Immunization Recommendations

Immunization schedules recommend the first MMR to be given the earliest at 12 months with a repeat vaccine at age 4 to 5 years. Only 2% to 5% of children will have adequate immunity if just the first vaccine is received. With the second dose, the immunity is boosted to 97% (Meissner, 2019).

MMR is provided under the following trade names:

• Immravax (Aventis Pasteur)
• Pluserx-MMR (SmithKline Beecham)
• MMR II (Merck).  

Currently the only contraindications for the vaccine are people with severe allergy, pregnancy, or immunosuppression due to the live virus. Precautions for consideration are people with thrombocytopenia, or family history of any seizures of any etiology (American Academy of Pediatrics, 2015). Parents of children who are immunocompromised and should not receive the vaccine should become the loudest proponents for the vaccine. Only by helping create herd immunity can they protect their own child.

It is significant to know that the MMR contains a live virus. It is not recommended for those with HIV, AIDS, or a neutropenic condition. Although the virus is attenuated, and the possibility of actually receiving measles from the vaccine is extremely low, it must be considered carefully for those who already have a depleted immune system. All vaccines work on the biology of immunology, which is the body's ability to recognize an antigen and build up antibodies to fight it.

When a vaccine is received by an individual, the person is considered to have passive immunity, whereas, when a person develops the antibodies naturally from direct exposure to the antigen they have active immunity. Most vaccines are synthesized chemically and deactivated, so they carry no live antigen, exceptions being the MMR and chicken pox.

A new vaccine includes the chicken pox varicella with the MMR and is called MMRV. It is given at the same recommended time frame of 12 to 15 months with the second dose at age 4 to 6 years. In the United States the measles vaccine is only available in combination formulations, such as the measles-mumps-rubella (MMR) and measles-mumps-rubella-varicella (MMRV) vaccine.

To recap: the CDC recommendation is to receive the first dose of MMR live vaccine on or before the first birthday. The ideal window for the first vaccine is 12 to 15 months of age. The second dose of MMR should be given at least 4 weeks (28 days) apart from the first vaccine but is actually recommended at age 4 to 6. If an infant received the first MMR before age 12 months due to international travel, that infant should still receive the scheduled two doses. Only written documentation of the vaccines is valid.

If there is an outbreak of measles in a community and an infant younger than 12 months is traveling to the area, the CDC does recommend the dose at 6 to 11 months, unless there are any contraindications. Studies have shown that infants vaccinated younger than 12 months of age may not reach the 97% effectiveness of immunity. The recommendation is that the infant should receive the vaccine before traveling internationally but receive the second vaccine as per the usual schedule. If an older person missed the vaccine schedule times, it is recommended they receive both doses, but 28 days apart, to establish adequate immunity.

If a person who has been immunized but does not show immunity, the recommendation is to repeat the vaccination. If the status of initial immunity is unknown, it is also recommended to simply offer the initial vaccination rather than order a serology test. Laboratory evidence of immunity is acceptable (including for international travel) if the initial vaccination is undocumented. Having an undocumented memory of the disease may not be acceptable, unless the person was born before 1957.

For those born before 1957, it is assumed they have already had the disease and do not require the vaccine. Unlike the live vaccine that is given now, a killed vaccine was given between 1963 and 1967. It was given to less than 1 million adults, which represents < 5% of all living adults. If someone received the killed vaccine during this time even with proof of documentation, they are advised to receive another vaccination of the MMR.

Measles illness during pregnancy can cause premature labor, spontaneous abortion, and birth defects. For mothers with measles who should be on isolation and are breastfeeding, breast milk given to their infant is still approved by the CDC. Although most vaccines are not given during pregnancy, the annual flu vaccine has been approved. Making sure all vaccines are up to date, including the measles through the MMR, should be done before pregnancy.

Evidence of immunity against measles is acceptable if one of the following is met:

• Written documentation of age-appropriate vaccination with a live measles virus–containing vaccine
• Laboratory evidence of immunity or serologic confirmation of the disease
• Born before 1957
• Disease history

The CDC accepts evidence of immunity with written documentation of one or more doses of the live measles vaccine (MMR) administered after the first birthday. It also accepts two doses of MMR for school-age children and adults who may be at high risk as evidence of immunity.

