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Canadian Immunization Guide

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Part 4
Active Vaccines

Mumps Vaccine

Key Information (Refer to text for details)

What

  • Outbreaks of mumps continue to occur in Canada and the proportion of cases aged 20 years and older has increased.
  • Complications such as orchitis and oophoritis are relatively frequent; permanent sequelae like deafness are rare.
  • Mumps vaccine is available as measles-mumps-rubella (MMR) or measles-mumps-rubella-varicella (MMRV) vaccine.
  • Mumps vaccine effectiveness has been estimated at 62% to 91% for one dose and 76% to 95% for two doses.
  • Reactions to MMR and MMRV vaccine are generally mild and transient and include pain and redness at the injection site, low-grade fever and rash.

Who

  • Mumps-containing vaccine is recommended for routine immunization of children and for immunization of children and adolescents who missed mumps immunization on the routine schedule.
  • Mumps-containing vaccine is recommended for susceptible adults born in 1970 or later.
  • Adults born before 1970 can be presumed to have acquired natural immunity to mumps; however, susceptible health care workers, travellers and military personnel should receive MMR vaccine, regardless of the year of birth.

How

  • Routine childhood immunization: administer two doses of mumps-containing vaccine (MMR or MMRV); the first dose at 12 to 15 months of age and the second dose at 18 months of age or any time thereafter, but should be given no later than around school entry.
  • Children and adolescents who are previously unimmunized: administer two doses of mumps-containing vaccine. The minimum interval between doses of MMR vaccine is 4 weeks. MMRV vaccine may be used in healthy children aged 12 months to 12 years. The recommended interval between 2 doses of MMRV vaccine is at least 3 months; a minimum interval of 6 weeks between doses may be used if rapid, complete protection is required.
  • Susceptible adults born in 1970 or later: administer one dose of MMR vaccine. Those who are at the greatest risk of mumps exposure (travellers to destinations outside of North America, health care workers, students in post-secondary educational settings, and military personnel) should receive two doses of MMR vaccine.
  • Susceptible health care workers and military personnel born before 1970: administer two doses of MMR vaccine at least 4 weeks apart.
  • Susceptibletravellers born before 1970: administer one
  • dose of MMR vaccine.
  • Susceptiblestudents born before 1970: consider administering one dose of MMR vaccine

Why

  • Mumps occurs worldwide and outbreaks continue to occur
  • Complications of mumps disease are relatively frequent although permanent sequalae are rare.
  • MMR and MMRV vaccines are safe and effective.

Significant revisions since the last chapter update are highlighted in the CIG Table of Updates which is available on the PHAC website.

For additional information, refer to previously published National Advisory Committee on Immunization (NACI) Statements and Statement Updates.

Epidemiology

Disease description

Infectious agent
Mumps virus is a member of the Paramyxoviridae family.

Reservoir
Humans

Transmission
Mumps virus is transmitted primarily by droplet spread, as well as BY direct contact with saliva of an infected person. The incubation period is about 16 to 18 days. Virus has been isolated from saliva 7 days before to 9 days after the onset of parotitis, with maximum infectiousness between 2 days before to 5 days after onset of symptoms.

Risk factors
In general, people who have not had mumps or who have not been successfully vaccinated are at risk of being infected. In Canada, most adults born before 1970 can be presumed to have acquired natural immunity to mumps; however, some individuals may not have had this infection and still may be susceptible. A second dose of mumps vaccination was routinely given along with measles and rubella (MMR) for measles control, beginning in 1996 to 1997. Depending on the age at which the second dose was given, people born before 1996 may have received only one done of mumps-containing vaccine, and so may still be susceptible if primary or secondary vaccine failure occurred. Adolescents and adults who are at greatest risk of exposure to mumps include students in secondary and post-secondary educational settings, military personnel, health care workers and travellers to destinations outside of North America.

Seasonal and temporal patterns
Historically, the incidence of mumps peaked in the spring and winter months in temperate zones, but now there are sporadic cases and outbreaks.

