dose of MMR vaccine at 12 months of age or 4 weeks after the 1st dose, whichever is later. They should receive their final dose of measles-containing vaccine as MMRV vaccine at 18 months of age as routinely recommended.
Serological testing for immunity to measles
Serological testing for immunity to measles (and mumps, rubella and varicella) is not recommended before or after routine administration of the 2-dose childhood schedule of these vaccines.
However, serological testing for measles immunity may be helpful:
- if it is uncertain whether the person has a history of natural immunity
- if it is uncertain whether the person has received 2 doses of measles-containing vaccine
- if a woman is planning pregnancy or pregnant (see also Rubella, Varicella and Vaccination for women who are planning pregnancy, pregnant or breastfeeding)
Alternatively, these people (with the exception of pregnant women and immunocompromised people) can receive MMR vaccine without serological testing. There is no known increase in adverse events from vaccinating people with pre-existing immunity to one or more of the vaccine antigens. See Adverse events.
Serological tests for immunity to measles can detect antibody produced by both previous natural infection and vaccination. Sensitivity varies by assay and clinical setting (including time since vaccination).1
When interpreting serological testing results, it may be useful to discuss the results with the laboratory that performed the test, to ensure that decisions are based on all relevant clinical information.
View recommendation detailsVaccines, dosage and administration
Measles vaccines available in Australia
The Therapeutic Goods Administration website provides product information for each vaccine.
See also Vaccine information and Variations from product information for more details.
Combination vaccines
Registered for use in people aged ≥12 months.
MMR — measles-mumps-rubella combination vaccine
Lyophilised pellet in a monodose vial with separate diluent.
Each 0.5 mL reconstituted dose contains:
- ≥1000 tissue culture infectious dose 50% (TCID50) of live attenuated measles virus (Enders’ attenuated Edmonston strain)
- ≥12,500 TCID50 of live attenuated mumps virus (Jeryl Lynn B level strain)
- ≥1000 TCID50 of live attenuated rubella virus (Wistar RA 27/3 strain)
- 14.5 mg sorbitol
- 1.9 mg sucrose
- 14.5 mg hydrolysed porcine gelatin
- ≤0.3 mg recombinant human albumin
- <1 ppm fetal bovine serum
- 25 µg neomycin
For Product Information and Consumer Medicine Information about vaccineName visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥12 months.
MMR — measles-mumps-rubella combination vaccine
Lyophilised pellet in a monodose vial with a pre-filled diluent syringe.
Each 0.5 mL reconstituted dose contains:
- ≥103.0 cell culture infectious dose 50% (CCID50) of live attenuated measles virus (Schwarz strain)
- ≥103.7 CCID50 of live attenuated mumps virus (RIT 4385 strain, derived from the Jeryl Lynn strain)
- ≥103.0 CCID50 of live attenuated rubella virus (Wistar RA 27/3 strain)
- lactose
- neomycin sulphate
- sorbitol
- mannitol
- phenylalanine
For Product Information and Consumer Medicine Information about Priorix visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥9 months.
MMRV — measles-mumps-rubella-varicella combination vaccine
Lyophilised pellet in a monodose vial with a pre-filled diluent syringe.
Each 0.5 mL reconstituted dose contains:
- ≥103.0 cell culture infectious dose 50% (CCID50) of live attenuated measles virus (Schwarz strain)
- ≥104.4 CCID50 of live attenuated mumps virus (RIT 4385 strain, derived from the Jeryl Lynn strain)
- ≥103.0 CCID50 of live attenuated rubella virus (Wistar RA 27/3 strain)
- ≥103.3 plaque-forming units of live attenuated varicella-zoster virus (Oka strain)
- lactose
- neomycin
- sorbitol
- mannitol
For Product Information and Consumer Medicine Information about Priorix-tetra visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in children aged 12 months to 12 years.
MMRV — measles-mumps-rubella-varicella combination vaccine
Lyophilised powder in a monodose vial with a pre-filled diluent syringe.
