M-M-R II

(MEASLES, MUMPS, and

RUBELLA VIRUS VACCINE LIVE)
DESCRIPTION
M-M-R II (Measles, Mumps, and Rubella Virus Vaccine Live) is a live virus vaccine for vaccination
against measles (rubeola), mumps, and rubella (German measles).
M-M-R II is a sterile lyophilized preparation of (1) ATTENUVAX (Measles Virus Vaccine Live), a
more attenuated line of measles virus, derived from Enders' attenuated Edmonston strain and
propagated in chick embryo cell culture; (2) MUMPSVAX (Mumps Virus Vaccine Live), the Jeryl Lynn
(B level) strain of mumps virus propagated in chick embryo cell culture; and (3) MERUVAX II (Rubella
Virus Vaccine Live), the Wistar RA 27/3 strain of live attenuated rubella virus propagated in WI-38 human
diploid lung fibroblasts.{1,2}
The growth medium for measles and mumps is Medium 199 (a buffered salt solution containing
vitamins and amino acids and supplemented with fetal bovine serum) containing SPGA (sucrose,
phosphate, glutamate, and recombinant human albumin) as stabilizer and neomycin.
The growth medium for rubella is Minimum Essential Medium (MEM) [a buffered salt solution
containing vitamins and amino acids and supplemented with fetal bovine serum] containing recombinant
human albumin and neomycin. Sorbitol and hydrolyzed gelatin stabilizer are added to the individual virus
harvests.
The cells, virus pools, and fetal bovine serum are all screened for the absence of adventitious agents.
The reconstituted vaccine is for subcutaneous administration. Each 0.5 mL dose contains not less
than 1,000 TCID50 (tissue culture infectious doses) of measles virus; 12,500 TCID50 of mumps virus; and
1,000 TCID50 of rubella virus. Each dose of the vaccine is calculated to contain sorbitol (14.5 mg), sodium
phosphate, sucrose (1.9 mg), sodium chloride, hydrolyzed gelatin (14.5 mg), recombinant human albumin
(0.3 mg), fetal bovine serum (<1 ppm), other buffer and media ingredients and approximately 25 mcg of
neomycin. The product contains no preservative.
Before reconstitution, the lyophilized vaccine is a light yellow compact crystalline plug. M-M-R II, when
reconstituted as directed, is clear yellow.
CLINICAL PHARMACOLOGY
Measles, mumps, and rubella are three common childhood diseases, caused by measles virus,
mumps virus (paramyxoviruses), and rubella virus (togavirus), respectively, that may be associated with
serious complications and/or death. For example, pneumonia and encephalitis are caused by measles.
Mumps is associated with aseptic meningitis, deafness and orchitis; and rubella during pregnancy may
cause congenital rubella syndrome in the infants of infected mothers.
The impact of measles, mumps, and rubella vaccination on the natural history of each disease in the
United States can be quantified by comparing the maximum number of measles, mumps, and rubella
cases reported in a given year prior to vaccine use to the number of cases of each disease reported in
1995. For measles, 894,134 cases reported in 1941 compared to 288 cases reported in 1995 resulted in
a 99.97% decrease in reported cases; for mumps, 152,209 cases reported in 1968 compared to 840
cases reported in 1995 resulted in a 99.45% decrease in reported cases; and for rubella, 57,686 cases
reported in 1969 compared to 200 cases reported in 1995 resulted in a 99.65% decrease.{3}
Clinical studies of 284 triple seronegative children, 11 months to 7 years of age, demonstrated that
M-M-R II is highly immunogenic and generally well tolerated. In these studies, a single injection of the
vaccine induced measles hemagglutination-inhibition (HI) antibodies in 95%, mumps neutralizing
antibodies in 96%, and rubella HI antibodies in 99% of susceptible persons. However, a small percentage
(1-5%) of vaccinees may fail to seroconvert after the primary dose (see also INDICATIONS AND USAGE,
Recommended Vaccination Schedule).
A study{4} of 6-month-old and 15-month-old infants born to vaccine-immunized mothers demonstrated
that, following vaccination with ATTENUVAX, 74% of the 6-month-old infants developed detectable
neutralizing antibody (NT) titers while 100% of the 15-month-old infants developed NT. This rate of
seroconversion is higher than that previously reported for 6-month-old infants born to naturally immune
mothers tested by HI assay. When the 6-month-old infants of immunized mothers were revaccinated at

