Measles, Mumps, and Rubella

Global Speaker Slide Deck

Epidemiology and Burden of
Measles, Mumps, and Rubella
 Impact of the COVID Pandemic on
Immunization

As per NFID, COVID-19 has impacted vaccination rates drastically

Ø 50 % drop in measles, mumps, rubella vaccinations 1
Ø 42 % drop in diphtheria and whooping cough vaccinations 1
Ø 73 % drop in HPV vaccinations 1

WHO warns
Disruption of immunization services, even for brief periods, can increase numbers of susceptible
individuals and raise the likelihood of outbreak-prone VPDs.2

Such VPD outbreaks may increase morbidity and mortality predominantly in young infants and other
vulnerable groups, which can cause greater burden on health systems already strained by the
COVID-19 response.2

1. https://www.nfid.org/2020/04/28/covid-19-and-routine-vaccinations-what-parents-need-to-know/ Accessed on 27/05/2020

2. https://apps.who.int/iris/bitstream/handle/10665/331590/WHO-2019-nCoV-immunization_services-2020.1-eng.pdf

3
 WHO 2 JUNE ARTICLE

“Timely immunization against common childhood diseases

not only save lives but requires fewer resources than
responding to outbreaks. It also helps to reduce the burden
on an already strained health systems.”

4
 22 Mei 2020

5
IDAI
 Measles Is a Highly Transmissible Viral Infection1

Measles Pathogenesis and Clinical Features1–6

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Transmission Incubation Communicability Disease

Aerosols generated Incubation time of Highly communicable, Initial prodromal phase of:
during coughing or by 2 weeks before the onset with >90% secondary • Fever
direct contact with of disease symptoms attack rates that can • Cough
contaminated respiratory occur from 4 days • Coryza
secretions before to 4 days after
the onset of rash A few days later a generalized
maculopapular skin rash appears,
often in combination with
conjunctivitis. At the onset of rash,
Koplik spots also develop in the oral
mucosa

1. Measles (Rubeola). Centers for Disease Control and Prevention Web site. https://www.cdc.gov/measles/about/transmission.html. Accessed March
5, 2019. 2. de Swart RL. Pediatr Infect Dis J. 2008;27(10 suppl):S84–S88. 3. World Health Organization. Wkly Epidemiol Rec. 2009;84:349–360. 4.
Public Health Image Library. Centers for Disease Control and Prevention Web Site. https://phil.cdc.gov/details.aspx?pid=1150. Accessed March 5,
6 2019. 5. Public Health Image Library. Centers for Disease Control and Prevention Web Site. https://phil.cdc.gov/details.aspx?pid=3187. Accessed
March 5, 2019. 6. Centers for Disease Control and Prevention. Chapter 13: Measles. In: Hamborsky J, et al. Epidemiology and Prevention of Vaccine-
Preventable Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 209-230.
 While the Global Incidence Has Decreased, Measles
Remains a Threat1,2
Global Incidence of Measles, by WHO Region (2000 and 2018)1,2
Europe

37 K 54 K

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Eastern Mediterranean
2000
2018
Western Pacific
Americas
39 K 19 K
177 K
19 K
10 K 2000
1. 8 K 2018
2000 2018
2000 2018
Southeast Asia
Africa
79 K
520 K 61 K
25 K
2000 2018
2000 2018

A total of 189,392 measles cases were reported worldwide in 20181,a

a
Confirmed measles cases (Clin+Epi+Lab) through November 2018.
WHO = World Health Organization.
1. Global measles and rubella update, November 2018. World Health Organization Web site.
7 http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/Global_MR_Update_November_2018.pdf?ua=1.
Accessed March 5, 2019. 2. Measles: reported cases by WHO region. World Health Organization Web site.
http://apps.who.int/gho/data/view.main.1520_62. Accessed March 5, 2019.
 Measles Is a Common and Often Deadly Disease Among
Young Children, Particularly in Developing Countries1-3

Global Incidence of Measles Deaths, by WHO Region (2017 and 2018)

Europe2

Click to editEastern
Master title style
Mediterranean 2 100 Western Pacific2

24 K 2017 1.3 K

Americas1 2017 2017

Africa2 Southeast Asia2

86
48 K 36 K
As of
November 2018
2017 2017

A total of 109,638 measles deaths were reported worldwide in 20172

The majority of these deaths were in children <5 years of age3

WHO = World Health Organization.

