Give the Measles, Mumps, and Rubella (MMR) Vaccine

Many childhood illness have been almost wiped out thanks to vaccines. The measles, mumps, and rubella (MMR) vaccine is an important part of both childhood and adult immunization schedules. As a healthcare provider, your goal is to communicate the need for vaccination to your patients and provide safe, easy vaccines with appropriate aftercare. Do this by following clinical procedures and educating your patients, and you will both have a safe, positive vaccination experience.

Steps

Giving MMR at the Correct Times

1. Administer MMR to children at 12-15 months and 4-6 years of age. According to the U.S. Centers for Disease Control and Prevention (CDC), you should give children two doses of MMR at different times. Give the first shot of MMR to children between 12-15 months of age, and the second shot between 4-6 years old. Kids need both doses to have the best immunity.
   • As long as the second dose is 28 days after the first dose, children can get the second dose earlier. The important thing is to give two shots at least 28 days apart.
   • Children between the ages of 1-12 years can get the MMRV vaccine instead, which covers varicella (chickenpox) as well as measles, mumps, and rubella.
2. Ensure teens are up to date on their MMR vaccine. Teens who attend college or another post-high school institution should be able to show evidence of immunity to measles, mumps, and rubella. If not, administer two doses of MMR at least 28 days apart.
   • ”Evidence of immunity” is when your patient can show written proof that they have been vaccinated, have had all three diseases, or have had blood tests done showing they are immune to all three diseases. Check your patient's medical records or try to consult with their previous doctor.
3. Vaccinate adults who are not immune. Give one dose to adults who cannot demonstrate evidence of immunity. Adults born before 1957 do not need the vaccine, however.

Determining if You Can Safely Give MMR

1. Screen for a history of allergic reaction. Do a complete history and physical exam and review your patient’s vaccination history before administering the vaccine. Ask if your patient is taking any medications, has any allergies, or has ever reacted to a vaccine previously. Do not give it if they have ever had a severe allergic reaction (anaphylaxis) to a component of the vaccine or to the antibiotic neomycin.
2. Do NOT give MMR to a pregnant woman. Pregnancy is a contraindication to giving the MMR vaccine – do not give pregnant women this injection. If your female patient is unsure whether she is pregnant, do a urine test to ensure she is not before administering the vaccine. Let her know this is for her and her baby's safety.
   • Wait until after the baby is born to give the vaccine.
   • Advise women not to get pregnant for 4 weeks after getting the vaccine.
3. Avoid the MMR vaccine in immunocompromised patients. Severe immunocompromise is a contraindication to the MMR vaccine. Take a thorough medical history of your patient. Do not give them MMR if they suffer from poor immunity due to any of the following:
   • HIV with severe immunocompromise (having the virus alone is not a contraindication if they are in generally good health)
   • Any type of cancer
   • Current chemotherapy or radiation therapy
   • Congenital immunodeficiency
   • Long-term immunosuppressive therapy, such as with corticosteroids
4. Weigh the risks and benefits of the vaccine if certain conditions are present. Some circumstances are not contraindications to the vaccine, but may make it more likely the patient will have an adverse reaction or the vaccine may not work properly. Don’t give the vaccine if any of these conditions are present, unless the benefit outweighs the risk. Use your best clinical judgment! Consider deferring the MMR vaccine if:
   • The patient received antibody-containing blood products in the last 11 months
   • The patient has a history of thrombocytopenia or thrombocytopenia purpura
   • The patient will need TB testing or interferon-gamma release assay (IGRA) testing within the next few days; do not give the vaccine if you suspect active TB is present
   • The patient is moderately to severely ill (mild acute illness is usually not a problem)

Talking to Your Patients About MMR

1. Answer your patient’s questions and alleviate their fears. Many patients, especially parents thinking about vaccinating their child, are nervous about vaccines. They may think that vaccines can make their child ill. Explain that immunizations do not cause illness. Help parents and patients understand that measles, mumps, and rubella are very serious illnesses that were common in children before vaccines existed, and that getting any of these illnesses is much more dangerous than getting the vaccine.
   • Address their questions calmly and directly so they feel like you're on the same team. Ask outright, “Do you have any fears or concerns about vaccines that we can discuss?”
2. Explain that vaccines do not cause autism. There is a common misconception that vaccines can cause autism in children. This must be very scary for parents, so be sure to address this fear and explain that it simply is not true. Caution parents about believing everything they read on the internet, and direct them to reliable sources of information such as the CDC.
   • Offer a lead-in to the conversation like, “I know some parents worry that vaccines can cause autism or health problems. If you have those concerns, I’d like to discuss them until you understand and feel comfortable.”
3. Explain MMR in language that a layperson will understand. Give your patients information about MMR that is understandable and relatable. Avoid talking down to your patients or saying they should vaccinate their child because it’s the “right thing,” or because you “said so.” Explain that vaccines are safe and will help protect their child – and other people’s children – from life-threatening illnesses.
   • Avoid terminology like, “MMR is a live attenuated vaccine in which the virulence of the pathogen is reduced.” Instead, say something like, “The measles vaccine uses a weak form of the virus. It’s strong enough to get your body to made defenses to it, but not strong enough to make you sick.”
4. Tell your patient about common side effects. Explain that immunizations can cause minor reactions like soreness, swelling, and redness at the site of the injection, and a low fever. Notify your patient that this is not dangerous or uncommon, and it is not a sign that the vaccine is making them or their child sick. Explain that it is their immune system making the defenses it needs. Let them know you're available to help if they have any questions or concerns.