15 months, they developed antibody titers equivalent to the 15-month-old vaccinees. The lower
seroconversion rate in 6-month-olds has two possible explanations: 1) Due to the limit of the detection
level of the assays (NT and enzyme immunoassay [EIA]), the presence of trace amounts of undetectable
maternal antibody might interfere with the seroconversion of infants; or 2) The immune system of
6-month-olds is not always capable of mounting a response to measles vaccine as measured by the two
antibody assays.
There is some evidence to suggest that infants who are born to mothers who had wild-type measles
and who are vaccinated at less than one year of age may not develop sustained antibody levels when
later revaccinated. The advantage of early protection must be weighed against the chance for failure to
respond adequately on reimmunization.{5,6}
Efficacy of measles, mumps, and rubella vaccines was established in a series of double-blind
controlled field trials which demonstrated a high degree of protective efficacy afforded by the individual
vaccine components.{7-12} These studies also established that seroconversion in response to
vaccination against measles, mumps, and rubella paralleled protection from these diseases.{13-15}
Following vaccination, antibodies associated with protection can be measured by neutralization
assays, HI, or ELISA (enzyme linked immunosorbent assay) tests. Neutralizing and ELISA antibodies to
measles, mumps, and rubella viruses are still detectable in most individuals 11 to 13 years after primary
vaccination.{16-18} See INDICATIONS AND USAGE, Non-Pregnant Adolescent and Adult Females, for
Rubella Susceptibility Testing.
The RA 27/3 rubella strain in M-M-R II elicits higher immediate post-vaccination HI, complement-fixing
and neutralizing antibody levels than other strains of rubella vaccine{19-25} and has been shown to
induce a broader profile of circulating antibodies including anti-theta and anti-iota precipitating
antibodies.{26,27} The RA 27/3 rubella strain immunologically simulates natural infection more closely
than other rubella vaccine viruses.{27-29} The increased levels and broader profile of antibodies
produced by RA 27/3 strain rubella virus vaccine appear to correlate with greater resistance to subclinical
reinfection with the wild virus,{27,29-31} and provide greater confidence for lasting immunity.
INDICATIONS AND USAGE
Recommended Vaccination Schedule
M-M-R II is indicated for simultaneous vaccination against measles, mumps, and rubella in individuals
12 months of age or older.
Individuals first vaccinated at 12 months of age or older should be revaccinated prior to elementary
school entry. Revaccination is intended to seroconvert those who do not respond to the first dose. The
Advisory Committee on Immunization Practices (ACIP) recommends administration of the first dose of
M-M-R II at 12 to 15 months of age and administration of the second dose of M-M-R II at 4 to 6 years of
age.{32} In addition, some public health jurisdictions mandate the age for revaccination. Consult the
complete text of applicable guidelines regarding routine revaccination including that of high-risk adult
populations.
Measles Outbreak Schedule
Infants Between 6 to 12 Months of Age
Local health authorities may recommend measles vaccination of infants between 6 to 12 months of
age in outbreak situations. This population may fail to respond to the components of the vaccine. Safety
and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have not been
established. The younger the infant, the lower the likelihood of seroconversion (see CLINICAL
PHARMACOLOGY). Such infants should receive a second dose of M-M-R II between 12 to 15 months of
age followed by revaccination at elementary school entry.{32}
Unnecessary doses of a vaccine are best avoided by ensuring that written documentation of
vaccination is preserved and a copy given to each vaccinee's parent or guardian.
Other Vaccination Considerations
Non-Pregnant Adolescent and Adult Females
Immunization of susceptible non-pregnant adolescent and adult females of childbearing age with live
attenuated rubella virus vaccine is indicated if certain precautions are observed (see below and
PRECAUTIONS). Vaccinating susceptible postpubertal females confers individual protection against
subsequently acquiring rubella infection during pregnancy, which in turn prevents infection of the fetus
and consequent congenital rubella injury.{33}

Women of childbearing age should be advised not to become pregnant for 3 months after vaccination
and should be informed of the reasons for this precaution.
The ACIP has stated "If it is practical and if reliable laboratory services are available, women of
childbearing age who are potential candidates for vaccination can have serologic tests to determine
susceptibility to rubella. However, with the exception of premarital and prenatal screening, routinely
performing serologic tests for all women of childbearing age to determine susceptibility (so that vaccine is
given only to proven susceptible women) can be effective but is expensive. Also, 2 visits to the
health-care provider would be necessary one for screening and one for vaccination. Accordingly,
rubella vaccination of a woman who is not known to be pregnant and has no history of vaccination is
justifiable without serologic testing and may be preferable, particularly when costs of serology are high
and follow-up of identified susceptible women for vaccination is not assured."{33}
Postpubertal females should be informed of the frequent occurrence of generally self-limited arthralgia
and/or arthritis beginning 2 to 4 weeks after vaccination (see ADVERSE REACTIONS).
Postpartum Women
It has been found convenient in many instances to vaccinate rubella-susceptible women in the
immediate postpartum period (see PRECAUTIONS, Nursing Mothers).
Other Populations
Previously unvaccinated children older than 12 months who are in contact with susceptible pregnant
women should receive live attenuated rubella vaccine (such as that contained in monovalent rubella
vaccine or in M-M-R II) to reduce the risk of exposure of the pregnant woman.
Individuals planning travel outside the United States, if not immune, can acquire measles, mumps, or
rubella and import these diseases into the United States. Therefore, prior to international travel,
individuals known to be susceptible to one or more of these diseases can either receive the indicated
monovalent vaccine (measles, mumps, or rubella), or a combination vaccine as appropriate. However,
M-M-R II is preferred for persons likely to be susceptible to mumps and rubella; and if monovalent
measles vaccine is not readily available, travelers should receive M-M-R II regardless of their immune
status to mumps or rubella.{34-36}
Vaccination is recommended for susceptible individuals in high-risk groups such as college students,
health-care workers, and military personnel.{33,34,37}
According to ACIP recommendations, most persons born in 1956 or earlier are likely to have been
infected with measles naturally and generally need not be considered susceptible. All children,
adolescents, and adults born after 1956 are considered susceptible and should be vaccinated, if there
are no contraindications. This includes persons who may be immune to measles but who lack adequate
documentation of immunity such as: (1) physician-diagnosed measles, (2) laboratory evidence of
measles immunity, or (3) adequate immunization with live measles vaccine on or after the first
birthday.{34}
The ACIP recommends that "Persons vaccinated with inactivated vaccine followed within 3 months by
live vaccine should be revaccinated with two doses of live vaccine. Revaccination is particularly important
when the risk of exposure to wild-type measles virus is increased, as may occur during international
travel."{34}
Post-Exposure Vaccination
Vaccination of individuals exposed to wild-type measles may provide some protection if the vaccine
can be administered within 72 hours of exposure. If, however, vaccine is given a few days before
exposure, substantial protection may be afforded.{34,38,39} There is no conclusive evidence that
vaccination of individuals recently exposed to wild-type mumps or wild-type rubella will provide
protection.{33,37}
Use With Other Vaccines
See DOSAGE AND ADMINISTRATION, Use With Other Vaccines.
CONTRAINDICATIONS
Hypersensitivity to any component of the vaccine, including gelatin.{40}
Do not give M-M-R II to pregnant females; the possible effects of the vaccine on fetal development
are unknown at this time. If vaccination of postpubertal females is undertaken, pregnancy should be
avoided for three months following vaccination (see INDICATIONS AND USAGE, Non-Pregnant
Adolescent and Adult Females and PRECAUTIONS, Pregnancy).

