I've used them on my windows
To see the clear outside,
If I read the Op-eds,
I shudder, shuttered and hide.

I've spread them 'neath my plates and cups,
My shelves all neat and tidy;
But the headlines made it clear to me
My glass is more half empty.

They had a place in the litter box
For **** to scratch and squat;
I laid them round my garden plants,
They made fine insect traps.
Rolled and twirled they'd start a fire,
I could fold them into hats.
They cleaned the grease from BBQs,
And they're safe to pick up glass.
Crumple them for packaging,
They work as school book covers;
Add water and some flour,
To shape papier mache lovers.
Fold seeds in them to germinate,
Then use them for compost;
There's many ways to employ
Your Times and local Post.

But I won't subscribe to Dailies
For the felling of our trees;
And yet I miss my papers,
And the ways they worked for me.
But when enthroned,
You'll hear me grouse,
There's no **** paper in this ****-house.

My cell works well to scroll and swipe,
But it's only good for a virtual wipe.

A REACTIONARY TRACT FOR THE TIMES

(Phi Beta Kappa Poem, Harvard, 1946)

Ares at last has quit the field,
The bloodstains on the bushes yield
To seeping showers,
And in their convalescent state
The fractured towns associate
With summer flowers.

Encamped upon the college plain
Raw veterans already train
As freshman forces;
Instructors with sarcastic tongue
Shepherd the battle-weary young
Through basic courses.

Among bewildering appliances
For mastering the arts and sciences
They stroll or run,
And nerves that steeled themselves to slaughter
Are shot to pieces by the shorter
Poems of Donne.

Professors back from secret missions
Resume their proper eruditions,
Though some regret it;
They liked their dictaphones a lot,
T hey met some big wheels, and do not
Let you forget it.

But Zeus' inscrutable decree
Permits the will-to-disagree
To be pandemic,
Ordains that vaudeville shall preach
And every commencement speech
Be a polemic.

Let Ares doze, that other war
Is instantly declared once more
'Twixt those who follow
Precocious Hermes all the way
And those who without qualms obey
Pompous Apollo.

Brutal like all Olympic games,
Though fought with smiles and Christian names
And less dramatic,
This dialectic strife between
The civil gods is just as mean,
And more fanatic.

What high immortals do in mirth
Is life and death on Middle Earth;
Their a-historic
Antipathy forever gripes
All ages and somatic types,
The sophomoric

Who face the future's darkest hints
With giggles or with prairie squints
As stout as Cortez,
And those who like myself turn pale
As we approach with ragged sail
The fattening forties.

The sons of Hermes love to play
And only do their best when they
Are told they oughtn't;
Apollo's children never shrink
From boring jobs but have to think
Their work important.

Related by antithesis,
A compromise between us is
Impossible;
Respect perhaps but friendship never:
Falstaff the fool confronts forever
The **** Prince Hal.

If he would leave the self alone,
Apollo's welcome to the throne,
Fasces and falcons;
He loves to rule, has always done it;
The earth would soon, did Hermes run it,
Be like the Balkans.

But jealous of our god of dreams,
His common-sense in secret schemes
To rule the heart;
Unable to invent the lyre,
Creates with simulated fire
Official art.

And when he occupies a college,
Truth is replaced by Useful Knowledge;
He pays particular
Attention to Commercial Thought,
Public Relations, Hygiene, Sport,
In his curricula.

Athletic, extrovert and crude,
For him, to work in solitude
Is the offence,
The goal a populous Nirvana:
His shield bears this device: Mens sana
Qui mal y pense.

Today his arms, we must confess,
From Right to Left have met success,
His banners wave
From Yale to Princeton, and the news
From Broadway to the Book Reviews
Is very grave.

His radio Homers all day long
In over-Whitmanated song
That does not scan,
With adjectives laid end to end,
Extol the doughnut and commend
The Common Man.

His, too, each homely lyric thing
On sport or spousal love or spring
Or dogs or dusters,
Invented by some court-house bard
For recitation by the yard
In filibusters.

To him ascend the prize orations
And sets of fugal variations
On some folk-ballad,
While dietitians sacrifice
A glass of prune-juice or a nice
Marsh-mallow salad.

Charged with his compound of sensational
*** plus some undenominational
Religious matter,
Enormous novels by co-eds
Rain down on our defenceless heads
Till our teeth chatter.

