Measles vaccines: Canadian Immunization Guide

For health professionals

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Last partial content update: April 2025

This chapter was updated based on the following statements from the National Advisory Committee on Immunization (NACI):

• February 13, 2025: Updated recommendations on measles post-exposure prophylaxis

This information is captured in the table of updates.

Last complete chapter revision: April 2015

On this page

• Key information
• Epidemiology
• Preparations authorized for use in Canada
• Immunogenicity, efficacy and effectiveness
• Recommendations for use
  • Healthy infants, children and adolescents (0 months to less than 18 years of age)
  • Healthy adults (18 years of age and older)
  • Table 1: Criteria for presumptive measles immunity
  • Booster doses and re-immunization
  • Post-exposure prophylaxis
    • Table 2: Summary of recommended measles post-exposure prophylaxis strategies for infants and immunocompetent individuals
    • Table 3: Summary of updated recommended measles post-exposure prophylaxis strategies for pregnant women and pregnant individuals by risk level
    • Table 4: Summary of updated recommended measles post-exposure prophylaxis strategies for individuals 6 months of age and older who are immunocompromised
  • Outbreak control
• Vaccination of specific populations
• Serologic testing
• Administration practices
• Storage requirements
• Safety and adverse events
  • Common and local adverse events
  • Contraindications and precautions
• Other considerations
• Chapter revision process
• Acknowledgments
• Selected references

Key information

What

• Measles occurs worldwide and is one of the most highly communicable diseases.
• Canada has some imported cases and occasional outbreaks of measles.
• Measles-containing vaccine is available as measles-mumps-rubella (MMR) or measles-mumps-rubella-varicella (MMRV) vaccine.
• Measles-containing vaccine or human immunoglobulin (Ig) may be used for measles post-exposure immunization in susceptible persons, depending on the circumstances.
• The efficacy of a single dose of measles vaccine given at 12 or 15 months of age is estimated to be 85% to 95%. With a second dose, efficacy is almost 100%.
• Reactions to MMR vaccine are generally mild and transient and include pain and redness at the injection site, fever less than 39°C, and rash. Reactions to MMRV vaccine include: pain and redness at the injection site and fever less than 39°C in 10% or more of vaccine recipients; measles-like, rubella-like or varicella-like rash, swelling at the injection site and fever greater than 39°C in less than 10% of vaccine recipients.
• When the first dose is administered to children 12 to 23 months of age as MMRV vaccine, there is a higher risk of fever and febrile seizures in the 7 to 10 days after vaccination when compared to separate administration of MMR and univalent varicella vaccine at the same visit. This risk is estimated at about 1 additional febrile seizure for every 2,300 to 2,800 doses of MMRV vaccine.

Who

• Measles-containing vaccine is recommended for routine immunization of children and for immunization of children and adolescents who missed measles immunization on the routine schedule.
• Measles-containing vaccine is recommended for susceptible adults born in or after 1970.
• Adults born before 1970 are generally presumed to have acquired natural immunity to measles; however, susceptible health care workers, travellers to destinations outside of Canada, and military personnel should receive MMR vaccine, regardless of year of birth.

How

• Routine childhood immunization: 2 doses of any measles-containing (MMR or MMRV) vaccine. The first dose of measles-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 no later than around school entry.
• Children and adolescents who are previously unimmunized: 2 doses of measles-containing vaccine. MMRV vaccine may be used in healthy children aged 12 months to less than 13 years.
• Susceptible adults born in or after 1970: 1 dose of MMR vaccine. Those who are at the greatest risk of measles exposure (travellers to destinations outside of Canada, health care workers, students in post-secondary educational settings, and military personnel) should receive 2 doses of MMR vaccine.
• Susceptible health care workers and military personnel born before 1970: 2 doses of MMR vaccine.
• Susceptible travellers to destinations outside of Canada born before 1970: 1 dose of MMR vaccine.
• Susceptible students in post-secondary educational settings born before 1970: 1 dose of MMR vaccine should be considered.

Why

• People who have not had measles disease or who have not been vaccinated are at risk of infection.
• Complications of measles disease occur in about 10% of measles cases.

Epidemiology

Disease description

Infectious agent

Measles (rubeola, red measles) is caused by measles virus, a member of the Paramyxoviridae family. For additional information about the measles virus, refer to the Pathogen safety data sheet.

Reservoir

Humans.

