You can hear the voices of our peers being silenced, ignored, shunned and distorted.
Staggering out of their bedroom doorways to the street corner to score a dime bag.
Bright, insightful millennials freezing in search of warmth from something to believe in that will encourage them to look forward to see another day.
Where our economy has made financial prudence clear when talking about education, yet price tags of university tuition's skyrocket.
The refused, the ones with hope but no money or scholarships; tread the streets with the echoes of electro house pulsing in their skulls.
Those who strip themselves down and shred their own morals to scraps just to find themselves and to see their own limitations.
Searching for answers to the unknown, to ascertain what they are, who they are and why.
Timid in high school, pushed along with nothing and no one to put their creative vigor into.
The squeakiest wheels that were never even considered to be given a good greasing.
Faculties giving them lethargic hellos on the first day of school, bestowing celebrated goodbyes to them on graduation day, diplomas in hand.
Now are the ones slumped over in a lackadaisical position contemplating how they can afford an education.
They work eight to ten at seven twenty five an hour Monday to Friday; and weekends staying in as not to blow their earnings.
Those who commute to university and balance a job with it, I applaud you.
The bewilderment of adulthood, the overabundance of pressure and responsibility.
Awakened from nightmares of lost opportunities, missed trains and lost contacts.
To step out of bed and splash water onto a severely distressed face and staring into a mirror with a despairing look.
Then hoping a bus to Garfield to bring back weight for all the embryonic smokers not yet at the point of make or break, just save up enough to pave my own way.
Gazing at the town on a roof top, chugging down the tenth…no…twelfth beer of the night wondering how this all happened.
Wild sensations of kissing an attractive stranger, the rush of touching on things never felt, tasting pleasures only the lucky have known.
The passionate, yet dissolute yearning for that ever eluding ******* adrenaline. Pounding, Pounding, Pounding until the culmination of energy has come.
Flip sided to those dizzying, tear jerking thoughts of suicide, annihilation of ones being, the contradictions of their faith in themselves and the people around them.
Unexplainable waves of anxiety crashing onto the shore of a diminutive island of optimism
Striving to look past the panic, the gloominess and fury that may or may not be present. But to remain composed and press forward to what awaits them.
Coffee keeps them going. Cup after cup, late night cramming every bit they can; into their caffeine driven psyches until the indisputable crash and failure.
Packs and packs of menthol cigarettes to calm their rattling nerves but at the same time killing them slowly. Their lives will seem shorter than the time it took to finish one bogey when death is near.
Marijuana induced ventures to run down burger shacks, laughing hysterical in the car ride, eyes heavy with a most ridiculous elastic grin extending from ear to ear. While inside millions of thoughts and realizations of consciously simple speculations and troubles become clear and unproblematic. So the joy is mirrored outside in.
LSD trips in Petruska dancing and singing in the rain! Making music, making love; playing pretend and creating art. Becoming a family while kicking back under the warmth of an illuminated tree on a cool fall night.
MDMA streaming through the body, everything is as it should be
Beautiful, lovely to touch, wondrous to stroke, marvelous to move.
To contact and connect, converse and converge with the dwelling desire to share what you feel with everyone for it would be selfish and unpleasant to keep it in.
Mushrooms oh the emotional overflow I need not say more but ****.
Then there are over the counter candies, Oxycontin, ******, Adderall and Xanax, painkillers and antidepressants. Ups, downs, side ways and backwards.
Selling addiction and dependency legally to kids. Making heroine, ******* and speed easily obtainable to them. Changing the names and giving out prescriptions so the parents can feel like they're actually helping their children but are subconsciously making it easier on themselves because they cannot handle the way their offsprings actually are. Some parents a feel it is the only way, I wish it wasn't so. Becoming zombies, mindless addicts before they even start to mature into puberty. I've seen it, firsthand front row.
Oh, the monotonous, mundane rituals and agendas of our lives. School, work, sleep eat, the sluggish schedules and repetitions of yesterday's conversations and redundancy of itineraries we had plotted months prior.
Same people, the constant faces of boredom that groan in apathy and hold the fear of complacency.
We talk about how hum drum out lives have become and what we could to put some color in our world but don’t.
We speak of how unfair the system is but ultimately confuse ourselves and everyone else due to lack or organization and dedication so nothing is changed.
We speak of breath taking women we want to share ****** fantasies with but can’t even muster enough courage to send a trivial friend request.
Texting away for hours trying to court those who now occupy our minds and possess our hearts hoping they may allow us to acquire their attention and affection. Calling them only to receive futile dial tones and know we are being evaded.
Weeping on and on for seemingly endless time frames of a dilapidated relationship that was so strained that a miniscule breeze could cause it to collapse but still clinging to every memory as if they were vital hieroglyphics depicting your very essence.
Brilliant theories blurted out in a drunken stupor.
Ingenious hypothesis shrouded in marijuana smoked out room.
Remembrance of friends long gone.
The marines, the navy.
The casualties of drug addiction.
The conquerors or their afflictions.
The scholars.
The insane locked away on the flight deck never to be seen again.
Teenage mothers unsure of themselves, abandoned by their families for they believe that they brought fictional shame upon the family’s name. The fate of the child is unclear but the mother’s everlasting love shines through any obscurities in its way.
Dear mother of the new born winter’s moon may the aura of life protect you and your baby.
The father gone without a trace.
He will never know his daughter.
And it will haunt him forever.
Parents bringing up their kids with values and morals, The Holy Bible, mantras and meditation, the Holy Quran, The Bhagavad Gita, and Upanishads. Islamic anecdotes and Jewish parables.
The names all different
The message the same
The stories unlike
Goals equivalent
Faith
Kabala, Scientology and Wicca
Amish and Mormons
All separate paths that intertwine and runoff each other then pool into the plateau of eternal life.
But do we have faith in our country, our government?
They do not have faith in us. Cameras on every street corner, FBI agents stalking social media, recordings of our personal lives and police brutality. 4th amendment where have you gone?
We say farewell to Oresko the last veteran of the last great war. And revisit the Arab spring, Al-Assad’s soldiers opening fire on innocent protesters, one hundred fifteen thousand lay dead. Bin laden dead, Hussein hanged, Gaddafi receiving every ounce of his comeuppance. War, terrorism, the fear of being attacked or is it an excuse to secure our nation's investments across the sea? Throwing trillions of dollars to keep the ****** machine cranking away, taxes, pensions, credit scores, insurance and annuities all cogs in the convoluted contraptions plight.
My dear friend contemplates this every night laying in bed, fetal position; the anxiety if having to be a part of this.