In fake Hermetic uniforms
Behind our battle-line, in swarms
That keep alighting,
His existentialists declare
That they are in complete despair,
Yet go on writing.

No matter; He shall be defied;
White Aphrodite is on our side:
What though his threat
To organize us grow more critical?
Zeus willing, we, the unpolitical,
Shall beat him yet.

Lone scholars, sniping from the walls
Of learned periodicals,
Our facts defend,
Our intellectual marines,
Landing in little magazines
Capture a trend.

By night our student Underground
At cocktail parties whisper round
From ear to ear;
Fat figures in the public eye
Collapse next morning, ambushed by
Some witty sneer.

In our morale must lie our strength:
So, that we may behold at length
Routed Apollo's
Battalions melt away like fog,
Keep well the Hermetic Decalogue,
Which runs as follows:--

Thou shalt not do as the dean pleases,
Thou shalt not write thy doctor's thesis
On education,
Thou shalt not worship projects nor
Shalt thou or thine bow down before
Administration.

Thou shalt not answer questionnaires
Or quizzes upon World-Affairs,
Nor with compliance
Take any test. Thou shalt not sit
With statisticians nor commit
A social science.

Thou shalt not be on friendly terms
With guys in advertising firms,
Nor speak with such
As read the Bible for its prose,
Nor, above all, make love to those
Who wash too much.

Thou shalt not live within thy means
Nor on plain water and raw greens.
If thou must choose
Between the chances, choose the odd;
Read The New Yorker, trust in God;
And take short views.

I daydream that the
recruiters go out of their way
not to promise dates and even
marriage with **** Nordic blond
beautiful co-eds for the players.
I daydream that they the recruiter bring
in local so-called cool jet set
types to add spice to the recruiting
process.
I daydream that the recruiters
take notice of whether the local
layout of the campus is ideal for the players
and that they show 'em around
the campus and in the city or town (including
"campus town") of the respective schools.
I daydream that they definitely
don't promise under the table money
and everything is on the up and up.
I daydream that they
emphasize the liberal arts programs
of the respective colleges
and suggest to the players that the
combination of a good liberal arts education
and skills learned in sports could lead to a good position later on.
I daydream that they emphasize
the building up of what I call
the two key faces of college football
and basketball programs - depth
and balance of the players.
I daydream that they emphasize
that the players obey conduct rules.
I daydream that they emphasize
the well-roundedness of their
respective programs.

droplets raked the dirt

pouring

pounding the sleep from our eyes

the kind that Netflix and Hollywood send to sets

where the ground is scorched

where we mourn the hads and thens
the eds and the whens
and we dance in the puddles

and the creeks

and wish for sunnier days

Longing for clouds in shallow ground.
To go back to the place i was found.
The whispers of wind crossing my breath.

In every instant I can see the clocks turn.
Have i come to myself to learn?

In these times of cloudy days iv learned to frown.

Become a clown...
Cover my face...
Live in secret....
In a nightmarish place.

Its all i can do to survive in this space

There is no grace in this empty place
No space.....
No space at all....
In this empty place.

Looking back threw the pages I awaken the memory.

I live in my thoughts in an enigmatic place.
Not clear where the others are.

Its all i can do to survive in this...
There is no space in this empty place.

No space....
No space at all....
In this empty space.

In dream my reality is delusion...
In walking my delusions are dream.

So cold of dreams I welcome to finally fill.

The chill has become so sharp I cant take this part.

Its all i can do to survive in this.....
There is no space in this empty place.

No space.......
No space at all......
In this empty space.

Have i come to myself to learn?

I have to face.......
that someone else needs to fill that space.

No space......
No space......
In the empty space.

Not clear where the others are..... I have left that place.

Left that place......
Left that place....
That painful place.

Clouds in shallow grounds.

*Living with Chiari Malformation, Ehlers-Danlos syndrome (EDS) and Dysautonomia

Oh wow lookie there!
What a marvelous creature

If you look closely over there you'll be able to see it
a wild hidden disability!

Usually they are invisible to the untrained eye
But I, Stene Irwiv will show you how you can sometimes spot them!

Now all of them look different, but here are a few examples.