Prevention and Screening Strategies

Although measles was declared eliminated in the United States in the year 2000, ongoing outbreaks throughout the nation have been reported. In 2019 the number of annual cases of measles has exceeded the number of cases in any year since the eradication was declared. The 91% of cases that have been reported are of unvaccinated or unknown vaccination status and the majority of these cases are among children. Recent CDC reports also reveal that 20% of these cases are coming from international sources (eg, immigrants, international students, and tourists) who bring the disease into the United States.

General strategies that help prevent measles transmission include:

• Community vaccination, the main prevention for all settings, including schools, hospitals and the general public. Prevention through 95% vaccination in all communities remains the best approach.
• Screening is generally not done, as there is no screen for measles until the patient presents with symptoms. Screening for compliance with CDC vaccine recommendations is done however by the public-school systems that require documentation before registration for school.

Educating Parents and Communities

In the original movement against vaccines deceptively created by Wakefield (1993), the media played a large role in the controversy by publicizing the falsehoods and helping to create the confusion (Moore, 2006). The public's fear of vaccines was created through "science by press conference" rather than real science. Unfortunately, poorly backed scientific evidence was presented as truth to the public and the damage of misinformation has continued. To rectify the misperceptions that Wakefield's sham has played in causing the decline of vaccinated children, we must redouble our efforts to make the truth available to every parent.

Healthcare workers who live in ethnically tight-knit communities can spread the word where they themselves live. They may find suspicion toward the American government by ethnically diverse immigrant populations who do not trust allopathic or Western medicine. By educating and using trusted individuals within their own community, public awareness programs and even vaccine clinics could be made acceptable.

Teaching parents about the safety of the vaccine is essential to adherence to CDC recommendations. Public safety campaigns that provide printed and audiovisual materials in physician offices, hospitals, schools, and pubic venues is a proactive approach. Many states mandate the documentation of CDC recommended vaccines before admission into public schools. Schools still allow a parent to opt out of vaccines due to religious or personal values.

In many states, legislators have proposed a bill to ban vaccine exemptions (Goldstein-Street, 2019). Knowing that herd immunity requires at least 95% vaccine compliance, then working to prevent communities from dipping below that will help prevent the measles epidemics. The delicate balance between personal freedoms and community health is currently being debated state by state.

Helping parents understand the vaccine schedule and catch-up process is helpful. When pediatricians provide the overview schedule of recommended well-child visits, parents can anticipate doctor visits and schedule them accordingly. Having parents schedule the 1-year well-child visit ahead of time is a proactive approach. It is estimated that 1 in 4 children who get measles will be hospitalized and that there is a 90% chance a child without the vaccine will contract the disease. A key fact for parents to know is that measles is preventable.

Making vaccines affordable through insurance—or even free with public assistance programs such as Medicaid—can help decrease the barrier of cost. The Affordable Care Act has made efforts to cover the expense of vaccines for many populations.

The role of all healthcare professionals is to be well-informed about measles and the MMR, and to educate correctly the patients they come in contact with about the value and safety of vaccines. For those who work with vulnerable populations, advocacy for vaccine campaigns can be extremely helpful. The health of our entire American community depends on 95% of herd immunity being vaccinated. Every effort to inform and educate the general public about adherence to these guidelines can make the difference.

Global Efforts

Worldwide campaigns are making progress. Formal entities such as the American Red Cross and its counterparts across the world have created initiatives to reach communities far from medical services where they bring the clinics and vaccines to the people.

One organization, UNICEF, tries to partner with governments, private entities, and non-governmental agencies to provide immunizations to communities and families in under-developed countries. In addition to public awareness and education campaigns, their program includes efforts to create partnerships to develop solar power and technology so as to deliver the vaccines protected from extreme temperatures (UNICEF, 2018).

Source: UNICEF, UN0293818/Keïta. Used under UN copyright guidance.

In transient communities of migrant workers, or in Third World nations, parents may work in harsh conditions with their infants strapped to their backs as they work. Their survival is focused on working for food, and infant care is secondary. In a typical scenario of millions of physical laborers worldwide, Ramata, known as a "goldmine woman," scratches the dirt in a goldmine valley all day with her baby strapped to her back (see above photo). Her Mali community was only 47% vaccinated. When UNICEF workers came to her actual worksite to offer free vaccines, she said that was her "greatest treasure of the day."