Transmission

Measles is one of the most highly communicable infectious diseases with greater than 90% secondary attack rates among susceptible persons. The virus is transmitted by the airborne route, respiratory droplets, or direct contact with nasal or throat secretions of infected persons. The incubation period is about 10 days (range, 7 to 18 days). The interval from exposure to appearance of rash averages 14 days. Cases are infectious from 4 days prior to rash onset to 4 days after rash onset. People who recover from measles have permanent immunity to the disease.

Risk factors

People who have not had measles disease or who have not been vaccinated are at risk of infection. In Canada, adults born before 1970 are generally presumed to have acquired natural immunity to measles.

Persons at greatest risk of exposure to measles

Adolescents and adults at greatest risk of exposure to measles include:

• travellers to destinations outside of Canada
• health care workers
• military personnel
• students in post-secondary educational settings

Seasonal and temporal patterns

Historically, measles disease occurred primarily in late winter and spring in temperate zones. It is now restricted to sporadic cases and outbreaks in Canada.

Spectrum of clinical illness

Symptoms of measles include prodromal fever, cough, coryza, conjunctivitis, Koplik spots (white spots on the inner lining of the mouth) and a rash that typically begins on the face, advances to the trunk and then to the arms and legs. Complications such as otitis media and pneumonia occur in about 10% of reported cases, even more commonly in those who are poorly nourished and chronically ill, and in infants less than 1 year of age. Measles encephalitis occurs in approximately 1 of every 1,000 reported cases and may result in permanent brain damage. Measles infection can cause subacute sclerosing panencephalitis (SSPE), a rare but fatal disease. Mortality is estimated at 95%. Approximately 4 to 11 per 100,000 cases of measles result in SSPE. The risk of developing SSPE increases in infected individuals under 5 years of age to 18 per 100,000 cases. Measles during pregnancy can lead to serious complications such as pneumonitis, hepatitis, premature labour, spontaneous abortion and low birth weight infants. Measles in an immunocompromised person may be severe.

Disease distribution

Incidence and prevalence

Global

Measles occurs worldwide and is one of the most highly communicable infectious diseases. In late 2023, a global increase in measles activity was reported. On December 14, 2023, the World Health Organization issued an urgent warning about measles after an "alarming" 30-fold rise in cases across Europe since 2022.

National

Measles has been eliminated in Canada since 1998; however, with increasing measles activity globally, reduced vaccination rates, and increased international travel measles cases in Canada will continue to occur. Comprehensive updates on the epidemiology of measles in Canada are published annually in the Canadian Communicable Disease Report (CCDR) and weekly in the PHAC Measles & Rubella Monitoring Report.

Refer to Measles for health professionals for more information, including disease description, distribution and epidemiology.

Preparations authorized for use in Canada

Measles-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)
• ProQuad^® (live attenuated combined measles, mumps, rubella and varicella vaccine), Merck Canada Inc. (MMRV)

In Canada, measles vaccine is only available in combination with mumps and rubella vaccine (MMR) or mumps, rubella and varicella vaccine (MMRV). In some other countries, measles vaccine alone is given.

Human immunoglobulin products that may be used for measles post-exposure prophylaxis

• GamaSTAN^® (immunoglobulin [human]), Grifols Therapeutics LLC. (Ig)
• Gammagard Liquid^® (immunoglobulin [human]), Takeda Canada Inc. (Ig)
• Gammagard^® S/D (immunoglobulin [human]), Takeda Canada Inc. (Ig)
• Gamunex^® (immunoglobulin [human]), Grifols Therapeutics LLC. (Ig)
• IGIVnex^® (immunoglobulin [human]), Grifols Therapeutics LLC. (Ig)
• Octagam^® 5% (immunoglobulin [human]), OCTAPHARMA Pharmazeutika Produktionsges, m.b.H. (Ig)

All Ig products that may be used for measles post-exposure prophylaxis (PEP) are only available through the Canadian Blood Services (CBS) and Héma Québec (HQ). The human Ig dosages recommended for measles PEP may differ from what is contained in product monographs as measles PEP is an off-label use for most of these products. For recommended dosages, please refer to Tables 2 to 4 for additional information. For complete prescribing information, consult the CBS or HQ websites and the product leaflet or information contained within the product monograph available through Health Canada's Drug product database.