See that buddy over there? I've been watching over this lad for a while now
Notice how he walks slowly almost like a waddle?
He also stops to rest more often than the usual guy
He's not lazy! just sore.
Make sure to be careful and don't touch him unexpectedly!
See my friend here has Fibromyalgia, it causes widespread chronic pain.
It can also cause migraines, mood swings, and memory issues
but remember, since these symptoms are usually invisible on the surface
this disability is often overlooked or even called fake by strangers,
but also doctors! ******!

This next one is a doozy
my mate right here looks pretty average on first glance,
but if you look closer you might be able to spot what makes her so special.
This lovely lady right here has Ehlers Danlos Syndrome.
Because of the defect in her collagen,
her skin and ligaments are unusually stretchy.
if you were to touch her skin you might feel that it is very soft and fragile
and when she stands you might see her knees and other joints bend back farther that usual.
She's not just 'double jointed' though,
because of the stretchy ligaments, she and others with EDS are at risk of joint dislocations and chronic pain everyday!
EDS doesn't just cause pain though,
it can also increases a person's risk of ***** rupture or heart problems!
Double ******!

Remember though, these disabilities can't always be seen
so don't judge people prematurely.
You see, the person you think is lazy for sitting in the handicapped seats on the bus,
or maybe the person parked in a handicapped spot who appears to be fine,
or even just the people walking down the street,
any one of them might have an invisible disability.
but just because they are invisible, that doesn't mean they aren't real.
I hope you all enjoyed the show.
I'm Stene Irwiv, and this has been Chronic Illness Hunter.

My Wings Fail Mother Nature.

In my world the sun always shines behind windows tainted....  the color of pink curtains draped threw its rays.

Someone take me away from the darkness ....I succumb.... feels so dark.

The walls that contain me are to keep me safe..... with its  dry stale air.... artificial  light .... keeping me from flight.

I need the light...... not just any light... one that shines a special way.....down on our  oceans, sees and bays......the one that shines on the wild.......it defines my purpose so I do not decline.

I miss my mother....... Mother Nature was always able to sooth the pain in my brain..... encourage me to dance.... to sing along.

All this eases the constant shame and for a moment I feel I belong..

She showed me many things  Id never had known on my own.

I learned to swim with her  fish and run with her deer....... she taught me to feel so much,  such love in her heart, she taught me to speak without any words and showed me many of natures cures.

I became addicted to her drawl and now her loss is causing a withdrawal......... like a drug screaming for my all.

Now I have to rely on man...... a concept not to familiar to me..... I suffer in his hands..... suffer so....why cant they just let me go.

Man was the only creature my Mother could not tell me of........ I was only told I was different.... Not like them.....that I would see.

God...I beg to walk in her grass ...dance in her winds...run in her rains...and feel her healing hands.
"I can't get up!"

I do not understand, its not all about this pain.....it is bearable at times when i try real hard......so why can't I get up.....work or play?

I just sit there so quiet as to not even think......?

Can't get up to just sit in the sun?.......... there is nothing left but man out there?.....

Its just "not" the same.

I really do...... as strong as my heart can want to go..... but my legs tire... I can not run.... my wings, to just lift them....how heavy they fell.

I am afraid now as the times I have run well..... in... "deceiving me".... my wings still failed.

God....I can take the pain....all the pain you can give.....It's taking my Mother  from me I can not stand!

I am not meant to sit here and dwell, I do not deserve to be in hell.

To many times I should have died...so many times I just tried.

But you still forgave me.......... I question why....this world is hard and I don't belong....

I cry so hard...for being barred....with absolutely no regard ....such tears I cry knowing  how easy it is for them to just discard my life.

What shame I feel deep inside....

I keep looking to be rescued for a hero to come...but  ....no hoof stomping sounds ......No white horse on my  drive...... it always stays predictably quiet.

I don't think I trust man or ever did....I think they have forgotten me trapped in here trapped in this land.

I don't think I'm going to be rescued or swept away.....I don't think I will ever be that miracle in....

....I am just one of the forgotten who hide inside....no one to speak of...... as they shut their eyes and cast their own lies in order to survive.

I guess no one can lift me from my pain.....no one cares I'm not there......so it really doesn't matter....as if I cared?

I care about my God...My mother and the few that understand....the ones who have helped me because they just can.

It is ok they laugh at my neck in a noose..... its been always abuse.

