www.elitecme.com | 2019 | INFECTIOUS DISEASE, DISASTER PLANNING & WOUND CARE 31 tegrated into a number of successful national vaccination programs (PHE, 2014). In summary, PHE stated that based on all available evidence, as well as the support of multiple professional bodies, the MMR vaccine product is the safest way to protect children from measles, mumps, and rubella (PHE, 2014). M-M-R II‚Ñ¢ (measles, mumps, and rubella virus vaccine) is a proprietary live virus vac- cination developed and marketed by Merck & Company (Merck, 2017-1). Its proper use in clinical practice is governed by informa- tion included in the package insert, as well as within vaccine schedules developed and pub- lished by the Centers for Disease Control and Prevention’s ACIP, in conjunction with the American Academy of Pediatrics. In February of 2018, the Centers for Disease Control and Prevention published the most current vacci- nation schedule, effective immediately (CDC, 2018). Key changes to the vaccination schedule compared to the 2017 version include: • Modification of the international travel recommendations for children; • Addition of recommendations for use of the MMR vaccine product for children in the instance of a mumps outbreak; • A reduction in the number of vaccina- tions (from two to one) in adults born after 1957 without evidence of immunity to measles, mumps or rubella; • Addition of a recommendation to vacci- nate adults at high risk of contracting mumps (CDC, 2018-1). VACCINATION SCHEDULE FOR CHILDREN All children should receive two doses of the vaccine, separated by at least four weeks. The first dose should be administered between 12 and 15 months of age. Any doses adminis- tered before the child’s first birthday should not be counted as part of the two-dose series. The second dose should be administered between four and six years of age, before the child enters school (CDC, 2018-1). In the case of unvaccinated children, ACIP recommends that children and adolescents receive two doses of MMR vaccine product at least four weeks apart (CDC, 2018-1). The MMR vaccination schedule is some- what modified in cases of international travel. In infants aged six to 11 months, patients should receive the initial dose before depar- ture, followed by re-vaccination with two doses at age 12-15 months (children in high risk areas should receive the first revaccina- tion at 12 months of age). In the case of older, unvaccinated children, they should receive two doses of MMR vaccine product separated by at least four weeks prior to departure (CDC, 2018-1). In cases where children who have received =2 doses of a mumps-containing vaccine and are at a high risk of exposure to a mumps out- break should receive a single dose of MMR vaccine product (CDC, 2018-1). Written vaccination documentation with the date of receipt and the vaccination admin- istered should be the only accepted proof of vaccination. Those lacking adequate docu- mentation should be vaccinated according to the immunization schedule. Documentation of vaccination should be included in the patient’s permanent medical record; a copy of the documentation should be provided to the immunized individual (CDC, 2015). MMRV (ProQuad, Merck) is an immuniza- tion that adds varicella to the standard MMR vaccination. It is approved by the FDA for use in children 12 months to 12 years old. Since two doses of varicella are recommended for children at the same intervals as MMR vac- cine, the MMRV vaccination can be substi- tuted for the separate MMR and varicella vaccines. However, the use of MMRV vaccine for the first dose at age 12 to 23 months has been associated with an increased risk of fever and febrile seizures, as compared to separate doses of MMR and varicella vaccines admin- istered separately. Although febrile seizures were reported in clinical trials after the sec- ond dose of MMRV vaccine administration, it was hypothesized that that these seizures may have been related to concurrent viral infec- tions (Merck, 2017). Therefore, providers should discuss the risks and benefits of using MMRV vaccine with par- ents and caregivers. Unless the adult expresses a strong preference for an MMRV vaccine, the Centers for Disease Control and Prevention (CDC) recommends separate doses of MMR and varicella vaccines for the first dose in chil- dren 12 to 47 months of age. For the second dose, as well as the initial dose in children = 48 months, the use of the MMRV vaccine is preferred over separate immunizations of the component vaccines (MMR and varicella vac- cines) (Marin, et al. 2010). VACCINATION SCHEDULE FOR ADULTS Adults born on or after 1957 without proof of immunity to measles, mumps, or rubella should receive one dose of MMR vaccine, unless they have a contraindication or evi- dence of immunity to all three diseases (CDC, 2018-2). Adults born before 1957 that are attending college, working in the health care arena, or traveling internationally should receive two doses of MMR vaccine at least 28 days apart (CDC, 2018-2). In the case of pregnant women without evidence of immunity to rubella, one dose of MMR vaccine may be administered upon the completion or the termination of pregnancy, prior to their discharge from the hospital. All women of child-bearing potential without immunity are advised to receive one dose of MMR vaccine (CDC, 2018-2). MMR vaccines should not be given to cer- tain immunocompromised subjects. This includes those with malignancies of the bone marrow or lymphatic system or people are currently receiving administered systemic immunosuppressive treatment (CDC, 2018-2). The suitability of HIV patients for MMR immunization is a function of their CD4+ lymphocyte counts. If the patient’s count is =200 cells/µl for at least six months and is not currently afflicted with measles, mumps, or rubella, s/he can be immunized following the typical adult vaccination schedule (CDC, 2018-2). Adults who were vaccinated using KMV or an unknown product between 1963 and 1967 should be revaccinated (CDC, 2018-2). Any adults who received either inactivated mumps vaccine or a vaccine of unknown type that are at a high risk for a mumps infection should be considered for revaccination with two doses of MMR vaccine product separated by at least 28 days (CDC, 2018-2). Blood testing for measles immunity does not need to be completed before a vaccina- tion against measles, unless the medical facil- ity determines it to be cost-effective. Testing should only be done if there are systems in place to ensure that patients who are deter- mined to be susceptible to measles receive appropriate vaccination in a timely manner |  CONTINUING EDUCATION