Each 0.5 mL reconstituted dose contains:
- ≥103.00 culture infectious dose 50% (TCID50) of live attenuated measles virus (Enders’ attenuated Edmonston strain)
- ≥104.30 TCID50 of live attenuated mumps virus (Jeryl Lynn B level strain)
- ≥103.00 TCID50 of live attenuated rubella virus (Wistar RA 27/3 strain)
- ≥103.99 plaque-forming units of live attenuated varicella-zoster virus (Oka/Merck strain)
- 20 mg sucrose
- 11 mg hydrolysed porcine gelatin
- 2.5 mg urea
- 16 mg sorbitol
- 0.38 mg monosodium L-glutamate
- 0.25 mg recombinant human albumin
- 5 µg neomycin
- residual components of MRC-5 cells
- 0.5 µg bovine serum albumin
For Product Information and Consumer Medicine Information about ProQuad visit the Therapeutic Goods Administration website.
View vaccine detailsDose and route
The dose of Priorix and M-M-R-II (MMR) vaccine for both children and adults is 0.5 mL given by either subcutaneous or intramuscular injection.
The dose of ProQuad and Priorix-tetra (MMRV) vaccine for children <14 years of age is 0.5 mL given by either subcutaneous or intramuscular injection.14
Co-administration with other vaccines
People can receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines or other inactivated vaccines.15 If a person does not receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines, wait at least 4 weeks between vaccinations.16,17
Measles, mumps and rubella vaccines are not available separately as an alternative to MMR vaccine. However, a monovalent varicella vaccine is available (see Varicella).
If a person receives MMR vaccine at the same time as monovalent varicella vaccine, use separate syringes and injection sites. Do not mix MMR vaccine and monovalent varicella vaccine together before injection.
Interchangeability of MMR-containing vaccines
The 2 brands of MMR vaccine are interchangeable, so the 2nd MMR vaccine dose does not have to be the same brand as the 1st.
The same principle applies to the 2 MMRV vaccines,15 although they are not recommended in a 2-dose schedule.
Contraindications and precautions
Contraindications
Anaphylaxis to vaccine components
MMR and MMRV vaccines are contraindicated in people who have had:
- anaphylaxis after a previous dose of any MMR-containing vaccine
- anaphylaxis after any component of an MMR-containing vaccine
See Anaphylaxis in Adverse events for more details about MMR vaccination for people with a known egg allergy.
Pregnant women
MMR-containing vaccines are contraindicated in pregnant women.
Vaccinated women should avoid pregnancy for 28 days after vaccination.18
There is no risk to pregnant women from contact with people who have recently been vaccinated. The vaccine viruses is not transmitted from vaccinated people to susceptible contacts.19
See also Rubella, Varicella, Vaccination for women who are planning pregnancy, pregnant or breastfeeding and Table. Vaccines that are contraindicated in pregnancy: live attenuated vaccines for more details.
Breastfeeding women can receive MMR vaccines. See also Rubella.
People who are immunocompromised
MMR-containing vaccines contain live attenuated viruses and are contraindicated in people who are immunocompromised. This means that MMR-containing vaccines are contraindicated in:
- people who are significantly immunocompromised because of a medical condition(s)
- people receiving high-dose systemic immunosuppressive therapy, such as chemotherapy, radiation therapy or oral corticosteroids
See Vaccination for people who are immunocompromised for more details.
For more details on using live attenuated vaccines in people receiving corticosteroid therapy, see Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids in Vaccination for people who are immunocompromised.
Precautions
Vaccination after receiving immunoglobulin or a blood product
A recent blood transfusion with washed red blood cells is not a contraindication to MMR or MMRV vaccines.
People who have received an immunoglobulin-containing blood product should wait 3–11 months before receiving a measles-containing vaccine. This is because the immunoglobulin may impair the expected immune response to the vaccine.17,20
The interval between receiving the blood product and the vaccine depends on the amount of immunoglobulin in each product.17 See Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination and Vaccination for people who have recently received normal human immunoglobulin and other blood products.
People may receive MMR vaccine at the same time as anti-D immunoglobulin, but at different injection sites. They can also receive MMR vaccine at any time before or after anti-D immunoglobulin. Anti-D immunoglobulin does not interfere with the antibody response to the vaccine.
Immunoglobulin or blood product administration after vaccination
People who have received a measles-containing vaccine should not receive immunoglobulin-containing products for 3 weeks after vaccination, unless the benefits of receiving the blood product outweigh the benefits of vaccination. If the person receives an immunoglobulin-containing product within 3 weeks after a measles-containing vaccine, the vaccinated person should be either:
- revaccinated later at the appropriate time, as indicated in Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination, or
- tested for immunity 6 months later and then revaccinated if seronegative
People may receive anti-D immunoglobulin at any time after receiving MMR vaccine.