Never did I disbelieve in you father...... even when I turned by back in anger and said I didn't agree.

I have faith there is reasons for me to be the one...the one to hold the brunt of the pain.....make me responsible for others games.....make me suffer in another name...take on all the shame.

I can accept this but I beg you now....just give me back my Mother somehow.... I promise to move on from this and make you proud.

But my wildness is somehow...more important to me than I could ever tell.................my silent words.....  my language she knows.....just get me out ..........tell me my job is done.

I do not mind dying alone, but until then I need to go, there are things I need to do....people to touch and show the way.

I can not do this when my light is dark....please release me so I can show....that my life was worth this great big show.

I need to stretch my wings and fly again.....forget those who tried to steal my glow.

As long as you and I know who I am....your love will help my wings expand......so I can sore high above our land.

Please let me see my Mother again.

AL

*Living with Chiari Malformation, Ehlers–Danlos syndrome (EDS) and Dysautonomia.

It hard to know
Why i was expelled
From the fundamentals of poetry.

Each day
Like a loyal monk
i played my flute
With the basket
Over my head.
As the lemmings
Passed
In quadrangles of co-eds.
For everything i must remember
Something must be forgotten.

Often the days
Of learning
Have attempted to remove
Both the marrow and my intuition
From my bones.

Learning is to suppress
Creativity within
Like a poor mouse
Dreams of cheese.

In the first graduation
A woman matriculated
From Adam’s rib.

Into my textbook
i stuffed the snowflakes
i have cut craftiness
With my artless intellect.


Learning
Is ego
And i am
Priest of nothingness.

Some times
The best koans
Make ice-cream cones.

Where do society's extremists abide?
Rallies and Racists go side by side.
BBQs offer up well-done bigots;
On Jordan's lap dance the zealots.
Dogmatists rant in wild front rows,
True believers don't put on such shows?
Sexists cower in coastal Compounds,
Sects marry often in Salt Lake towns.
Troglodytes tan beneath southern suns.
Sepratists hold their final stand
On this side of The Rio Grande;
Fanatics occupy far Left and Right,
Partisans Op Eds are meant to enlight.
Mysoginists grab till they have blisters,
Huns and louts date brothers and sisters.
Philistines take our private spaces,
And whistle-blowers can't show their faces.

Of all the ists I know and abhor,
The musicist is a bigoted boor;
A connoisseur I abjure,
Who chooses tunes he insists
Are superior than my interests,
And disses tunes I like best.

So now I'll lay my needle down,
I've turned the table that goes round,
And plead musicists won't hesitate
To enjoy the tunes... don't discriminate.

what should, could... what one would otherwise
do-not-do...
when language policing is so enforced
that i just... have to... punctuate a stutter or
at least suppose so on
a racial slur, a slurp-up stricken by ice,
and cold... and if lambs had elbows...
this modus operandi of post-colonial peoples
this crucifixion self-laceration
hard-on... which i want a taste of:
bad person, forever... murderer...
since there was no censor at work
around an added G: for giggle's worth...
and an existent R - although in english
there's no trill of it... no thrill, of it so...
nay bovver...
'aggis neeps 'n' tatties...
      otherwise the swede of the suede
is a bit like digesting blue & shoe...
once upon a time two bottles of wine
and i'd be off my rockers in
a little town in Essex where the women
are as fine as nuns and
sooner a cow-*****-******* for milk than...
Juan a-hey-presto... stand... night...
unbearable...
the less *** i've had the more
this... one-armed gambit does... the more...
of the trickery...
not overloading on the use
of a definite article...
but... it's so much easier to curl a hand
into a makeshift ******...
solipsistic *** lives... of... mostly men...
a bit like... regressing / seeing double...
homosexual ***-lives in literature from
the 20th century...
******* literature from the 20th century...
heterosexual antics of men
in the 21st century...
almost a: gleich scheiße,
           anders deckel...
                dekiel.... almost a loan word...
           living in close proximity of: zee schwaben
haben saschisch... aben aben...
perhaps the grammatical
juxtaposing is akin to ancient
Latin, my concern for: anders deckel
or deckel anders...
   same ****, different cover... cover's different...
overstating a fact with
a... conjunction or is it, is, the it...
preposition of... the it is is... Beckett's last
lunch... an hour of sunshine...
keep all chalky 'andy...
beside the apostrophe and the hyphen-conjugate...
glue's not glue:
blue is blue...
green is green...
but there's also... grue...
which is not... y'ella...