8 1. Pan American Health Organization/World Health Organization. Epidemiological Update: Measles. 30 November 2018, Washington, D.C.:
PAHO/WHO; 2018. 2. Dabbagh A et al. MMWR Morb Mortal Wkly Rep. 2018;67:1323–1329. 3. Measles. World Health Organization Web site.
http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed March 5, 2019.
 Complications From Measles Can Affect Multiple
Organ Systems1,2

Most measles-related deaths are caused by complications associated

with the disease3
Opportunistic Infections
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Many complications are caused by disruption of the epithelial surfaces and
immunosuppression, which can increase susceptibility to opportunistic infections1,2

Respiratory Complications
Including otitis media, mastoiditis, croup, tracheitis, and pneumonia1

Neurologic Complications
Including febrile convulsions, encephalitis, and subacute sclerosing panencephalitis1

Gastrointestinal Complications
Including diarrhea, appendicitis, hepatitis, pancreatitis, and stomatitis1

Ophthalmic Complications
Including keratitis, corneal ulceration or perforation, central vein occlusion, and blindness1

9
1. Perry RT et al. J Infect Dis. 2004;189(suppl 1):S4–S16. 2. de Swart RL. Pediatr Infect Dis J. 2008;27(10 suppl):S84–S88. 3. Measles.
World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed March 5, 2019.
 Mumps Pathogenesis and Clinical Features

Mumps Pathogenesis and Clinical Features1−4

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Transmission Incubation Communicability Disease

The mumps virus is The incubation period Contagiousness is Short prodromal phase of:
transmitted via the is ≈15−24 days similar to that of • Low-grade fever
airborne spread of • Anorexia
influenza and
• Myalgia
respiratory droplets rubella. Infected • Malaise
or direct contact patients are most • Headache
contagious
1−2 days before the Infection can remain localized to
onset of clinical the respiratory tract, but can
symptoms and for also affect other organs and
several days systems
afterward • Parotids
• Central nervous system
• Urinary tract
• Genital organs
1. Hviid A et al. Lancet. 2008;371:932–944. 2. Causes: mumps. National Health Service Web site.
https://www.nhs.uk/conditions/mumps/causes/. Accessed March 5, 2019. 3. Public Health Image Library. Centers for Disease Control and
10 Prevention Web site. https://phil.cdc.gov/phil/details.asp?pid=130. Accessed March 5, 2019. 4. Centers for Disease Control and Prevention.
Chapter 15: Mumps. In: Hamborsky J, et al. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington D.C. Public
Health Foundation. 2015; 248-260.
 Mumps Cases Continue to Be Reported Worldwide
With the Greatest Increase in the Western Pacific1
Global Incidence of Mumps, by WHO Region (2000 and 2017)
Europe

243 K
Click Eastern
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Mediterranean 2000
27 K

2017 Western Pacific

Americas
66 K 43 K 335 K
143 K

44 K 45 K 2000 2017 2000 2017

2000 2017
Southeast Asia
Africa

9K 62 K
39 K 41 K
2000 2017
2000 2017

A total of 552,779 mumps cases were reported worldwide in 2017a

11 aConfirmed mumps cases (Clin+Epi+Lab).

WHO = World Health Organization.
1. Global Health Observatory data repository. World Health Organization Web site. http://apps.who.int/gho/data/. Accessed March 5, 2019.
 Complications From Mumps Can Affect Multiple
Organ Systems1

≈97% of patients with mumps experience swelling of the parotid

gland, the most common complication of mumps

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Glandular Complications
Including parotitis, submaxillary and/or sublingual gland
inflammation, epididymoorchitisa, mastitisb, oophoritis, and
pancreatitis

Neurologic Complications
Including meningitis and encephalitis

Other Complications
Including myocarditis, deafness (transient or permanent), and nephritis

12
aMalepatients ≥12 years of age. bFemale patients ≥12 years of age.
1. Rubin SA et al. In: Plotkin SA et al. Mumps Vaccine. 7th ed. Elsevier Saunders; 2017:663−688.
 Rubella Pathogenesis and Clinical Features

Rubella Pathogenesis and Clinical Features1−3

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Transmission Incubation Communicability Disease

Rubella is a viral It can take 2−3 weeks Rubella is only Symptoms of rubella include:
infection spread via for symptoms to moderately • A maculopapular rash, sometimes
droplets of moisture develop contagious. The pruritic
from the nose or throat disease is most • Swollen glands around the head and
neck
contagious when
• Fever
the rash first • Cold-like symptoms such as cough or
appears, but virus runny nose
may be shed from • Aching and painful joints (more
7 days before to common in adults)
5–7 days or more
after rash onset Infection is most serious in pregnant
women during the first 20 weeks of
pregnancy, as the virus can disrupt
fetal development
1. Rubella (German measles). National Health Service Web site. http://www.nhs.uk/Conditions/Rubella/Pages/Introduction.aspx. Accessed March 5,
13 2019. 2. Public Health Image Library. Centers for Disease Control and Prevention Web site. https://phil.cdc.gov/Details.aspx?pid=712. Accessed
March 5, 2019. 3. Centers for Disease Control and Prevention. Chapter 20: Rubella. In: Hamborsky J, et al. Epidemiology and Prevention of
Vaccine-Preventable Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 325-340.
 Infections Early in Pregnancy Can Cause CRS,
Which May Be Under-reported1,2

