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ABSTRACT. The purpose of this statement is to inform of school children (5 to 19 years of age) with measles
physicians of a modification in the recommendation of had received a single dose of measles-containing
the appropriate age for routine administration of the vaccine after their first birthday; this was in contrast
second dose of measles–mumps–rubella (MMR) vaccine. to children ,5 years of age with measles, of whom
The implementation of the two-dose measles vaccine only 8% had been appropriately vaccinated.4 The
schedule has improved the control of measles, but some
outbreaks continue to occur in school children, al-
AAP recommendation was targeted to have the most
though >95% of children in school have received one immediate impact by preventing disease in children
dose of vaccine. Because most measles vaccine failures attending middle (or junior high) school and high
are attributable to failure to respond to the first dose, that school.
all children receive two doses of measles-containing vac- In 1989, the Advisory Committee on Immuniza-
cine is essential for the control of measles. Routine ad- tion Practices (ACIP) of the US Public Health Service
ministration of the second dose of MMR vaccine at also recommended the use of a second dose of mea-
school entry (4 to 6 years of age) will help prevent school- sles-containing vaccine, but in 4- to 6-year-old
based outbreaks. Physicians should continue to review (school entry-age) children.5 The primary reason for
the records of all children 11 to 12 years of age to be choosing this age group was accessibility; revaccina-
certain that they have received two doses of MMR vac-
cine after their first birthday. Documenting that all
tion of children at school entry was believed to be
school children have received two doses of measles-con- more feasible than the revaccination of older chil-
taining vaccine by the year 2001 will help ensure the dren.
elimination of measles in the United States and contrib-
ute to the global effort to control and possibly eradicate RECOMMENDED CHILDHOOD IMMUNIZATION
measles. SCHEDULE
Since 1995, the AAP, ACIP, and the American
ABBREVIATIONS. AAP, American Academy of Pediatrics; MMR, Academy of Family Physicians have published
measles–mumps–rubella; ACIP, Advisory Committee on Immu- jointly the Recommended Childhood Immunization
nization Practices; CDC, Centers for Disease Control and Preven- Schedule, which allows for the second dose of MMR
tion; IgM, immunoglobulin M. to be administered at 4 to 6 years of age or at 11 to 12
years of age. Policies for implementing the two-dose
BACKGROUND strategy have varied by state; some states require the
1989 Recommendation for a Two-dose Measles Vaccine second dose for entry into elementary school,
Policy whereas other states require the second dose of mea-
I
n 1989, the American Academy of Pediatrics sles-containing vaccine for entry into middle school.
(AAP) recommended that two doses of measles- For the 1996 to 1997 school year, only six states had
containing vaccine be given to all children after no second-dose requirement (Centers for Disease
their first birthday.1 Under routine circumstances, Control and Prevention, [CDC], unpublished data).
the AAP recommended that for both doses, measles– The AAP has advised health care providers for chil-
mumps–rubella (MMR) vaccine be used and that the dren of the need to comply with state school law
first dose be given at 15 months of age (which was requirements;6 however, differences in age cohort
subsequently revised to 12 to 15 months) and the implementation have created some confusion and
second dose be given at ;11 to 12 years of age. frustration among physicians, school officials, and
During 1989, more than 17 800 measles cases were parents.
reported—the largest number reported since 1978.2
Although the incidence of measles had increased in MEASLES EPIDEMIOLOGY SINCE 1989
all age groups, a dramatic increase in persons 15 to From 1989 through 1991, more than 55 000 cases
19 years of age was seen. In addition, numerous and 147 measles-related deaths were reported.7 Most
outbreaks of measles occurred in schools despite im- cases occurred in children #5 years of age who had
munization rates of $96%.3 From 1985 to 1989, 65% not received measles immunizations, although the
number of cases in school children also increased
substantially.