Spectrum of clinical illness
About 40% of those infected with mumps develop acute parotitis, which is unilateral in about 25% of cases. Non-specific or primarily respiratory symptoms occur in about one-half of those infected. Subclinical infection is common. Although complications are relatively frequent, permanent sequelae are rare. Before the widespread use of vaccine, mumps was a major cause of viral meningitis. Mumps meningoencephalitis can, rarely, result in permanent neurologic sequelae, including paralysis, seizures, cranial nerve palsies and hydrocephalus. Permanent deafness may occur, at an estimated rate of 0.5 to 5.0 per 100,000 mumps cases. Orchitis occurs in 20% to 30% of post-pubertal male cases and oophoritis in 5% of post-pubertal female cases. Involvement of the reproductive organs is commonly unilateral; therefore, sterility is rare. Mumps infection in pregnancy has not been associated with congenital malformations, but mumps infection during the first trimester of pregnancy may increase spontaneous abortion.

Disease distribution
Incidence/prevalence

Global
Mumps occurs worldwide, with cases reported throughout the year and epidemics occurring every two to five years. Mumps remains endemic in many countries, and mumps vaccine is used in only 59% of World Health Organization (WHO) member states.

Between 2004 and 2006, there was a large mumps outbreak in the United Kingdom (UK), with more than 70,000 cases. In 2006, there was a multi-state outbreak in the United States of America (USA), with over 2,500 cases. In 2009, there were more than 7,400 cases of mumps in England and Wales, mostly among unvaccinated young adults. In June 2009, a large outbreak of mumps occurred in New York and New Jersey in the USA. The outbreak mainly affected school age males from a faith-based community. Of those with known vaccination status, 88% had received at least one dose of mumps-containing vaccine before the outbreak and 75% had received two doses.

National
Since the approval of mumps vaccine in 1969, the number of reported mumps cases has decreased by more than 99%, from an average of 34,000 cases reported per year in the early 1950s to fewer than 400 cases per year in the early 1990s. A further reduction in incidence was observed following the introduction of the routine second dose of MMR vaccine in 1996 to 1997 for control of measles. The annual number of cases has continued to decrease; during the period 2000 to 2006, an average of 81 cases were reported annually, ranging from 28 (2003) to 201 cases (2002). However, in 2007 there were over 1,000 cases and in 2008 there were almost 750 reported cases, mainly as a result of outbreaks in several provinces.

The age distribution of mumps in Canada has changed. While the total number of reported cases decreased, the proportion of reported cases aged 20 years and older increased from 14% in 1988-1990 to 64% in 2003-2005. Conversely, the proportion of cases aged 1 to 9 years fell from 49% to 17% during the same period.

Recent outbreaks

In Canada, large outbreaks of mumps have been uncommon in recent years. In 2007, large outbreaks occurred in Nova Scotia, New Brunswick and Alberta with a total of 1,159 confirmed cases, accounting for 90% of the total cases in Canada that year. The majority (58%) of cases occurred in persons aged 20 to 29 years, many of who were college or university students. Immunization history was known for less than one-half of the mumps cases. Of those known, 8% had received two or more doses, 73% had received one dose, and 19% had received no mumps immunization. The viral strain in the 2007 outbreaks was identical to the strain (genotype G) detected in the previous Nova Scotia outbreaks, the 2006 US multi-state outbreak, and the UK epidemic.

In 2008, large outbreaks occurred in Alberta, Ontario and British Columbia (BC). In Alberta, the 2007 outbreak continued with an additional 280 cases in 2008. In Ontario, a total of 324 outbreak cases were reported, of which 289 were confirmed. The cases ranged in age from less than 1 year to 45 years (average age 11) with no sex difference. The majority of cases (95.7%) occurred in unimmunized individuals. The BC outbreak included 183 reported cases, of which 133 were confirmed. The outbreak started in a largely unimmunized faith-based community. One-half of the cases were in the 0 to 19 year old age group. Nearly one-half of the cases (46%) were unimmunized and 28% of the cases had unknown immunization history.

Beginning in October 2009, an outbreak of mumps occurred among a faith-based community in Quebec with 23 confirmed cases. The outbreak was linked to a large mumps outbreak in New York and New Jersey in the USA. All cases were male and aged 8 to 47 years.

Preparations Authorized for Use in Canada

Mumps-containing vaccines
  • M-M-R® II (live, attenuated combined measles, mumps and rubella vaccine), Merck Canada Inc. (MMR)
  • PRIORIX® (live, attenuated combined measles, mumps and rubella vaccine), GlaxoSmithKline Inc. (MMR)
  • PRIORIX-TETRA® (live, attenuated combined measles, mumps, rubella and varicella vaccine), GlaxoSmithKline Inc. (MMRV)

In Canada, mumps vaccine is available only in combination with measles and rubella vaccine (MMR) or measles, rubella and varicella vaccine (MMRV). In many countries outside of Canada, measles vaccine alone is given and mumps vaccination is not offered.