The rubella virus can disrupt fetal development and cause a wide range of health
problems, known as CRS1
Global Incidence of CRS, by WHO Region (2000 and 2016)3
Americas
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Europe title style
Southeast Asia

80 0 47 6 26
319

2000 2016 2000 2016 2000 2016

Eastern Mediterranean Africa Western Pacific

0 9 0 14 3 19

2000 2016 2000 2016 2000 2016

• The burden of CRS may be underestimated in routine surveillance2

• One model suggests that there may have been as many as 105,000
(95% CI: 54,000–158,000) CRS cases globally in 20102
CRS = congenital rubella syndrome; WHO = World Health Organization; CI = confidence interval.
1. Centers for Disease Control and Prevention. Chapter 20: Rubella. In: Hamborsky J, et al. Epidemiology and Prevention of Vaccine-Preventable
14 Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 325-340. 2. Vynnycky E et al. PLoS One. 2016;11:e0149160. 3. Congenital
rubella syndrome: reported cases by WHO region. World Health Organization. http://apps.who.int/gho/data/view.main.1520_55. Accessed March 5,
2019.
 Acquired Rubella Infection and CRS Can Be Associated
With Serious Complications and Birth Defects1,2

Orthopedic Complications
Arthralgia or frank arthritis occurs in up to 60% of postpubertal women with
rubella infections1

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Neurologic Complications
Postinfectious encephalopathy occurs in 1 in 5,000 to 1 in 10,000 cases
of rubella1

Hematologic Complications
Transient thrombocytopenia is reported in 1 in 3,500 cases of rubella, and
purpuric rash occurs in 1 in 1,500 cases of rubella1

Complications to Pregnancies
When infection occurs during early pregnancy, the resulting CRS can have
serious consequences, including miscarriage, stillbirths, and a number of
birth defects2

15 CRS = congenital rubella syndrome.

1. Banatvala JE et al. Lancet. 2004;363:1127–1137. 2. Congenital rubella syndrome. Centers for Disease Control and Prevention Web site.
https://www.cdc.gov/vaccines/pubs/surv-manual/chpt15-crs.html. Accessed March 5, 2019.
 A Number of Measles, Mumps, and Rubella
Outbreaks Have Been Reported Recently1
Overview of Recent Selected Outbreaks of Measles, Mumps, and Rubella1–14
Measles Mumps Rubella

Click to edit Master title style England2

142 Poland4
19
USA: West
2016 Germany3
Coast10 2016
125 1,548
Portugal9 Romania5
2014−2015 2014−2015
USA: 28 3,400 Japan6
Ohio13
USA: Illinois 12
383 Italy 1
2016−2017 5,442
2017
317 4,487 (5 CRS)
2014 Israel7 2013
2015−2016 2017 262
USA: Hawaii11
2017 1,009
Venezuela 14
2017−2018
5,643
Brazil14
Madagascar8
2018 9,898 67,422
2018
2018−2019

CRS = congenital rubella syndrome; USA = United States of America.

