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MMR’s successor – MMRV

What is MMRV?

MMRV is the quadruple vaccination against measles, mumps and rubella (MMR; more here) and chicken pox (also known as varicella). Varicella vaccination (developed in Japan) has been used in Japan for twenty years and in the USA since 1995. In 2006, the varicella vaccination was combined with MMR to make MMRV. MMRV was licensed in 2005 and is a routine vaccination in many countries including the USA, Germany and Australia. The advantages of this are to reduce the number of injections and therefore increasing acceptance and uptake, hence increasing coverage. Two injections of MMRV give 94% efficiacy against chicken pox.

Children given the MMRV are more likely than children given MMR to have a fever which might suggest a more rigorous immune response.  The greater worry is the associated increase in febrile seizures within two weeks of vaccination although the increase was only 8 children out of 10,000 children (for MMRV) to 3. 5 children per 10,000 children (for MMR). This increase in febrile seizures is small and only occurs in children between 12-23 months; after the age of two years there is no significant difference. Although febrile seizures are frightening for parents, there is no risk of any long-term harm to the child.  There is also worry over an universal chicken pox vaccination increasing the likelihood of shingles later in life (only people exposed to chicken pox virus can get shingles) but the rate of shingles had been increasing in the USA, and other countries, before the introduction of the varicella vaccine and did not accelerate when the vaccine was introduced. This suggests to me that there is no link between shingles and the vaccine and therefore this is a needless worry.

Why immunise against varicella in the UK?

The world health organisation recommends routine vaccination to be considered in countries that can afford it and where it is a relatively important public health concern, a socio-economic problem and where at least 85% coverage is achievable. Varicella is considered a mild disease in children and compared to measles and mumps it is. In the USA, where records of chicken pox cases are kept, evidence shows that its introduction has benefitted the economy when the loss of work hours while parents look after a sick child and the hospitalisation costs verses the cost of the vaccine are compared.

Per 100,000 people Top - number of cases Bottom - hospitalisations in red and deaths in green

Per 100,000 people
Top – number of cases
Bottom – hospitalisations in red and deaths in green

Will introducing a new vaccine into the UK be a problem?

MMR uptake rates are still not at 95% in the UK, which is what the WHO recommends. Introducing MMRV, especially with the associated scaremongering around febrile seizures, may reduce uptake further. People still worry about ingredients in the vaccine (e.g. can they be given to children with an egg allergy?), the age of the child (two years or over is considered ideal), how long the vaccination lasts and the potential increase in another more deadly strain developing. These diseases are considered to be too mild and uncommon to warrant vaccination by a lot of people. Parents usually quote a second or third hand experience of an MMR-vaccine link, vaccine failure or adverse events. Several parents who rejected MMR had direct experience of caring for children with autism. Tony and Cherie Blair refusing to confirm the immunisation status of their child did nothing to alleviate parents’ fears.

Parents, falsely, seem to believe in the benefits of natural immunity and how it can be boosted by good nutrition. They also, erroneously, think exposure to low levels of disease causing bugs will boost immunity (they seem to be misunderstanding the hygiene-hypothesis). Although true to an extent, this does not apply to measles, mumps and rubella.

How to introduce a new vaccine?

Parents want GPs to provide impartial advice and give them a leaflet outlining the facts. They do not want to be judged and assumed to be stupid when in fact a lot of parents who do not give their child MMR on time are actually highly educated. Views on disease severity are based on personal experience rather than facts and exposure to increased disease susceptibility is motivation to vaccinate (e.g. in ethically diverse communities or during foreign holidays). Parents use official information leaflets to educate themselves about the disease and adverse symptoms and the decision to vaccinate is an emotional one rather than logical.

Trust in health professionals and vaccine policy is central to acceptance therefore effective communication comparing the facts of disease and vaccine risks in perspective is key. As parents think two years is a better age for immunisations, catch-up campaigns can target 24-36 month olds when parents may be more willing to vaccinate. Face-to-face contact by non-judgemental health providers, whether it is the GP, practice nurse or health visitor, is required.

Although controversial, compulsory vaccination should be considered. This will protect children who cannot be immunised for health reasons and children less than 12 months old for whom these vaccines do not work.

Epetition – Introduction of MMRV vaccine in the UK


Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised trial.

Prevention of varicella: Update of recommendations for use of quadrivalent and monovalent varicella vaccines in children.

Economic evaluation of the routine childhood immunisation program in the United States, 2009.

UK parents’ decision-making about measles-mumps-rubella (MMR) vaccine 10 years after the MMR-autism controversy: A qualitative analysis.

Varicella Vaccination in Japan, South Korea, and Europe.


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Tarnjit Khera (2014). MMR’s successor – MMRV

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How many needles will go into my child?

Now that my daughter is approaching her first birthday, it is time to get her vaccinated, again. This time there are choices: Do I go with the triple MMR injection (the standard choice) so it will be half the pain, half and fuss and free; or do I go with the single injections which means multiple trips, multiple screams and I’ll be paying for the privilege? Whilst on the subject of childhood vaccinations, how about chicken pox (also known as varicella)? Are measles, mumps and rubella any worse than chicken pox?
How affective are these vaccinations? As a parent and scientist I decided to find out what the literature states.

