MMR vaccination

In recent years concerns have been raised in the popular press about possible side effects from the MMR vaccine, which is given to infants to guard against measles, mumps and rubella. Although this has led to a drop in the levels of vaccination, the advice from health professionals continues to be in favour of vaccination, because even if the claimed side effects were shown to be true, failure to vaccinate would still statistically pose the greater health risk due to the detrimental effects of the diseases themselves. 

Notes Measles, mumps and rubella vaccines are generally administered in the form of a combined measles/mumps/rubella vaccine (MMR vaccine). 

IGIM should be injected into a deltoid or gluteal muscle. It does not affect the immune response of inactivated vaccines, oral polio virus, or yellow fever vaccine. The administration of live vaccines [e.g., measles, mumps, rubella (MMR) vaccine] concomitantly with IGIM may decrease the immune response significantly thus, MMR and varicella vaccine should be delayed for at least 3 and 5 months, respectively, after IGIM has been administered. Additionally, IGIM should not be given within 2 weeks of the MMR administration or within 3 weeks of the varicella vaccine to maximize the efficacy of the immunization.1... 

Rubella component Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and oounsel women regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. 

The vaccine should not be given to immunosuppressed patients (except those infected with HIV) or pregnant women. HIV-infected persons who have never had measles or have never been vaccinated should be given measles-containing vaccine unless there is evidence of severe immunosuppression. The vaccine should not be given within 1 month of any other live vaccine unless the vaccine is given on the same day (as with the MMR vaccine). Measles vaccine is indicated in all persons born after 1956 or in those who lack documentation of wild virus infection either by history or antibody titers. 

The vaccine should not be given to immunosuppressed individuals, although MMR vaccine should be administered to young children with HIV without severe immunosuppression as soon as possible after their first birthday. The vaccine should not be given to individuals with anaphylactic reaction to neomycin. 

At the same time Wakefield and co-workers " described an inflammatory bowel condition apparently related to young children with an ASD. As a tentative suggestion the possibility that this might also be related to MMR vaccination was raised which resulted in cries of dismay, mostly from the UK Department of Health but also from certain sections of the medical profession. There is certainly good evidence that these disorders are chronologically related to the time of MMR vaccination and, in addition, measles virus, sometimes claimed to be of vaccine origin, has been found in bowel tissue but a convincing causal relationship has been widely discounted. 

Many of the more prominent vaccine preparations in current medical use consist of attenuated viral particles (Table 10.11). Mumps vaccine consists of live attenuated strains of Paramyxovirus parotitidis. In many world regions, it is used to routinely vaccinate children, often a part of a combined measles, mumps and rubella (MMR) vaccine. Several attenuated strains have been developed for use in vaccine preparations. The most commonly used is the Jeryl Linn strain of the mumps vaccine, which is propagated in chick embryo cell culture. This vaccine has been administered to well over 50 million people worldwide and, typically, results in seroconversion rates of over 97%. The Sabin (oral poliomyelitis) vaccine consists of an aqueous suspension of poliomyelitis virus, usually grown in cultures of monkey kidney tissue. It contains approximately 1 million particles of poliomyelitis strains 1, 2 or 3 or a combination of all three strains. 

Live attenuated virus vaccines for measles, mumps and rubella (MMR) have been combined into a single vaccine known as MMR vaccine. The MMR vaccine is effective as the single-virus vaccine composed of the respective strains and has been shown to be highly effective. The immunity induced by MMR is long lasting and may be lifelong. 

Combination vaccines are more convenient in use and are exploited in the familiar DPT and MMR vaccines. However, there is always the possibility of autoimmune reactions and an increased risk of side effects. As noted, these issues have been obscured legally by claims that autism in children is caused by such combinations or the use of thiomersalate as a mercurial preservative. Scientifically it is probably safe to say that these side effects have not been demonstrated convincingly but these issues have caused difficulties for the manufacturers. 