1. Communicable disease threats report, 10-16 September 2017, week 37. European Centre for Disease Prevention and Control Web site. ecdc.europa.eu/en/publications-data/communicable-disease-threats-
report-10-16-september-2017-week-37. Accessed March 5, 2019. 2. Laboratory confirmed cases of measles, mumps and rubella, England: October to December 2016. Public Health England Web site.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/594801/hpr0817__mmr.pdf. Accessed March 5, 2019. 3. Measles and rubella monitoring: July 2015. European Centre for Disease
Prevention and Control Web site. http://ecdc.europa.eu/en/publications/Publications/measles-rubella-quarterly-surveillance-july-2015.pdf. Accessed March 5, 2019. 4. Measles and rubella monitoring: July 2017.
European Centre for Disease Prevention and Control Web site. https://ecdc.europa.eu/sites/portal/files/documents/measles%20-rubella-monitoring-170424.pdf. Accessed March 5, 2019. 5. Measles outbreaks
across Europe threaten progress towards elimination. World Health Organization Web site. http://www.euro.who.int/en/media-centre/sections/press-releases/2017/measles-outbreaks-across-europe-threaten-
progress-towards-elimination. Accessed March 5, 2019. 6. Nationwide rubella epidemic−Japan, 2013. Centers for Disease Control and Prevention Web site.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a1.htm. Accessed March 5, 2019. 7. Indenbaum V et al. Euro Surveill. 2017;22:pii: 30605. 8. Outbreaks and Emergencies Bulletin, Week 07: 11-17 February
2019. WHO Web site. https://www.afro.who.int/publications/outbreaks-and-emergencies-bulletin-week-07-11-17-february-2019. Accessed March 5, 2019. 9. George F et al. Euro Surveill. 2017;22:pii: 30548. 10.
Measles outbreak―California, December 2014-February 2015. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a5.htm. Accessed March 5, 2019. 11.
16 Hawaii State Web site. http://health.hawaii.gov/docd/advisories/mumps/. Accessed March 5, 2019. 12. Mumps outbreak at a university and recommendation for a third dose of measles-mumps-rubella Vaccine—
Illinois, 2015–2016. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/mmwr/volumes/65/wr/mm6529a2.htm. Accessed March 5, 2019. 13. Measles cases in 2019. Centers for Disease
Control and Prevention Web site. https://www.cdc.gov/measles/cases-outbreaks.html. Accessed March 5, 2019. 14. Pan American Health Organization/World Health Organization. Epidemiological Update: Measles.
30 November 2018, Washington, D.C.: PAHO/WHO; 2018.
Global Vaccination Recommendations
for Measles, Mumps, and Rubella
 The WHO Strongly Encourages the Use of an
MMR Vaccine1

• Immunization against measles is recommended for all susceptible children and

Measles adults in whom measles vaccination is not contraindicated2

M • The standard for all national vaccination programs should be 2 doses of the
measles vaccine in childhood2

Click to edit Master title style Eliminate

• Routine mumps vaccination is recommended in countries with a well-established,

childhood vaccination program and the capacity to maintain high levels of coverage
with routine measles and rubella vaccination, and where the reduction of mumps
Mumps incidence is a public health priority1 The Global

M • The first dose of the mumps vaccine should be given at the age of 12−18 months,
and countries still using a 1-dose schedule are encouraged to add a routine second
Measles and
Rubella Strategic
Plan, launched by
dose1 the Measles &
Rubella Initiative in
2012, aims to
achieve measles
and rubella
• The integration of rubella vaccination into measles-vaccine delivery strategies (eg, the
elimination in
MMR vaccine) is recommended to interrupt rubella virus transmission and eliminate
Rubella ≥5 WHO regions
both rubella and CRS3

R
by 20204,5,a

• Countries should achieve and maintain immunization coverage of ≥80% with at least 1
dose of a rubella vaccine delivered through routine services or regular supplementary
immunization activities, or both3

aThe Measles & Rubella Initiative is a global partnership led by the American Red Cross, United Nations Foundation, CDC, UNICEF, and WHO.4
WHO = World Health Organization; MMR = measles, mumps, and rubella; CRS = congenital rubella syndrome; CDC = Centers for Disease Control and Prevention;
UNICEF = United Nations Children's Fund.
18 1. World Health Organization. Wkly Epidemiol Rec. 2007;82:49−60. 2. World Health Organization. Wkly Epidemiol Rec. 2017;92:205−228. 3. World Health Organization.
Wkly Epidemiol Rec. 2011;86:301−316. 4. Measles. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed March 5,
2019. 5. Rubella. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs367/en/. Accessed March 5, 2019.
 Initiatives Have Been Launched That Aim to Achieve
Measles and Rubella Elimination1

Global: World Health Assembly, 20101,2

Global Measles and Rubella
By 2015
1. MCV1 coveragea: ≥90% national
Strategic Plan3
2012−2020
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≥80% in every district
2. Measles reported incidence: <5 cases/million
3. Measles mortality reduction: >95% from the 2000 Vision
estimate Achieve and maintain a world
without measles, rubella, and
Regional2,3 CRS
By 2015
• Elimination of measles in 4 WHO regions
– AMR, EUR, EMR, WPR
• Elimination of rubella in 2 WHO regions
– AMR, EUR

By 2020
• Elimination of measles and rubella in at least 5 of
6 WHO Regions

a
Coverage among children aged 1 year.2
MCV1 = measles-containing vaccine, first dose; WHO = World Health Organization; AMR = Americas; EUR = Europe; EMR = Eastern
Mediterranean; WPR = Western Pacific; AFR = Africa; CRS = congenital rubella syndrome.
19 1. Measles. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed March 5, 2019.
2. Dabbagh A et al. MMWR Morb Mortal Wkly Rep: 2018;67:1323−1329. 3. Global Measles & Rubella Strategic Plan 2012-2020. Measles
and Rubella Initiative Web site. https://measlesrubellainitiative.org/learn/the-solution/the-strategy/. Accessed March 5, 2019.
 Resurgences of Measles in 2017 Led to Measles
Being Endemic in All Regions Again1