For complete prescribing information, consult the product leaflet or information contained within the product monograph available through the Health Canada's Drug Product DatabaseExternal Link. Refer to Contents of Immunizing Agents Available for Use in Canada in Part 1 for a list of vaccines available for use in Canada and their contents.

Efficacy, Effectiveness and Immunogenicity

Efficacy and effectiveness

Mumps vaccine effectiveness has been estimated at 62% to 91% for one dose and 76% to 95% for two doses. Mumps outbreaks have been reported in populations with greater than 95% coverage with single dose mumps-containing vaccine, suggesting that one dose of mumps-containing vaccine is not sufficient to prevent mumps outbreaks. In some instances, outbreaks have arisen in settings with high two-dose coverage. Waning immunity contributes to the risk of mumps in vaccinated individuals. There are no data regarding the efficacy of MMRV vaccine.

Immunogenicity

In clinical studies, a single injection of MMR vaccine induced measles antibodies in 95%, mumps antibodies in 96%, and rubella antibodies in 99% of previously seronegative children.

In a study of 12 month old children, a single dose of MMRV vaccine resulted in a seroconversion rate for measles, mumps, rubella and varicella of 98%, 97%, 98% and 93%, respectively. The seroconversion rates and geometric mean titres for individual components were not significantly different from those achieved after MMR plus univalent varicella vaccine or MMR vaccine alone. A study of children receiving two doses of MMRV vaccine during the second year of life noted seropositivity for measles, mumps, rubella and varicella of 99%, 97.4%, 100% and 99.4% respectively by the third year post-vaccination. Long-term persistence of anti-measles, anti-mumps, anti-rubella and anti-varicella antibodies following MMRV vaccinations are under evaluation.

Recommendations for Use

Children (12 months to 17 years of age)

Two doses of mumps-containing vaccine should be given for routine immunization of children and for immunization of children and adolescents who missed mumps immunization on the routine schedule. MMRV vaccine may be used in children aged 12 months to 12 years.

Students in secondary educational settings should have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease.

Adults (18 years of age and older)

Routine immunization: adults born before 1970 are generally presumed to have acquired natural immunity to mumps; however, some of these individuals may be susceptible. Adults without contraindications, born in 1970 or later who do not have documented evidence of receiving mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps infection should be immunized with one dose of MMR vaccine.

Health care workers, regardless of their year of birth, who do not have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should receive two doses of MMR vaccine. Refer to Workers.

Students in post-secondary educational settings, born in 1970 or later, who do not have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should receive two doses of MMR vaccine. In students born before 1970, administration of one dose of MMR vaccine should be considered.

Military personnel, regardless of their year of birth, who do not have documented evidence of receiving two doses of a mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should receive two doses of MMR vaccine.

Travellers to destinations outside of North America, born in 1970 or later, who do not have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease, should receive two doses of mumps-containing vaccine. Travellers born before 1970 who do not have documented evidence of receiving a mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should receive one dose of MMR vaccine. Refer to Travellers.

Table 1 provides a summary of criteria for mumps immunity. Refer to Schedule.

Table 1: Criteria for immunity to mumps
Routine Health care workers Travellers to destinations outside North America Students in secondary or post-secondary educational settings Military personnel
Footnote 1
Mumps-containing vaccine
Footnote 2
Refer to additional recommendations for health care workers, travellers to destinations outside of North America, students in post-secondary educational settings and military personnel

Documentation of vaccination:

OR

History of laboratory confirmed infection

OR

Laboratory evidence of immunity

OR

Born before 1970

Documentation of vaccination with 2 dosesTable 1 - Footnote 1 (regardless of year of birth)

OR

History of laboratory confirmed infection

OR

Laboratory evidence of immunity

Documentation of vaccination:

OR

History of laboratory confirmed infection

OR

Laboratory evidence of immunity

Documentation of vaccination:

OR

History of laboratory confirmed infection

OR

Laboratory evidence of immunity

Documentation of vaccination with 2 dosesTable 1 - Footnote 1 (regardless of year of birth)

OR

History of laboratory confirmed infection

OR

Laboratory evidence of immunity

Persons with inadequate immunization records

Children and adults lacking adequate documentation of immunization should be considered unimmunized and started on an immunization schedule appropriate for their age and risk factors, unless known to be immune based on laboratory testing. MMR or MMRV vaccine, as appropriate, may be given regardless of possible previous receipt of the vaccine, because additional adverse events associated with repeated immunization have not been demonstrated. Refer to Immunization of Persons with Inadequate Immunization Records in Part 3 for additional general information.