Anaphylactic or anaphylactoid reactions to neomycin (each dose of reconstituted vaccine contains

approximately 25 mcg of neomycin).
Febrile respiratory illness or other active febrile infection. However, the ACIP has recommended that
all vaccines can be administered to persons with minor illnesses such as diarrhea, mild upper respiratory
infection with or without low-grade fever, or other low-grade febrile illness.{41}
Patients receiving immunosuppressive therapy. This contraindication does not apply to patients who
are receiving corticosteroids as replacement therapy, e.g., for Addison's disease.
Individuals with blood dyscrasias, leukemia, lymphomas of any type, or other malignant neoplasms
affecting the bone marrow or lymphatic systems.
Primary and acquired immunodeficiency states, including patients who are immunosuppressed in
association with AIDS or other clinical manifestations of infection with human immunodeficiency
viruses;{41-43} cellular immune deficiencies; and hypogammaglobulinemic and dysgammaglobulinemic
states. Measles inclusion body encephalitis{44} (MIBE), pneumonitis{45} and death as a direct
consequence of disseminated measles vaccine virus infection have been reported in
immunocompromised individuals inadvertently vaccinated with measles-containing vaccine.
Individuals with a family history of congenital or hereditary immunodeficiency, until the immune
competence of the potential vaccine recipient is demonstrated.
WARNINGS
Due caution should be employed in administration of M-M-R II to persons with a history of cerebral
injury, individual or family histories of convulsions, or any other condition in which stress due to fever
should be avoided. The physician should be alert to the temperature elevation which may occur following
vaccination (see ADVERSE REACTIONS).
Hypersensitivity to Eggs
Live measles vaccine and live mumps vaccine are produced in chick embryo cell culture. Persons with
a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives, swelling of the mouth
and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion may be at an
enhanced risk of immediate-type hypersensitivity reactions after receiving vaccines containing traces of
chick embryo antigen. The potential risk to benefit ratio should be carefully evaluated before considering
vaccination in such cases. Such individuals may be vaccinated with extreme caution, having adequate
treatment on hand should a reaction occur (see PRECAUTIONS).{46}
However, the AAP has stated, "Most children with a history of anaphylactic reactions to eggs have no
untoward reactions to measles or MMR vaccine. Persons are not at increased risk if they have egg
allergies that are not anaphylactic, and they should be vaccinated in the usual manner. In addition, skin
testing of egg-allergic children with vaccine has not been predictive of which children will have an
immediate hypersensitivity reaction...Persons with allergies to chickens or chicken feathers are not at
increased risk of reaction to the vaccine."{47}
Hypersensitivity to Neomycin
The AAP states, "Persons who have experienced anaphylactic reactions to topically or systemically
administered neomycin should not receive measles vaccine. Most often, however, neomycin allergy
manifests as a contact dermatitis, which is a delayed-type (cell-mediated) immune response rather than
anaphylaxis. In such persons, an adverse reaction to neomycin in the vaccine would be an erythematous,
pruritic nodule or papule, 48 to 96 hours after vaccination. A history of contact dermatitis to neomycin is
not a contraindication to receiving measles vaccine."{47}
Thrombocytopenia
Individuals with current thrombocytopenia may develop more severe thrombocytopenia following
vaccination. In addition, individuals who experienced thrombocytopenia with the first dose of M-M-R II (or
its component vaccines) may develop thrombocytopenia with repeat doses. Serologic status may be
evaluated to determine whether or not additional doses of vaccine are needed. The potential risk to
benefit ratio should be carefully evaluated before considering vaccination in such cases (see ADVERSE
REACTIONS).