Refer to Contents of immunizing agents authorized for use in Canada in Part 1 for lists of vaccines and passive immunizing agents authorized for use in Canada and their contents.

Immunogenicity, efficacy and effectiveness

Immunogenicity

In clinical studies a single injection of MMR vaccine induced measles antibodies in 95% of previously seronegative children.

In 12 month old children, a single dose of MMRV vaccine results in similar seroconversion rates as those achieved after concomitant administration of MMR vaccine and univalent varicella vaccine. A study of children receiving 2 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.

Efficacy and effectiveness

The efficacy of a single dose of measles-containing vaccine given at 12 or 15 months of age is estimated to be 85% to 95%. With a second dose, efficacy in children approaches 100%. However, measles outbreaks have occurred in populations with high immunization coverage rates. Due to the high infectivity of measles at least 95% of the population needs to be immunized for herd immunity.

Recommendations for use

Healthy infants, children and adolescents

Routine schedule

Healthy infants (0 months to less than 6 months of age)

Infants under 6 months of age are not considered for vaccination as maternally derived antibodies can interfere with the immune response to the vaccine. Additionally, the efficacy and safety of the MMR vaccine has not been established in this age group.

Healthy infants (6 months to less than 12 months of age)

Infants under 12 months of age are not currently recommended for routine immunization with measles-containing vaccines in Canada. However, measles vaccines should be given at an earlier age than usual (e.g., MMR vaccine may be given as early as 6 months of age) for children travelling outside of Canada where the disease is of concern or travelling to locations experiencing outbreaks. Additionally, in a measles outbreak, susceptible individuals 6 months of age and older may receive MMR vaccine.

Refer to Travellers and Outbreak control for additional information.

Healthy children (12 months to less than 13 years of age)

For routine immunization of children aged 12 months to less than 13 years, 2 doses of measles-containing vaccine, using either MMR or MMRV vaccine, should be administered. The first measles-containing vaccine dose should be administered at 12 to 15 months of age and the second dose at 18 months of age or any time thereafter, but no later than around school entry.

Catch-up and accelerated schedules

Healthy children (12 months to less than 13 years of age)

Two doses of measles-containing vaccine, using either MMR or MMRV vaccine, should be administered to children less than 13 years of age who were not immunized on the routine schedule. For preschool aged children, 2 doses of measles-containing vaccine should be administered before school entry (4 to 6 years of age). The minimum interval between doses of measles-containing vaccine is 4 weeks.

Healthy adolescents (13 to less than 18 years of age)

Measles-susceptible adolescents (refer to Table 1: Criteria for presumptive measles immunity) should receive 2 doses of MMR vaccine, given at least 4 weeks apart.

Healthy adults (18 years of age and older)

Routine schedule

Measles-susceptible adults (refer to Table 1: Criteria for presumptive measles immunity) should receive 1 or 2 doses of MMR vaccine as appropriate for age and risk factors. If 2 doses are needed, MMR vaccine should be administered with a minimum interval of 4 weeks between doses.

Adults born before 1970 are generally presumed to have acquired natural immunity to measles; however, some of these individuals may be susceptible.

Adults without contraindications, born in or after 1970 who do not meet the definition of presumptive measles immunity (refer to Table 1: Criteria for presumptive measles immunity) should be immunized with 1 dose of MMR vaccine.

Booster doses and re-immunization

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

Post-exposure prophylaxis

The goal of measles post-exposure prophylaxis (PEP) is to prevent severe disease, including hospitalization, as well as to prevent mortality. If a case of measles is identified, it is important to contact trace and quickly identify contacts who are likely susceptible to measles infection. Administration of measles PEP as soon as possible following measles exposure is recommended and should be offered to individuals not expected to be immune to measles. Year of birth, previous vaccination, history of measles infection, and in some cases, use of serological testing (e.g., serum anti-measles IgG assays), can be considered to determine measles PEP eligibility. Specific populations (e.g., infants, pregnant women and pregnant individuals, or those who are immunocompromised) have additional considerations.