Preparing Your Materials

1. Check and prepare the vaccine you’re about to give. Check and re-check the vial label of the vaccine you’re about to give. Check the expiration date – if it’s expired, dispose of it and use a fresh one. Check the labeling to see if the vaccine requires specific handling, for instance shaking the vaccine vial and/or using the reconstituting mix (diluent).
   • Use the “Rights” checklist: Right patient, right vaccine and diluent (when applicable), right time (right patient age, time interval, vaccine isn’t expired), right dosage, right route/needle, right site, right documentation.
2. Select a 5/8” needle. Choose a needle that is 5/8” long and between 23-25 gauge. Use a new, sterile needle for every injection. Remove the packaging and screw the needle onto the syringe. Only uncap the needle when you’re ready to use it.
3. Draw up 0.5ml of the MMR vaccine. Wipe the rubber stopper of your vaccine vial with an alcohol swab. Uncap your needle and insert it through the rubber stopper. Pull back on the plunger until you have filled the syringe to just past the 0.5ml mark. Remove the needle from the stopper and push gently on the plunger to squirt a small amount of the vaccine out – make sure this removes any bubbles and gets the liquid to the 0.5ml mark.
   • This is the right dose for both children and adults.

Administering the Vaccine

1. Wash your hands. Wash your hands thoroughly with warm water and soap. Lather the soap for at least 30 seconds and scrub under your nails, between your fingers, and up your wrists. Dry your hands with a clean paper towel.
   • You can also put on disposable gloves to administer the injection. Make sure your patient doesn’t have a latex allergy; if so, use non-latex gloves.
2. Select the injection site. MMR is delivered subcutaneously, into the fatty tissue beneath the skin and above the muscle layer. For patients under 12 months old, choose a fatty site over the upper outer (anterolateral) thigh muscle. For anyone over 12 months, you can use the anterolateral thigh or the fatty tissue over the triceps muscle.
   • Ask adult patients if they prefer one injection site over another.
3. Clean the injection site with an alcohol wipe. Open a new, sterile alcohol wipe. Rub the site in a circular motion starting in the center and extending out 2-3 inches. Let the alcohol dry.
   • If giving more than one vaccine, use a separate injection site for each one. You can give MMR on the same day as other vaccines.
4. Give the shot at a 45° angle to the patient’s body. Stabilize the arm or leg that will receive the injection with your non-dominant hand. Gently pinch up the skin into a tent to allow for better access to the fatty layer. Hold the needle about an inch from your patient. Warn your patient that it's time, and quickly insert the needle at a 45° angle to the patient’s body. Push down on the plunger with steady pressure to inject the vaccine.
   • Remove the needle at the same angle you inserted it.
   • Dispose of the needle in a sharps container. Do not attempt to recap the needle unless it has a built-in safety cap device.
5. Wipe and bandage the area. Apply gentle pressure to the area immediately after removing the needle. Cover this with a small piece of gauze and hold it in place with medical tape. Inform your patient they can remove the bandage later that day.

Providing Documentation and Aftercare

1. Document the vaccination. Record the date, dose, and injection site of the vaccination in your EMR (Electronic Medical Records) or paper records, as advised by your administrator. Enter the data into an immunization information system if one is used in your setting.
2. Give your patient documentation. A Vaccine Information Statement (VIS) contains information about the benefits and risks of each vaccine. If possible, give your patients and patients’ parents a copy of a VIS with each vaccination. In the pediatric population, provide a vaccination schedule for the parents indicating which are completed and which are next, and encourage them to schedule an appointment for the next vaccination.
3. Provide medical management options for common reactions. If your patient complains of swelling, redness, pain, itching, or mild bleeding at the injection site, assure them this is normal. Then provide medical management to make them feel more comfortable:
   • For pain, redness, swelling, or itching, apply a cold compress to the area. Give adults a mild pain reliever like ibuprofen.
   • If the injection site is bleeding, apply a bandage over the area. If it continues to bleed, place a thick gauze pad over the site and tell your patient to apply constant pressure.
   • Raise their arm above the level of their heart for several minutes to slow bleeding.
4. Warn your patients what danger signs to watch out for. Very rarely, a patient may experience a severe allergic reaction to a vaccine called anaphylaxis. Watch out for the following signs, and alert your patient or a second party to do the same and seek emergency medical care if they arise:
   • Quick onset of itching all over
   • Sudden or severe skin redness or hives
   • Swelling of the lips, face, tongue, or throat
   • Wheezing or shortness of breath
   • Abdominal cramps
   • Drop in blood pressure and possible loss of consciousness

Tips

• If you give another vaccine on the same day, use separate injection sites. Choose sites at least 1-2 inches apart so you can monitor for reactions.
• Have an emergency kit available that contains epinephrine in case the patient has a severe reaction.
• Consult the CDC’s downloadable vaccination schedules for babies, kids and teens, and adults on their website if you need to.

Warnings

• You can give MMR and varicella vaccines on the same day, but if they’re not on the same day then separate them by at least 28 days.

Sources and Citations

See also

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• Administer Vaccines
• Diagnose Farmer's Lung
• Live With an Allergy to Aspirin
• Reduce Your Exposure to Pollen
• Recognize Peanut Allergies
• Know When to Take Antihistamines
• Get Your Nose to Stop Running With Allergies
• Get Tested for Food Allergies
• Fight Hay Fever

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