PRECAUTIONS
General
Adequate treatment provisions, including epinephrine injection (1:1000), should be available for
immediate use should an anaphylactic or anaphylactoid reaction occur.
Special care should be taken to ensure that the injection does not enter a blood vessel.
Children and young adults who are known to be infected with human immunodeficiency viruses and
are not immunosuppressed may be vaccinated. However, vaccinees who are infected with HIV should be
monitored closely for vaccine-preventable diseases because immunization may be less effective than for
uninfected persons (see CONTRAINDICATIONS).{42,43}
Vaccination should be deferred for 3 months or longer following blood or plasma transfusions, or
administration of immune globulin (human).{47}
Excretion of small amounts of the live attenuated rubella virus from the nose or throat has occurred in
the majority of susceptible individuals 7 to 28 days after vaccination. There is no confirmed evidence to
indicate that such virus is transmitted to susceptible persons who are in contact with the vaccinated
individuals. Consequently, transmission through close personal contact, while accepted as a theoretical
possibility, is not regarded as a significant risk.{33} However, transmission of the rubella vaccine virus to
infants via breast milk has been documented (see Nursing Mothers).
There are no reports of transmission of live attenuated measles or mumps viruses from vaccinees to
susceptible contacts.
It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually
may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin test is to be
done, it should be administered either before or simultaneously with M-M-R II.
Children under treatment for tuberculosis have not experienced exacerbation of the disease when
immunized with live measles virus vaccine;{48} no studies have been reported to date of the effect of
measles virus vaccines on untreated tuberculous children. However, individuals with active untreated
tuberculosis should not be vaccinated.
As for any vaccine, vaccination with M-M-R II may not result in protection in 100% of vaccinees.
The health-care provider should determine the current health status and previous vaccination history
of the vaccinee.
The health-care provider should question the patient, parent, or guardian about reactions to a previous
dose of M-M-R II or other measles-, mumps-, or rubella-containing vaccines.
Information for Patients
The health-care provider should provide the vaccine information required to be given with each
vaccination to the patient, parent, or guardian.
The health-care provider should inform the patient, parent, or guardian of the benefits and risks
associated with vaccination. For risks associated with vaccination see WARNINGS, PRECAUTIONS, and
ADVERSE REACTIONS.
Patients, parents, or guardians should be instructed to report any serious adverse reactions to their
health-care provider who in turn should report such events to the U.S. Department of Health and Human
Services through the Vaccine Adverse Event Reporting System (VAERS), 1-800-822-7967.{49}
Pregnancy should be avoided for 3 months following vaccination, and patients should be informed of
the reasons for this precaution (see INDICATIONS AND USAGE, Non-Pregnant Adolescent and Adult
Females, CONTRAINDICATIONS, and PRECAUTIONS, Pregnancy).
Laboratory Tests
See INDICATIONS AND USAGE, Non-Pregnant Adolescent and Adult Females, for Rubella
Susceptibility Testing, and CLINICAL PHARMACOLOGY.
Drug Interactions
See DOSAGE AND ADMINISTRATION, Use With Other Vaccines.
Immunosuppressive Therapy
The immune status of patients about to undergo immunosuppressive therapy should be evaluated so
that the physician can consider whether vaccination prior to the initiation of treatment is indicated (see
CONTRAINDICATIONS and PRECAUTIONS).
The ACIP has stated that "patients with leukemia in remission who have not received chemotherapy
for at least 3 months may receive live virus vaccines. Short-term (<2 weeks), low- to moderate-dose
systemic corticosteroid therapy, topical steroid therapy (e.g. nasal, skin), long-term alternate-day

treatment with low to moderate doses of short-acting systemic steroid, and intra-articular, bursal, or
tendon injection of corticosteroids are not immunosuppressive in their usual doses and do not
contraindicate the administration of [measles, mumps, or rubella vaccine]."{33,34,37}
Immune Globulin
Administration of immune globulins concurrently with M-M-R II may interfere with the expected
immune response.{33,34,47}
See also PRECAUTIONS, General.
Carcinogenesis, Mutagenesis, Impairment of Fertility
M-M-R II has not been evaluated for carcinogenic or mutagenic potential, or potential to impair fertility.
Pregnancy
Pregnancy Category C
Animal reproduction studies have not been conducted with M-M-R II. It is also not known whether
M-M-R II can cause fetal harm when administered to a pregnant woman or can affect reproduction
capacity. Therefore, the vaccine should not be administered to pregnant females; furthermore, pregnancy
should be avoided for 3 months following vaccination (see INDICATIONS AND USAGE, Non-Pregnant
Adolescent and Adult Females and CONTRAINDICATIONS).
In counseling women who are inadvertently vaccinated when pregnant or who become pregnant
within 3 months of vaccination, the physician should be aware of the following: (1) In a 10-year survey
involving over 700 pregnant women who received rubella vaccine within 3 months before or after
conception (of whom 189 received the Wistar RA 27/3 strain), none of the newborns had abnormalities
compatible with congenital rubella syndrome;{50} (2) Mumps infection during the first trimester of
pregnancy may increase the rate of spontaneous abortion. Although mumps vaccine virus has been
shown to infect the placenta and fetus, there is no evidence that it causes congenital malformations in
humans;{37} and (3) Reports have indicated that contracting wild-type measles during pregnancy
enhances fetal risk. Increased rates of spontaneous abortion, stillbirth, congenital defects and prematurity
have been observed subsequent to infection with wild-type measles during pregnancy.{51,52} There are
no adequate studies of the attenuated (vaccine) strain of measles virus in pregnancy. However, it would
be prudent to assume that the vaccine strain of virus is also capable of inducing adverse fetal effects.
Nursing Mothers
It is not known whether measles or mumps vaccine virus is secreted in human milk. Recent studies
have shown that lactating postpartum women immunized with live attenuated rubella vaccine may secrete
the virus in breast milk and transmit it to breast-fed infants.{53} In the infants with serological evidence of
rubella infection, none exhibited severe disease; however, one exhibited mild clinical illness typical of
acquired rubella.{54,55} Caution should be exercised when M-M-R II is administered to a nursing
woman.
Pediatric Use
Safety and effectiveness of measles vaccine in infants below the age of 6 months have not been
established (see also CLINICAL PHARMACOLOGY). Safety and effectiveness of mumps and rubella
vaccine in infants less than 12 months of age have not been established.
Geriatric Use
Clinical studies of M-M-R II did not include sufficient numbers of seronegative subjects aged 65 and
over to determine whether they respond differently from younger subjects. Other reported clinical
experience has not identified differences in responses between the elderly and younger subjects.
ADVERSE REACTIONS
The following adverse reactions are listed in decreasing order of severity, without regard to causality,
within each body system category and have been reported during clinical trials, with use of the marketed
vaccine, or with use of monovalent or bivalent vaccine containing measles, mumps, or rubella:
Body as a Whole
Panniculitis; atypical measles; fever; syncope; headache; dizziness; malaise; irritability.
Cardiovascular System
Vasculitis.
Digestive System
Pancreatitis; diarrhea; vomiting; parotitis; nausea.