People with HIV
The following people with HIV may receive MMR vaccine:18,21-25
- asymptomatic children >12 months of age with an age-specific CD4+ count of ≥15%
- adults with a CD4+ cell count ≥200 cells per μL
See People with HIV in Vaccination for people who are immunocompromised.
There have been no studies on combination MMRV vaccines in asymptomatic people with HIV or people with an age-specific CD4+ count of ≥15%. Therefore, it is recommended that these groups receive only MMR vaccine (and monovalent varicella vaccine — see Varicella).23,25,26
No data are available on the safety, immunogenicity or efficacy of MMRV vaccines in children with HIV. These children should receive MMR vaccine and monovalent varicella vaccine, not MMRV vaccine.18,20
People receiving corticosteroid therapy
People on low-dose systemic corticosteroids can receive MMR-containing vaccines. Low-dose systemic corticosteroid therapy includes:
Children aged <16 years who weigh ≤10 kg and are on doses of
- ≤2 mg per kg per day for less than 14 days
- 1 mg per kg per day for less than 30 days
Children aged <16 years who weigh >10 kg and are on doses of
- <10 mg per day for less than 28 days
- <20 mg per day less than 14 days
All people aged ≥16 years who are on doses of <20 mg per day for any duration
People receiving high-dose corticosteroids can receive MMR-containing vaccines after they have stopped corticosteroid therapy for at least 1 month (see Contraindications).27
Some experts suggest temporarily stopping lower doses of steroids 2–3 weeks before vaccination with live viral vaccines, if possible.20,27
See also Vaccination for people who are immunocompromised.
Household contacts of people who are immunocompromised
Household contacts of people who are immunocompromised should ensure that they are age-appropriately vaccinated against, or are immune to, measles, mumps, rubella and varicella.
Household contacts of people who are immunocompromised can safely receive measles-containing vaccines, because the vaccine viruses are not transmissible from vaccinated people to others.18
If using MMRV vaccine, see Varicella for details about varicella vaccine virus transmission.
People receiving long-term aspirin or salicylate therapy
There is no need to avoid salicylates before or after receiving MMR or MMRV vaccine.
People taking long-term salicylate therapy (aspirin) can receive MMRV vaccine if needed. The benefit is likely to outweigh any possible risk of Reye syndrome after vaccination with a varicella-containing vaccine (see Varicella).
People with a history of thrombocytopenia
Thrombocytopenia is a rare adverse event associated with MMR vaccination (see Adverse events).19,28,29
In children who have had an episode(s) of idiopathic thrombocytopenia purpura (ITP), the risk of vaccine-associated thrombocytopenia after a dose of MMR vaccine is uncertain.18,29 However, a systematic review concluded that MMR vaccination, either a 1st or 2nd dose, did not lead to a recurrence of ITP.30 In children due for their 2nd dose, serological testing can be used to determine whether the child needs the extra dose of MMR or MMRV vaccine.
People with possible IFNAR1 deficiency
IFNAR1 deficiency is a rare inherited condition affecting some people of Western Polynesian heritage, including Tongan, Samoan and Niuean. It is associated with severe illness and death from certain viral infections and also potentially from some live attenuated viral vaccines, including the measles, mumps and rubella (MMR) vaccine.31 Currently, diagnosis of IFNAR1 deficiency prior to vaccination is challenging and there is no established treatment.
Healthcare providers need to be aware that children of Western Polynesian heritage who present for medical attention and are very unwell in the 1-2 weeks following MMR vaccine may need further investigation by an immunologist to assess for an immune deficiency. Any suspected adverse event following immunisation should be reported. Family members of individuals who have had a severe reaction to a live attenuated viral vaccine, or are related to someone with known IFNAR1 deficiency, should be referred to an immunologist before having the MMR vaccine. Children who have safely received a first dose of MMR vaccine are highly unlikely to have IFNAR1 deficiency.31
Advice on vaccination of children or adults who have been diagnosed with IFNAR1 or any other specific immune deficiency should be sought from their immunologist, noting that disease from wild-type measles and mumps is probably more severe than from the vaccine viruses.31
Personal or close family history of seizures or convulsions
Children with a personal or close family history of seizures or convulsions can receive MMR or MMRV vaccine.
Ensure that the parents or carers understand that the child may develop a fever 6–14 days after vaccination.18 Advise parents or carers about how to manage the fever with paracetamol and other measures (see Adverse events following immunisation in After vaccination).