The recommendations in this statement do not indicate an exclusive course Improved vaccine coverage in preschool children,
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
particularly in large urban centers, has led to a de-
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- cline in measles disease incidence, with ,1000 cases
emy of Pediatrics. reported annually since 1992 and only 309 cases re-
PEDIATRICS
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2018101 No. 1 January 1998 129
ported in 1995 (the smallest number of cases ever 1985 through 1991, most of the 12- to 19-year-old
reported).8,9 children in whom measles developed had received a
The vaccination status of measles cases by age at single dose of measles-containing vaccine, and most
onset of rash for the 10-year period between 1985 and vaccine failures were in this age group. From 1992
1994 is shown in the Figure. Children #2 years of age through 1994, the incidence of measles disease de-
constituted the largest proportion of cases reported; clined in all age groups, and most children in whom
.90% of these children were unvaccinated. From measles developed were unvaccinated. Although
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can result in the development of low antibody titers entry, and the current epidemiology of measles in the
to measles and a reduced immune response to sub- United States support the administration of the second
sequent revaccination that may not be sustained.24,26 dose at 4 to 6 years of age. There are specific, individual
Because MMR vaccine is routinely given at or after circumstances in which the interval between doses
12 months of age, concern about a lack of a sustained could be as short as 1 month, such as for children
immune response to a second dose of measles-con- entering school without documentation of having re-
taining vaccine should be minimal. Infants who re- ceived any measles vaccination and to control measles
ceive measles vaccine before 12 months of age should outbreaks in child care settings.6 Administration of a
receive two subsequent doses of MMR vaccine be- second dose of MMR vaccine to healthy or mildly
ginning at or after 12 months of age. symptomatic HIV-infected children as soon as 1 month
The rate of adverse reactions associated with re- after receiving their first dose to optimize the likelihood
vaccination of immune persons is lower than the rate of an immune response to this vaccine is advised.31
observed in persons who are not immune.6 Serologic Additional information on the use of measles-contain-
(antibody) screening of children before administra- ing vaccine in HIV-infected children will be forthcom-
tion of the second dose of MMR is not warranted and ing in a statement from the AAP.
may pose a barrier to reimmunization. Because im-
munity develops in almost all children who receive Adolescents
two doses of measles-containing vaccine, antibody The AAP, ACIP, American Academy of Family
screening after revaccination is not indicated. Physicians, and the American Medical Association
have published recommendations on the immuniza-
MUMPS AND RUBELLA tion of adolescents with an emphasis on establishing
As with measles, most mumps and rubella vaccine a routine health care visit for immunizations at 11 to
failures seem to be primary vaccine failures.27,28 12 years of age.32,33 Health care professionals are
Asymptomatic reinfection has occurred in persons who strongly encouraged to ensure that all 11- to 12-year-
received only one dose of rubella vaccine, and mumps old children have received two doses of MMR, that a
has occurred in highly immunized populations, raising tetanus and diphtheria toxoid booster is adminis-
concern about the protection induced by a single tered, and that the three-dose schedule for hepatitis B
mumps vaccination.29,30 Johnson et al,23 evaluated the vaccine has been initiated if not completed. The phy-
antibody responses to the second dose of mumps and sician also should ensure that the child has had vari-
rubella vaccines (given as MMR) in 4- to 6-year-old and cella or has received the varicella vaccine. If indi-
11- to 13-year-old children. The mumps geometric cated, other vaccines, including influenza and
mean antibody titers were somewhat, but not signifi- pneumococcal vaccines, should be provided, as
cantly, lower before and after revaccination in 11- to should other preventive services.
13-year-old children compared with the 4- to 6-year- Older adolescents should have their vaccination
olds. Compared with the 11- to 13-year-olds, a statisti- status assessed at each visit to their health care pro-
cally significant greater percentage of 4- to 6-year-old vider, and any deficiencies should be corrected.
children had evidence of enzyme-linked immunosor- Health care professionals should be particularly
bent assay antibody and neutralizing antibody to ru- aware to ensure that older, healthy, nonpregnant
bella before revaccination.23 In both groups, 100% of adolescents and young adults have received two
children were seropositive for rubella and mumps an- doses of MMR vaccine.
tibody 3 to 4 weeks after revaccination.
Although the question of secondary rubella vaccine FINANCIAL IMPACT
failures has been raised during follow-up intervals of This revision in the age for routinely administering
up to 16 years, almost all patients had detectable anti- the second dose of MMR will not have a substantial
body when more sensitive assays were used.28 No data effect on the overall cost of immunizing children. In
are available on the persistence of antibody for .10 some states, however, children will receive the second
years in children who have received two doses of dose sooner than they might have previously. There-
mumps or rubella vaccine. The overall decrease of ru- fore, this revision will result in a temporary increase in
bella cases in the United States in recent years and the expenditures in those states. However, the earlier ad-
absence of outbreaks in older vaccinated populations ministration of the second dose should help prevent
suggest that the issue of secondary vaccine failures measles outbreaks and result in cost savings to schools,
may not be clinically relevant. local and state health departments, and parents.
AMERICAN
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Age for Routine Administration of the Second Dose of Measles−Mumps−Rubella
Vaccine
Committee on Infectious Diseases
Pediatrics 1998;101;129
DOI: 10.1542/peds.101.1.129
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