Endocrine System
Diabetes mellitus.
Hemic and Lymphatic System
Thrombocytopenia (see WARNINGS, Thrombocytopenia); purpura; regional lymphadenopathy;
leukocytosis.
Immune System
Anaphylaxis and anaphylactoid reactions have been reported as well as related phenomena such as
angioneurotic edema (including peripheral or facial edema) and bronchial spasm in individuals with or
without an allergic history.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
Arthralgia and/or arthritis (usually transient and rarely chronic), and polyneuritis are features of
infection with wild-type rubella and vary in frequency and severity with age and sex, being greatest in
adult females and least in prepubertal children. This type of involvement as well as myalgia and
paresthesia, have also been reported following administration of MERUVAX II.
Chronic arthritis has been associated with wild-type rubella infection and has been related to
persistent virus and/or viral antigen isolated from body tissues. Only rarely have vaccine recipients
developed chronic joint symptoms.
Following vaccination in children, reactions in joints are uncommon and generally of brief duration. In
women, incidence rates for arthritis and arthralgia are generally higher than those seen in children
(children: 0-3%; women: 12-26%),{17,56,57} and the reactions tend to be more marked and of longer
duration. Symptoms may persist for a matter of months or on rare occasions for years. In adolescent
girls, the reactions appear to be intermediate in incidence between those seen in children and in adult
women. Even in women older than 35 years, these reactions are generally well tolerated and rarely
interfere with normal activities.
Nervous System
Encephalitis;
encephalopathy;
measles
inclusion
body
encephalitis
(MIBE)
(see
CONTRAINDICATIONS); subacute sclerosing panencephalitis (SSPE); Guillain-Barr Syndrome (GBS);
acute disseminated encephalomyelitis (ADEM); transverse myelitis; febrile convulsions; afebrile
convulsions or seizures; ataxia; polyneuritis; polyneuropathy; ocular palsies; paresthesia.
Encephalitis and encephalopathy have been reported approximately once for every 3 million doses of
M-M-R II or measles-, mumps-, and rubella-containing vaccine administered since licensure of these
vaccines.
The risk of serious neurological disorders following live measles virus vaccine administration remains
less than the risk of encephalitis and encephalopathy following infection with wild-type measles (1 per
1000 reported cases).{58,59}
In severely immunocompromised individuals who have been inadvertently vaccinated with measlescontaining vaccine; measles inclusion body encephalitis, pneumonitis, and fatal outcome as a direct
consequence of disseminated measles vaccine virus infection have been reported (see
CONTRAINDICATIONS). In this population, disseminated mumps and rubella vaccine virus infection
have also been reported.
There have been reports of subacute sclerosing panencephalitis (SSPE) in children who did not have
a history of infection with wild-type measles but did receive measles vaccine. Some of these cases may
have resulted from unrecognized measles in the first year of life or possibly from the measles vaccination.
Based on estimated nationwide measles vaccine distribution, the association of SSPE cases to measles
vaccination is about one case per million vaccine doses distributed. This is far less than the association
with infection with wild-type measles, 6-22 cases of SSPE per million cases of measles. The results of a
retrospective case-controlled study conducted by the Centers for Disease Control and Prevention
suggest that the overall effect of measles vaccine has been to protect against SSPE by preventing
measles with its inherent higher risk of SSPE.{60}
Cases of aseptic meningitis have been reported to VAERS following measles, mumps, and rubella
vaccination. Although a causal relationship between the Urabe strain of mumps vaccine and aseptic
meningitis has been shown, there is no evidence to link Jeryl Lynn mumps vaccine to aseptic
meningitis.
Respiratory System
Pneumonia; pneumonitis (see CONTRAINDICATIONS); sore throat; cough; rhinitis.