MMRV vaccines are only recommended for use as the 2nd dose of measles-containing vaccine. This is because the risk of fever and febrile convulsions is higher if children receive MMRV vaccine as their 1st dose. See Recommendations and Adverse events.
Tuberculin skin testing after MMR vaccination
The measles virus inhibits the response to tuberculin. Tuberculin-positive people may become tuberculin-negative for 4–6 weeks after measles infection, and measles-containing vaccines have a similar effect.18,32 Because of this, a tuberculin skin test (TST; Mantoux) may be unreliable for at least 4–6 weeks in people who have received MMR vaccine.
There are no studies on if or how MMR or MMRV vaccination affects the results of interferon-gamma release assays used for testing for M. tuberculosis infection.33
Adverse events
Adverse events after receiving a measles-containing vaccine are generally mild and well tolerated.1 Adverse events are much less common after the 2nd dose of MMR or MMRV vaccine than after the 1st dose.
Measles-containing vaccine has been shown to be safe and well-tolerated when given to infants as young as 6 months of age.34
Fever and febrile convulsions
MMR vaccines
People who receive MMR vaccine may develop a fever 7–10 days (range 5–12 days) after vaccination. This can last 2–3 days. The fever may be associated with malaise and/or a non-infectious rash. Up to 15% of young children receiving MMR vaccine develop a high fever (>39.4°C).1,18
An increased risk of febrile seizures of about 1 case per 3000–4000 doses occurs in the same time period.18
This time frame coincides with the period of peak measles vaccine virus replication.
Inform vaccine recipients, or their parents or carers, about:
- possible symptoms occurring 5–12 days after vaccination
- how to manage the symptoms, including using paracetamol for fever
See Adverse events following immunisation in After vaccination.
MMRV vaccines
In clinical trials, people who received MMRV vaccine had higher rates of fever than people who received MMR vaccine and monovalent varicella vaccine at the same time but at separate sites.35-38 Rates of fever were highest in young children who received MMRV vaccine as their 1st dose.
Post-marketing studies in the United States identified an approximately 2-fold increased risk of fever and febrile convulsions 7–10 days39 (or 5–12 days)40 after vaccination in children who received MMRV vaccine as a 1st dose. MMRV recipients were compared with recipients of separate MMR and varicella vaccines. MMRV vaccination resulted in 1 additional febrile seizure for every 2300 doses compared with separate MMR and varicella vaccination.39 Children in these studies were mostly 12–23 months of age.
In the United States, post-marketing studies did not find an increase in fever or febrile convulsions after children received the 2nd dose of ProQuad (MMRV) vaccine. However, most 2nd-dose recipients were aged 4–6 years, an age at which the incidence of febrile convulsions is low.41 This side effect profile is expected to be similar in children who receive Priorix-tetra.
Rare adverse events
Anaphylaxis
Anaphylaxis after receiving an MMR vaccine is very rare (1.8–14.4 per million doses).18
Although no cases of anaphylaxis were reported in MMRV vaccine clinical trials, the incidence is likely to be similar to that of MMR vaccine.
Anaphylaxis after vaccination is probably due to anaphylactic sensitivity to gelatin or neomycin, not an egg allergy. Measles and mumps (not rubella or varicella) vaccine viruses are grown in chick embryo tissue cultures, but measles- and mumps-containing vaccines have negligible amounts of egg ovalbumin. See Variations from product information and Vaccination for people who have had an adverse event following immunisation.
People with an egg allergy can safely receive an MMR or MMRV vaccine.19,42,43 Skin testing is not needed before vaccination.19
Thrombocytopenia
Thrombocytopenia has been very rarely associated with the rubella or measles component of MMR vaccine. It is usually self-limiting and occurs in 3–5 per 100,000 doses of MMR vaccine.19,28,29 This is considerably less frequent than after natural measles, mumps and rubella infections.29
Any association with MMRV vaccine is expected to be similar.
