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Measles is an acute, highly communicable viral disease with prodromal fever, conjunctivitis, coryza, cough, and Koplik spots on the buccal mucosa. A characteristic red blotchy rash appears around the third day of illness, beginning on the face and becoming generalized. Measles is frequently complicated by middle ear infection or diarrhea. The disease can be severe, with bronchopneumonia or brain inflammation leading to death in approximately 2 of every 1,000 cases.

Risk for Travelers

The risk of exposure to measles outside the United States could be high. Measles remains a common disease in many countries of the world, including some developed countries in Europe and Asia.

Prevention

Vaccine

Measles vaccine contains live, attenuated measles virus. It is available as a single-antigen preparation or combined with live, attenuated mumps or rubella vaccines, or both. Combined measles, mumps, and rubella (MMR) vaccine is recommended whenever one or more of the individual components are indicated.

A second dose is expected to induce immunity in most vaccinees who do not respond to the first dose. The second dose should be administered at 4–6 years of age and should be separated from the first dose by at least 28 days. See Vaccine Recommendations for Infants and Children for a discussion of measles immunization schedule modifications for infants who will be traveling.

MMR may be administered simultaneously (but in a different site) with any other live or inactivated vaccine. Inactivated vaccines and typhoid vaccines may be administered at any time before or after live measles-containing vaccine. However, if MMR vaccine and live yellow fever vaccine are not administered simultaneously, they should be separated by an interval of at least 28 days. (See U.S. Public Health Service Recommendations for more details.)

Adverse Reactions

Fever and rash are the most common adverse reactions following MMR vaccine and are usually attributable to the measles component. Approximately 5% of vaccinees have fever >39.4° C (>103° F) or a generalized rash. Fever and rash usually occur 7–12 days after vaccination and last 1–2 days. Transient lymphadenopathy sometimes occurs after MMR and is attributable to the rubella component. Parotitis has been reported rarely after MMR receipt and is attributable to the mumps component of the vaccine. Joint symptoms (arthralgia or arthritis or both) are reported in 25% or fewer of rubella-susceptible postpubertal women who receive MMR or other rubella-containing vaccine. Joint symptoms are usually mild and transient. Allergic reactions have been reported after MMR vaccine, ranging from mild (urticaria or wheal and flare at the injection site, generalized rash, and pruritis) to severe anaphylactic reactions. Severe allergic reactions are estimated to occur less than once per million doses. Clinically apparent low platelet counts have been reported at a rate of <1 case per 30,000 doses. Central nervous system conditions, including aseptic meningitis, encephalitis, and encephalopathy, have been reported after MMR receipt, but are very uncommon (<1 one case per million doses).

Adverse reactions occur only in susceptible vaccine recipients and do not appear to be age related. Reactions following the second dose of MMR (except allergic reactions) occur only among the small proportion of persons who do not respond to the first dose.

Precautions and Contraindications

Allergy. Persons with severe allergy (i.e., hives, swelling of the mouth or throat, difficulty breathing, hypotension, and shock) to gelatin or neomycin or who have had a severe allergic reaction to a prior dose of MMR should not be vaccinated with MMR except with extreme caution.

In the past, persons with a history of anaphylactic reactions after eating eggs were considered to be at increased risk of serious reactions after receipt of measles- and mumps-containing vaccines, which are produced in chick embryo fibroblasts. However, recent data suggest that anaphylactic reactions to measles- and mumps-containing vaccines are not associated with hypersensitivity to egg antigens, but to other components of the vaccines (such as gelatin). The risk for serious allergic reactions following receipt of these vaccines by egg-allergic persons is extremely low, and skin testing with vaccine is not predictive of allergic reaction to vaccination. MMR may be administered to egg-allergic persons without prior routine skin testing or the use of special protocols.

Pregnancy. Pregnant women should not receive MMR vaccine. Pregnancy should be avoided for 1 month after receipt of monovalent measles vaccine and MMR or other rubella-containing vaccines. Close contact with pregnant women is not a contraindication to MMR vaccination.

