Vaccines, maintenance, and PEP

The information below is provided for informational purposes only and does not represent treatment or vaccine guidelines from the AAD. Please refer to your local, state, or national guidelines for treatment and vaccine guidelines.

1. What are the guidelines for routine MMR vaccination?^1,2

The routine vaccination schedule for measles, mumps, rubella (MMR), or measles, mumps, rubella, and varicella (MMRV) vaccines includes two doses. The Centers for Disease Control (CDC) child immunization schedule calls for the first dose is administered at 12 to 15 months of age, and the second dose at 4 to 6 years.

If catch-up immunizations are needed, the interval between the two vaccine doses may be shortened. For the MMR vaccine, the minimum interval is at least 4 weeks apart. If the MMRV vaccine is used, the doses of varicella should be at least 3 months apart for children younger than 13 years of age and 4 weeks part for adolescents 13 years or older.³

For infants under 6 months, maternal antibodies provide protection.

Infants aged 6 to 12 months may receive the MMR vaccine, especially if traveling internationally or during an outbreak, for temporary protection. If traveling internationally, infants 6 to 12 months should receive one dose of MMR vaccine at least two weeks before departure. However, this dose does not count toward the recommended two-dose series, and they will still need the full vaccination series later to ensure long-term immunity.

2. Is routine MMR serology required?⁴

The CDC guidelines suggest that routine serology for MMR immunity is generally not necessary for individuals who have received the recommended two doses of the MMR vaccine (one at 12 to 15 months and another at 4 to 6 years) and have a documented vaccine history. However, serologic testing may be recommended in certain situations, such as for individuals with uncertain vaccine histories, pregnant women with unclear vaccination status (especially for rubella immunity), and healthcare workers.

3. How do I manage measles?^5-7

Vaccination is the only method of preventing measles. There is no specific antiviral therapy for measles. Medical care is supportive to relieve symptoms and address complications such as pneumonia and secondary bacterial infections.

4. Can Vitamin A supplementation treat measles?^7,8

Vitamin A can be used in children and infants in the U.S. with severe measles as a component of supportive management, particularly in patients who are malnourished and Vitamin A deficient. All children or adults with measles should receive two doses of vitamin A supplementation, given 24 hours apart, to reduce the risk of complications and mortality associated with measles. However, Vitamin A is not an effective treatment or preventative measure for measles. Vitamin A should be administered under the supervision of a clinician and is not a substitute for vaccination. Of note, overuse of Vitamin A can lead to toxicity, and high-dose supplementation should be administered under the guidance of a clinician.

For further information on Vitamin A supplementation dosing, please visit the WHO/UNICEF/IVACG Task Force Guide on the use of Vitamin A supplementation.

5. What are the guidelines for post-exposure vaccination and immunoglobulin administration?^2,4

People exposed to measles who cannot readily show adequate presumptive evidence of immunity should be offered post-exposure prophylaxis (PEP). Public health officials can help identify eligible people, assess contraindications, and weigh the benefits.

There are two types of PEP for measles. To potentially provide protection or modify the clinical course of disease among susceptible people, administer one of these:

• Measles, mumps, and rubella (MMR) vaccine (if within 72 hours of initial measles exposure)

• Immunoglobulin (IG) (if within 6 days of exposure)

  • The recommended intramuscular immunoglobulin (IMIG) dose is 0.5mL/kg, regardless of the contact’s immune status

Do not administer the MMR vaccine and IG simultaneously. This practice invalidates the vaccine.

6. What are the guidelines for vaccination in immunocompromised patients and other vulnerable populations?

The MMR vaccine is a live, attenuated vaccine, and there may be special considerations around MMR vaccination for certain vulnerable patient populations. All family members and close contacts over the age of 12 months of immunocompromised individuals should receive two doses of MMR vaccine, at least 28 days apart, unless they have documented measles immunity.⁹ Maintaining herd immunity with a 95% vaccination rate is important to reduce the risk of measles in vulnerable populations who are unable to receive the vaccination themselves.^1,10

Pregnant people¹¹

The MMR vaccine is contraindicated in pregnant people but may be given after pregnancy or at least 1 month before getting pregnant.

Patients on systemic immunosuppressive agents^12,13

If you are in a high-risk area for measles and your patient is on systemic immunosuppressive therapy, you may need to have a shared decision-making discussion to determine whether they should be vaccinated.

• Apremilast: There are no contraindications to the MMR vaccine.¹⁴

• Azathioprine: EULAR guidelines suggest that the MMR vaccine may be administered for patients on low-dose azathioprine (<3 mg/kg/day).¹⁴

• Cyclosporine: The MMR vaccine may be administered, but it is generally recommended to defer the subsequent dose of cyclosporine for 2 to 4 weeks after vaccination.^14,15

• Deucravacitinib: The MMR vaccine may be administered, but it is generally recommended to discontinue therapy for 1 day prior to vaccination and 2 to 4 weeks after vaccination.