Skin
Stevens-Johnson syndrome; erythema multiforme; urticaria; rash; measles-like rash; pruritis.
Local reactions including burning/stinging at injection site; wheal and flare; redness (erythema);
swelling; induration; tenderness; vesiculation at injection site.
Special Senses Ear
Nerve deafness; otitis media.
Special Senses Eye
Retinitis; optic neuritis; papillitis; retrobulbar neuritis; conjunctivitis.
Urogenital System
Epididymitis; orchitis.
Other
Death from various, and in some cases unknown, causes has been reported rarely following
vaccination with measles, mumps, and rubella vaccines; however, a causal relationship has not been
established in healthy individuals (see CONTRAINDICATIONS). No deaths or permanent sequelae were
reported in a published post-marketing surveillance study in Finland involving 1.5 million children and
adults who were vaccinated with M-M-R II during 1982 to 1993.{61}
Under the National Childhood Vaccine Injury Act of 1986, health-care providers and manufacturers
are required to record and report certain suspected adverse events occurring within specific time periods
after vaccination. However, the U.S. Department of Health and Human Services (DHHS) has established
a Vaccine Adverse Event Reporting System (VAERS) which will accept all reports of suspected
events.{49} A VAERS report form as well as information regarding reporting requirements can be
obtained by calling VAERS 1-800-822-7967.
DOSAGE AND ADMINISTRATION
FOR SUBCUTANEOUS ADMINISTRATION
Do not inject intravascularly.
The dose for any age is 0.5 mL administered subcutaneously, preferably into the outer aspect of the
upper arm.
The recommended age for primary vaccination is 12 to 15 months.
Revaccination with M-M-R II is recommended prior to elementary school entry. See also
INDICATIONS AND USAGE, Recommended Vaccination Schedule.
Children first vaccinated when younger than 12 months of age should receive another dose between
12 to 15 months of age followed by revaccination prior to elementary school entry.{32} See also
INDICATIONS AND USAGE, Measles Outbreak Schedule.
Immune Globulin (IG) is not to be given concurrently with M-M-R II (see PRECAUTIONS, General and
PRECAUTIONS, Drug Interactions).
CAUTION: A sterile syringe free of preservatives, antiseptics, and detergents should be used for each
injection and/or reconstitution of the vaccine because these substances may inactivate the live virus
vaccine. A 25 gauge, 5/8" needle is recommended.
To reconstitute, use only the diluent supplied, since it is free of preservatives or other antiviral
substances which might inactivate the vaccine.
Single Dose Vial First withdraw the entire volume of diluent into the syringe to be used for
reconstitution. Inject all the diluent in the syringe into the vial of lyophilized vaccine, and agitate to mix
thoroughly. If the lyophilized vaccine cannot be dissolved, discard. Withdraw the entire contents into a
syringe and inject the total volume of restored vaccine subcutaneously.
It is important to use a separate sterile syringe and needle for each individual patient to prevent
transmission of hepatitis B and other infectious agents from one person to another.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to
administration whenever solution and container permit. M-M-R II, when reconstituted, is clear yellow.
Use With Other Vaccines
M-M-R II should be given one month before or after administration of other live viral vaccines.
M-M-R II has been administered concurrently with VARIVAX [Varicella Virus Vaccine Live
(Oka/Merck)], and PedvaxHIB [Haemophilus b Conjugate Vaccine (Meningococcal Protein Conjugate)]
using separate injection sites and syringes. No impairment of immune response to individually tested

vaccine antigens was demonstrated. The type, frequency, and severity of adverse experiences observed
with M-M-R II were similar to those seen when each vaccine was given alone.
Routine administration of DTP (diphtheria, tetanus, pertussis) and/or OPV (oral poliovirus vaccine)
concurrently with measles, mumps and rubella vaccines is not recommended because there are limited
data relating to the simultaneous administration of these antigens.
However, other schedules have been used. The ACIP has stated "Although data are limited
concerning the simultaneous administration of the entire recommended vaccine series (i.e., DTaP [or
DTwP], IPV [or OPV], Hib with or without Hepatitis B vaccine, and varicella vaccine), data from numerous
studies have indicated no interference between routinely recommended childhood vaccines (either live,
attenuated, or killed). These findings support the simultaneous use of all vaccines as recommended."{62}
HOW SUPPLIED
No. 4681 M-M-R II is supplied as follows: (1) a box of 10 single-dose vials of lyophilized vaccine
(package A), NDC 0006-4681-00; and (2) a box of 10 vials of diluent (package B). To conserve
refrigerator space, the diluent may be stored separately at room temperature.
Storage
To maintain potency, M-M-R II must be stored between -58F and +46F (-50C to +8C). Use of
dry ice may subject M-M-R II to temperatures colder than -58F (-50C).
Protect the vaccine from light at all times, since such exposure may inactivate the viruses.
Before reconstitution, store the lyophilized vaccine at 36F to 46F (2C to 8C). The diluent may be
stored in the refrigerator with the lyophilized vaccine or separately at room temperature. Do not freeze
the diluent.
It is recommended that the vaccine be used as soon as possible after reconstitution. Store
reconstituted vaccine in the vaccine vial in a dark place at 36F to 46F (2C to 8C) and discard if not
used within 8 hours.
For information regarding stability under conditions other than those recommended, call 1800-MERCK-90.
REFERENCES
1. Plotkin, S.A.; Cornfeld, D.; Ingalls, T.H.: Studies of immunization with living rubella virus: Trials in children with a strain cultured
from an aborted fetus, Am. J. Dis. Child. 110: 381-389, 1965.
2. Plotkin, S.A.; Farquhar, J.; Katz, M.; Ingalls, T.H.: A new attenuated rubella virus grown in human fibroblasts: Evidence for
reduced nasopharyngeal excretion, Am. J. Epidemiol. 86: 468-477, 1967.
3. Monthly Immunization Table, MMWR 45(1): 24-25, January 12, 1996.
4. Johnson, C.E.; et al: Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles
Vaccine Era, Pediatrics, 93(6): 939-943, 1994.
5. Linneman, C.C.; et al: Measles Immunity After Vaccination: Results in Children Vaccinated Before 10 Months of Age, Pediatrics,
69(3): 332-335, March 1982.
6. Stetler, H.C.; et al: Impact of Revaccinating Children Who Initially Received Measles Vaccine Before 10 Months of Age,
Pediatrics 77(4): 471-476, April 1986.
7. Hilleman, M.R.; Buynak, E.B.; Weibel, R.E.; et al: Development and Evaluation of the Moraten Measles Virus Vaccine, JAMA
206(3): 587-590, 1968.
8. Weibel, R.E.; Stokes, J.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 3. Clinical and Serologic Aspects in a Field
Evaluation, N. Engl. J. Med. 276: 245-251, 1967.
9. Hilleman, M.R.; Weibel, R.E.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 4. Protective Efficacy as Measured in
a Field Evaluation, N. Engl. J. Med. 276: 252-258, 1967.
10. Cutts, F.T.; Henderson, R.H.; Clements, C.J.; et al: Principles of measles control, Bull WHO 69(1): 1-7, 1991.
11. Weibel, R.E.; Buynak, E.B.; Stokes, J.; et al: Evaluation Of Live Attenuated Mumps Virus Vaccine, Strain Jeryl Lynn, First
International Conference on Vaccines Against Viral and Rickettsial Diseases of Man, World Health Organization, No. 147, May
1967.
12. Leibhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; et al: Vaccination With RA 27/3 Rubella Vaccine, Am. J. Dis. Child. 123: 133-136,
February 1972.
13. Rosen, L.: Hemagglutination and Hemagglutination-Inhibition with Measles Virus, Virology 13: 139-141, January 1961.