Falling apart on the inside but on the outside, an Adonis, *******, Casanova wanna be. Who worshiped the almighty dollar, gripping it so tightly until it made change, drank until he had his fill falling face first into the snow. The guy who lead on legions of clueless girls wearing their hearts on their sleeves not knowing he had a girlfriend the entire time. Arranging secret meetings in hidden gardens, streaking into the early morning. Driving to Ewing in his yellow Mustang to woo a sado masochistic girl. The chains and whips do nothing to him he is already numbed by the thrill. Then he comes home, lays in bed until one, with no job and having people pay for his meals.
He knows what he does and who he is wrong. He recites and regurgitates excuses endlessly. He cries because he knows he is weak, he knows he must fix himself. I sit on the edge of myself with my fingers crossed hoping maybe, maybe he will set himself straight.
My chum who can talk his way out of any confrontation and into a woman’s *******. Multitudes of amorous affairs in backrooms, backseats, front rows of movies theaters. Selfish, boastful and ignorant, yet woman fling themselves at him like catapulted boulders over a medieval battle field just to say hello. These girls blind to see what going on, for their eyes were taken by low self esteem. A need to be accepted, to feel wanted even only for fifteen minutes. Poor self image, daddy issues, anorexic razor blade slicing sirens screaming on about counted calories and social status. Their uncontrollable mental breakdowns and emotional collapse. Their uncles who ***** them, their parents who split up and confusing their definition of love and loyalty for the rest of their lives. Broken homes, domestic abuse and raised voices, sending jolts of fright into the young girl’s fragile minds. I send my sorrows to you ladies, to see such beautiful creatures suffer then be used and thrown away with the ****** that was just ****** deep into their *****.
Then I see women and men of marvelous stature, romantic in the streets holding everyone and everything in high regards. Finding beauty in anything and anyone. Enjoying every second as if the rapture was over head eating exotic foods from unheard of countries and cultures. Bouncing to the sound of whimsical , reverb ricochets and sense stimulating music. Huffing inspiration to create something out of thin air. Dancing to retired jazz and swing albums as if no time had past since their conception. Wearing bold colors and patterns, thrifty leather shoes or suede.
Dawning pre-owned blazers because why spend hundreds of dollars on new clothes just to look good but feel uncomfortable with a hole in your pocket. Dressing up but dressing down, so class yet urban I love it, chinos, pea coats and flannels so simple but chic.
At night they go to underground dens, sweaty bodies, loud music and freedom. Expressive manifestations glowing fueled with MDMA and other substances to further their enjoyment of the dark glorious occasion. Kandi kids sporting colorful bracelets, not watches for time is of no concern to them, they have all eternity they know that.
Going to book stores, coffee shops just to have some peace of mind and a moment of silence to themselves so that can weave the tapestry of imaginative innovation. Writing their own versions of the same story, endless doors of perception, reading news papers and taking it with a grain of salt. Watching the news on TV with a hand full of salt. Searching for the real story so they can know if the world they all live in is actually safe.
She who made her own way breaking hearts, rolling blunts and making deals. The flower child of the modern age, left the rainy days in search of radiant sunshine, idealistic. Reality was subjective, purple dyed hair, multicolored sweater with sandals on her feet. A ten inch bowl with bud from California packed in tightly. Coming from Dumont to Bergenfeild then on to Philly to Mount Vernon. Off to Astoria and the Heights. Now to Sweden laying in the grassy plains below the mountains. Good for you my friend whom I have loved, may fortunes of unsullied joy come to you and all you meet.
Since you’ve left I have encountered drunken burly firemen just trying to have a good time. Pounding down Pabst Blue Ribbon as if it were water; as if it were good tasting beer. But heroes none the less.
EMT's, young eighteen years old high school graduates, saving lives reviving people who are a mere inch close to death.
Sport stars getting scholarships thanks to their superior skills and strength.
Striking beauty school students who are into making the people of this world a little bit more beautiful on the outside.
All these people, successful, doing things. Departing to their desired destinations. I see inside them, they carry baggage, loneliness and insecurities. I can feel their guilt slowing them down. All have their loads but it’s the way they carry them that shows who they really are. And to me their all gems.
Not far in Paterson I watch the junkies limping across busy winding street, perusing a severely needed fix. “Diesel!” they shout beneath flickering streetlights, asking for spare change and if bold enough a ride to some shady sketchy place. I give them a dollar and politely decline. They’ll die without it. Vomiting up bile and blood, twitches and shivers are all you feel when it’s not in you. They cannot stop, they need help. Why not help them instead of “assisting” those who are homosexual? Cleansing so they can be granted entry to the kingdom of God. Looking down on people who have found love and understanding and a deep attraction to others who just so happen to share alike genitals.
Narrow minded uproars about the spread of AIDS, nonsense! The puritanical onslaught of those who want nothing more than the rest of us, love. "Gay", "****", "******", "queer", how about "kind", "funny", "genuine human being"? The right to be married and divorced should be an option for everyone to enjoy. The strains and hardships of matrimony are yours if you want them. If you don’t agree don’t hate or harm just allow them to be peacefully. Same goes for anything for that matter, Jehovah's going door to door, Mormons from Burbank. New ideas are never a bad thing, they’re not a waste of time. On average you have about eighty years to mull over your options.
Some people don’t live long enough to do so, cancer is rampant, blood diseases, ****** diseases, natural disasters coming right out of left field and blindsiding the innocent bystanders of both hemispheres. Some go through life handicapped, autism is apparent these days. Schizophrenia, Asperburgers, ADD and ADHD. Some lose their golden memories of their many valuable years walking down Alzheimer's Lane, not being able to remember whatever transpired only a few moments ago but revisiting gold nuggets from from fifty-some-odd years ago with ease. Some go through life delusional or bipolar. Some can't even sleep at night but they still carry on. And if assistance is needed it is our job as a race to help our brothers and sisters, no one deserves to be excluded from the gala of life. Or be denied by society and pumped with brightly colored pills from doctors promising a cure but prescribing a crutch.
Finding solace in sincerity.
The serendipity of it all hasn’t been uncovered and that keeps me going.
“Radiate boundless love towards the entire world above, below and across. Unhindered without ill will without enmity.” Oh Buddha the truth as it ever was.
Who is he who keeps these thoughts from the conscious minds of the population?
Who is it that distracts us from the humbling beauty and overwhelming devastation of this place of existence we’re in?
It’s they who do under the table parlor trick behind our backs.
Those who broadcast mind numbing so called reality TV shows without an underlying value or meaning.
Those who produce music, proclaiming extravagance to be the end all be all gluttonous goal we all should aim to achieve.
And those who turn noble causes into money making scams and defile pure ideas.
And of course those who give false promises of easily obtained  bright futures, those who don’t care, those who steal, ****, curse, bad mouth and lie. But still manage to get elected into positions that more or less decide out fates. Monsters, demons, banshees howling inconsequential worries and leaving us deaf to hear the real issues.
The

HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to us e
M-M-R II safely and effectively. See full prescribing information
for M-M-R II.
M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live)
Suspension for subcutaneous injection
Initial U.S. Approv al: 1978
-------------------------------INDICATIONS AND USAGE-------------------------------
M-M-R II is a vaccine indicated for active immunization for the
prevention of measles, mumps, and rubella in individuals 12 months of
age and older. (1)
-------------------------- DOSAGE AND ADMINISTRATION--------------------------
Administer a 0.5-mL dose of M-M-R II subcutaneously. (2.1)
• The first dose is administered at 12 to 15 months of age. (2.1)
• The second dose is administered at 4 to 6 years of age. (2.1)
------------------------DOSAGE FORMS AND STRENGTHS -----------------------
Suspension for injection (0.5-mL dose) supplied as a lyophilized
vaccine to be reconstituted using accompanying sterile diluent. (3)
---------------------------------- CONTRAINDICATIONS ----------------------------------
• Hypersensitivity to any componentof the vaccine. (4.1)
• Immunosuppression. (4.2)
• Moderate or severe febrile illness. (4.3)
• Active untreated tuberculosis. (4.4)
• Pregnancy. (4.5, 8.1)
-------------------------- WARNINGS AND PRECAUTIONS --------------------------
• Use caution when administering M-M-R II to individuals with a
history of febrile seizures. (5.1)
• Use caution when administering M-M-R II to individuals with
anaphylaxis or immediate hypersensitivity following egg ingestion.
(5.2)
• Use caution when administering M-M-R II to individuals with a
history of thrombocytopenia. (5.3)
• Immune Globulins (IG) and other blood products should not be
given concurrently with M-M-R II. (5.4, 7.2)
----------------------------------ADVERSE REACTIONS----------------------------------
See full prescribing information for adverse reactions occurring duri ng
clinical trialsor the post-marketing period. (6)
To report SUSPECTED ADVERSE REACTIONS, contact Merck
Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-8 7 7 -
888-4231 or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.
-----------------------------------DRUG INTERACTIONS----------------------------------
• Administration of immune globulins and other blood products
concurrently with M-M-R II vaccine may interfere with the
expected immune response. (7.2)
• M-M-R II vaccination may result in a temporary depression of
purified protein derivative (PPD) tuberculin skin sensitivity. (7.3)
-------------------------- USE IN SPECIFIC POPULATIONS--------------------------
• Pregnancy: Do not administer M-M-R II to females who are
pregnant. Pregnancy should be avoided for 1 month following
vaccination with M-M-R II. (4.5, 8.1, 17)
See 17 for PATIENT COUNSELING INFORMATION and FDA
approv ed patient labeling.
Rev ised: 06/2020
FULL PRESCRIBING INFORMATION: CONTENTS
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Dose and Schedule
2.2 Preparation andAdministration
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
4.1 Hypersensitivity
4.2 Immunosuppression
4.3 Moderate or Severe Febrile Illness
4.4 Active Untreated Tuberculosis
4.5 Pregnancy
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
5.2 Hypersensitivity to Eggs
5.3 Thrombocytopenia
5.4 Immune Globulins and Transfusions
6 ADVERSE REACTIONS
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
7.2 Immune Globulinsand Transfusions
7.3 Tuberculin Skin Testing
7.4 Use with Other Live Viral Vaccines
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
8.2 Lactation
8.4 Pediatric Use
8.5 Geriatric Use
11 DESCRIPTION
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.6 Persistence of Antibody Responses After Vaccination
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
14 CLINICAL STUDIES
14.1 Clinical Efficacy
14.2 Immunogenicity
15 REFERENCES
16 HOW SUPPLIED/STORAGE AND HANDLING
17 PATIENT COUNSELING INFORMATION
Sections or subsections omitted from the full prescribing info rma tion
are not listed.
2
FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
M-M-R® II is a vaccine indicated for active immunization for the prevention of measles, mumps, and
rubella in individuals 12 months of age and older.
2 DOSAGE AND ADMINISTRATION
For subcutaneous use only.
2.1 Dose and Schedule
Each 0.5 mL dose is administered subcutaneously.
The first dose is administered at 12 to 15 months of age. A second dose is administered at 4 to 6
years of age.
The second dose may be administered prior to 4 years of age, provided that there is a minimum
interval of one month between the doses of measles, mumps and rubella virus vaccine, live {1-2}.
Children who received an initial dose of measles, mumps and rubella vaccine prior to their first
birthday should receive additional doses of vaccine at 12-15 months of age and at 4-6 years of age to
complete the vaccination series [see Clinical Studies (14.2)].
For post-exposure prophylaxis for measles, administer a dose of M-M-R II vaccine within 72 hours
after exposure.
2.2 Preparation and Administration
Use a sterile syringe free of preservatives, antiseptics, and detergents for each injection and/or
reconstitution of the vaccine because these substances may inactivate the live virus vaccine. To
reconstitute, use only the diluent supplied with the vaccine since it is free of preservatives or other
antiviral substances which might inactivate the vaccine.