Positive Progress Reasons for Continued

as of 2018 Vigilance as of 2018

Western Pacific and The Western Pacific region 4 of 6 regions experienced Significant
lowest measles achieved its lowest-ever measles significant measles outbreaks1 measles
incidence incidence. Additionally, its first outbreaks
2 countries were verified as having
eliminated rubella1

Averted deaths in Several countries in Europe and Measles

Immunization activities in Southeast
Southeast Asia South America as well as the region elimination
Asia averted an estimated 622,000
of the Americas lost measles status lost
measles deaths in 20171
elimination status1

European region Two countries in the European

increased coverage Region increased their measles
vaccine coverage by 10%.1

20 1. Strategic Advisory Group of Experts on Immunization. 2018 Assessment Report of the Global Vaccine Action Plan. World Health
Organization Web site. https://www.who.int/immunization/global_vaccine_action_plan/sage_assessment_reports/en/. Accessed March 5,
2019.
 IDAI 2017 :
Vaksinasi MMR pada usia 15 bulan,
21 dosis kedua pada usia 5 tahun
Clinical Value Measles, Mumps, &
Rubella, Virus Vaccine Live
 The Safety and Immunogenicity of Measles, Mumps, &
Rubella, Virus Vaccine Live as a First and/or Second Dose Has
Been Studied Extensively in Clinical Trials1

Studied Extensively in Clinical Trials

At least 23 clinical trials from 1988 to 2009 have been conducted,
postlicensing of MMR Vaccine, demonstrating that MMR Vaccine
is well-tolerated and immunogenic

More Than 14,000 Children Received MMR Vaccine in

Trials
14,221 children, from 10 months to 6 years of age, received
MMR Vaccine as a first or second dose in these studies

23
1. Kuter BJ et al. Pediatr Infect Dis J. 2016;35(9):1011−1020.
 Efficacy of MMR Vaccine[Measles, Mumps, & Rubella,
Virus Vaccine Live] and Concomitant Use With Other
Vaccines

Established Efficacy
The efficacy and duration of immunity of the individual MMR Vaccine
components have been established in a series of double-blind controlled trials1

Seroconversion
Studies have also established that seroconversion in response to vaccination
against MMR paralleled protection from those diseases1

Long-lasting Protection
Antibodies associated with protection against all 3 MMR viruses, measured by
neutralization assays or ELISA tests, were still detectable in most individuals
11−13 years after primary vaccination1

Concomitant Use With Other Pediatric Vaccines

There is evidence to support the concomitant use of MMR Vaccine with other
pediatric vaccines: varicella, diphtheria, tetanus, pertussis, Haemophilus
influenzae type B, hepatitis B, and/or oral polio vaccine2
24 MMR = measles, mumps, and rubella; ELISA = enzyme-linked immunosorbent assay.
1. International Physicians Circular, MMR Vaccine, Worldwide Product Labeling, MRL. Whitehouse Station, NJ: Merck & Co., Inc.; 2016. 2.
Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011−1020.
 Efficacy of the Individual MMR Vaccine[Measles,
Mumps, & Rubella, Virus Vaccine Live] Components

Vaccine Component
in MMR Vaccine Efficacy

Measles From the CDC

Enders’ attenuated

M
• 93% effective after 1 dose2
Edmonston strain1
• 97% effective after 2 doses2

Mumps From the CDC

Jeryl Lynn (B-level)

M
• 78% effective after 1 dose2,3
mumps strain1
• 88% effectiveness after 2 doses2,3

Rubella
Wistar RA 27/3
R rubella strain1,4
Vaccine highly effective (95%−100%)4

CDC = Centers for Disease Control and Prevention.

1. International Physicians Circular, MMR Vaccine, Worldwide Product Labeling, MRL. Whitehouse Station, NJ: Merck & Co., Inc.; 2016.
2.Vaccines and preventable diseases. Centers for Disease Control and Prevention Web site.
25 https://www.cdc.gov/vaccines/vpd/mmr/hcp/about.html. Accessed March 5, 2019. 3. Epidemiology and prevention of vaccine-preventable
diseases. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html. Accessed March 5,
2019. 4. Rubella. World Health Organization Web site. https://www.who.int/ith/vaccines/rubella/en/. Accessed March 5, 2019.
 MMR Vaccine[Measles, Mumps, & Rubella, Virus Vaccine Live]
Demonstrated Seroconversion Rates of >92% After 1 Dose
Across Measles, Mumps, and Rubella in Clinical Trials1