14. Brown, G.C.; et al: Fluorescent-Antibody Marker for Vaccine-Induced Rubella Antibodies, Infection and Immunity 2(4): 360-363,
1970.
15. Buynak, E.B.; et al: Live Attenuated Mumps Virus Vaccine 1. Vaccine Development, Proceedings of the Society for
Experimental Biology and Medicine, 123: 768-775, 1966.
16. Weibel, R.E.; Carlson, A.J.; Villarejos, V.M.; Buynak, E.B.; McLean, A.A.; Hilleman, M.R.: Clinical and Laboratory Studies of
Combined Live Measles, Mumps, and Rubella Vaccines Using the RA 27/3 Rubella Virus, Proc. Soc. Exp. Biol. Med. 165:
323-326, 1980.
17. Unpublished data from the files of Merck Research Laboratories.
18. Watson, J.C.; Pearson, J.S.; Erdman, D.D.; et al: An Evaluation of Measles Revaccination Among School-Entry Age Children,
31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract #268, 143, 1991.
19. Fogel, A.; Moshkowitz, A.; Rannon, L.; Gerichter, Ch.B.: Comparative trials of RA 27/3 and Cendehill rubella vaccines in adult
and adolescent females, Am. J. Epidemiol. 93: 392-393, 1971.
20. Andzhaparidze, O.G.; Desyatskova, R.G.; Chervonski, G.I.; Pryanichnikova, L.V.: Immunogenicity and reactogenicity of live
attenuated rubella virus vaccines, Am. J. Epidemiol. 91: 527-530, 1970.
21. Freestone, D.S.; Reynolds, G.M.; McKinnon, J.A.; Prydie, J.: Vaccination of schoolgirls against rubella. Assessment of
serological status and a comparative trial of Wistar RA 27/3 and Cendehill strain live attenuated rubella vaccines in 13-year-old
schoolgirls in Dudley, Br. J. Prev. Soc. Med. 29: 258-261, 1975.
22. Grillner, L.; Hedstrom, C.E.; Bergstrom, H.; Forssman, L.; Rigner, A.; Lycke, E.: Vaccination against rubella of newly delivered
women, Scand. J. Infect. Dis. 5: 237-241, 1973.
23. Grillner, L.: Neutralizing antibodies after rubella vaccination of newly delivered women: a comparison between three vaccines,
Scand. J. Infect. Dis. 7: 169-172, 1975.
24. Wallace, R.B.; Isacson, P.: Comparative trial of HPV-77, DE-5 and RA 27/3 live-attenuated rubella vaccines, Am. J. Dis. Child.
124: 536-538, 1972.
25. Lalla, M.; Vesikari, T.; Virolainen, M.: Lymphoblast proliferation and humoral antibody response after rubella vaccination, Clin.
Exp. Immunol. 15: 193-202, 1973.
26. LeBouvier, G.L.; Plotkin, S.A.: Precipitin responses to rubella vaccine RA 27/3, J. Infect. Dis. 123: 220-223, 1971.
27. Horstmann, D.M.: Rubella: The challenge of its control, J. Infect. Dis. 123: 640-654, 1971.
28. Ogra, P.L.; Kerr-Grant, D.; Umana, G.; Dzierba, J.; Weintraub, D.: Antibody response in serum and nasopharynx after naturally
acquired and vaccine-induced infection with rubella virus, N. Engl. J. Med. 285: 1333-1339, 1971.
29. Plotkin, S.A.; Farquhar, J.D.; Ogra, P.L.: Immunologic properties of RA 27/3 rubella virus vaccine, J. Am. Med. Assoc. 225:
585-590, 1973.
30. Liebhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; Horstmann, D.M.: Vaccination with RA 27/3 rubella vaccine. Persistence of
immunity and resistance to challenge after two years, Am. J. Dis. Child. 123: 133-136, 1972.
31. Farquhar, J.D.: Follow-up on rubella vaccinations and experience with subclinical reinfection, J. Pediatr. 81: 460-465, 1972.
32. 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
47(RR-8): May 22, 1998.
33. Rubella Prevention: Recommendation of the Immunization Practices Advisory Committee (ACIP), MMWR 39(RR-15): 1-18,
November 23, 1990.
34. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP), MMWR 38(S-9): 5-22,
December 29, 1989.
35. Jong, E.C., The Travel and Tropical Medicine Manual, W.B. Saunders Company, p. 12-16, 1987.
36. Committee on Immunization Council of Medical Societies, American College of Physicians, Phila., PA, Guide for Adult
Immunization, First Edition, 1985.
37. Recommendations of the Immunization Practices Advisory Committee (ACIP), Mumps Prevention, MMWR 38(22): 388-400,
June 9, 1989.
38. King, G.E.; Markowitz, L.E.; Patriarca, P.A.; et al: Clinical Efficacy of Measles Vaccine During the 1990 Measles Epidemic,
Pediatr. Infect. Dis. J. 10(12): 883-888, December 1991.
39. Krasinski, K.; Borkowsky, W.: Measles and Measles Immunity in Children Infected With Human Immunodeficiency Virus, JAMA
261(17): 2512-2516, 1989.
40. Kelso, J.M.; Jones, R.T.; Yunginger, J.W.: Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gelatin, J.
Allergy Clin. Immunol. 91: 867-872, 1993.