Pregnancy and breastfeeding

Immunity to measles, mumps and rubella should be reviewed in women of reproductive age, and vaccination should be recommended to non-pregnant susceptible women. Ideally, the immunization status of women intending to become pregnant should be reviewed and vaccines updated as necessary prior to conception. Women should delay pregnancy by 4 weeks following vaccination with a live vaccine.

MMR and MMRV vaccines should generally not be given during pregnancy because of the theoretical risk to the fetus; however, there is no evidence demonstrating a teratogenic or other risk from such vaccines. There was no evidence of Congenital Rubella Syndrome in any of the offspring of 226 women inadvertently vaccinated during pregnancy. Inadvertent immunization with MMR vaccine is not a reason for pregnancy termination. In some situations, potential benefits of MMR vaccination may outweigh risks, such as during measles or rubella outbreaks, in which case vaccination may be considered in consultation with public health officials.

Women who are breastfeeding can be vaccinated with MMR vaccine.

Refer to Contraindications and Precautions. Refer to Immunization in Pregnancy and Breastfeeding in Part 3 for additional general information.

Persons/residents in health care institutions

Susceptible residents of long-term care facilities should receive measles, mumps and rubella-containing vaccine, as well as all routine immunizations appropriate for their age and risk factors. Refer to Immunization of Persons/Residents in Health Care Institutions in Part 3 for additional general information.

Immunocompromised persons

In general, immunocompromised persons should not receive live vaccines because of the risk of disease caused by the vaccine strains. When considering immunization of an immunocompromised person with a live vaccine, approval from the individual's attending physician should be obtained before vaccination. For complex cases, referral to a physician with expertise in immunization or immunodeficiency is advised. Refer to Immunocompromised persons in the Measles Vaccine in Part 4 for additional information.

Household contacts

Susceptible household contacts of immunocompromised people should receive a mumps-containing vaccine as appropriate for age and risk factors.

Refer to Contraindications and Precautions. Refer to Immunization of Immunocompromised Persons in Part 3 for additional information.

Persons with chronic diseases
Neurologic disorders

People with conditions such as autism spectrum disorders or demyelinating disorders (including multiple sclerosis) should receive all routinely recommended immunizations, including MMR or MMRV vaccine. Refer to Immunization of Persons with Chronic Diseases in Part 3 for additional general information.

Travellers

Protection against mumps is especially important for people planning travel to destinations outside of North America. Travellers born in 1970 or later, who do not have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should receive two doses of mumps-containing vaccine.

Travellers born before 1970, who do not have documented evidence of receiving mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease, should receive one dose of MMR vaccine.

Mumps is endemic in many countries. Refer to mumps incidence rates in WHO member countriesExternal Link for additional information.

Refer to Immunization of Travellers in Part 3 for additional general information.

Persons new to Canada

Health care providers who see persons newly arrived in Canada should review the immunization status and update immunization for these individuals. In many countries outside of Canada, mumps and rubella vaccines are in limited use and measles vaccine alone is given. A Canadian study showed that more than one-third of new immigrants and refugees, particularly women, were susceptible to measles, mumps, or rubella. Refer to Immunization of Persons New to Canada in Part 3 for additional general information.

Workers

It is recommended that all health care workers be immune to mumps. Health care workers, regardless of their year of birth, who do not have documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed mumps disease should be vaccinated accordingly so that they have received two doses of MMR vaccine. Refer to Immunization of Workers in Part 3 for additional general information.

Post-exposure immunization

Post-exposure MMR vaccination does not prevent or alter the clinical severity of mumps. It may be considered if repeated exposure to mumps is anticipated. If exposure to mumps does not cause infection, post-exposure vaccination with MMR vaccine should induce protection against subsequent infection. There is no evidence of increased risk of adverse reactions from immunization with MMR vaccine if an individual is already immune to one or more components of the vaccine or infected by mumps virus.There are no data on the use of MMRV vaccine in post-exposure situations. Passive immunization with human immune globulin (Ig) is not effective in preventing mumps.