Encephalopathy
It is uncertain whether people can develop encephalopathy after MMR vaccination. If they do, it is at least 1000 times less frequent than encephalopathy as a complication from natural infection.1
Lymphadenopathy, arthralgia and parotitis
Other rare adverse events attributed to MMR vaccine include:18
Conditions not linked to MMR vaccination
MMR vaccine is not associated with:
- autism
- autistic spectrum disorder
- inflammatory bowel disease
No credible scientific evidence supports a link between MMR and these conditions. Most proponents of the link have retracted this claim.44,45 There is a substantial body of evidence to refute these claims.46-49
Nature of the disease
Measles is caused by a paramyxovirus from the genus Morbillivirus. The measles virus is an RNA virus with 6 structural proteins, 3 complexed to the RNA and 3 associated with the viral envelope. The 2 envelope proteins — F (fusion) and H (haemagglutinin) — are the most important in pathogenesis.1
The measles virus can survive for up to 2 hours in air. It is rapidly inactivated by:1,19
- heat
- light
- extremes of pH
Pathogenesis
Measles is a highly infectious, acute viral illness. The incubation period is usually 10–14 days.
Transmission
Measles is spread by respiratory secretions, including by aerosols.19 It is infectious from the beginning of the prodromal period (typically 2 to 4 days before rash onset) and for up to 4 days after the rash appears.50 See Symptoms of measles.
Clinical features
Symptoms of measles
The prodrome lasts 2–4 days. It is characterised by:
- fever
- malaise
- cough
- coryza
- conjunctivitis
A maculopapular rash typically begins on the face and upper neck, and then becomes generalised.
Complications of measles
Measles is often a severe disease. Frequent complications are:1,19
- otitis media (in around 9% of people)
- pneumonia (in around 6%)
- diarrhoea (in around 8%)
Acute encephalitis occurs in 1 per 1000 cases, and has a mortality rate of 10–15%. A high proportion of survivors have permanent brain damage.51
Subacute sclerosing panencephalitis is a late complication of measles. It occurs, on average, 7 years after infection.1
Complications from measles are more common and more severe in:1
- people who are chronically ill
- children <5 years of age
- adults
Measles infection during pregnancy can result in miscarriage and premature delivery. It is not associated with congenital malformation.1
Death from measles
During the resurgence of measles in the United States between 1989 and 1991, subacute sclerosing panencephalitis (SSPE) subsequently occurred in about 22 per 100,000 measles cases (0.022%). This was significantly higher than the previous estimate of 1 SSPE case per 100,000 measles cases (0.001%).19 SSPE causes progressive brain damage and is always fatal.
About 60% of acute measles deaths are from pneumonia, especially in young children. Complications, including death, from encephalitis are more often seen in adults.1,19
Epidemiology
Measles in Australia
In March 2014, the World Health Organization (WHO) declared that endemic measles was eliminated from Australia. This was because an endemic measles strain had not been circulating for several years.52
However, measles cases in Australia continue to occur, mainly in non-immune travellers and their contacts. When these travellers return to Australia, they can cause measles outbreaks, typically of limited size and duration.53
In 2014, Australia had 340 measles notifications — a notification rate of 1.4 per 100,000 population. This was 2.3 times the mean of the previous 5 years and an increase of 110% compared with 2013.13 Of the measles cases in 2014, 75% were confirmed to be either imported or import related.13 Most cases were in infants aged <12 months who are too young to be immunised, and in adolescents and adults aged 30–39 years. In 2019, Australia had 285 cases of measles reported54,55, up from the 81 cases in 2017 (0.3 cases per 100,000 population).54 This resurgence of cases was also associated with under-vaccinated travellers.55
The last measles death in Australia was recorded in 1995.3,56 Since 1998, subacute sclerosing panencephalitis has caused 2 deaths in Australia — 1 in 1999 and 1 in 2004.57,58
Global measles elimination
Measles remains one of the leading causes of death among young children, even though a safe and cost-effective vaccine is available. WHO is overseeing efforts to eliminate measles worldwide through immunisation and surveillance strategies.59 After extensive vaccination campaigns, global measles deaths decreased by 84% — from more than 550,000 in 2000 to less than 90,000 in 2016.60
In 2003, the Expanded Programme on Immunization for the WHO Western Pacific Region (WPRO) listed measles elimination as a regional goal.61 Although WPRO did not meet its 2012 target date, the measles elimination initiative led to a significant decline in cases, with the lowest level of transmission recorded in 2012.62
Strategies for achieving measles control and elimination across all WHO regions are continually being developed and implemented.63,64
During the COVID-19 pandemic, measles vaccination coverage rates fell around the world, with more than 40 million children missing a dose. Together with a decline in measles surveillance, measles is now again an imminent threat globally, emphasising the need to achieve high population immunity through vaccination.65
Vaccine information
Monovalent measles vaccine is not available in Australia. People receive measles vaccine as either MMR or MMRV vaccine.