• Dupilumab: The MMR vaccine may be administered to patients receiving dupilumab in a shared decision-making capacity.^16-18

  • The available literature on patients who received vaccinations while using dupilumab overall suggests that live vaccines are safe and that the vaccine efficacy, in general, is not affected by dupilumab. An expert Delphi panel agreed that the use of live vaccines in patients receiving dupilumab was likely safe and effective.¹⁶

• JAK inhibitors: The MMR vaccine may be administered, but it is generally recommended to discontinue therapy for 1 week prior to vaccination and 2 to 4 weeks after vaccination.

• Methotrexate: While guidelines currently advise against administering the MMR vaccine to patients on low dose methotrexate (<0.4 mg/kg/week), data suggests a potential for safe vaccination with the second booster dose. A retrospective study involving 124 pediatric patients with rheumatic disease, all receiving methotrexate, demonstrated no cases of measles, rubella, mumps, or varicella infection following administration of the live measles-mumps-rubella-varicella (MMRV) booster. This study focused solely on booster vaccinations and did not evaluate the safety of the primary MMR series.^15,19

• Tacrolimus: The MMR vaccine may be administered to patients on oral tacrolimus in a shared decision-making capacity.^13,20

• TNF-α inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors: The MMR vaccine may be administered, but it is generally recommended to discontinue therapy for 2 to 3 half-lives prior to vaccination and 2 to 4 weeks after vaccination.

• Other immunosuppressive therapies (e.g. rituximab, mycophenolate mofetil, cyclophosphamide): MMR vaccination is contraindicated during therapy. It is generally recommended to administer live vaccines at least 1 month prior to starting therapy or 3 months after stopping immunosuppressive therapy (after 6 months for rituximab and mycophenolate).^14,21,22

Patients with severe primary or acquired immunodeficiency (severe combined immunodeficiency, Wiskott-Aldrich syndrome, and DiGeorge)^23,24

• The MMR vaccine is contraindicated in these populations, but PEP with immunoglobulin administration should be considered after exposure.

Patients with hematologic malignancies (leukemia, lymphoma, myeloma)^13,23,24

• In patients with active disease who are undergoing chemotherapy, the MMR vaccine is contraindicated.

• Revaccination can be considered 3 to 6 months after completion of chemotherapy.

Patients who are solid organ transplant recipients²⁵

• If possible, the MMR vaccine should be administered at least 4 weeks prior to transplantation.

• The MMR vaccine is contraindicated in the post-transplantation stage while patients are on immunosuppressive therapy.

• Revaccination may be considered 24 months after transplantation.

Patients who are hematopoietic stem cell transplant recipients^13,24,25

• If possible, the MMR vaccine should be administered at least 4 weeks prior to transplantation.

• Patients are likely to lose immunity post-transplantation, and revaccination may be considered 12 to 24 months after transplantation.

Patients living with HIV^12,23

• If CD4+ count ≥15% for over 6 months (≤5 years old) or ≥200 cells/µL (for patients >5 years old): The two-dose MMR vaccine is recommended.

• If CD4+ count <15% for over 6 months (for patients ≤5 years old) or <200 cells/µL (for patients >5 years old): the MMR vaccine is contraindicated.

• Note: If the MMR vaccine was administered before antiretroviral therapy initiation, consider obtaining serologic testing and revaccinating if there is no serologic evidence of immunity.

What is appropriate post-exposure prophylaxis for vulnerable patients?²⁴

• Severely immunocompromised patients should obtain immediate administration of intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin within 6 days of exposure. Severely immunocompromised patients include patients with severe primary immunodeficiency; patients who have received a bone marrow transplant until at least 12 months after finishing all immunosuppressive treatment, or longer in patients who have developed graft-versus-host disease; patients on treatment for acute lymphocytic leukemia within and until at least 6 months after completion of immunosuppressive chemotherapy; and patients with a diagnosis of AIDS or HIV-infected persons with severe immunosuppression defined as CD4 percent <15% (all ages) or CD4 count <200 lymphocytes/mm3 (aged >5 years) and those who have not received the MMR vaccine since starting effective antiretroviral therapy. Some experts include HIV-infected persons who lack recent confirmation of immunologic status or measles immunity in this group.

• Mild to moderately immunocompromised patients should consider post-exposure MMR vaccination within 72 hours if there are no contraindications.

7. When is an MMR booster for adults required?

A very small proportion of adults (less than 5%) may have received the killed measles vaccine from 1963 through 1967 during childhood. The Advisory Committee on Immunization Practices (ACIP) recommends re-vaccinating anyone who received a measles vaccine of unknown type, inactivated measles vaccine, or further attenuated measles vaccine accompanied by IG or high-titer measles immune globulin (no longer available in the US) during these years with 1 or 2 doses.⁹

Note: Older adults born after 1957 and vaccinated between 1968 and 1989 likely received just one dose of the measles vaccine instead of the two doses that are standard today. However, one dose alone is highly effective, providing more than enough protection for most people, and this patient population generally does not need to receive another dose unless they fall into one of the risk categories below.⁹

There are several situations in which the CDC recommends two doses of measles vaccine for adults considered at high risk. That includes people in college settings, those who work in health care, those who live or are in close contact with immunocompromised people, or those who will travel internationally.²⁶

8. Is the measles vaccine required for patients born before 1957?^11,27

Serologic studies have demonstrated that it can be assumed that people born before 1957 had measles and are immune.