First of all is it worth the bother? Are these diseases really that bad? Let’s take a look at each one individually:

Measles: Measles is highly contagious, meaning it is very each to catch from an infected person. Measles can only survive by direct contact, if it is continually passed on from person to person like the serial killer’s soul in Fallen. It is passed via coughing and sneezing while children are in close contact. Therefore, if a child attends nursery, play groups or school, which are all full of snotty children, they are bound to infect one another, especially since their ‘secretions’ are left everywhere – hands, toys and each other. Due to the temperate climate in the UK, outbreaks usually occur in late winter and early spring during term time. Before vaccinations, there were 500,000 cases with 100 deaths per year. The single vaccine was introduced in the 1960s and the number of cases decreased to less than 100,000 with about 13 deaths. After the MMR was introduced in 1988, the number of cases reduced to less than 10,000 with no more than one death per year (98% reduction in cases before vaccinations were introduced). Measles can lead to complications in up to 40% of infections, mainly in the old and young (mainly babies, toddlers and preschoolers). The most common complication is pneumonia. Blindness can also occur, as can inflammation of the brain and spinal cord (encephomyelitis). Measles is on the World Health Organisation’s list of diseases that can be eradicated but 95% of the population needs to immunised to protect those that cannot be immunised due to medical conditions (e.g. another illness, immune system not working properly).

A simplified diagram showing how the illness progresses and when it is contagious

A simplified diagram showing how the illness progresses and when it is contagious

Mumps: Mumps causes swelling of the glands that produce saliva (parotid glands) – painful! It can also cause inflammation in the fluid surrounding the brain as well as complications with inflamed testis or ovaries which could lead to your children unable to have children of their own (therefore no grandchildren for you). Again, it is spread by direct contact with an infected person through coughs and sneezes. One study also showed that over a quarter of pregnant women who caught mumps during their first three months of pregnancy had a miscarriage but another study did not agree with this finding – so more work needed.

A simplified diagram showing how the illness progresses and when it is contagious

A simplified diagram showing how the illness progresses and when it is contagious

Rubella: Rubella is also known as German measles. In comparison to measles and mumps, it is considered a mild disease but if it is caught during early pregnancy, the child could be born with cataract, deafness and/or heart disease. Before the rubella vaccination was introduced, Rubella cases numbered 12,500,000 in the USA and Europe, with 11,000 fetal deaths. Therefore, if a pregnant woman has not had the rubella vaccine and her children or any children she spends time with catch rubella because they have not been immunised either can potentially cause her unborn child to be born with medical problems. The symptoms of rubella include swollen glands behind the ears and back of the neck and, especially in adults, joint pain.

A simplified diagram showing how the illness progresses and when it is contagious

A simplified diagram showing how the illness progresses and when it is contagious

Single vaccination: The single vaccines were introduced into the UK in the 1960s but due low uptake, the MMR triple vaccine was introduced. The single vaccine means six injections over months in the same place, each with the same side effects but the MMR is just two injections (one at 13 months of age and the second when the child turns 4 or 5). For over 90% of the population, one injection is enough and the second just boosts immunity. This means multiple trips to the surgery and possibly having to take a few days off work.

Chicken pox (varicella): Infection with chicken pox means there is a chance of getting shingles later in life. Shingles causes a painful rash which then develops into itchy blisters. It can also cause complications where the nerve pain lasts for months. Again, chicken pox infections occur mostly in 1-9 year old children during the winter and spring. It is highly infectious and spread via coughs and sneezes. However, as more children attend nurseries and pre-school, the age of infection is reducing. Although chicken pox is thought of as a mild disease, it can lead to serious complications, mainly in the young, old and ill. These complications can affect the brain or cause pneumonia. Out of every 1000 infections, 2-5 will need hospitalisation. The chicken pox vaccine is routinely used in the USA where the number of children getting chicken pox is now fewer. The vaccine is over 80% effective and has been taken up by other countries such as Uruguay, Germany, Taiwan, Canada and Australia. However, it is not available on the NHS as a routine vaccination nor is it offered privately at my GP surgery. If I want my daughter to be protected from chicken pox, I will have to pay for it.

A simplified diagram showing how the illness progresses and when it is contagious

A simplified diagram showing how the illness progresses and when it is contagious

There are no cures for these illnesses. The best that can be done is keep the patient comfortable and allow them to rest while they recover.

How about the MMRV? This is all four vaccines in one – measles, mumps, rubella and chicken pox. The combined injection was tested in over 5000 children in Europe and was shown to be over 94% effective in preventing these diseases. So why has the UK not yet taken it up? Is it because of the unwarranted worries parents still have about the autism link to MMR? This seems to be the case. In fact, there is a link between being overweight and autism (See this blog). There are also concerns about it increasing febrile seizures in children. It sounds serious but it turns out that it is relatively common in children with a fever. For more about MMRV see this blogpost.

Personally, I would have opted for the MMRV if it was available in the UK but as it is not, I’ll go with the MMR and then pay for the chicken pox vaccination.

Update 28th March 2014: Correction – The varicella vaccination is available at my GP surgery but for a fee. 

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Scitkk by Tarnjit Khera is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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