Immunogenicity
1 dose of measles-containing vaccine provides long-term immunity in most people.1,66 However, around 5% of people fail to develop immunity to measles after 1 dose.18 After a 2nd vaccine dose, about 99% of people are immune to measles.
Studies have demonstrated that a dose of measles-containing vaccine given as young as 6 months of age can be seroprotective67-69 but requires 2 additional doses be given on the recommended schedule.
Clinical trials of MMR vaccine compared with MMRV vaccine were mainly done in children 12 months to 6 years of age. MMRV vaccines produce similar rates of seroconversion to all 4 vaccine components as MMR and monovalent varicella vaccines given at the same time at separate injection sites.35-38
Vaccine effectiveness
Measles-containing vaccines are 90–95% effective in developed countries that have high vaccination coverage and low measles incidence.1 In Australia, the overall vaccine effectiveness is about 96% for 1 dose and 99% for 2 doses of measles-containing vaccine.70 A Cochrane review reported 1-dose vaccine effectiveness to be 95%.69 However, some studies, especially in regions such as Asia and Africa, have shown effectiveness to be lower in 1-dose recipients.72
A review by the World Health Organization (WHO) reported that the pooled vaccine effectiveness estimate for dose 1 of a measles-containing vaccine administered at 4. 5–9 months of age was 72%.34
Transporting, storing and handling vaccines
Transport according to National vaccine storage guidelines: Strive for 5.73 Store at +2°C to +8°C. Do not freeze. Protect from light.
Both MMR and MMRV vaccines must be reconstituted. Add the entire contents of the diluent container to the vial containing the pellet.
Shake until the pellet completely dissolves.
Use reconstituted Priorix (MMR), M-M-R II (MMR) and Priorix-tetra (MMRV) vaccines as soon as practicable. If reconstituted vaccine must be stored, hold at +2°C to +8°C for no more than 8 hours.
Use reconstituted ProQuad (MMRV) vaccine immediately. If it must be stored, hold at:
- +2°C to +8°C for no more than 2.5 hours, or
- +20°C to +25°C for no more than 1 hour
Public health management
Notifying measles
Measles is a notifiable disease in all states and territories in Australia, and is an urgent public health priority.
The Communicable Diseases Network Australia national guidelines for measles2 have details on:
- current case definitions
- testing
- post-exposure prophylaxis of contacts
State and territory public health authorities can provide further advice about the public health management of measles.
Managing measles cases
There is no specific therapy for an acute measles infection.
Managing contacts of measles cases
Non-immune people who are exposed to measles should receive an MMR vaccine (or MMRV in some instances) for post-exposure prophylaxis, ideally within 72 hours of exposure. See Table. Post-exposure prophylaxis needed within 6 days (144 hours) of 1st exposure for people exposed to measles.
Children >12 months of age who have received 1 dose of measles-containing vaccine can receive their 2nd dose earlier that the scheduled 18-month age milestone if:
- they have or are at risk of coming in contact with a person with measles2 (see Recommendations and Table. Post-exposure prophylaxis needed within 6 days (144 hours) of 1st exposure for people exposed to measles)
- it has been at least 4 weeks since the 1st dose
If varicella vaccination is also indicated, MMRV vaccine can be used. However, MMRV vaccine is not routinely recommended as the 1st dose of MMR-containing vaccine in children aged <4 years (see Recommendations).
If a child receives the 2nd dose of measles-containing vaccine early, they are considered to have completed their vaccination schedule. They do not need another dose at ≥18 months of age, as long as they received the 2 measles-containing vaccine doses at ≥12 months of age and at least 4 weeks apart.
Post-exposure vaccination beyond 72 hours of first measles exposure to measles is not as effective as vaccine given within 72 hours, that is as soon as possible after exposure. However, in settings with large numbers of people with uncertain vaccination histories and immunity (e.g. in high schools, adult workplaces(, where further cases of measles may occur, MMR vaccination, even if ≥72 hours after exposure, may reduce the likelihood of ongoing transmission.
Normal human immunoglobulin
In some individuals and settings, normal human immunoglobulin (NHIG), rather than MMR or MMRV, is recommended for post exposure prophylaxis. In these contexts, NHIG may be given up to 6 days (144 hours) post exposure (see Table. Post-exposure prophylaxis needed within 6 days (144 hours) of 1st exposure for people exposed to measles).2 Public health authorities decide when NHIG is needed.