Withdraw the entire volume of the supplied diluent from its vial and inject into lyophilized vaccine vial.
Agitate to dissolve completely. Discard if the lyophilized vaccine cannot be dissolved.
Withdraw the entire volume of the reconstituted vaccine and inject subcutaneously into the outer
aspect of the upper arm (deltoid region) or into the higher anterolateral area of the thigh.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to
administration, whenever solution and container permit. Visually inspect the vaccine before and after
reconstitution prior to administration. Before reconstitution, the lyophilized vaccine is a light yellow
compact crystalline plug, when reconstituted, is a clear yellow liquid. Discard if particulate matter or
discoloration are observed in the reconstituted vaccine.
To minimize loss of potency, administer M-M-R II as soon as possible after reconstitution. If not used
immediately, the reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from
light, for up to 8 hours. Discard reconstituted vaccine if it is not used within 8 hours.
3 DOSAGE FORMS AND STRENGTHS
M-M-R II vaccine is a suspension for injection supplied as a single dose vial of lyophilized vaccine to
be reconstituted using the accompanying sterile diluent [see Dosage and Administration (2.2) and How
Supplied/Storage and Handling (16)]. A single dose after reconstitution is 0.5 mL.
4 CONTRAINDICATIONS
4.1 Hypersensitivity
Do not administer M-M-R II vaccine to individuals with a history of hypersensitivity to any component
of the vaccine (including gelatin) {3} or who have experienced a hypersensitivity reaction following
administration of a previous dose of M-M-R II vaccine or any other measles, mumps and rubellacontaining vaccine. Do not administer M-M-R II vaccine to individuals with a history of anaphylaxis to
neomycin [see Description (11)].
4.2 Immunosuppression
Do not administer M-M-R II vaccine to individuals who are immunodeficient or immunosuppressed due
to disease or medical therapy. Measles inclusion body encephalitis {4} (MIBE), pneumonitis {5} and death
as a direct consequence of disseminated measles vaccine virus infection have been reported in
3
immunocompromised individuals inadvertently vaccinated with measles-containing vaccine. In this
population, disseminated mumps and rubella vaccine virus infection have also been reported.
Do not administer M-M-R II to individuals with a family history of congenital or hereditary
immunodeficiency, until the immune competence of the potential vaccine recipient is demonstrated.
4.3 Moderate or Severe Febrile Illness
Do not administer M-M-R II vaccine to individuals with an active febrile illness with fever >101.3F
(>38.5C).
4.4 Active Untreated Tuberculosis
Do not administer M-M-R II vaccine to individuals with active untreated tuberculosis (TB).
4.5 Pregnancy
Do not administer M-M-R II to individuals who are pregnant or who are planning on becoming
pregnant within the next month [see Use in Specific Populations (8.1) and Patient Counseling Information
(17)].
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
There is a risk of fever and associated febrile seizure in the first 2 weeks following immunization with
M-M-R II vaccine. For children who have experienced a previous febrile seizure (from any cause) and
those with a family history of febrile seizures there is a small increase in risk of febrile seizure following
receipt of M-M-R II vaccine [see Adverse Reactions (6)].
5.2 Hypersensitivity to Eggs
Individuals with a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives,
swelling of the mouth and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion
may be at an enhanced risk of immediate-type hypersensitivity reactions after receiving M-M-R II vaccine
.The potential risks and known benefits should be evaluated before considering vaccination in these
individuals.
5.3 Thrombocytopenia
Transient thrombocytopenia has been reported within 4-6 weeks following vaccination with measles,
mumps and rubella vaccine. Carefully evaluate the potential risk and benefit of vaccination in children
with thrombocytopenia or in those who experienced thrombocytopenia after vaccination with a previous
dose of measles, mumps, and rubella vaccine {6-8} [see Adverse Reactions (6)].
5.4 Immune Globulins and Transfusions
Immune Globulins (IG) and other blood products should not be given concurrently with M-M-R II [see
Drug Interactions (7.2)]. These products may contain antibodies that interfere with vaccine virus
replication and decrease the expected immune response.
The ACIP has specific recommendations for intervals between administration of antibody containing
products and live virus vaccines.
6 ADVERSE REACTIONS
The following adverse reactions include those identified during clinical trials or reported during postapproval use of M-M-R II vaccine or its individual components.
Body as a Whole
Panniculitis; atypical measles; fever; syncope; headache; dizziness; malaise; irritability.
Cardiovascular System
Vasculitis.
Digestive System
Pancreatitis; diarrhea; vomiting; parotitis; nausea.
Hematologic and Lymphatic Systems
Thrombocytopenia; purpura; regional lymphadenopathy; leukocytosis.
Immune System
Anaphylaxis, anaphylactoid reactions, angioedema (including peripheral or ****** edema) and
bronchial spasm.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
4
Nervous System
Encephalitis; encephalopathy; measles inclusion body encephalitis (MIBE) subacute sclerosing
