Combined MMR vaccine in childhood – rubella

This fact box will help you to weigh the benefits and harms of the combined vaccine against measles, mumps, and rubella (MMR). The focus of this fact box is on rubella. The information and numbers are based on the best scientific evidence currently available.

This fact box was developed by the Harding Center for Risk Literacy.

What is rubella?

Rubella is a highly contagious viral infection. Besides the typical rash, additional symptoms such as high temperature, headache, inflammation of the respiratory tract, and painful swelling of the lymph nodes in the neck and behind the ears may occur. Pregnant women are particularly at risk because the virus may be transmitted to the unborn child and cause serious harms, depending on the week of pregnancy. The infection is spread through airborne droplets when infected people cough, sneeze, or speak [4].

Was bedeutet eine Rötelninfektion in der Schwangerschaft?

Wenn sich eine Frau in den ersten vier Schwangerschaftsmonaten mit dem Rötelnvirus ansteckt, kommt es bei etwa 70 bis 90 von je 100 ungeborenen Kindern zu schweren Fehlbildungen, zum Beispiel am Innenohr, Herz, Auge oder Gehirn. Man nennt das Rötelnembryopathie. Auch eine Fehlgeburt ist dadurch möglich. Ab dem fünften Schwangerschaftsmonat treten solche Schädigungen des ungeborenen Kindes nur noch selten auf [1, 2].

What is a combined MMR vaccine?

The vaccination against rubella is usually administered as a combined vaccine against measles, mumps, and rubella – hence the abbreviation MMR [4].

Who might consider the combined MMR vaccine?

Infants aged 11 to 14 months receive the first dose of the combination vaccine as part of their basic immunization series. The second vaccination, generally scheduled for children aged 15 to 23 months, is a precautionary measure in case the first vaccination did not lead to the development of immunity. Furthermore, all adults born after 1970 who have not been vaccinated, who have been vaccinated just once, or whose vaccination status is unknown may consider having a one-off combined MMR vaccination [4].

Fact box combined MMR vaccine in childhood – rubella
Fact box combined MMR vaccine in childhood – rubella © Harding Center for Risk Literacy
What does the fact box show?

The fact box shows the possible benefits and harms of the combined MMR vaccine for people without vaccination in their childhood compared to people with vaccination in case of exposure to the rubella virus later in life.

The table may be read as follows:

If 10,000 people who had not been vaccinated against rubella were exposed to the rubella virus, 4,000 to 9,000 would be expected to contract rubella. In contrast, 40 to 270 of 10,000 vaccinated people would contract rubella after exposure to the virus.

The numbers in the fact box are rounded. For the benefits, the numbers are based on model calculations. These calculate the probabilities of infections, symptomatic diseases, and frequencies of symptoms taking into consideration the effectiveness of the vaccine.

What other aspects should be considered?

Allergic reactions to the MMR vaccine are very rare. However, children with a severe allergy to eggs should be closely monitored after vaccination.

The fact box contains model calculations of the possible benefits and harms that may be expected after exposure to the rubella virus.The frequency of exposure to the virus depends on many factors, such as the opportunities for the rubella virus to spread and the proportion of vaccinated people. Widespread vaccination additionally provides protection for people who normally cannot be vaccinated (herd immunity). This population, which includes people with weakened immune systems and pregnant women, benefits from the slower spread of the virus.

The combined MMR vaccination protects against measles and mumps as well. The vaccine is also available in combination with chickenpox (varicella-zoster virus) as an MMR+V vaccine [4].

Do the results provide proof (evidence) for the benefits and harms of the vaccination?

Overall the evidence is of moderate quality. On the one hand, the contagion indices (proportion of those exposed to the rubella virus who become infected) and manifestation indices (proportion of those infected by the rubella virus who are symptomatic) have not been researched with adequate randomized controlled trials. On the other hand, the degree of effectiveness of the vaccine has been validated across various populations with different study designs. Thus, there is at least evidence that symptoms of rubella are reduced among vaccinated people versus unvaccinated people.

Version history of the fact box
  • April 2016 (last update)

Information within the fact box was obtained from the following sources:

Data based on clinical practice are missing, e.g. information from textbooks and physicians on the prevalence (frequency) of the infection, thecontagion and manifestation indices, and current patient studies. Data based on clinical practice only partly correspond to the current vaccines and to the current health conditions of the German and Swiss populations.

The data on febrile seizure are based on two cohort studies with, respectively, 456,000 and 537,000 children aged 12 to 23 months. The vaccine contained the “Jeryl-Linn” strain of the virus.The data on low platelet counts (thrombocytopenia) are based on a patient control study with 139 children aged 13 to 24 months.

[1] Demicheli V, Rivetti A, Debalini MG et al. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev2012;2:CD004407.

[2] Doerr HW, Gerlich WH. Medizinische Virologie: Grundlagen, Diagnostik, Prävention und Therapie viraler Erkrankungen. Georg Thieme 2010.

[3] Plotkin S, Orenstein W, Offit P. Vaccines. 6 ed: Saunders 2012.

[4] Robert Koch-Institut. RKI-Ratgeber für Ärzte: Röteln. 2010;, Access date 22 Aug 2016.

[5] Wichmann PD, Ultsch B. Effektivität, Populationseffekte und Gesundheitsökonomie der Impfungen gegen Masern und Röteln. Bundesgesundheitsbl Gesundheitsforsch Gesundheitssch2013;56(9):1260-9.

[6] Friese K, Mylonas I, Schulze A (ed.). Infektionserkrankungen der Schwangeren und des Neugeborenen. Springer 2013.

[7] Quast U, Stück B, Deutsches Grünes Kreuz. Ärzte Merkblatt2002.

[8] Black C, Kaye JA, Jick H. MMR vaccine and idiopathic thrombocytopaenic purpura. BJCP 2003;55(1):107-11.

[9] Patja A, Mäkinen-Kiljunen S, Davidkin I, et al. Allergic reactions to measles-mumps-rubella vaccination. Pediatrics 2001;107(2):e27.

[10] Vestergaard M, Hviid A, Madsen KM et al. MMR vaccination and febrile seizures: evaluation of susceptible subgroups and long-term prognosis. JAMA 2004;292(3):351-7.

[11] Wilson K, Hawken S, Kwong JC et al. Adverse events following 12 and 18 month vaccinations: a population-based, self-controlled case series analysis. PLoS One 2011;6(12):e27897.

Documentation on how the numbers in the fact box were determined is available on request.