Range of Seroconversion Rates After

Vaccination Across 20 Studies

Measles
92.8%−100%
M

Mumps
97.7%−100%
M

Rubella
92.8%−100%
R
26
1. Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011−1020.
 MMR Vaccine[Measles, Mumps, & Rubella, Virus Vaccine Live]
Was Generally Well-tolerated in Clinical Trials, Supported by
Decades of Postmarketing Surveillance Data1

The most common AEFIsa,b reported in temporal association following

administration of MMR Vaccine1,c

Event Reporting Rate per

AEFI
Million Doses Distributedd

Pyrexia 5.49
Rash 4.63

Injection site reaction 2.19

Febrile convulsion 1.34

Vasovagal/
syncope cases
0.85

aIndividual reports can contain more than 1 AEFI/event. This table represents the number of events reported from HCPs.
bAll temporally related HCP AEFIs were included, without regard to the causal relationship, and coded in the terminology used by the reporter.
Additionally, case reports from the published literature were included.
c
As found in the Merck postmarketing database through September 30, 2010.
dThe reporting rate of AEFIs was calculated by dividing the number of each AEFI by the number of M–M–R doses distributed from 1978 through
II
27 September 30, 2010 (575 million doses) multiplied by 1 million to quantify the amount of morbidity associated with the use of the vaccine.
AEFI = adverse experience following immunization; HCP = health care provider.
1. Lievano F et al. Vaccine. 2012;30:6918−6926.
 Breakthrough Infection of Measles, Mumps, or Rubella
After MMR Vaccine[Measles, Mumps, & Rubella, Virus
Vaccine Live] Was Consistently Low1

Event Reporting Rate per

Disease AEFI
Million Doses Distributeda

Postvaccination 0.58
Mumps
Breakthrough
infection
0.87

Postvaccination 0.91
Measles
Breakthrough
infection
0.11

Postvaccination 0.10
Rubella
Breakthrough
infection
0.02

a
The reporting rate of AEFIs was calculated by dividing the number of each AEFI by the number of M–M–RII doses distributed from 1978 through
28 September 30, 2010 (575 million doses) multiplied by 1 million to quantify the amount of morbidity associated with the use of the vaccine.
MMR = measles, mumps, and rubella; AEFI = adverse experience following immunization.
1. Lievano F et al. Vaccine. 2012;30:6918–6926.
Real-World Impact of MMR
Vaccine[Measles, Mumps, &
Rubella, Virus Vaccine Live]
 Over 700 Million Doses of MMR Vaccine[Measles, Mumps, & Rubella,
Virus Vaccine Live] Have Been Distributed Globally and >30 Years of
Postmarketing Surveillance Data Demonstrate That the Vaccine Is
Well-Tolerated1,2

Over 700 Million Doses of MMR Vaccine Were

Distributed
Globally, >700 million doses of MMR Vaccine have been distributed
as of 2018, since the vaccine was licensed1

Global Reach of MMR Vaccine

MMR Vaccine is licensed in 73 countries around the world

MMR Vaccine Is Well-Tolerated

For every 1 million doses distributed, 31 AEs are reported after
vaccination2,3

30
AE = adverse event.
1. Data on file, Merck & Co., Inc. 2. Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011–1020. 3. Lievano F et al. Vaccine. 2012;30:6918–6926.
 Data from the CDC Highlight the Impact of Vaccination
on the Natural History of Measles, Mumps, and Rubella
in the United States1
Measles1-2
>99%
530,217 Decrease
Cases
120
Cases

1953−1962 2017

Mumps1-2

96%
162,344 Decrease
Cases
6,109
Cases

1963−1968 2017

Rubella1-2

>99%
47,745 Decrease
Cases
7
Cases

31 1966−1968 2017
CDC = Centers for Disease Control and Prevention; MMR = measles, mumps, and rubella.
1. Centers for Disease Control and Prevention. Impact of Vaccines in the 20th and 21st Centuries. In: Hamborsky J, et al. Epidemiology and Prevention of Vaccine-
Preventable Diseases. 13th ed. Washington D.C. Public Health Foundation. 2019; Appendix E: E-5. 2. Roush SW et al. JAMA. 2007;298:2155−2163.
Safety of MMR Vaccine[Measles, Mumps,
& Rubella, Virus Vaccine Live]
 Aseptic Meningitis After MMR Vaccination Is a Known
Complication That Can Carry Substantial Management
Costs1,2
Aseptic Meningitis
Aseptic meningitis is a syndrome characterized by meningeal inflammation not
caused by an identifiable bacterial pathogen in the CSF3

Incubation Period
The incubation period following immunization is 2−3 weeks, and the clinical
course is similar to that of the natural disease.2 The risk of developing this
complication varies, depending on the vaccine strain and the manufacturer2

