2.1 Measles vaccine

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    The measles vaccine is a live attenuated virus vaccinei [1]Citation 1.World Health Organization. The immunological basis for immunization series: module 7: measles: update 2020 [Internet]. Geneva: World Health Organization; 2020 [cited 2024 Apr 15]. 
    https://iris.who.int/handle/10665/331533     , [2]Citation 2.Weekly Epidemiological Record (WER), 28 April 2017, vol. 92, no. 17 (pp. 205–228) [EN/FR] - World | ReliefWeb [Internet]. 2017 [cited 2024 Apr 15]. 
    https://reliefweb.int/report/world/weekly-epidemiological-record-wer-28-april-2017-vol-92-no-17-pp-205-228-enfr     .
     

    2.1.1 Composition

    Most of the vaccines currently in use are derived from the Edmonston strain of the measles virus: Schwarz, Edmonston-Zagreb, AIK-C and Moraten. Vaccines derived from other strains are also available: CAM-70, TD-97, Leningrad-16 and Shanghai-191.

    There is no significant difference (in terms of efficacy and adverse effects) between these vaccines, and all strains may be used interchangeably.

    The vaccines may contain stabilisers (sorbitol or hydrolysed gelatine) and a small amount of neomycin, but no thiomersal. 

     

    2.1.2 Dose and route of administration 

    Children under 2 years: 0.5 mL per dose, IM route, anterolateral thigh.  
    Children 2 years and over, adolescents and adults: 0.5 mL per dose, SC route, lateral upper arm.

    Vaccines in the form of microarray patches applied to the skin are currently being studied. Eliminating the need for needles or cold chain, they could potentially simplify vaccination in the coming years [3]Citation 3.Peyraud N, Zehrung D, Jarrahian C, Frivold C, Orubu T, Giersing B. Potential use of microarray patches for vaccine delivery in low- and middle-income countries. Vaccine. 2019;37(32):4427-4434. https://doi.org/10.1016/j.vaccine.2019.03.035  .
     

    2.1.3 Age and vaccine response

    The persistence of maternal antibodies affects the vaccine response. Depending on the titre of passively acquired maternal antibodies, infants are in theory protected until age 6 to 9 months. Children born to mothers who were vaccinated in childhood are not protected for as long as those whose mothers are protected naturally by the disease.

     

    The optimal age for vaccination (first and second doses) varies depending on the local epidemiological situation. It is a trade-off between the child’s risk of contracting the illness during the first few months of life and the need to get a high seroconversion rate.  

     

    When the first dose of the vaccine is administered to children between 9 and 12 months of age, the seroconversion rate is approximately 85%, even in the absence of detectable maternal antibodies, due to the immune immaturity typical at this stage of life.

     

    This increases to 90-95% when children are vaccinated at 12 months. Several studies have tended to show that seroconversion is even higher if the vaccine is administered at 15 months but does not increase further if the vaccine is administered beyond age 15 months.

     

    Children with a weak immune response to the initial vaccination generally develop protective antibody levels with the second dose administered after age 12 months (seroconversion > 95% after two doses).

    Seroconversion appears 10 to 14 days after vaccination, with a peak between the 21st and 28th days. 

     

    The protection conferred by primary vaccination lasts several decades. The antibody level declines over time, but immunological memory persists. When a vaccinated person is exposed to the virus, the immune response is rapidly reactivated. 
     

    2.1.4 Contraindications

    • History of anaphylactic reaction to any of the vaccine components (neomycin or gelatine) or to a previous measles vaccine injection. 

    • Severe immune deficiency (known or clinically suspected):  

      • Congenital or acquired

      • HIV infection: symptomatic children and/or CD4 T lymphocytes < 25% 

      • Leukaemia, advanced lymphoma, or serious neoplastic disease

      • Immunosuppressant drugs (high-dose corticosteroids, antineoplastic chemotherapy, etc.). 

    • Ongoing severe acute infection. A minor infection is not a contraindication.
       

    2.1.5 Special situations

    Malnutrition

    Most studies have shown that the immune response to vaccination is the same in non-malnourished and malnourished children. However, malnutrition increases the risk of contracting the disease and developing severe complications [4]Citation 4.SbarraAN, Jit M, Mosser JF, et al. Population-Level Risk Factors Related to Measles Case Fatality: A Conceptual Framework Based on Expert Consultation and Literature Review. Vaccines. 2023;11(8):1389. http://doi.org/10.3390/vaccines11081389, [5]Citation 5.Bhaskaram P. Measles & malnutrition. Indian J Med Res. 1995 Nov;102:195-9. https://pubmed.ncbi.nlm.nih.gov/8675238/  . Malnourished children are routinely vaccinated in feeding programmes starting at age 6 months (dose 0). They later receive two routine doses in accordance with the national immunisation schedule.

