Vaccine Information: M-M-R II (Page 2 of 4)

7 DRUG INTERACTIONS

7.1 Corticosteroids and Immunosuppressive Drugs

M-M-R II vaccine should not be administered to individuals receiving immunosuppressive therapy, including high dose corticosteroids. Vaccination with M-M-R II vaccine can result in disseminated disease due to measles vaccine in individuals on immunosuppressive drugs [see Contraindications (4.2)].

7.2 Immune Globulins and Transfusions

Administration of immune globulins and other blood products concurrently with M-M-R II vaccine may interfere with the expected immune response {911} [see Warnings and Precautions (5.5)]. The ACIP has specific recommendations for intervals between administration of antibody containing products and live virus vaccines.

7.3 Tuberculin Skin Testing

It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin skin test with tuberculin purified protein derivative (PPD) is to be done, it should be administered before, simultaneously with, or at least 4 to 6 weeks after vaccination with M-M-R II vaccine.

7.4 Use with Other Live Viral Vaccines

M-M-R II vaccine can be administered concurrently with other live viral vaccines. If not given concurrently, M-M-R II vaccine should be given one month before or one month after administration of other live viral vaccines to avoid potential for immune interference.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

M-M-R II vaccine is contraindicated for use in pregnant women because infection during pregnancy with the wild-type viruses has been associated with maternal and fetal adverse outcomes.

Increased rates of spontaneous abortion, stillbirth, premature delivery and congenital defects have been observed following infection with wild-type measles during pregnancy. {12,13} Wild-type mumps infection during the first trimester of pregnancy may increase the rate of spontaneous abortion.

Infection with wild-type rubella during pregnancy can lead to miscarriage or stillbirth. If rubella infection occurs during the first trimester of pregnancy, it can result in severe congenital defects, Congenital Rubella Syndrome (CRS). Congenital Rubella Syndrome in the infant includes but is not limited to eye manifestations (cataracts, glaucoma, retinitis), congenital heart defects, hearing loss, microcephaly, and intellectual disabilities. M-M-R II vaccine contains live attenuated measles, mumps and rubella viruses. It is not known whether M-M-R II vaccine can cause fetal harm when administered to pregnant woman. There are no adequate and well-controlled studies of M-M-R II vaccine administration to pregnant women.

All pregnancies have a risk of birth defect, loss or other adverse outcomes. In the US general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Available data suggest the rates of major birth defects and miscarriage in women who received M-M-R II vaccine within 30 days prior to pregnancy or during pregnancy are consistent with estimated background rates (see Data).

Data

Human Data

A cumulative assessment of post-marketing reports for M-M-R II vaccine from licensure 01 April 1978 through 31 December 2018, identified 796 reports of inadvertent administration of M-M-R II vaccine occurring 30 days before or at any time during pregnancy with known pregnancy outcomes. Of the prospectively followed pregnancies for whom the timing of M-M-R II vaccination was known, 425 women received M-M-R II vaccine during the 30 days prior to conception through the second trimester. The outcomes for these 425 prospectively followed pregnancies included 16 infants with major birth defects, 4 cases of fetal death and 50 cases of miscarriage. No abnormalities compatible with congenital rubella syndrome have been identified in patients who received M-M-R II vaccine. Rubella vaccine virus can cross the placenta, leading to asymptomatic infection of the fetus. Mumps vaccine virus has also been shown to infect the placenta {14}, but there is no evidence that it causes congenital malformations or disease in the fetus or infant.

The CDC established the Vaccine in Pregnancy registry (1971-1989) of women who had received rubella vaccines within 3 months before or after conception. Data on 1221 inadvertently vaccinated pregnant women demonstrated no evidence of an increase in fetal abnormalities or cases of Congenital Rubella Syndrome (CRS) in the enrolled women {15}.

8.2 Lactation

Risk Summary

It is not known whether measles or mumps vaccine virus is secreted in human milk. Studies have shown that lactating postpartum women vaccinated with live attenuated rubella vaccine may secrete the virus in breast milk and transmit it to breast-fed infants. {16,17} In the breast-fed infants with serological evidence of rubella virus vaccine strain antibodies, none exhibited severe disease; however, one exhibited mild clinical illness typical of acquired rubella. {18,19}

The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for M-M-R II, and any potential adverse effects on the breastfed child from M-M-R II or from the underlying maternal condition. For preventive vaccines, the underlying maternal condition is susceptibility to disease prevented by the vaccine.

8.4 Pediatric Use

M-M-R II vaccine is not approved for individuals less than 12 months of age. Safety and effectiveness of measles vaccine in infants below the age of 6 months have not been established [see Clinical Studies (14)]. Safety and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have not been established.

8.5 Geriatric Use

Clinical studies of M-M-R II did not include sufficient numbers of seronegative subjects aged 65 and over to determine whether they respond differently from younger subjects.