Recommended measles PEP strategies vary by population and may include measles-containing vaccine and human immunoglobulin (Ig) given either as intramuscular Ig (IMIg) or intravenous Ig (IVIg). When indicated, PEP should be given as soon as possible after exposure. Prophylactic use of MMR vaccine has been shown to be effective if provided within 72 hours of exposure while the prophylactic use of human immunoglobulin (Ig) has been shown to be effective in modifying or preventing disease if administered within 6 days after exposure to measles. IVIg administration requires in-hospital administration and active patient monitoring over several hours of infusion, performed by appropriately trained staff. Providers of IVIg should review the respective product monographs and CBS guidelines prior to IVIg administration. Ig should be considered for the following groups of individuals at risk of measles, if they are contacts of measles, including:

• pregnant women and pregnant individuals
• individuals who are immunocompromised
• infants ˂ 6 months of age
• immunocompetent infants 6 to 11 months old who present between 73 hours and 6 days after exposure

In assessing the extent of measles exposure and deciding between MMR vaccine and Ig for post-exposure management, it is also important to consider that Ig provides only short-term protection and requires postponing the administration of MMR vaccine. Long-term protection against measles is only provided following immunization with MMR vaccine. For guidelines on the interval between administration of Ig preparations and MMR or MMRV refer to Table 1 in Blood products, human immunoglobulin and timing of immunization in Part 1.

Despite the use of MMR vaccine or Ig for post-exposure management, measles infection may occur. Exposed individuals should be counseled regarding signs and symptoms of measles; avoiding contact with others should they become ill with symptoms compatible with measles; and the need to seek medical care, including advising health care workers of the possibility of measles before going to a health care setting so that appropriate precautions can be taken.

Considerations on use of immunoglobulin products for measles PEP

While convention has been to limit volume per injection to 2 mL in children and 3 to 5 mL in adults (depending on site and muscle mass), there are no data to inform the maximum volumes for IM injections. To facilitate administration of IMIg in children 6 months of age and older, injection volumes of up to 3 mL could be considered to reduce the number of injections, using clinical judgement. For high volume injections, the anterolateral thigh is generally preferred due to the greater muscle mass. Clinical judgement should be used when selecting the most appropriate site for IMIg administration.

IMIg is no longer recommended for individuals weighing more than 30 kg due to the lack of evidence of the efficacy/effectiveness of IMIg administered at dosages below 0.5 mL/kg. In some circumstances, such as in remote communities, there may be a preference to give IMIg instead of IVIg, due to the healthcare facility and personnel resources required to administer IVIg. More than 15 mL of IMIg can be administered using clinical judgement.

Individuals who are immunocompetent

Year of birth, previous vaccination status, serology and history of measles infection should be considered when determining measles PEP eligibility among immunocompetent individuals.

A measles-containing vaccine is expected to offer some protection as post-exposure prophylaxis when administered within 72 hours of exposure to individuals who can mount a humoral response to primary vaccination. However, it is important, particularly during an ongoing measles outbreak, to continue to offer measles-containing vaccine, even if >72h since exposure, to provide long-term protection. Although a measles-containing vaccine is not known to provide protection after 72 hours of exposure, starting or completing a two-dose series in immunocompetent individuals 12 months of age and older should not be delayed as it provides long term protection.

Refer to Infants and Pregnant women and pregnant individuals for additional information.

Year of birth

Those born prior to 1970 in Canada are likely to have been exposed to measles through natural infection. For contacts born outside of Canada, the birth year cut-off of 1970 for expected measles immunity can be applied for measles PEP, with the exception of the United States where the birth year of 1957 should be used.

Previous vaccination status

Immunocompetent individuals who have received two doses of a measles-containing vaccine after 12 months of age (given at least 4 weeks apart) are expected to maintain long lasting protection against measles. However, breakthrough infections can occur among vaccinated individuals especially in the context of exposures at close distance or for a prolonged period of time (e.g., household contact). Breakthrough infections are generally milder and less likely to result in severe outcomes of measles including hospitalization and death.

History of measles infection

Documented laboratory evidence of previous measles infection or immunity should be used to inform eligibility for PEP. Immunocompetent individuals with a past measles infection are expected to maintain long lasting protective immunity against measles infection.

Infants

Infants less than 6 months of age are not expected to have immunity to measles and should be offered Ig as soon as possible and within 6 days of exposure.

IMIg should be provided to infants under 6 months of age at a dose of 0.5mL/kg, to a maximum of 15mL administered over multiple injection sites. If injection volume is a major concern, or if recipients weigh >30 kg, or if access to IVIg is more feasible than access to IMIg, IVIg can be administered at a concentration of 400 mg/kg.