NHIG is a sterile solution of immunoglobulin, mainly IgG. It contains antibodies that are commonly present in adult human blood.
In Australia, the Australian Red Cross Blood Service supplies NHIG as a 16% solution.
Normal human immunoglobulin-VF (human)
160 mg/mL immunoglobulin (mainly IgG) prepared from Australian blood donations.
Supplied in 2 mL and 5 mL vials.
Also contains glycine.
View immunoglobulin detailsAdministration of NHIG
Give NHIG by deep intramuscular injection, using an appropriately sized needle. Introduce the NHIG slowly into the muscle, to reduce pain.
Never administer NHIG intravenously. This could cause severe adverse events. To ensure that the needle is not in a small vessel, try to draw back on the syringe after intramuscular insertion.
A special product for intravenous use — called NHIG (intravenous) — is for people who need large doses of immunoglobulin.
For more details about the use of intravenous immunoglobulins, see Criteria for the Clinical Use of Intravenous Immunoglobulin in Australia.74
Recommendations for using NHIG
NHIG contains enough antibody against measles to prevent infection or reduce disease severity but does not provide long term protection against infection.
Age or immune status | Has received 0 doses of MMR vaccine, or unknown | Has received 1 dose of MMR vaccine | Has received 2 doses of MMR vaccine |
---|---|---|---|
Immunocompromised (any age) | Give normal human immunoglobulin (NHIG) — 0.5 mL/kg to maximum of 15 mL | Give NHIG — 0.5 mL/kg to maximum of 15 mL | Give NHIG — 0.5 mL/kg to maximum of 15 mL |
Birth to 5 months |
Give NHIG — 0.2 mL/kg, only if either:
|
Not applicable
|
Not applicable
|
6–11 months |
If <72 hours since exposure:
If ≥72 hours since exposure:
|
Not applicable | Not applicable |
12 months to <18 months |
If ≥72 hours since exposure:
|
If <72 hours since exposure:
|
Not necessary |
≥18 months, or born during or since 1966, and not pregnant |
If <72 hours since exposure:
|
Give MMR or MMRV vaccine (based on age). | Not necessary |
Pregnant |
|
|
Not necessary |
MMR = measles-mumps-rubella; MMRV = measles-mumps-rubella-varicella; NHIG = normal human immunoglobulin Source: Adapted from the Communicable Diseases Network Australia national guidelines for measles2 Administration of vaccine at >72 hours post exposure or immunoglobulin at 6 days (144 hours) post exposure is unlikely to be effective and is not recommended. For preterm (premature) infants who have been exposed to measles, using maternal vaccination history as a guide for Post-exposure prophylaxis requirements is not recommended. |
Variations from product information
People with egg allergy
The product information for Priorix, M-M-R II and Priorix-tetra states that people with a history of anaphylactic or anaphylactoid reactions to egg should not receive these vaccines.
The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that these people can receive Priorix, M-M-R II, Priorix-tetra or ProQuad.18
Women planning pregnancy
The product information for M-M-R II and ProQuad recommends that women of child-bearing age should avoid pregnancy for 1 month after vaccination.
ATAGI recommends that these women should avoid pregnancy for 28 days after vaccination,18 as for Priorix and Priorix-tetra.
People taking salicylates
The product information for ProQuad and Priorix-tetra states that people should avoid taking salicylates for 6 weeks after vaccination. This is because Reye syndrome has been reported after using salicylates during natural varicella infection.
ATAGI recommends that non-immune people on long-term salicylate therapy can receive varicella-containing vaccines, because the benefit is likely to outweigh any possible risk of Reye syndrome after vaccination.
Recommended ages for MMR vaccines
The product information for M-M-R II and Priorix states vaccine is for use in children ≥12 months of age.
ATAGI recommends that children ≥6 months can receive both MMR vaccines in certain circumstances, including travel to highly endemic areas and during outbreaks.
Recommended ages for MMRV vaccines
The product information for ProQuad states that this vaccine is for use in children 12 months to 12 years of age. The product information for Priorix-tetra states that children ≥9 months of age can receive this vaccine.
ATAGI recommends that children up to 14 years of age can receive both MMRV vaccines. ATAGI also recommends that MMRV vaccine should not be used routinely as the 1st dose of MMR-containing vaccine in children aged <4 years.
References
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- MacIntyre CR, McIntyre PB. MMR, autism and inflammatory bowel disease: responding to patient concerns using an evidence-based framework [editorial]. Medical Journal of Australia 2001;175:127-8.