Outbreak control

With the implementation of a two dose schedule for mumps vaccine, it is expected that large outbreaks of mumps will occur less frequently. However, cases that do occur may result in transmission of mumps, usually among unvaccinated children and young adults who have not received two doses of vaccine and who were born after wide circulation of natural mumps disease was common. Outbreaks have also occurred in populations who are predominantly vaccinated with two doses of mumps-containing vaccines. In outbreak situations, a dose of mumps-containing vaccine is, recommended for those born in or after 1970 who received only one dose of a mumps-containing vaccine. At-risk populations will need to be further defined by the age groups and settings involved in the outbreak. For further information regarding mumps outbreak control refer to the Public Health Agency of Canada's (PHAC) Supplement: Guidelines for the Prevention and Control of Mumps Outbreaks in Canada.

Vaccine Administration

Dose, route of administration, and schedule

Dose
Each dose is 0.5 mL.

Route of administration
MMR vaccine should be administered subcutaneously; MMRV can be administered subcutaneously or intramuscularly. Refer to Vaccine Administration Practices in Part 1 for additional information.

Schedule

Children (12 months to 12 years of age)
For routine immunization of children aged 12 months to 12 years, two doses of mumps-containing vaccine (MMR or MMRV) should be administered. The first dose of mumps-containing vaccine should be administered at 12 to 15 months of age and the second dose at 18 months of age or any time thereafter, but should be given no later than around school entry.

The recommended minimum interval between doses of MMR vaccine is 4 weeks. Children who previously received a single dose of MMR vaccine should receive a second dose at least 4 weeks after the first dose. The recommended interval between two doses of MMRV vaccine is at least 3 months; a minimum interval of 6 weeks between doses may be used if rapid, complete protection is required.

Adolescents (13 to 17 years of age)
Mumps-susceptible adolescents should receive two doses of MMR vaccine given at least 4 weeks apart.

Adults (18 years of age and older)
Mumps-susceptible adults should receive one or two doses of MMR vaccine as appropriate for age and risk factors (refer to Table 1). If two doses are needed, MMR vaccine is administered with a minimum interval of 4 weeks between doses.

Booster doses and re-immunization

Re-immunization with mumps-containing vaccine after age and risk appropriate vaccination is not necessary.

Serologic Testing

Serologic testing is not recommended before or after receiving mumps-containing vaccine. Although generally used as criteria for immunity, the presence of mumps-specific IgG, as determined by enzyme immunoassay (EIA), does not necessarily predict the presence of neutralizing antibodies and, thus, immunity. Conversely, the absence of detectable mumps-specific IgG does not mean the person is susceptible. For further information regarding mumps serology refer to the PHAC Supplement: Guidelines for the Prevention and Control of Mumps Outbreaks in Canada.

Storage Requirements

M-M-R® II: Should be maintained at +10°C or colder during shipment. Freezing during shipment will not affect potency of the vaccine. The vaccine should be protected from light. Before reconstitution, the vial of vaccine should be stored at +2°C to +8°C or colder. The diluent may be stored in the refrigerator or at room temperature and must not be frozen.

PRIORIX®: Should be stored in a refrigerator at +2°C to +8°C and protected from light. The diluent may be stored separately at room temperature.

PRIORIX-TETRA®: The vaccine and diluent should be stored in a refrigerator at +2°C to +8°C and not frozen. The vaccine should be protected from light.

Refer to Storage and Handling of Immunizing Agents in Part 1 for additional general information.

Simultaneous Administration With Other Vaccines

Live vaccines given by the parenteral route may be administered concomitantly with all other vaccines during the same visit, using different injection sites and separate needles and syringes. In general, if two live parenteral vaccines are not administered concomitantly, there should be a period of at least 4 weeks before the second live parenteral vaccine is given. Exceptions are varicella-containing vaccines, such as MMRV vaccine:

  • Administer doses of varicella-containing vaccine at least 3 months apart for children 1 to 12 years of age. If rapid, complete protection against varicella is required, a minimum interval of 6 weeks between 2 doses may be used for children 1 to 12 years of age.
  • Administer doses of varicella vaccine at least 6 weeks apart for those 13 years of age and over.
  • Do not concomitantly administer varicella-containing vaccines with smallpox vaccine; in the rare event that both are needed, administer varicella-containing vaccine and smallpox vaccine at least 4 weeks apart.