          a bluegreen: present grew:
for not yellow...

and i will... entertain... language policing...
over... slurring... past punctuation markers...
like... every time i see a choc-sensation...
no offense - you want the manure skin analogy...
because choc is counter-productive block...
well... let me get on my one remaining
good knee and play tongue the custard
for a Malcolm Noble...

     i would just hate to appease...
it's so ******* boring i'm turning into a boorish
**** of apathy...
by some lineage of argumentation
i've heard the lazy etymological
"argument" that...
from the Caucus... a ****-asian male...
the argument: Paul's a pole...
a pole a Paul's Paul...
            what's missing in... less than germ-
-anic...
                   like it's so simply
Slav(e)...

         less a ****** show & tell a whitey
clad in a bleached ghost necking-tie...
off-on-the-offensive...
   i.e. attack...
      there's a klaus nigge...
      a deutsche photographer...
there's... nigh-ger-ia...
            there's also a Nigh-Ger...
  giggle glutton... gargle... growing pains
in both groin... und gut...

cages i see cages i see tongues in iron
maidens i see souls in hell
and thoughts in limbo...

sound capture... i want to scoop some letters
as almost dead:

  ж = зъ = ż...
    imagine my disbelief at the lack of
orthographical aesthetic...
it only took a dot above the Z
to encourage...

perhaps in braille
perhaps in katakana:

         ⠛⠛⠗

         but letters as atoms of sound...
or methane...
ta-
         ma-
                      -ah
                                   -e contra -eh:
the tetragrammaton my vowel
catcher...
         no surprise of a fire...

hence the surd... like an apostrophe...
extending the saxon
spelling of words into compounds
in the field of chemistry...
a herr adams that wealth of the nations
shamed
jean-paul sartre... lived with his mother
because...

i'll have to leave it to stutter...
overtly punctuated...
no, no surprises...
it's a slur like it might be allowed
for urbanites
and listening to wap folk...
but no: wrap it up
on the horizon... already excluded...
so back to no drawing board...

spikes-up mein jerky chin of a Lee
and says: it's n'ah ah... LEAN...
****** my tongue is harsh but
not towing some unfathomable tie-up...
it's byzantine bilingual
but not... schizoid-teasing-afro-affluence...
like me taking a stab
at living in... h'almighty: Ghana...
visit... Raw-Andy... the Rwandese... plumber...

whereas the romantic affairs
of men are mostly... linear...
the romantic affairs of women
are... overbearingly... cyclic... thus...
what thus?

i'm strapped to a gimmick
and a pseudo expression of lingo...
i'm spineless... death-core....

replenishing the walking abortion(s)...
this ****-job of a man
this scrap heap of egg
and nullifying shells...
like this gargantuan homosexual
**** would never begin
or end with a flower-eater
quest for...
              a drunkard's ****, side...

there aren't enough hours in a day
to want to... beside having to...
listen to bbc radio 3...
once upon a time there was
me guilty of a radio 4 escapade...
but... where there's a t.v.
i'm pretty sure there's no fire-
                           -place....

like the old addition of curating
an attic space: might it be an "also"
cave... without ridicule...
underappreciated...
undermined... this tongue that
does the waggling...
like slurp majestic of floral pattern
*****... well...
i'm tired of the sort of freedom
thus, presented...

here comes the bundle... the bulge...
heaving criss-cross and X's
at the ha ha: stubble pin-point...
yahoo fro Idaho...
this whittle sort
of green patch of land 'n'
h'america..

    my yours truly...
       delving into shelved
secrecies of gluck-winding-back...
clock... there's the admiral...
the hour of our wait...
                the ice creasing a shallot being sliced...
the agony of the wait... the agony
of a yawn... the elongated

tears over an onion...
         if i could claim ownership
for a woman to deposit her
scrutiny of mortality...

yes, this shadow,
yes: this noon...
yes this dwarf of me in shadow grit
drifting toward an apart...