Infants 6 months to under 12 months of age

Susceptible infants 6 months to under 12 months of age, who are not known to be immunocompromised, who are exposed to measles should be offered MMR vaccine within 72 hours of their exposure. When MMR vaccine is provided prior to 12 months of age, 2 additional doses of measles-containing vaccine must be administered after the child is 12 months old (and at least 4 weeks after the previous dose) to ensure long lasting immunity. If more than 73 hours and less than 6 days have occurred since measles exposure, IMIg should be administered at a dosage of 0.5 mL/kg.

In rare instances, children 6 months to under 12 months of age who have been vaccinated with a measles-containing vaccine may be identified as measles contacts and considered for post-exposure prophylaxis. In this situation, clinical judgement should be used, considering factors such as the nature and intensity of exposure, limited evidence on the VE of 1 dose of MMR in this age group, and timing of previous dose. Providing MMR within 72 hours of exposure could be considered, however an additional 2 doses after 12 months of age, given at least 4 weeks apart, are required for long-term protection. Serological testing (with results expected within 24 hours of sampling time) can be done, and if negative, IMIg should be administered (within 6 days of exposure). If considering administration of IMIg after receipt of MMR, refer to the CIG, Part 1, Blood products, human immunoglobulin and timing of immunization.

Children 12 months of age or older

Susceptible children 12 months of age and older who are exposed to measles should be given MMR vaccine within 72 hours of their exposure, unless contraindicated.

Pregnant women and pregnant individuals

For pregnant women and pregnant individuals, year of birth, previous vaccination status and/or history of measles infection, and documented laboratory evidence of measles infection or immunity should be used to inform eligibility for PEP. In specific circumstances, use of serological testing (e.g., serum anti-measles IgG assays) can be considered to inform measles PEP strategies if results are available within 24 to 48 hours of sampling time that allows for Ig PEP administration within 6 days of exposure. If a pregnant woman or pregnant individual meets any of the criteria for expected measles immunity for PEP, measles PEP is not recommended.

Refer to Table 3. Summary of updated recommended measles post-exposure prophylaxis strategies for pregnant women and pregnant individuals by risk level for additional information.

Individuals who are immunocompromised

Guidance for measles PEP for individuals who are immunocompromised is based on their level of immunocompromise. Immunocompromising conditions and immunosuppressive therapies are heterogenous in the level of immunocompromise, leading to variability in both an individual's risk of contracting severe measles after an exposure, and the likelihood that past vaccination or infection will confer protective immunity against measles after the onset of immunocompromise. The recommended measles PEP strategies for individuals who are immunocompromised are therefore grouped by extent of immunocompromise, the likelihood of maintaining measles-antibody mediated protection from past vaccination or infection, and the ability to safely receive a measles-containing vaccine. The immunocompromising medical conditions, and therapies that result in immunosuppression found in Table 4 are not comprehensive. Assessment of severity of immunocompromising condition is best determined by consulting with the treating physician, infectious disease expert/immunologist, or special immunization clinic. Additionally, as new immunomodulatory drugs become authorized or if various combinations of immunomodulatory drugs are used, advice from clinical experts should be sought as to the degree of immunosuppression likely to be induced and the effect on immunity from past measles infection and/or vaccination.

For individuals who are already receiving Ig replacement therapy (as IVIg or SCIg), Ig for measles PEP is not required if the last dose of IVIg (at least 400 mg/kg) was received within three weeks prior to measles exposure, or if SCIg (at least 200 mg/kg) was received for 2 consecutive weeks prior to measles exposure. If outside of these parameters, administer the individual's usual dose as soon as possible.

If an individual is immunocompromised and pregnant, or immunocompromised and over 6 months of age, treat them as per the guidance for immunocompromised persons.

Refer to Table 4. Summary of updated recommended measles post-exposure prophylaxis strategies for individuals 6 months of age and older who are immunocompromised for additional information.

Refer to Immunocompromised persons for additional information.

Serological testing to inform measles PEP strategies

In specific circumstances, use of serological testing (e.g., serum anti-measles IgG assays) should be considered to inform measles PEP strategies only if results are available within 24 to 48 hours of sampling time that allows for Ig PEP administration within 6 days of exposure.

Outbreak control

Immunization with measles-containing vaccine is an integral element of a comprehensive measles outbreak prevention and management strategy. In a measles outbreak, susceptible individuals 6 months of age and older may receive MMR vaccine. However, if given between 6 months and less than 12 months of age, 2 additional doses of measles-containing vaccine (given at least 4 weeks apart) must be administered after the child is 12 months old to ensure long lasting immunity to measles.