panencephalitis (SSPE); Guillain-Barré Syndrome (GBS); acute disseminated encephalomyelitis (ADEM);
transverse myelitis; febrile convulsions; afebrile convulsions or seizures; ataxia; polyneuritis;
polyneuropathy; ocular palsies; paresthesia.
Respiratory System
Pneumonia; pneumonitis; sore throat; cough; rhinitis.
Skin
Stevens-Johnson syndrome; acute hemorrhagic edema of infancy; Henoch-Schönlein purpura;
erythema multiforme; urticaria; rash; measles-like rash; pruritus; injection site reactions (pain, erythema,
swelling and vesiculation).
Special Senses — Ear
Nerve deafness; otitis media.
Special Senses — Eye
Retinitis; optic neuritis; papillitis; conjunctivitis.
Urogenital System
Epididymitis; orchitis.
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 Globulinsand Transfusions
Administration of immune globulins and other blood products concurrently with M-M-R II vaccine may
interfere with the expected immune response {9-11} [see Warnings and Precautions (5.4)]. 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.
5
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 viruses 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 lactatingpostpartum 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 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.
6
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 effectivenes s 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. {22-28}
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. {29-34} These studies also established that seroconversion in response to vaccination
against measles, mumps and rubella paralleled protection. {35-38}
14.2 Immunogenicity
Clinical studies enrolling 284 triple seronegative children, 11 months to 7 years of age, demonstrated
that M-M-R II vaccine is immunogenic. In these studies, a single 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 with Measles Virus Vaccine, Live
(previously US-licensed, manufactured by Merck), 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.
15 REFERENCES
1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices, MMWR
43(RR-1): 1-38, January 28, 1994.
2. Measles, Mumps, and Rubella — Vaccine Use and Strategies for Elimination of Measles, Rubella, a n d Co n g e nita l Ru b e lla
Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practice s (ACIP), M M WR
47(RR-8): May 22, 1998.
3. Kelso, J.M.; Jones, R.T.; Yunginger, J.W.: Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gel atin , J.
Allergy Clin. Immunol. 91: 867-872, 1993.
4. Bitnum, A.; et al: Measles Inclusion Body Encephalitis Caused by the Vaccine Strain of Measles Virus. Cl i n . In fect. Di s. 2 9 :
855-861, 1999.
5. Angel, J.B.; et al: Vaccine Associated Measles Pneumonitis in an Adult with AIDS. Annals of Internal Medicine, 129: 1 0 4 -1 06 ,
1998.
6. Cecinati V, et al. Vaccine administration and the development of immune thrombocyto pe ni c p urp u ra i n ch i ld re n. Hu m an
Vaccines & Immunotherapeutics 9:5, 2013.
7. Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic Purpura after Measles-Mumps-Rubella Vaccination: A Systematic
Review of the Literature and Guidance for Management. J Ped 156(4): 2010.
8. Andrews N, Stowe J, Miller E, Svanstrom H, Johansen K, Bonhoeffer J, et al. A collaborative approach to investigating th e ri sk
of thrombocytopenic purpura after measles-mumps-rubella vaccination in England and Denmark. Vaccine. 2012;30:3042‐6.
9. Rubella Prevention: Recommendation of the Immunization Practices Advisory Committee (ACIP), MM WR 3 9 (RR-1 5 ): 1 -1 8 ,
November 23, 1990.
7
10. Peter, G.; et al (eds): Report of the Committee on Infectious Diseases, Twenty-fourth Edition, American Academy of Pediatri cs,
344-357, 1997.
11. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP), MMWR 38(S-9): 5-22,
December 29, 1989.
12. Eberhart-Phillips, J.E.; et al: Measles in pregnancy: a descriptive study of 58 cases. Obstetrics and Gynecology, 82(5): 797-801,
November 1993.
13. Jespersen, C.S.; et al: Measles as a cause of fetal defects: A retrospective study of ten measles epidemics in Greenland. Acta
Paediatr Scand. 66: 367-372, May 1977.
14. Yamauchi T, Wilson C, Geme JW Jr. Transmission of live, attenuated mumps virus to the hu m a n p l ace n ta . N En g l J M e d .
1974;290(13):710‐712.
15. Rubella Vaccination during Pregnancy —United States, 1971-1988. JAMA. 1989;261(23):3374–3383.
16. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. II.
Maternal-neonatal interactions, J. Infect. Dis. 145: 661-666,1982.
17. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. I.
Development and characterization of specific immunologic reactivity in breast milk, J. Infect. Dis. 145: 654-660, 1982.
18. Landes, R.D.; Bass, J.W.; Millunchick, E.W.; Oetgen, W.J.: Neonatal rubella following postpartum maternal i mm un izatio n , J.
Pediatr. 97: 465-467, 1980.
19. Lerman, S.J.: Neonatal rubella following postpartum maternal immunization, J. Pediatr. 98: 668, 1981. (Letter)
20. Plotkin, S.A.; Cornfeld, D.; Ingalls, T.H.: Studiesof immunization with living rubella virus: Trialsin children with a strain culture d
from an aborted fetus, Am. J. Dis. Child. 110: 381-389, 1965.
21. Plotkin, S.A.; Farquhar, J.; Katz, M.; Ingalls, T.H.: A new attenuated rubella virus grown in human fi bro b la sts: Evi d e n ce fo r
reduced nasopharyngeal excretion, Am. J. Epidemiol. 86: 468-477, 1967.
22. Weibel, R.E.; Carlson, A.J.; Villarejos, V.M.; Buynak, E.B.; McLean, A.A.; Hilleman, M.R.: Clinical and Labo ra tory Stu d ie s o f