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Page history
Minor updates to clinical guidance around post-exposure prophylaxis for people exposed to measles.
Updates to Epidemiology section to provide the most up-to-date information.
Information added to contraindications and precautions regarding vaccination of people with possible IFNAR1 deficiency.
Detailed guidance on vaccinating adults and children taking corticosteroids.
Editorial update of guidance on the age at 1st MMR dose for children, to correct typographical error.
Recommendation for travellers updated to provide more information about the age group of travellers who require 2 doses of MMR vaccine.
Guidance under Co-administration with other vaccines updated.
Nature of the disease section updated to define the prodromal period.
Vaccine information section updated to clarify WHO vaccine effectiveness estimate.
The recommended age at which infants can receive MMR vaccine in special circumstances has been lowered from 9 months to 6 months. Infants as young as 6 months of age can receive MMR vaccine for travel to highly endemic areas during outbreaks and as post-exposure prophylaxis.
For post-exposure prophylaxis, infants from 6 months can be offered MMR vaccine in place of normal human immunoglobulin.
Changes to 4.9.4 Vaccines; 4.9.5 Transport, storage and handling; 4.11 Mumps and 4.18 Rubella); 4.9.10 Precautions; and 4.9.11 Adverse events
4.9.4 Vaccines
Correction of text due to incorrect nomenclature (Refer also Chapters, 4.11 Mumps and 4.18 Rubella and 4.22 Varicella).
Updating of text for consistency with new product information. In particular, the source of animal derived gelatin was updated to specify porcine gelatin. (Refer also Chapters, 4.11 Mumps, 4.18 Rubella, 4.21 Typhoid, 4.22 Varicella and Appendices 3 & 4).
4.9.5 Transport, storage and handling
Amendment of text to align with new product information on storage of vaccine at various temperatures (Refer also Chapters, 4.11 Mumps and 4.18 Rubella).
4.9.10 Precautions, 4.9.11 Adverse events
Moving text on egg allergy from Precautions to Adverse Events to be consistent with other chapters (Refer also Chapters, 4.11 Mumps, 4.18 Rubella and 4.22 Varicella).
4.9.11 Adverse events
Addition of text on ovalbumin quantity in vaccine.
Minor updates to clinical guidance around post-exposure prophylaxis for people exposed to measles.
Updates to Epidemiology section to provide the most up-to-date information.
Information added to contraindications and precautions regarding vaccination of people with possible IFNAR1 deficiency.
Detailed guidance on vaccinating adults and children taking corticosteroids.
Editorial update of guidance on the age at 1st MMR dose for children, to correct typographical error.
Recommendation for travellers updated to provide more information about the age group of travellers who require 2 doses of MMR vaccine.
Guidance under Co-administration with other vaccines updated.
Nature of the disease section updated to define the prodromal period.
Vaccine information section updated to clarify WHO vaccine effectiveness estimate.
The recommended age at which infants can receive MMR vaccine in special circumstances has been lowered from 9 months to 6 months. Infants as young as 6 months of age can receive MMR vaccine for travel to highly endemic areas during outbreaks and as post-exposure prophylaxis.
For post-exposure prophylaxis, infants from 6 months can be offered MMR vaccine in place of normal human immunoglobulin.
Changes to 4.9.4 Vaccines; 4.9.5 Transport, storage and handling; 4.11 Mumps and 4.18 Rubella); 4.9.10 Precautions; and 4.9.11 Adverse events
4.9.4 Vaccines
Correction of text due to incorrect nomenclature (Refer also Chapters, 4.11 Mumps and 4.18 Rubella and 4.22 Varicella).
Updating of text for consistency with new product information. In particular, the source of animal derived gelatin was updated to specify porcine gelatin. (Refer also Chapters, 4.11 Mumps, 4.18 Rubella, 4.21 Typhoid, 4.22 Varicella and Appendices 3 & 4).
4.9.5 Transport, storage and handling
Amendment of text to align with new product information on storage of vaccine at various temperatures (Refer also Chapters, 4.11 Mumps and 4.18 Rubella).
4.9.10 Precautions, 4.9.11 Adverse events
Moving text on egg allergy from Precautions to Adverse Events to be consistent with other chapters (Refer also Chapters, 4.11 Mumps, 4.18 Rubella and 4.22 Varicella).
4.9.11 Adverse events
Addition of text on ovalbumin quantity in vaccine.