For detailed information on outbreak control beyond vaccination and post-exposure prophylaxis strategies, refer to Guidelines for measles outbreak in Canada in the Canada Communicable Disease Report (CCDR).

Vaccination of specific populations

Students in post-secondary educational settings

Students in post-secondary educational settings are one of the groups at greatest risk of measles exposure. Students in post-secondary educational settings who do not meet the definition of presumptive measles immunity (refer to Table 1: Criteria for presumptive measles immunity):

• should receive 2 doses of MMR vaccine if born in or after 1970
• should consider 1 dose of MMR vaccine if born before 1970

Refer to Immunization of adults in Part 3 for additional information.

Persons with inadequate immunization records

Children and adults who are susceptible to measles, including those lacking adequate documentation of immunization, should be started on an immunization schedule appropriate for their age and risk factors. Measles-containing vaccine 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 information.

Pregnancy and breastfeeding

Routine immunization, including completing immunization prior to pregnancy, continues to be essential to protect individuals. Immunity to measles should be reviewed in women and people of reproductive age who may become pregnant and vaccination should be recommended to susceptible non-pregnant women and susceptible people who may become pregnant. Women and people who may become pregnant should delay pregnancy by at least 4 weeks following vaccination with a measles-containing vaccine.

MMR and MMRV vaccines are generally contraindicated in pregnancy because there is a theoretical risk to the fetus. In some situations, potential benefits of vaccination with MMR vaccine may outweigh risks such as during measles or rubella outbreaks, in which case vaccination may be considered based on recommendations from public health officials. However, termination of pregnancy should not be recommended following inadvertent immunization with either of these vaccines on the basis of fetal risks following maternal immunization.

Susceptible breastfeeding women and breastfeeding individuals should be vaccinated with MMR vaccine.

Refer to Post-exposure prophylaxis for additional information on recommended measles PEP strategies for pregnant women and pregnant individuals.

Refer to Blood products, human immunoglobulin and timing of immunization in Part 1 for information about measles vaccination of post-partum women who have received Rh immunoglobulin (RhIg).

Refer to Immunization in pregnancy and breastfeeding in Part 3 for additional information.

Patients in health care institutions

Susceptible residents of long-term care facilities should receive measles, mumps and rubella-containing vaccine as appropriate for their age and risk factors.

Refer to Immunization of patients in health care institutions in Part 3 for additional information.

Persons with chronic diseases

Age-appropriate measles-containing vaccine should routinely be provided to individuals with chronic diseases who are not immunocompromised.

Refer to Immunization of persons with chronic diseases in Part 3 for additional general information about vaccination of people with chronic diseases.

Immunocompromised persons

Individuals who are immunocompromised, either due to underlying conditions or immunosuppressive agents, are more susceptible to infections including measles. They may be more likely to experience more severe disease and complications. The safety and effectiveness of the measles vaccine is determined by the type of immunodeficiency and degree of immunosuppression. Routine immunization, including completing immunization prior to beginning immunosuppressive therapy, continues to be important. When considering immunization of an immunocompromised person with a live vaccine, consultation with 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 Individuals who are immunocompromised for additional information on recommended measles PEP strategies for these individuals.

Refer to Immunization of immunocompromised persons in Part 3 for additional information.

Travellers

Protection against measles is especially important for people planning travel. Travellers to destinations outside of Canada, born in or after 1970, who do not meet the definition of presumptive measles immunity (refer to Table 1: Criteria for presumptive measles immunity) should receive 2 doses of measles-containing vaccine.

Measles vaccines should be given at an earlier age than usual for children travelling outside of Canada where the disease is of concern or travelling to locations experiencing outbreaks. MMR vaccine may be given as early as 6 months of age; however, 2 additional doses of measles-containing vaccine must be administered after the child is 12 months old to ensure long lasting immunity to measles. Infants under 6 months of age are not considered for vaccination. The efficacy and safety of the MMR vaccine has not been established in this age group.

Travellers to destinations outside of Canada, born before 1970, who do not meet the definition of presumptive measles immunity (refer to Table 1: Criteria for presumptive measles immunity) should receive 1 dose of MMR vaccine.