Mumps Vaccines and Aseptic Meningitis

Several attenuated mumps vaccines have been associated with aseptic
meningitis.2 The risk of association is very low and varies according to the
vaccine strain. It can range from 1 per 1 million to 1 per 1,000 doses of vaccine.2

Costs
The standardized costs (in 2012 USD) of managing meningitis cases from
studies in low- and middle-income countries in the Americas ranged from $1,934
to $12,9091
MMR = measles, mumps, and rubella; CSF = cerebrospinal fluid; USD = US dollars.
33 1. Portnoy A et al. Vaccine. 2015;33(suppl 1):A240−A247. 2. Observed rate of vaccine reactions: measles, mumps and rubella vaccines.
World Health Organization web site. http://www.who.int/vaccine_safety/initiative/tools/MMR_vaccine_rates_information_sheet.pdf. Accessed
March 5, 2019. 3. Irani DN. Neurol Clin. 2008;26:635−655.
 MMR Vaccine[Measles, Mumps, & Rubella, Virus Vaccine Live]
Contains the Jeryl Lynn Strain of the Mumps Virus, Which Is
Associated With the Lowest Incidence of Postvaccination Aseptic
Meningitis Among Other Mumps Vaccines Strains Currently in Use1,2

Range of Rates of
Mumps
Aseptic Meningitis
Strain
(Rate/1 M Doses)
Jeryl Lynn 1−10
L-Zagreb 13−900
Leningrad-3 200−1000

Urabe 90−490

The Jeryl Lynn strain of the mumps vaccine has not

been shown to cause aseptic meningitis3

1. International Physicians Circular, MMR Vaccine, Worldwide Product Labeling, MRL. Whitehouse Station, NJ: Merck & Co., Inc.; 2016.
34 2. Bonnet MC et al. Vaccine. 2006;24:7037−7045. 3. Observed rate of vaccine reactions: measles, mumps and rubella vaccines. World
Health Organization web site. http://www.who.int/vaccine_safety/initiative/tools/MMR_vaccine_rates_information_sheet.pdf. Accessed
March 5, 2019.
 At Least 25 Studies Have Shown No Association
Between the MMR Vaccine and Autism1

Five cohort studies involving 1,256,407 children as well as 5 case-control studies

involving 9,920 children, were included in a meta-analysis of the relationship
between vaccine administration and subsequent development of autism or ASDs2

Exposure Type OR for Autism or ASD

OR: 0.84;
MMR vaccination2 95% CI: 0.70 to 1.01; I2 = 0.00;
P=0.55

No evidence has been found linking vaccination and a

subsequent risk of developing autism or autism spectrum
disorders following multiple studies2,3

MMR = measles, mumps, and rubella; OR = odds ratio; CI = confidence interval; I2 = statistical heterogeneity.
35 1. MMR vaccine does not cause autism: examine the evidence! Immunization Action Coalition Web site.
http://www.immunize.org/catg.d/p4026.pdf. Accessed March 5, 2019. 2. Taylor LE et al. Vaccine. 2014;32:3623−3629. 3.Hviid A et al. Ann
Intern Med. 2019;.doi: 10.7326/M18-2101.
 Post-Licensure Study: Global Safety Surveillance
Data for M-M-R : 32 tahun pengamatan (1978-2010)

• 17,536 AEs voluntarily reported/~575 million doses distributed

• ~31 AEs/1 million doses distributed
Kesimpulan:
“Vaksin MMR memiliki Profil keamanan yang baik dan dapat ditoleransi
dengan baik ”
36
Lievano et al Vaccine 2012
 Isu tentang Vaksin MMR
• Brian Deer dkk 200 : wakefield
MEMALSUKAN riwayat Pasien agar
pengacara menuntut produsen Vaksin.
• Dari 12 anak : 5 anak ada masalah
perkembangan sebelum divaksinasi, 7 anak
tidak pernah Autis.
• Lancet Mar.3, 2004 : 10 dari 12 co-authors
menarik pendapatnya : karena data tidak
cukup.
• Lancet Feb. 2, 2010 : Editor menarik artikel
wakefield dkk 1998 karena beberapa
bagian makalah terbukti tidak bener.
• British Journal of Medicine. Jan 5, 2011 :
Wakefield menerima $674.000 dari
pengacara yang menangani tuntutan orang
tua.
• May 24, 2011 : Ijin praktek Wakefield
dicabut karena menyalahgunakan posisi
dan profesinya.