    Pregnancy 

    Measles often causes severe complications both for the mother and the foetus (spontaneous abortion) or newborn (preterm, low birth weight).

    In principle, live vaccines should not be administered to pregnant women. However, no adverse outcomes from vaccinating a pregnant woman have been reported for either foetus or mother. During an epidemic, the risk/benefit of vaccination should be discussed. 

    HIV infection [6]Citation 6.Centers for Disease Control and Prevention (CDC). ACIP vaccine-specific recommendations [Internet]. Atlanta: CDC; 2022 [cited 2024 Apr 15]. 
    https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html    , [7]Citation 7.Mehtani NJ, Rosman L, Moss WJ. Immunogenicity and Safety of the Measles Vaccine in HIV-Infected Children: An Updated Systematic Review. Am J Epidemiol. 2019 Jun 18. https://academic.oup.com/aje/article-abstract/188/12/2240/5519889?redirectedFrom=fulltext 

    All HIV-infected children without severe clinical and/or laboratory-confirmed immune deficiency should be vaccinated at age 6 months (dose recorded as dose 0), followed by the two routine doses in accordance with the national immunisation schedule.

    In immunodepressed children, an additional dose is recommended once immune function has been restored (in general, after six to twelve months of antiretroviral therapy) or, when laboratory testing is available, once the CD4 lymphocyte count reaches 25%. 

    Immunoglobulins and other blood products

    If a child has received immunoglobulins or blood products aCitation a.For blood products that are susceptible to containing immunoglobulins, immunoglobulins can block the antigenic sites of the vaccine involved in triggering the immune response.   3 to 6 months before vaccination or within 2 weeks after vaccination, administer an additional dose of vaccine 3 to 6 months later. 

    Prolonged corticosteroid therapy 

    Patients receiving ≥ 2 mg/kg daily of prednisolone are vaccinated: 

    • As soon as treatment is stopped if the duration of treatment is < 14 days

    • One month after treatment is stopped if the duration of treatment is ≥ 14 days. 
       

    2.1.6 Adverse effects

    Adverse effects are generally minor and transient. 

    • In the first 24 hours, mild pain and tenderness at the injection site. 

    • 7 to 12 days after vaccination:  

      • Fever > 39 °C lasting 1 to 2 days in 5 to 15% of cases; the fever can sometimes cause seizures (1/3000)

      • Transient skin rash in 2% of cases, sometimes with catarrhal symptoms

      • Rarely: thrombocytopenic purpura (1/30,000 to 1/100,000)

      • Very rarely: encephalitis (1/1 million). 

    • Anaphylactic reactions to one of the components of the vaccine: rare (3.5 to 10 cases per million). 

    Apart from anaphylactic reactions, there is a smaller risk of adverse reactions from the second dose. 

     

    2.1.7 Combination vaccines and co-administration of multiple vaccines

    Combination vaccines 

    Vaccines come in either monovalent or combined form, that is, associated with other vaccines in the same syringe. Approved combination vaccines do not reduce the immunogenicity of the measles vaccine component. Consult the national protocol for each country. 
     

    The available combination vaccines are: 

    • MR: measles and rubella

    • MMR: measles, mumps and rubella 

    • MMRV: measles, mumps, rubella and varicella 

    Combining vaccines 

    Provided different syringes and different injection sites are used, measles vaccine can be administered at the same time as most other vaccines: diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae, oral or inactivated polio, yellow fever, varicella, pneumococcal, meningococcal, and Japanese encephalitis.

    To avoid the risk of one immune response interfering with another, different live vaccines should be administered at least four weeks apart. The oral polio vaccine (OPV) is an exception to this rule, and can be administered at any time – before, along with, or after measles vaccination. 
     

    2.1.8 Vaccine storage

    Lyophilised vaccine

    To be kept refrigerated between +2 °C and +8 °C. Long-term storage at temperatures between –70 °C and –20 °C is possible but not necessary in peripheral locations.

    Diluent

    To be stored at room temperature. However, at least 12 hours before reconstitution, it should be placed in the refrigerator to avoid thermal shock to the lyophilised vaccine (a temperature difference may reduce vaccine efficacy). Do not freeze. 

    Reconstituted vaccine

    The reconstituted vaccine is sensitive to heat and light. It must be kept refrigerated between +2 °C and +8 °C, protected from light, and if possible used within an hour – but never more than 6 hours – after reconstitution. 

    Footnotes
    • (a)

      For blood products that are susceptible to containing immunoglobulins, immunoglobulins can block the antigenic sites of the vaccine involved in triggering the immune response. 

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