Breast-feeding is not a contraindication to MMR vaccination of either a woman or an infant. MMR vaccination has no effect on antibiotics or antimalarial drugs, and the drugs do not reduce the immunogenicity of MMR. Women taking these products should be vaccinated as usual.

Immunosuppression. Replication of vaccine viruses can be prolonged in persons who are immunosuppressed or immunodeficient for any reason (e.g., who have congenital immunodeficiency, HIV infection, leukemia, lymphoma, or generalized malignancy, or who are receiving therapy with alkylating agents, antimetabolites, radiation, or large doses of corticosteroids). Evidence based on case reports has linked infection with measles vaccine virus to subsequent death in six severely immunosuppressed persons. For this reason, persons who are severely immunosuppressed for any reason should not be given MMR vaccine. Healthy, susceptible close contacts of severely immunosuppressed persons may be vaccinated.

In general, persons receiving large daily doses of corticosteroids (>2 mg per kg per day or >20 mg per day of prednisone) for 14 days or moreshould not receive MMR vaccine because of concern about vaccine safety. MMR and its component vaccines should be avoided for at least 1 month after cessation of high-dose therapy. Persons receiving low-dose or short-course (<14 days) therapy; alternate-day treatment; maintenance physiologic doses; or topical, aerosol, intra-articular, bursal, or tendon injections may be vaccinated. Although persons receiving high doses of systemic corticosteroids daily or on alternate days during an interval of <14 days generally can receive MMR or its component vaccines immediately after cessation of treatment, some experts prefer waiting until 2 weeks after completion of therapy. Persons receiving cancer chemotherapy or radiation who have not received these treatments for at least 3 months may receive MMR or its component vaccines.

Measles disease can be severe in persons with HIV infection. Available data indicate that vaccination with MMR has not been associated with severe or unusual adverse events in HIV-infected persons without evidence of severe immunosuppression, although antibody responses have been variable. MMR vaccine is recommended for all asymptomatic HIV-infected persons and should be considered for symptomatic persons who are not severely immunosuppressed. Asymptomatic HIV-infected infants, children, and adolescents do not need to be evaluated and tested for HIV infection before MMR or other measles-containing vaccines are administered. A theoretical risk of an increase (probably transient) in HIV viral load after MMR vaccination exists because such an effect has been observed with other vaccines. The clinical significance of such an increase is not known.

MMR and other measles-containing vaccines are not recommended for HIV-infected persons with evidence of severe immunosuppression (e.g., a very low CD4+ T-lymphocyte count), primarily because of the report of a case of measles pneumonitis in a measles vaccine recipient who had an advanced case of AIDS. Refer to the Advisory Committee on Immunization Practices (ACIP) statement on MMR [1] for additional details on vaccination of persons with symptomatic HIV infection.

Acute Illness. Vaccination of travelers with moderate or severe acute illness should be postponed until their condition has improved. Minor illnesses, such as upper respiratory infections with or without low-grade fever, do not preclude vaccination.

Immune Globulin or Other Antibody-Containing Blood Products. MMR or its component vaccines should be administered at least 14 days before the administration of antibody-containing blood products, such as IG. Because passively acquired antibodies might interfere with the response to the vaccine, MMR should be delayed after administration of blood products. The length of delay varies from 3 to 11 months, depending on the type of blood product received. (See U.S. Public Health Service Recommendations for more details.)

Tuberculosis. Tuberculosis can be exacerbated by measles disease. There is no evidence, however, that live measles virus vaccine has such an effect. Purified protein derivative (PPD) tuberculin testing is not a prerequisite for vaccination with MMR or other measles-containing vaccine. PPD testing has no effect on the response to MMR vaccination. However, measles vaccine (and possibly mumps, rubella, and varicella vaccines) can suppress the response to PPD in a person infected with Mycobacterium tuberculosis. To minimize the risk of a false-negative interpretation, PPD testing should be delayed for 4–6 weeks after MMR vaccination. If PPD testing is needed, it should be done prior to MMR vaccination. In addition, the PPD may be applied at the same time as MMR is administered, because the mild immunosuppressive effect of the vaccine will not occur for several days after vaccination.