Oral and intranasal vaccines can be given at the same time as, or any time before or after any other live vaccine, regardless of the route of administration of the other live vaccine.

Refer to Timing of Vaccine Administration in Part 1 for additional general information.

Vaccine Safety and Adverse Events

Refer to Vaccine Safety Part 2 for additional general information.

Common and local adverse events
MMR vaccine

Adverse events following MMR immunization occur much less frequently and are far less severe than those associated with natural disease. Adverse reactions are less frequent after the second dose of vaccine and tend to occur only in those not protected by the first dose. Six to 23 days after MMR immunization, approximately 5% of immunized children experience malaise and fever, with or without rash, lasting up to 3 days. Parotitis, rash, lymphadenophy, and joint symptoms also occur occasionally after MMR immunization

MMRV vaccine

Pain and redness at the injection site, low-grade fever or both occur in 10% or more of vaccinees. Rash, including measles-like, rubella-like and varicella-like rash, as well as swelling at the injection site and moderate fever, greater than 39°C occur in 1% to less than 10% of vaccinees. As varicella-like rashes that occur within the first two weeks after immunization may be caused by wild-type virus, health care providers should obtain specimens using viral transport media from a lesion of the vaccinee to ensure that varicella disease is not confused with a reaction to vaccination.

Rubella-containing vaccines

Acute transient arthritis or arthralgia may occur 1 to 3 weeks after immunization with rubella-containing vaccine; it lasts for about 1 to 3 weeks, and rarely recurs. It is more common in post-pubertal females, among whom arthralgia develops in 25% and arthritis in 10% after immunization with rubella-containing vaccine. There is no evidence of increased risk of new onset, chronic arthropathies or neurologic conditions.

Less common and serious or severe adverse events
MMR and MMRV vaccines

Serious adverse events are rare following immunization and, in most cases, data are insufficient to determine a causal association. As with other vaccines, anaphylaxis following vaccination with MMR or MMRV vaccine may occur but is very rare.

Immune Thrombocytopenic Purpura (ITP)

Rarely, ITP occurs within 6 weeks after immunization with MMR or MMRV vaccine. In most children, post-immunization thrombocytopenia resolves within three months without serious complications. In individuals who experienced ITP with the first dose of MMR or MMRV vaccine, serologic status may be evaluated to determine whether an additional dose of vaccine is needed. The potential risk to benefit ratio should be carefully evaluated before considering further vaccination in such cases.

Encephalitis

Encephalitis has been reported in association with administration of measles vaccine in approximately 1 per million doses distributed in North America which is much lower than that observed with natural measles disease (1 per 1,000 cases).

Febrile seizures

Recent studies have found a higher risk of febrile seizures with the first dose of a MMRV vaccine (ProQuad®, not authorized for use in Canada) when compared to the concomitant administration of MMR and univalent varicella vaccine. Data from the US estimated that the risk of febrile seizures in the 5 to 12 days following the first dose of this MMRV vaccine is 1 for every 2,600 vaccinated children aged 12 to 23 months. Experience with the MMRV vaccine available in Canada is more limited; however, one study showed an additional risk of febrile seizures with MMRV vaccine compared to MMR and univalent varicella vaccines given as two separate products administered concomitantly. The risk with the vaccine used in Canada was smaller than the risk found with the product used in the USA. Close surveillance and further investigation are underway.

Other reported adverse events and conditions

In the mid to late 1990s, researchers from the UK reported an association between MMR vaccine and inflammatory bowel disease, and MMR vaccine and autism. Rigorous scientific studies and reviews of the evidence have been done worldwide, and there is now considerable evidence to refute those claims. In 2010, the original study suggesting a link between the MMR vaccine and autism was retracted.

Guidance on reporting Adverse Events Following Immunization (AEFI)

Vaccine providers are asked to report the following AEFI in particular, through local public health officials:

  • Febrile seizures within 30 days after vaccination with MMR or MMRV vaccine.
  • Varicella that is moderate (50 to 500 lesions) or severe (more than 500 vesicular lesions or associated complications or hospital admission) and occurs 7 to 21 days after vaccination with MMRV vaccine.
  • Any serious or unexpected adverse event felt to be temporally related to vaccination. An unexpected AEFI is an event that is not listed in available product information but may be due to the immunization, or a change in the frequency of a known AEFI.