10

41. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices, MMWR
43(RR-1): 1-38, January 28, 1994.
42. Center
for
Disease
Control:
Immunization
of
Children
Infected
with
Human
Type III/Lymphadenopathy-Associated Virus, Annals of Internal Medicine, 106: 75-78, 1987.

T-Lymphotropic

Virus

43. Krasinski, K.; Borkowsky, W.; Krugman, S.: Antibody following measles immunization in children infected with human T-cell
lymphotropic virus-type III/lymphadenopathy associated virus (HTLV-III/LAV) [Abstract]. In: Program and abstracts of the
International Conference on Acquired Immunodeficiency Syndrome, Paris, France, June 23-25, 1986.
44. Bitnum, A.; et al: Measles Inclusion Body Encephalitis Caused by the Vaccine Strain of Measles Virus. Clin. Infect. Dis. 29:
855-861, 1999.
45. Angel, J.B.; et al: Vaccine Associated Measles Pneumonitis in an Adult with AIDS. Annals of Internal Medicine, 129: 104-106,
1998.
46. Isaacs, D.; Menser, M.: Modern Vaccines, Measles, Mumps, Rubella, and Varicella, Lancet 335: 1384-1387, June 9, 1990.
47. Peter, G.; et al (eds): Report of the Committee on Infectious Diseases, Twenty-fourth Edition, American Academy of Pediatrics,
344-357, 1997.
48. Starr, S.; Berkovich, S.: The effect of measles, gamma globulin modified measles, and attenuated measles vaccine on the
course of treated tuberculosis in children, Pediatrics 35: 97-102, January 1965.
49. Vaccine Adverse Event Reporting System United States, MMWR 39(41): 730-733, October 19, 1990.
50. Rubella vaccination during pregnancy United States, 1971-1981. MMWR 31(35): 477-481, September 10, 1982.
51. Eberhart-Phillips, J.E.; et al: Measles in pregnancy: a descriptive study of 58 cases. Obstetrics and Gynecology, 82(5): 797-801,
November 1993.
52. Jespersen, C.S.; et al: Measles as a cause of fetal defects: A retrospective study of ten measles epidemics in Greenland. Acta
Paediatr Scand. 66: 367-372, May 1977.
53. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. II.
Maternal-neonatal interactions, J. Infect. Dis. 145: 661-666, 1982.
54. Landes, R.D.; Bass, J.W.; Millunchick, E.W.; Oetgen, W.J.: Neonatal rubella following postpartum maternal immunization, J.
Pediatr. 97: 465-467, 1980.
55. Lerman, S.J.: Neonatal rubella following postpartum maternal immunization, J. Pediatr. 98: 668, 1981. (Letter)
56. Gershon, A.; et al: Live attenuated rubella virus vaccine: comparison of responses to HPV-77-DE5 and RA 27/3 strains, Am. J.
Med. Sci. 279(2): 95-97, 1980.
57. Weibel, R.E.; et al: Clinical and laboratory studies of live attenuated RA 27/3 and HPV-77-DE rubella virus vaccines, Proc. Soc.
Exp. Biol. Med. 165: 44-49, 1980.
58. Bennetto, L; Scolding, N. Inflammatory/post-infectious encephalomyelitis. J Neurol Neurosurg Psychiatry 2004;75(Suppl 1):i228.
59. Fenichel, GM. Neurological complications of immunization. AnnNeurol 1982;12(2):119-28.
60. CDC, Measles Surveillance, Report No. 11, p. 14, September 1982.
61. Peltola, H.; et al: The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two dose vaccination
program. N. Engl. J. Med. 331: 1397-1402, 1994.
62. Centers for Disease Control and Prevention. Recommended childhood immunization schedule United States, January-June
1996, MMWR 44(51 & 52): 940-943, January 5, 1996.

For patent information: www.merck.com/product/patent/home.html

Copyright 2015 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved.
Revised: 10/2015
uspi-v205c-i-1510r005

11