Measles is endemic in many countries. Refer to the Public Health Agency of Canada's Travel Health Notices for information about measles outbreaks outside of Canada and to Immunization of travellers in Part 3 for additional 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 as necessary. 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 for additional information.

Workers

Health care workers

It is recommended that all health care workers be immune to measles. Health care workers, regardless of their year of birth, who do not have documented two doses of measles-containing vaccine or a documented IgG serology to measles should be vaccinated.

Military personnel

Military personnel are one of the groups at greatest risk of measles exposure. Military personnel, regardless of year of birth, who do not have documented two doses of measles-containing vaccine or a documented IgG serology to measles should be vaccinated.

Refer to Immunization of workers in Part 3 for additional information.

Serologic testing

Routine testing for laboratory evidence of measles immunity is not recommended for the general population. Serological testing may be indicated (e.g., for healthcare workers) to determine immune status. Serologic testing is not recommended before or after receiving measles-containing vaccine. If serology is inadvertently done subsequent to appropriate measles immunization and does not demonstrate immunity, measles re-immunization is not necessary.

Refer to Serological testing to inform measles PEP strategies for additional information.

Administration practices

Dose and route of administration

Dose

Each dose of measles-containing vaccine is 0.5 mL.

Route of administration

All MMR and MMRV vaccines may be administered either subcutaneously (SC) or intramuscularly (IM). Refer to the product monographs available through Health Canada's Drug Product Database.

Refer to Vaccine administration practices in Part 1 for additional information about pre-vaccination and post-vaccination counselling, vaccine preparation and administration technique, and infection prevention and control.

Interchangeability of vaccines

On the basis of expert opinion, the MMR vaccines authorized in Canada may be used interchangeably. Refer to Varicella vaccines for information about interchangeability of MMRV vaccines. Refer to Principles of vaccine interchangeability in Part 1 for additional general information.

Concurrent administration with other vaccines

MMR vaccine may be administered concurrently with, or at any time before or after, non-live vaccines, live oral vaccines, or live intranasal influenza vaccine (LAIV). Refer to Influenza vaccines for additional information about concurrent administration of MMR vaccine with LAIV.

MMR vaccine may be administered concurrently with other routinely provided live parenteral vaccines. If not given concurrently, a minimum interval of 4 weeks is recommended between administration of MMR and other live parenteral vaccines. This recommendation is to address the risk of interference from the vaccine given first on the vaccine given later.

Different injection sites and separate needles and syringes must be used for concurrent parenteral injections.

Refer to Timing of vaccine administration in Part 1 for additional information about concurrent administration of measles-containing vaccine with other vaccines.

Storage requirements

Refer to Storage and handling of immunizing agents in Part 1 for storage and handling recommendations for measles-containing vaccines.

Safety and adverse events

Common and local adverse events

Measles-Mumps-Rubella vaccine

Adverse events following immunization with MMR vaccine occur less frequently and are 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 individuals not protected by the first dose. Six (6) to 23 days after immunization with MMR vaccine, approximately 5% of immunized children experience malaise and fever (with or without rash) lasting up to 3 days. Parotitis, rash, lymphadenopathy, and joint symptoms also occur occasionally after immunization with MMR vaccine.

Measles-Mumps-Rubella-Varicella vaccine

Pain and redness at the injection site or fever less than 39°C occur in 10% or more of vaccine recipients. Rash, including measles-like, rubella-like and varicella-like rash, as well as swelling at the injection site and fever greater than 39°C, occur in 1% to less than 10% of vaccine recipients. As varicella-like rashes that occur within the first 2 weeks after immunization may be caused by wild-type virus (varicella virus circulating in the community), health care providers should obtain specimens from the vaccine recipient to determine whether the rash is due to natural varicella infection or to the vaccine-derived strain.

Rubella-containing vaccines

Acute transient arthritis or arthralgia may occur 1 to 3 weeks after immunization with rubella-containing vaccine, such as MMRV. 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.

Human immunoglobulin

Injection site reactions following receipt of standard human Ig include tenderness, erythema and stiffness of local muscles, which may persist for several hours. Mild fever or malaise may occasionally occur.

Less common and serious or severe adverse events

Serious adverse events are rare following immunization. Anaphylaxis following vaccination with MMR or MMRV vaccine may occur but is very rare.