Idiopathic thrombocytopenic purpura, also referred to as immune thrombocytopenic purpura, is a bleeding disorder characterised by destruction of platelets. Antiplatelet autoantibodies are present, suggesting an autoimmune aetiology. These antibodies label the platelets for destruction by macrophages in the spleen. The condition may be acute or chronic. Acute ITP is the most common form and is found most often in children. Some cases are associated with recent viral infections and immunisations, notably the measles, mumps, rubella (MMR) vaccine. Typically, the disease is transient with no evidence of vaccine-associated recurrence. The peak incidence occurs between the ages of... 

Two studies suggested a link between measles/MMR immunization and autism. Fudenberg reported that 15 of 40 patients with infantile autism developed symptoms within a week after MMR immunization (487). Wakefield and colleagues evaluated 12 children with chronic enterocolitis and regressive developmental disorders (470). The onset of behavioral symptoms was associated with MMR immunization in eight cases, as reported by the parents. Both reports were non-comparative and anecdotal. By chance alone some cases of autism will occur shortly after immunization, and most children in developed countries receive their first measles or MMR vaccination in the second year of life, when autism typically manifests. The imprecision of the interval between immunization and the onset of behavioral symptoms in the study by Wakefield and colleagues made these data suspect, even before their retraction. 

Data from an earlier study have been reanalysed to test the hypothesis that MMR vaccine might cause autism but that the induction interval needs to be short (495). Evidence for an increased incidence was sought using the case-series method. The study used data on all... 

MMR vaccines, including booster doses. The results of this study, combined with results obtained earlier by the same authors, provided powerful evidence against the hypothesis that MMR vaccine causes autism at any time after immunization. 

Black D, Prempeh H, Baxter T. Autism, inflammatory bowel disease, and MMR vaccine. Lancet 1998 351(9106) 905-6. 

Letter from the Chief Medical Officer, the Chief Nursing Officer, and the Chief Pharmaceutical Officer, Department of Health, London. Current vaccine and immunisation issues. 1. MMR vaccine, http //www.doh.gov.uk/cmo/cmoh.htm. 

Department of Health, England and Wales. MMR vaccine is not linked to Crohn s disease or autism conclusion of an expert scientific seminar. London Press release 98/109, 24 March 1998. 

In December 2005 the first cases of mumps were reported from a college campus in Iowa the source of the epidemic is unknown. The spread of the disease is multifactorial and includes the close contact of dormitory living and the fact that only 25 states and the District of Columbia require a two-dose MMR vaccine for college admission. The inexperience of young physicians who have most likely never seen mumps and the fact that mumps may not be considered in vaccinated individuals were also cited as factors. In addition, the MMR vaccine is not 100% effective, and susceptible persons who were not successfully immunized might be sufficient to sustain transmission. 

Erythema multiforme developed 8 hours after diphtheria-tetanus immunization in a 9-month-old infant (20). There have also been reports of erythema multiforme after hepatitis B vaccine, MMR vaccine, and DPT vaccine. 

Live measles virus vaccine is available in monovalent (measles only) form and in combinations measles-rubella (MR) and measles-mumps-rubella (MMR) vaccines. Measles vaccines based on further attenuated strains (beyond the level of the original strain, for example the Edmonston B strain or Schwarz strain) produces a mild or subclinical and non-communicable infection. 

MM vaccine) and with measles and rubella (MMR vaccine). Vaccines based on the following mumps vaccine strains are in use ... 

In a crossover study among 581 twin pairs aged between 14 months and 6 years only 0.5-4% had adverse reactions to MMR vaccine. The difference between the reaction rate reported in the immunized members of the twin pairs and those reported in the placebo-injected twin sisters or brothers showed that most of the reactions were temporally and not causally related to immunization. Respiratory symptoms, nausea, and vomiting were more frequent in the placebo-injected group than in the MMR-immunized group (9). 

In the four cases of encephalitis, a causal relation with MMR vaccine could not be excluded, because no other specific cause was detected. One child with acute... 

Table 1 Assessment of causality between MMR vaccination and 173 serious events...

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