Refer to Reporting Adverse Events Following Immunization (AEFI) in Canada and Vaccine Safety in Part 2 for additional information about AEFI reporting.

Contraindications and precautions

MMR and MMRV vaccines are contraindicated in persons with a history of anaphylaxis after previous administration of the vaccine and in persons with proven immediate or anaphylactic hypersensitivity to any component of the vaccine (with the exception of egg allergy [refer below]) or its container. Refer to Contents of Immunizing Agents Available for Use in Canada in Part 1 for a list of vaccines available for use in Canada and their contents. For mumps-containing vaccines, potential allergens include:

  • M-M-R® II: neomycin, phenol red, porcine gelatin, residual components of chick embryo cell cultures
  • PRIORIX®: egg protein, neomycin
  • PRIORIX-TETRA®: neomycin

In situations of suspected hypersensitivity or non-anaphylactic allergy to vaccine components, investigation is indicated, which may involve immunization in a controlled setting. Consultation with an allergist is advised.

The measles and mumps components of MMR and MMRV vaccines are produced in chick embryo cell culture and may contain traces of residual egg and chicken protein. The trace amount of egg and chicken protein in the vaccine appears to be insufficient to cause an allergic reaction in egg-allergic individuals. Skin testing is not recommended prior to vaccination as it does not predict reaction to the vaccine. MMR or MMRV vaccine can be administered in the routine manner to people who have a history of anaphylactic hypersensitivity to hens' eggs. Prior egg ingestion is not a prerequisite for immunization with egg protein-containing vaccine. For all vaccines, immunization should always be performed by personnel with the capability and facilities to manage adverse events post-vaccination. Refer to Anaphylactic Hypersensitivity to Egg and Egg-Related Antigens in Part 2 for additional information.

Children with a known or suspected family history of congenital or hereditary immunodeficiency that is a contraindication to vaccination with live vaccine should not receive live vaccines unless their immune competence has been established.

MMRV vaccine is contraindicated in persons with impaired immune function, including primary or secondary immunodeficiency disorders. Refer to Immunocompromised persons.

MMR and MMRV vaccines are contraindicated during pregnancy. Refer to Pregnancy and breastfeeding.

MMR vaccine is contraindicated in individuals with active, untreated tuberculosis. While tuberculosis may be exacerbated by natural measles infection, there is no evidence that measles-containing vaccines, such as MMR or MMRV have such an effect.

A history of febrile seizures or a family history of seizures is not a contraindication for the use of MMRV vaccine.

Administration of MMR or MMRV vaccine should be postponed in persons with a severe acute illness. Persons with a minor acute illness, with or without fever, may be vaccinated.

It is recommended to avoid the use of salicylates (e.g., acetylsalicylic acid [ASA]) for 6 weeks after immunization with MMRV vaccine because of an association between wild-type varicella, salicylate therapy and Reye's syndrome.

Refer to Contraindications, Precautions and Concerns in Part 2 for additional general information.

Drug interactions

Systemic antiviral therapy (such as acyclovir, valacyclovir, famciclovir) should be avoided in the peri-immunization period, as it may reduce the efficacy of varicella-containing vaccine such as MMRV. On the basis of expert opinion, it is recommended that people taking long-term antiviral therapy should discontinue these drugs, if possible from at least 24 hours before administration of MMRV vaccine and should not restart antiviral therapy until 14 days after.

The measles component in measles-containing vaccines can temporarily suppress tuberculin reactivity, resulting in false-negative results. If tuberculin skin testing or an Interferon Gamma Release Assay (IGRA) test is required, it should be done on the same day as immunization or delayed for at least 4 weeks after measles vaccination. Vaccination with measles-containing vaccine may take place at any time after tuberculin skin testing has been administered.

Passive immunization with human immune globulin (Ig) or receipt of most blood products can interfere with the immune response to MMR and MMRV vaccines. These vaccines should be given at least 14 days prior to administration of an Ig preparation or other blood product, or delayed until the antibodies in the Ig preparation or other blood product have degraded. If the interval between administration of vaccine and subsequent administration of an Ig preparation or other blood product is less than 14 days or before the antibody has degraded, the vaccine dose should be repeated after the recommended interval. The recommended interval between administration of an Ig preparation or other blood product and subsequent immunization varies, depending on the Ig preparation or blood product.

