MMR Vaccination is Not for Every One. Wait, what?

New measles cases are still being reported to the CDC and the number reported last week (21) was double that of the week before.US cases now number 1203, reported by 30 states, and 4 states are still dealing with outbreaks.

School will be in session across the country within the next 2 weeks and hundreds of thousands of  children still need to begin or complete the MMR series. ACIP-recommended MMR vaccination is essential to end the spread of new cases and to foster the herd immunity that helps protect those who can not receive the vaccine.

 It's true; not everyone should receive an MMR vaccine. Can you pick out the exception(s) among the following 5-year-olds?

1. A 5-year-old needs his second MMR dose before starting school. He was diagnosed with acute lymphoblastic leukemia at age 2 years, went into remission, and finished all chemotherapy 2 months ago. Can he receive the shot?

A. Yes, but only if his WBC is normal.
B. Yes, and there is no need for any testing.
C. No, he had a dose of MMR at age 1 year so doesn't need another.
D. No, but he can receive the vaccine after he has been off chemotherapy for 3 months.

Please click here for answer and discussion.

Answer: D. No,  but he can receive the vaccine after he has been off chemotherapy for 3 months. Patients with leukemia in remission need to wait 3 months after the last round of chemotherapy before receiving an MMR vaccine.

2. Another 5-year-old needs his second MMR injection before starting school. He has a lot of allergies including an anaphylactic reaction to egg requiring medical treatment. He also had a large local reaction to a neomycin containing antibiotic cream last year. Can he get the second dose of MMR?

A. Yes, neither of the allergies described above are contraindications for receipt of MMR.
B. No, both of the above allergies are contraindications to receipt of MMR.
C. No, an egg anaphylactic reaction  that required epinephrine to treat is a contraindication.
D.  No, the egg allergy is not a problem, but neomycin allergy is a contraindication

Please click here for answer and discussion.

Answer: A. Yes, neither of the allergies described above are contraindications for receipt of MMR. While some minuscule amount of neomycin is in the vaccine, only a previous anaphylactic reaction to neomycin is considered a contraindication. While the MMR vaccine is made in chick embryo fibroblasts, good data now exist showing even severe egg allergy is not a problem to receiving the MMR.

3. A third 5-year-old needs his second MMR before starting school. His history is significant for the development of idiopathic thrombocytopenic purpura (ITP) 2 weeks after his first MMR shot at age 13 months that required oral steroid treatment. Can he receive the second shot?

A. Yes, no relationship between ITP and MMR vaccine has been documented.
B. No, ITP is a contraindication; MMR vaccine has been shown to cause ITP and this is listed on the Vaccine Information Sheet (VIS) required by law to be given to the patient/guardian.
C. No, ITP is a contraindication; MMR vaccine has been shown to cause ITP, but this is not mentioned on the VIS.
D. Maybe. MMR vaccine has been shown to cause ITP  but receipt of a second MMR is a precaution, not a contraindication.

Please click here for answer and discussion.

Answer: D. Maybe. MMR vaccine has been shown to cause ITP  but receipt of a second MMR is a precaution, not a contraindication. As mentioned in the VIS sheet, the MMR can cause ITP rarely, as can natural measles disease. The most prudent approach in this case would be to draw blood for a measles antibody titer. If he is immune, the vaccine is not needed. If he is not immune, then you and the parent need to decide if you think the rare risk of ITP outweighs the risk of contracting measles with its greater risk of causing ITP, among other sequelae. The FDA considers a previous case of ITP a precaution, not a contraindication, for a subsequent MMR vaccine.


4. The fourth 5-year-old will be starting kindergarten in 3 months and needs his MMR, among other shots. He spent 5 months last year with relatives in India and you tell mom you would like to place a tuberculin skin test (PPD) on him to be sure he has not been exposed to tuberculosis. Specifically, you tell her:                      

A. You will give him his MMR and place the PPD today to be read in 48 hours.
B. You cannot do both the PPD and MMR on the same day since the PPD will interfere with the immune response to the MMR.
C. You cannot do both the PPD and MMR on the same day since the MMR will interfere with the interpretation of the PPD.

Please click here for answer and discussion.

Answer: A. you will give him his MMR and place the PPD today to be read in 48 hours. TB skin testing has no impact on the body's immune response to the MMR vaccine. The vaccine can, however, cause a false negative TB skin test, but not when the vaccine and test are placed on the same day. If not done on the same day, the recommendation is to wait 4 weeks after MMR vaccination before placing a PPD.

4. A 33-year-old new mom delivered a healthy baby yesterday and had her tubes tied. Her prenatal labs did not show any immunity to rubella. She plans to breast feed. Can she receive the MMR now or should she wait until she finishes breast feeding?

A. Yes, none of the three viral strains in the MMR transmitted in breast milk.
B. Yes, despite the fact that the rubella strain found in the MMR can cross into breast milk.
C. No, since the rubella strain found in the MMR can cross into breast milk, it is prudent to wait either until she stops breast feeding or the new infant turns 12 months of age.
D. No, since she cannot get pregnant again she does not need to be immune to rubella.

Please click here for answer and discussion.

Answer: B. Yes, despite the fact that the rubella strain found in the MMR can cross into breast milk. While rubella virus can be excreted in human breast milk, infants are rarely affected and if they are, the illness is easily handled because of the attenuated virus in the vaccine. Even if mom does not have any more children, she still should be vaccinated to protect other pregnant females through herd immunity.

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Resources

National Institutes of Health. Measles-mumps-rubella vaccine. Drugs and lactation database.

CDC.The Pink Book. Epidemiology and Prevention of Vaccine-Preventable Diseases. Measles. Accessed 8-21-19 and available at https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#contraindications