Measles-Mumps-Rubella vaccine and Measles-Mumps-Rubella-Varicella vaccine

Immune Thrombocytopenic Purpura

Rarely, Immune Thrombocytopenic Purpura (ITP) occurs within 6 weeks after immunization with MMR or MMRV vaccine. In all children, post-immunization thrombocytopenia requires medical care, but in most children, it resolves within 6 months. 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 for protection. The potential risk to benefit ratio should be carefully evaluated before considering 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 the incidence observed with natural measles disease (1 per 1,000 cases).

Measles-Mumps-Rubella-Varicella vaccine

Febrile seizures

When the first dose of measles-containing vaccine is administered to children 12 to 23 months as MMRV vaccine, there is a higher risk of fever and febrile seizures in the 7 to 10 days after vaccination when compared to separate administration of MMR and varicella vaccine at the same visit. This risk is estimated at about 1 additional febrile seizure for every 2,300 to 2,800 doses of MMRV vaccine.

Human immunoglobulin

Less common side effects following receipt of standard human Ig include flushing, headache, chills and nausea. Urticaria, angioedema and anaphylactic reactions may occur rarely.

Other reported adverse events and conditions

In the mid to late 1990s, researchers from the United Kingdom 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 found to be fraudulent and was retracted.

Guidance on reporting Adverse Events Following Immunization

Vaccine providers are asked to report the following adverse events following immunization (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 within 7 to 21 days after vaccination with MMRV vaccine.
• Any serious or unexpected adverse event 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 Adverse Events Following Immunization (AEFI) in Part 2 for additional information about AEFI reporting.

Contraindications and precautions

MMR and MMRV vaccines and Ig are contraindicated in persons with a history of anaphylaxis after previous administration of the product and in persons with proven immediate or anaphylactic hypersensitivity to any component of the product, with the exception of egg allergy for MMR and MMRV vaccines. Refer to Contents of immunizing agents authorized for use in Canada in Part 1 for lists of vaccines and passive immunizing agents authorized in Canada and their contents.

Human Ig preparations should not be given to people with known isolated IgA deficiency unless the benefit outweighs the risk, in which case the product should be given with caution and under close observation.

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.

Although 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 or 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 Contraindications and precautions 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.

Measles-containing vaccines can be contraindicated in persons with impaired immune function, including primary or secondary immunodeficiency disorders. Human Ig preparations should not be given to people with known isolated IgA deficiency unless the benefit outweighs the risk, in which case the product should be given with caution and under close observation. Refer to Immunization of immunocompromised persons in Part 3 for more information. MMR and MMRV vaccines are generally contraindicated during pregnancy because of the theoretical risk to the fetus. Refer to Immunization in pregnancy and breastfeeding in Part 3.

Measles-containing vaccines are contraindicated in individuals with active, untreated tuberculosis (TB) as a precautionary measure. Although TB may be exacerbated by natural measles infection, there is no evidence that measles-containing vaccines have such an effect. Nonetheless, anti-tuberculous therapy for active TB disease is advisable before administering measles-containing vaccines and it may be prudent to avoid live viral vaccines in those with active TB disease until treatment is underway. Consultation with an expert in infectious diseases is recommended.

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 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 (medications derived from salicylic acid, such as 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 and precautions in Part 2 for additional information.

Other considerations

Drug interactions

Systemic antiviral therapy

Systemic antiviral therapy (such as acyclovir, valacyclovir, famciclovir) should be avoided in the peri-immunization period, as it may affect the reproduction of the vaccine virus and consequently 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 vaccine administration.

Tuberculin skin testing or Interferon gamma release assay

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 performed and read.

Human immunoglobulin or other blood products

Passive immunization with human Ig or receipt of most other blood products can interfere with the immune response to MMR, MMRV and univalent varicella vaccines. These vaccines should be given at least 14 days prior to administration of an immunoglobulin preparation or blood product, or delayed until the antibodies in the Ig preparation or blood product have degraded. Refer to Blood products, human immunoglobulin and timing of immunization in Part 1 for additional information.

Chapter revision process

The chapter was updated based on the NACI statement: Updated recommendations on measles post-exposure prophylaxis prepared by R Krishnan, MI Salvadori, N Forbes, J Montroy, O Baclic, L Coward, F Khan, MC Tunis, R Harrison and M O'Driscoll.

Acknowledgments

The chapter update was prepared by L Coward, O Baclic and reviewed by MI Salvadori and C Jensen.

The CIG gratefully acknowledges the contribution of: N Haddad.

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