Palivizumab (RSVAb) and washed red blood cell transfusion do not interfere with the antibody response to MMR or MMRV vaccines. Refer to Blood Products, Human Immune Globulin and Timing of Immunization in Part 1 for additional information.

Other Considerations

Interchangeability of vaccines

On the basis of expert opinion, the MMR vaccines authorized in Canada may be used interchangeably. Refer to Principles of Vaccine Interchangeability in Part 1 for additional general information.

Selected References

  • American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, et al. (editors). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
  • Boulianne N, De Serres G, Ratnam S et al. Measles, mumps and rubella antibodies in children 5-6 years after immunization: effect of vaccine type and age at vaccination. Vaccine 1995;13(16):1611-6.
  • Caplan CE. Mumps in the era of vaccines. CMAJ 1999;160(6):865-6.
  • Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices Provisional Recommendations for Measles-Mumps-Rubella (MMR) 'Evidence of Immunity' Requirements for Healthcare Personnel. 2009. Accessed October 2010 at: http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-evidence-immunity-Aug2009-508.pdf
  • Centers for Disease Control and Prevention. Use of Combination Measles, Mumps, Rubella and Varicella Vaccine. Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2010;59(03):1-12.
  • Centers for Disease Control and Prevention. The Pink Book: Epidemiology and Prevention of Vaccine Preventable Diseases. Updated 11th ed.; May 2009.Accessed October 2010 at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm
  • Centers for Disease Control and Prevention. Measles, Mumps, and Rubella -- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1998; 47(RR-8):1-57.
  • Cooney MK, Fox JP, Hall CE. The Seattle Virus Watch, VI. Observations of infections with and illness due to parainfluenza, mumps, and respiratory syncytial viruses and Mycoplasma pneumoniae. Am J Epidemiol 1975;101(6):532-51.
  • Davidkin I, Valle M, Julkunen I. Persistence of anti-mumps virus antibodies after a two-dose MMR vaccination at nine-year follow-up. Vaccine 1995;13(16):1617-22.
  • Duclos P, Ward BJ. Measles vaccines: a review of adverse events. Drug Saf 1998;19(6):435-54.
  • Falk WA, Buchan K, Dow M et al. The epidemiology of mumps in Southern Alberta, 1980-1982. Am J Epidemiol 1989;130(4):736-49.
  • GlaxoSmithKline Inc. Product Monograph - PRIORIX-TETRA™. May 2010.
  • GlaxoSmithKline Inc. Product Monograph - PRIORIX®. November 2008.
  • Griffin MR, Ray WA, Mortimer EA et al. Risk of seizures after measles-mumps-rubella
    immunization. Pediatrics 1991;88(5):881-5.
  • Health Protection Agency, U.K. Confirmed cases of mumps by age and region: 1996-2005. Accessed October 2010 at: www.hpa.org.uk/infections/topics_az/mumps/data_reg_age.htm.
  • Jadavji T, Scheifele D, Halperin S. Thrombocytopenia after immunization of Canadian children, 1992 to 2001. Pediatr Infect Dis J 2003;22(2):119-22.
  • James JM, Burks AW, Roberson PK et al. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995;332(19):1262-6.
  • Merck Frosst Canada Ltd. Product Monograph - M-M-R® II. February 2009.
  • Miller E, Goldacre M, Pugh S et al. Risk of aseptic meningitis after measles, mumps and rubella vaccine in U.K. children. Lancet 1993;341(8851):979-82.
  • National Advisory Committee on Immunization. Updated recommendations for the use of varicella and MMR vaccines in HIV-infected individuals. Can Commun Dis Rep 2010;36(ACS-7):1-19.
  • National Advisory Committee on Immunization. Statement on measles-mumps-rubella-varicella vaccine. Can Commun Dis Rep 2010;36(ACS-9):1-22.
  • National Advisory Committee on Immunization. Statement on mumps vaccine. Can Commun Dis Rep 2007;33(ACS-8):1-10.
  • Peltola H, Heinonen OP, Valle M et al. The elimination of indigenous measles, mumps and rubella from Finland by a 12 year two-dose vaccination program. N Engl J Med 1994;331(21):1397-1402.
  • Public Health Agency of Canada. Supplement: Guidelines for the Prevention and Control of Mumps Outbreaks in Canada. Can Commun Dis Rep 2010;36(S1):1-46.
  • West R, Roberts PM. Measles, mumps and rubella vaccine: current safety issues. BioDrugs 1999;12(6):423-9.

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