37
Public Perception of MMR Vaccine[Measles,
Mumps, & Rubella, Virus Vaccine Live] and
Vaccination Rates
 Effective Communication Between HCPs and Parents Is
Key for Maintenance of Trust in Vaccination1

Misinformation and Decreases in MMR Vaccination Rates

Lack of information or misinformation has previously led to decreases
in MMR vaccination rates, which, in turn, led to resurgences in measles
outbreaks in multiple developed countries2−8

Trust in HCPs Guides Decisions About Vaccination

Along with barriers to vaccine uptake and the media’s
representation of disease and vaccination, parents’ trust in HCPs
is a key element guiding parental decision-making in childhood
vaccination1−3,9,10

Effective Communication Between HCPs and Parents Is Key

Effective communication between HCPs and parents can play a key role
in the maintenance of parents’ trust in vaccination1,8−12

HCP = health care provider; MMR = measles, mumps, and rubella.

1. Edwards KM et al. Pediatrics. 2016;138:pii: e20162146. 2. Brown KF et al. Vaccine. 2010;28:4235−4248. 3. Smith LE et al. Vaccine.
2017;35:6059−6069. 4. Muscat M. J Infect Dis. 2011;204(suppl 1):S353−S365. 5. Smith A et al. Vaccine. 2007;25:3996−4002. 6. Muscat M et al.
39 Lancet. 2009;373:383−389. 7. Salmon DA et al. Am J Prev Med. 2015;49(6 suppl 4):S391−S398. 8. Nyhan B et al. Pediatrics.
2014;133:e835−e842. 9. Giambi C et al. Vaccine. 2018;36:779−787. 10. Benin AL et al. Pediatrics. 2006;117:1532−1541. 11. Leask J et al. BMC
Pediatr. 2012;12:154. 12. Gust DA et al. Pediatrics. 2008;122:718−725.
 Take Home Messages

• 32 years of postmarketing surveillance • At least 23 clinical trials in >14,000

data demonstrate that MMR children demonstrate that MMR
Vaccine[Measles, Mumps, & Rubella, Vaccine was consistently
Virus Vaccine Live] is well-tolerated1 immunogenic, whether
30 years of post-marketing surveillance
SAFETY VACCINE administered alone or with other
• MMR Vaccine is associated with the
data demonstrate that the vaccine is
lowest incidence of postvaccination
EFFICACY routine pediatric vaccines1
well-tolerated
aseptic meningitis2 1,2
• MMR Vaccine demonstrated
• At least 25 studies have shown no seroconversion rates of >92% for
association between the MMR vaccine all 3 diseases after 1 dose across
and autism3 MMR in clinical trials1

• Widespread use of MMR Vaccine in • Effective communication

countries such as Finland and the between HCPs and parents is
United States has led to a key for parents’ maintenance of
reduction in incidence of >99% in MAINTAINING
trust in vaccination6−11
VACCINE
IMPACT
measles and rubella and ≥96% in HIGH RATES OF
mumps, compared with the VACCINATION
prevaccine era4,5

MMR = measles, mumps, and rubella.

1. Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011−1020. 2. Bonnet MC et al. Vaccine. 2006;24:7037−7045. 3. MMR vaccine does not cause autism: examine the
evidence! Immunization Action Coalition Web site. http://www.immunize.org/catg.d/p4026.pdf. Accessed March 5, 2019. 4. Lievano F et al. Vaccine.
40 2012;30:6918−6926. 5. Centers for Disease Control and Prevention. Impact of Vaccines in the 20th and 21st Centuries. In: Hamborsky J, et al. Epidemiology and
Prevention of Vaccine-Preventable Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; E-5. 6. Nyhan B et al. Pediatrics. 2014;133:e835−e842. 7.
Edwards KM et al. Pediatrics. 2016;138:pii: e20162146. 8. Giambi C et al. Vaccine. 2018;36:779−787. 9. Leask J et al. BMC Pediatr. 2012;12:154. 10. Benin AL et
al. Pediatrics. 2006;117:1532−1541. 11. Gust DA et al. Pediatrics. 2008;122:718−725.
 Take Home Messages

• Measles, Mumps dan Rubella adalah penyakit yang sangat menular

yang terjadi di seluruh dunia dan mempengaruhi semua kelompok
umur, terutama anak-anak1-3
• Vaksinasi MMR memberikan dampak signifikan terhadap upaya
pencegahan terhadap penyakit measles, mumps dan rubella di
berbagai negara dan sejalan dengan goals dari WHO.
• Studi klinis menunjukkan vaksin M-M-R mempunyai nilai
serokonversi yang tinggi setelah pemberian dosis pertama
• Global Safety Surveillance Data for M-M-R Vaccine : 32 year review
(1978-2010) menunjukkan M-M-R memiliki profil keamanan yang

41
baik dan juga ditoleransi dengan baik.