onions for the peel...
i tend to forget what and where
was... "fun"...
i'll hardly want to be left
having inherited
some variation of bias
with either children
or a grandiosity of grand-
   (angwy prefix lady said
so: sock 'em in)

        here's too, a forward...leisurerly
issued: from an Ottoman outpost...
i'm a bad man...
thought language police...
i'm a bad man...
i was inherently bad...
i'm bad i'm bad
i'm terribly... horridly...  anaemic... so...
self-lacerate moi...

cages in their 'eds...
language like afghan
******'s plenty..

better target practice with
those khaki attired
mustard clad foe...
to hell with the **-**-hoes...
i forget what's inclined by stressing
the dynamic of beta...
alpha resources...

as the crucified man said:
if i am not the alpha...
i'm not going to be
the BETA-BUCK-DELUX...

i'll be... last... omega.. "junction"...
yes... i'll be that... just that..
omega malph.

a need me sanity back
as anybody seen it?
salways in da las place ya look
so me eds up me ****
just in case irrappears

For three Voices

First Voice:

What is an ilk?

Second Voice:

Well, they got ‘em up in Montana, you know,
And Canada, and them countries like that
And they got horns and stuff; you can hunt ‘em
They make good eatin’, or that’s what they say

Third Voice:

Naw, man, ilks is what attaches to boats
That’s why you got to scrape the hulls each year
They’re kinda like sea urchins or barnacles
They make good eatin’, or that’s what they say

First Voice:

I read about ilks in the op-eds each day -
They make good eatin’, or that’s what they say

Suddenly you've gone
Togetherness is not long
I miss you deeply my son
My only one

With your death, you've taught me all the facts
How to understand the disease called EDS
Too much complex! It presented problems no one could accept
You were bearing these on your death bed

Pain! days and nights
Your spines were not that right
Muscle spasm on your backside
So do your heart and even your eye sights

Moving slow
Enema ***** helped to pass down the flow
That is called 'diarrhoea overflow'
You've suffered all these... no one knows

I couldn't sleep till the first light
Now forty days and forty nights
These nights were the worst nights in life
I must overcome to be right

Missing you is my only right
Can't see solace on my way tonight

Thar Thar! My son!
Wakes up!
And help me to survive first
Then advise me how to live my life

To my late son Nanda Phyo Win who passed away on 1st September 2020

Color’s dervish, wanton rays
bark big waves out to little eyes -
surmise that they could live so bright,
or cut their burden down in middle flight
with Pantone Answer. Limber fantasies
hung dainty on the wire, we blast
a spectrum: chilling op-eds,
townless crier making hay
from sunny days’ hot take.

Alarm us! Twist like windy satchels
full of Great Divide
between the Haves and Left-Behind.
And as the bank vanishes wage,
we colors come of age
in numbers borne to rap
the sounding toll upon its steady head
and leave for dead his monuments
to Avarice, Big Dollar pulled in tow -
it’s too much meat, you know.
Too sufferful for show
when corny love could fit the bill:
high-mounting, climbing still.

Arrest the cold diversions from
your living-time and feel the sun
whenever possible; the harbingers
of war will tremble color-ward
and drop the gun.

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.
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dungeonesque clanking, subterranean bass
shadowing his 6ft. nine in. horror-addled gait.
the bizarro treble of: decapitation/necrophilia/
dismemberment, introduce Ed Kemper to spaces
he lays comparative disproportion to.
neck like a Great Dane, drowsy bookish eyes
smeared behind circular glasses, decisive comb-over,
& walrus mustache.
his intelligence quotient test herded him where
geniuses reportedly dwell.
monstrously sidestepping from where things can't be
measured--murdering his mother & her friend, along
with six female co-eds (not to mention his grandparents
on a prior youthful conviction).
now imagine Ed, plain old Ed--taking a load off in a
soundless recording booth in prison.
clearing his throat & reading into a microphone--
hypnotically translating into a cavernous monotone.
jarring the listener to heightened attention with emphasis--
seventeen audiobooks were recorded by Ed Kemper for:
The Blind Project.
how ironical for such an elocution to bleed through--
in this way.

Appetite suppressants can be dangerous
when you have a history of EDs.
It’s so easy to lose yourself
when you are high as a kite.
It is so easy to drop 5,10,15,30 pounds
when even thinking about food
makes you incredibly nauseas.
It’s so easy to relapse into old behaviors
when you are fulfilling the dreams
of you from long ago.