Combined Live Measles, Mumps, and Rubella Vaccines Using the RA 27/3 Rubella Virus, Proc. So c. Exp . Bi ol. M e d. 1 6 5 :
323-326, 1980.
23. Watson, J.C.; Pearson, J.S.; Erdman, D.D.; et al: An Evaluation of Measles RevaccinationAmong School-Entry Age Ch i ld re n,
31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract #268, 143, 1991.
24. Unpublished data from the files of Merck Research Laboratories.
25. Davidkin, I.; Jokinen, S.; Broman, M. et al.: Persistence of Measles, Mumps, and Rubella Antibodies in a n M M R -Va ccina ted
Cohort: A 20-Year Follow-up, JID 197:950–6, April 2008.
26. LeBaron, W.; Beeler J.; Sullivan, B.; et al.: Persistence of Measles Antibodies After 2 Doses of Measles Vaccine in a
Postelimination Environment, Arch Pediatr Adolesc Med. 161:294-301, March 2007.
27. LeBaron, C.; Forghani, B.; Beck, C. et al.: Persistence of Mumps Antibodies after 2 Doses of Measles-Mumps-Rubella Vaccine,
JID 199:552– 60 , February 2009.
28. LeBaron, W.; Forghani, B.; Matter, L. et al.: Persistence of Rubella Antibodies after 2 Doses of Measles-Mumps-Rubella
Vaccine, JID 200:888–99, September 2009.
29. Hilleman, M.R.; Buynak, E.B.; Weibel, R.E.; et al: Development and Evaluation of the Moraten MeaslesVirusVa cci n e , JAM A
206(3): 587-590, 1968.
30. Weibel, R.E.; Stokes, J.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 3. Clinical and Serologic Aspects in a Fiel d
Evaluation,N. Engl. J. Med. 276: 245-251, 1967.
31. Hilleman, M.R.; Weibel, R.E.; Buynak, E.B.; et al:Live, Attenuated Mumps VirusVaccine 4. ProtectiveEfficacy as Measure d i n
a Field Evaluation, N. Engl. J. Med. 276: 252-258, 1967.
32. Cutts, F.T.; Henderson, R.H.; Clements, C.J.; et al: Principles of measles control, Bull WHO 69(1): 1-7, 1991.
33. Weibel, R.E.; Buynak, E.B.; Stokes, J.; et al: Evaluation Of Live Attenuated Mumps Virus Vaccine, Strain Jeryl Lynn, First
International Conference on VaccinesAgainst Viral and Rickettsial Diseases of Man, World Health Organization, No. 147, M a y
1967.
34. Leibhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; et al: Vaccination With RA 27/3 Rubella Vaccine, Am. J. Dis. Child. 123: 133-1 3 6,
February 1972.
35. Rosen, L.: Hemagglutination and Hemagglutination-Inhibition with Measles Virus, Virology 13: 139-141, January 1961.
36. Brown, G.C.; et al: Fluorescent-Antibody Marker for Vaccine-Induced Rubella Antibodies, Infection and Immunity 2(4): 360-363,
1970.
8
37. Buynak, E.B.; et al: Live Attenuated Mumps Virus Vaccine 1. Vaccine Development, Proceedings of the Society for
Experimental Biology and Medicine, 123: 768-775, 1966.
38. Hilleman M.R., Studies of Live Attenuated Measles Virus Vaccine in Man: II. Appraisal of Efficacy. Amer. J. o f Pu b l ic He a lth ,
52(2):44-56, 1962.
39. Johnson, C.E.; et al: Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles
Vaccine Era, Pediatrics, 93(6): 939-943, 1994.
16 HOW SUPPLIED/STORAGE AND HANDLING
No. 4681 ⎯ M-M-R II vaccine is supplied as follows:
(1) a box of 10 single-dose vials of lyophilized vaccine (package A), NDC 0006-4681-00
(2) a box of 10 vials of diluent (package B)
Exposure to light may inactivate the vaccine viruses.
Before reconstitution, refrigerate the lyophilized vaccine at 36°F to 46°F, (2°C to 8°C).
Store accompanying diluent in the refrigerator with the lyophilized vaccine or separately at room
temperature (68° to 77°F, 20° to 25°C). Do not freeze the diluent.
Administer M-M-R II vaccine as soon as possible after reconstitution. If not administered immediately,
reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from light, for up to 8
hours. Discard reconstituted vaccine if it is not used within 8 hours.
For information regarding the product or questions regarding storage conditions, call 1-800-
MERCK-90 (1-800-637-2590).
17 PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Patient Package Insert).
Discuss the following with the patient:
• Provide the required vaccine information to the patient, parent, or guardian.
• Inform the patient, parent, or guardian of the benefits and risks associated with vaccination.
• Question the patient, parent, or guardian about reactions to a previous dose of M-M-R II vaccine
or other measles-, mumps-, or rubella-containing vaccines.
• Question females of reproductive potential regarding the possibility of pregnancy. Inform female
patients to avoid pregnancy for 1 month following vaccination [see Contraindications (4.5) and
Use in Specific Populations (8.1)].
• Inform the patient, parent, or guardian that vaccination with M-M-R II may not offer 100%
protection from measles, mumps, and rubella infection.
• Instruct patients, parents, or guardians to report any adverse reactions to their health-care
provider. The U.S. Department of Health and Human Services has established a Vaccine
Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events
after the administration of any vaccine, including but not limited to the reporting of events required
by the National Childhood Vaccine Injury Act of 1986. For information or a copy of the vaccine
reporting form, call the VAERS toll-free number at 1-800-822-7967, or report online at
https://www.vaers.hhs.gov.
For patent information: www.merck.com/product/patent/home.html
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I saw you in winter,
and thought of tree branches feathered by starlight in poorly lit neighborhoods. A hearth where the more honest parts of myself, I am bared fetal, warmed upon, welcomed.

