Original Article
Thrombocytopenic Purpura after Measles-Mumps-Rubella Vaccination: A Systematic Review of the Literature and Guidance for Management

https://doi.org/10.1016/j.jpeds.2009.10.015Get rights and content

Objective

To determine the incidence of immune thrombocytopenic purpura (ITP) after measles-mumps-rubella (MMR) immunization compared with natural measles and rubella, its clinical course and outcome, and the risk of recurrence after repeat MMR vaccination.

Study design

We performed a systematic review of the Ovid MEDLINE (1950 to present) bibliographic database. We selected studies that reported cases of thrombocytopenia in a known number of children who were immunized with MMR vaccine before development of ITP. We also extracted data from the same and other studies regarding bleeding manifestations and the resolution of MMR-associated thrombocytopenia or thrombocytopenic purpura within 6 months. Finally, we studied the risk of ITP recurrence after MMR immunization or reimmunization.

Results

On the basis of 12 studies, the incidence of MMR-associated ITP ranged from 0.087 to 4 (median 2.6) cases per 100 000 vaccine doses. Severe bleeding manifestations were rare, and MMR-associated thrombocytopenia resolved within 6 months from diagnosis in 93% of the children. MMR vaccination of unimmunized patients with ITP and revaccination of patients with prior ITP did not lead to recurrence of thrombocytopenia.

Conclusions

MMR-associated ITP is rare, self-limited, and non-life threatening, and susceptible children with ITP should be immunized with MMR at the recommended ages.

Section snippets

Methods

We searched the Ovid MEDLINE In-Process & Other Non-Indexed Citations and Ovid MEDLINE 1950 to Present electronic bibliographic database on June 26, 2009, to identify articles that combined the terms measles or mumps or rubella or measles-mumps-rubella vaccine or the abbreviation “MMR” and thrombocytop(a)enia or thrombocytop(a)enic purpura with both the American and the British spelling for these terms. Additionally, we hand-searched the bibliographic references of relevant studies for

Results

Our initial search identified 206 potentially eligible publications. By applying the combined limits of English-only articles, humans, and children 0-18 years old, an additional 103 articles were automatically removed. However, manual search revealed 1 of them to be eligible. After removing 41 case reports, 36 journal articles, and 5 reviews that contained no data on MMR-associated ITP, the number of potentially eligible studies was limited to 22. A total of 13 additional studies were removed

Discussion

Our first goal was to calculate the incidence of thrombocytopenia after MMR vaccination compared with that after measles and rubella. The chance of developing ITP after MMR vaccination is approximately 2.6/100 000 vaccine doses (median value, range 0.087 to 4/100 000).17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 The risk of thrombocytopenia after natural measles or rubella is several fold higher ranging from 6 to 1200/100 000 cases.29, 30, 31, 32 Remarkably, there is no overlap in the

References (47)

  • D.J. Wilhelm et al.

    Thrombocytopenic purpura and pneumonia following measles vaccination

    Am J Dis Child

    (1967)
  • N.L. Saxton

    Thrombocytopenic purpura following the administration of attenuated live measles vaccine

    J Iowa Med Soc

    (1967)
  • H.J. Alter et al.

    Thrombocytopenic purpura following vaccination with attenuated measles virus

    Am J Dis Child

    (1968)
  • R.W. Kiefaber

    Thrombocytopenic purpura after measles vaccination (letter)

    N Engl J Med

    (1981)
  • J. Neiderud

    Thrombocytopenic purpura after a combined vaccine against morbilli, parotitis and rubella

    Acta Paediatr Scand

    (1983)
  • S. Azeemuddin

    Thrombocytopenic purpura after combined vaccine against measles, mumps, and rubella (letter)

    Clin Pediatr (Phila)

    (1987)
  • L. De Ritis et al.

    Thrombopenic purpura following measles vaccination

    Pediatr Med Chir

    (1990)
  • A.L. Rejjal et al.

    Thrombocytopenic purpura following measles-mumps-rubella vaccination

    Ann Trop Paediatr

    (1993)
  • R.A. Drachtman et al.

    Exacerbation of chronic thrombocytopenic purpura following measles-mumps-rubella immunization

    Arch Pediatr Adolesc Med

    (1994)
  • V. Vlacha et al.

    Recurrent thrombocytopenic purpura after repeated measles-mumps-rubella vaccination

    Pediatrics

    (1996)
  • S.S. Kashyape et al.

    Thrombocytopenia following MMR vaccination Indian Pediatr

    (2005)
  • Measles-United States, January-July 2008

    MMWR Morb Mortal Wkly Rep

    (2008)
  • U. Pedersen-Bjergaard et al.

    Thrombocytopenia induced by noncytotoxic drugs in Denmark 1968-91

    J Intern Med

    (1996)
  • Cited by (0)

    The authors declare no conflicts of interest.

    View full text