11 DESCRIPTION

M-M-R II vaccine is a sterile lyophilized preparation of (1) Measles Virus Vaccine Live, an attenuated line of measles virus, derived from Enders’ attenuated Edmonston strain and propagated in chick embryo cell culture; (2) Mumps Virus Vaccine Live, the Jeryl Lynn™ (B level) strain of mumps virus propagated in chick embryo cell culture; and (3) Rubella Virus Vaccine Live, the Wistar RA 27/3 strain of live attenuated rubella virus propagated in WI-38 human diploid lung fibroblasts. {20,21} The cells, virus pools, recombinant human serum albumin and fetal bovine serum used in manufacturing are tested and determined to be free of adventitious agents.

After reconstitution, each approximately 0.5 mL dose contains not less than 3.0 log10 TCID50 (tissue culture infectious doses) of measles virus; 4.1 log10 TCID50 of mumps virus; and 3.0 log10 TCID50 of rubella virus.

Each dose is calculated to contain sorbitol (14.5 mg), sucrose (1.9 mg), hydrolyzed gelatin (14.5 mg), recombinant human albumin (≤0.3 mg), fetal bovine serum (<1 ppm), approximately 25 mcg of neomycin and other buffer and media ingredients. The product contains no preservative.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

M-M-R II vaccination induces antibodies to measles, mumps, and rubella associated with protection which can be measured by neutralization assays, hemagglutination-inhibition (HI) assays, or enzyme linked immunosorbent assay (ELISA) tests. Results from efficacy studies or effectiveness studies that were previously conducted for the component vaccines of M-M-R II were used to define levels of serum antibodies that correlated with protection against measles, mumps, and rubella [see Clinical Studies (14)].

12.6 Persistence of Antibody Responses After Vaccination

Neutralizing and ELISA antibodies to measles, mumps, and rubella viruses are still detectable in 95-100%, 74-91%, and 90-100% of individuals respectively, 11 to 13 years after primary vaccination. {2228}

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

M-M-R II vaccine has not been evaluated for carcinogenic or mutagenic potential or impairment of fertility.

14 CLINICAL STUDIES

14.1 Clinical Efficacy

Efficacy of measles, mumps, and rubella vaccines was established in a series of double-blind controlled trials. {2934} These studies also established that seroconversion in response to vaccination against measles, mumps and rubella paralleled protection. {3538}

14.2 Immunogenicity

Clinical studies enrolling 284 triple seronegative children, 11 months to 7 years of age, demonstrated that subcutaneously administered M-M-R II vaccine is immunogenic. In these studies, a single subcutaneous injection of the vaccine induced measles HI antibodies in 95%, mumps neutralizing antibodies in 96%, and rubella HI antibodies in 99% of susceptible individuals.

A study of 6-month-old and 15-month-old infants born to mothers vaccinated with a measles vaccine in childhood, demonstrated that, following infant and toddler vaccination subcutaneously with Measles Virus Vaccine, Live (previously US-licensed, manufactured by Merck Sharp & Dohme LLC, Rahway, NJ, USA), 74% of the 6-month-old infants developed detectable neutralizing antibody titers while 100% of the 15-month-old infants vaccinated with Measles Virus Vaccine, Live or M-M-R II vaccine developed neutralizing antibodies {39}. When the 6-month-old infants of immunized mothers were revaccinated at 15 months with M-M-R II vaccine, they developed antibody titers similar to those of toddlers who were vaccinated previously at 15-months of age.

In an open label clinical trial (NCT00432523) 752 children 12 through 18 months of age received M-M-R II either intramuscularly (n=374) or subcutaneously (n=378), concomitantly with VARIVAX. Antibody responses to measles, mumps, and rubella viruses were measured by ELISAs using sera obtained 6 weeks postvaccination. For anti-measles virus, anti-mumps virus and anti-rubella virus, seroresponse rates were defined as the percentage of children seronegative at baseline who achieved antibody titers above the respective seroresponse threshold for each assay 6 weeks post vaccination. Seroresponse thresholds were defined as 255 mIU/mL, 10 EU/mL, and 10 IU/mL for anti-measles virus, anti-mumps virus, and anti-rubella virus antibodies, respectively. For each vaccine antigen at least 89% of enrolled children were seronegative at baseline. In a post hoc analysis, seroresponse rates to mumps and rubella viruses were noninferior for the intramuscular group compared to the subcutaneous group (the lower bound of the 95% confidence interval for the difference in seroresponse rates [intramuscular group minus subcutaneous group] ≥-5%). While the seroresponse rate to measles virus narrowly missed meeting the post hoc criterion of -5% for noninferiority (lower bound of the 95% CI for the difference in seroresponse rate -5.28%), it met the pre-specified criterion using a -10% noninferiority margin. For measles, mumps and rubella antigens the lower bound of the 95% CI of the seroresponse rates was ˃90% after intramuscular administration. The point estimates of the proportions of children achieving antibody titers above the seroresponse thresholds for measles, mumps, and rubella viruses were as follows: 94.3%, 97.7%, and 98.1%, respectively, in the intramuscular group and 96.1%, 98.1%, and 98.1%, respectively, in the subcutaneous group.

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