I saw you in spring,
and thought of long drives in the countryside in the rain. Ice cream melting from our chins dancing petrichor upon our toes, kissing by the sea shore.

I saw you in summer,
and thought of sleepy boathouses, uncovering ancient childhood treasures in the woods. A secret lake somewhere, the sky's reflection in promise. Windy hilltops upon which to blame each other for the sunrise.

I saw you in autumn,
and thought of scarfs and cafes, city streets and sunsets where we watched each others breath escape. Apartment staircases where windchill hibernates, the world slowing down around us from your window.

The first time I saw You, I thought to myself, "I could live there."

Janie pushes the metal book cart back into its parking space in the Document Delivery Department of the St. Louis Public Library and hangs the last sticky note for October 30, 2012 on the wall by the head of the department’s closed door. She retightens her brown scarf under her chin, tucking the wispy hairs above her ears back into hiding. Having your hair begin to prematurely gray as a teenager has dramatic effects on a person. Her mother wore scarves around her wrists when Janie was growing up and when Janie begin to wear scarves to conceal her salt-and-pepper hair, her mother just smiled. The clock hanging on the wall above the children’s section reads 11:28pm.
Two more minutes.
She reorganized the pens and books on her desk and set the box reading NOTES onto the right corner or her desk with three blue pens and a stack of note cards. Her coworkers learned fast that Janie does not like to talk. She does not like eye contact. She loves the silence, and never ever to ask her about her hair. Her manager gave her the NOTES box after about a month of horrible miscommunication and everyday it fills with requests for books or tasks that Janie has to complete. She completes the tasks one by one, alone, in her back office in the Reference Department and hangs the completed sticky notes on the wall by her manager’s door. She works the night shift and locks the library up every night. When she’s alone she can talk out loud to herself and those are the only voices she cares to hear.
“Goodnight, books. Good night, rooms.” Janie shut the heavy wooden door to the library, placed the color-coded keys in the front right pocket of her jacket, and began her walk to the bus stop one corner away. She avoids the main road, taking her first right onto a side street that she knows would spit her out right beside the bus stop.
“Goodnight Taco Bell Sign. Goodnight Rite-Aide. Goodnight Westside Apartments. Goodnight Jack-o-Lantern smile.” She stopped in the middle of the alley and peered up at the Jack-o-Lantern grinning down at her from the third story window above. “Mother wouldn’t’ve liked your smirk, Jack. She would’ve slapped that **** right off your face.” Janie, satisfied the pumpkin was put in its rightful place, smiled as she trotted on.
“Mother carved smiles into her arms and that’s why Daddy left, it is, it is.” She kicked at a crushed Mountain Dew can as she remembered that night from years ago.

“Mommy?” Janie pushed opened the door to her mother’s bedroom and saw the moving-boxes torn open and all their contents scattered across the floor. She tiptoed through piles of scarves and silverware and corkscrews until she reached the bathroom in her mom’s room.
“Come to us like rain, oh lord, come and stay and sting a while more, oh lord…” her mother’s voice was slipping off the tiled bathroom walls. Janie pushed open the door and saw the blood for the first time pouring from her mother’s wrist. Her mother was naked and perched on the bathroom sink, singing to a red razor blade.
“Mommy?”
“GET OUT!” Her mother jumped from the counter and perched on all fours on the floor. She began to growl and speak in a voice too deep to be coming from her own throat.
“Mommy! It’s Janie!” She began to cry as her mother, still naked and bleeding, twisted and writhed onto her back and began to crawl towards the door that Janie hid behind.


“Thirty-Three percent, dear. Just a thirty-three percent chance.” She shivered trying to clear the last memory of her mother with the words that all the shrinks had echoed to her over the years. “Schizophrenia is directly related to genetics, little is known about the type of Schizophrenia mother was diagnosed with except that it is definitely passed on genetically. But, there is only a thirty-three percent chance you could have it, dear. Thirty-three percent.” The sound of the bus stop ahead reminds her it is time to be silent again.
“Disorganized Schizophrenia.” She mouthed to herself as she stepped back out onto the busy street from her alleyway. She tightened her scarf and saw the bus pull into the pickup spot. She walked forward to the bus, again immersed in her self-imposed silence.
Stepping out of the February cold, Janie removes her wool scarf as the bus doors close behind her.
“Where to baby?” The driver smiles a sticky smile. Her nametag reads, “Shannon” and has a decaying Hello-Kitty sticker in the bottom left corner.
“The Clinton Street drop.” She hands the driver her $2.50 fare and avoids the woman’s questioning eyes. The night drivers are always more talkative, curious.
“Your ticket hon.” She tears Janie a ticket stub. “Everything is pretty dead this late, I’ll have you there in ten minutes top.”
Janie begins to shuffle towards the seats, ignoring the woman.
“You mind if I crank up the music?” The bus driver asks, purple fingernails scratching in her thick blonde hair. “I need to keep my eyes open and blood flowing and music is my fire of choice you know?”
“Sure.” Janie shrugs her bag onto her shoulder and walks on before the woman can say anything else.
“Route E-2, homebound.” Shannon’s voice crackles over the loudspeaker.
She shuffles down the bus towards her usual seat; second from the back right side.  Shannon starts the bus rolling before she reaches her seat and Janie can hear her singing along to “Summertime” by Janis Joplin. The bus floor, today, is sticky because of the morning rain. Two years of riding public transportation has taught Janie that staring at the floor as she walks to her seat is better than the risk of making eye contact. The bus is usually empty this late but if there ever happens to be anyone else on, it’s better not to converse. Safer that way.
She plops into her seat filling the indention that ghosts of past passengers left. The seat is still warm and Janie squirms around until the stranger heat is forgotten. She tightens her scarf and sighs. The brown pleather seatback in front of her is peeling towards the top. Janie leans forward and idly picks at the scab-like dangles of brown as she watches the sodden city canvas roll past her out the foggy window. As she picks, the hole grows. She twists and digs her unpainted nails into the seat until her hands feel wet, warm. Looking down, they are covered in blood and mud.
“What. The. Actual. ****.” she whispers, wiping her hands on her pants leg. She cautiously picks off another piece of pleather and a trickle of deep red begins to run from the seat back, clumps of mud now falling onto her knees. A puddle of blood and mire splatter down her legs and pool around her feet as she picks at the seat. Her white tights are definitely beyond saving now, so she digs faster until her thumbnail catches on something, bends back, and cracks. She gasps and withdraws her shaking hand, watching her own blood mix with the clotting muck in the seat, half of her thumbnail completely stripped off.
Looking around, all else seems normal. The driver is now muttering along to some banter by Kanye West, completely unaware of Janie’s predicament. She closes her eyes.
This is a dream, this is a dream, wake the **** up.
She opens her eyes to see the pool of filth around her feet trickling towards the front of the bus. Panic sets in with a whisper, They’re going to think it was you, your fault, you’ll be thrown in jail.
“But I didn’t do this.” She lashes out to herself. “I didn’t hurt anyone.”
Next stop, E-2. Shannon blares on the intercom.
“It’s just a dream, get your **** together, Janie.” She laughs at herself, manic.
Prove it! Her subconscious screams.
Convinced to end this moment she has to continue; Janie plunges her hand into the pleather grave one more time. Frantic and confused she laughs as she digs, spittle of muck splashing on her bus window.
Faster, faster, faster.
Deeper, deeper, deeper.
Realer, realer, real.
Wake up, now!
Then, as the bus slows, one last chuck of mud splatters to the floor and Janie sees a pink piece of her thumbnail stabbed into the white of a bone in the bottom of the seatback pit. Her white Ked’s were becoming so red they were almost black. She pulls her knees up to her chest and begins to rock back and forth. Clenching shut her eyes she begins to hum. Janie’s sweet soprano harmonizes with the buses deep droning purr, their wet melody interweaving with the driver’s alto and Lil Wayne’s screech made her feel dizzy as the bus turned right.
She take my money when I'm in need
Yeah she's a trifling friend indeed
Oh she's a gold digger way over town
That dig's on me
The bus slows to a stop and the bass is shaking. Janie is cold. She slowly peeks out of her right eye, expecting to be instantly immersed into the same dismal scene. The seatback is whole again. Releasing her knees, her feet fall back to the floor and her shaking fingers stroke the solid pleather.

“Ma’am? We’re at the Clinton Drop.”
Janie hurriedly picks up her bag and flees down the aisle to the bus doors.
“Everything alright, dear?” The bus driver asks, smiling.
“Fine, just fine.”
“You be safe out there tonight. The night is dark and only ghouls stroll the streets this late.”  Shannon laughed as Janie’s jaw dropped. “Happy Halloween, dear. It’s midnight, today is October 31st.”
The bus doors opened and a cold wind ****** the warm bot-air surrounding Janie into the streets. She begrudgingly followed, her mind spinning as she stepped onto the pavement. The doors slammed behind her and she turned to see Shannon pull out a tube of lipstick and smear it, red, across her cracked lips. Shannon made a duck-face in the mirror and reached down to crank up the music as loud as it would go. The bus exhaled and rolled forward, leaving Janie behind as it splashed through the potholes.
She surveys the surrounding midnight gloom and the street is quiet and dark. Even the stars are hidden behind swirling clouds. She begins to hum, hands in her pocket, and shuffle towards her apartment.
“Goodnight, stars. Goodnight, street.”
As she approaches her single-bedroom apartment, digging through her coat pocket for her keys, her thumb pulsates. She grasps the keys and pulls them out as she steps up to the apartment. Sticking the cold, silver key in the lock she looks down at her thumb and in the shadows of the porch sees half of the nail completely missing. She laughs as she pushes the door open to her bare apartment, light flooding out. Without any hesitation she closes the door behind her, sheds her clothes, and slips onto the mattress in the corner of the room gripping her thumb tight. She reaches out for the glass of milk on the floor beside her bed from the morning and it’s still cold. Nursing the milk, surrounded by blankets and solitude, she reminds herself,  “Only a thirty-three percent chance. A nice, small, round number. Small.”  
She sets down the empty glass and curls into the fetal position under the heavy blankets, pointer finger tracing circles on her thumb. Only when she has heated her blanket cocoon enough to feel safe does she remove her scarf and allow her thick white hair to fall around her face.
“Goodnight, room. Goodnight, mother,”

She lays awake,
Trembling in the dark
Whispers echoing around,
Cracking the glass
Shiny liquids fall slowly
From eyelids to floor
Hopelessly awaiting
For a knock on the door
The darkness surrounds
Each and every soul
The girl's heart melting
For it couldn't bear breaking
As the light made its way
Through the cracked glass
The tiny fetal form
Breathed in a rasp
Soon the weak heart
Slowed the last beat
The cracked window opened
Spreading the heat
But the darkened eyes
Light had no more
The soul had wandered
To the deadly shore

sometimes i seriously doubt
if i will ever recover
from this loss,
this bruise
from losing you.

sometimes i wake up in the middle of the night
to sweat soaked sheets and mascara-drenched pillow cases,
curled up in full fetal-position
and i think about you
and how i'm lucky that i even accomplish falling sleep
at all.

i think that's just the difference between the body and the mind -
the body won't stop contorting itself to match your
dissected heart
just because you did or did not decide to say
goodbye to someone.

and this is why i woke up with a knots like stones
inside of my back,
practically paralyzed
it's like my body is trying to punish me
for going against its
ferocious nature. all it wants
is to be back inside you.

sometimes i seriously doubt
if i will ever recover
from this loss,
this bruise
from losing you.

broken has made a cold home out of me.

there is a monster beneath
the lofty, billowing sheets of my bed
beneath the mattress
the box spring
the carefully crafted wooden frame.

[he lives in the shadows,
in the obscurity there.]

i should feel sheltered...safe,
underneath these sheets,
[like my mother’s arms
tucking me in tight,
don’t let the bed bugs bite.]

but when my arm dangles off my bed,
when i commit that fatal mistake,
i feel a draw to the ground
more forceful than the force of gravity
seizing my hand
paining to pull me under.
and i know it is the monster.
i feel his yearning
for the blood and guts of a child...
his desire to rip me apart
like a lion does his prey.

i take back control of my hand,
wrap my arms around myself,
feigning safety.
for as we all know
that monster could very well
clamber, creep out
climb onto my bed
and swallow me whole.

i don’t know why he hasn’t yet --
perhaps he likes the challenge
of waiting for me
to be susceptible enough to
forget myself
and leave my arm suspended
for more than
just a moment.

i am curled up into a fetal position
paralyzed by my fear.
the anxiety invades my joints
so that i cannot move anymore.
i fall into a fitful sleep
and wake up to sunshine radiating
through my window,
casting the intricate patterns of
my curtains on the rug.

during the day,
the monster cannot survive.
but when nighttime falls
the darkness returns,
my trepidation returns
and the monster is alive.
well, again.