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-
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Feels my pain
On a rainy day
Speaking winds
Where have you been?

Travel unseen
Breaking through
My heart fights
My brain wont give up

My clouds full of water
Commence to pour tear drops
Cleansing life resurrecting hope
Attacking in millions

Feeding mother earth
Trees, plants, animals
Covering my tearz
Thoughts begin to clear

Water strikes my skin
Neutralizing ice cold
My soul comforts to unfold
My sky My cry Never lie

People avoid my pouring rain
Shutting down closing doors
While I soar ready to explore
My skies transform heavy grey

Hoping it can last and forever stay...

i slipped inside an atom to see what i was made of,
and i saw you there too.
hanging out with molecules,
we created as we went.
our dna collided,
neutralizing all that was,
evolving into something else.
we realized it was still us, and that
change was the essence of our creativity.
We stopped holding on,
and flew freely through every dimension.
and when we were done,
i went inside.

the world is a dryer.


if there is a washing machine section within our universe, I am unaware of it.

I don't work that rotation. I work the dry shift.

tumble low heat, fluff, repeat.

repeat.

in almost every dryer known to mankind, some contraption serves as the lint trap. collect all of the lint and excess laundry fluff as it goes through the dry cycle.

in this world, in this universe; if the human race consists of the articles of clothing in the dryer, I am the lint trap.

it sounds almost cutesy when phrased like that. dryer lint is fluffy and soft and the combination of all the different fibers of the various clothing.

I'm the trap, though. the filter.

I must absorb and filter the excess fiber from every article of clothing. if the entire human race is in this dry cycle; I absorb and filter their raveling ends.

it's ******* exhausting.



here's a better analogy. have you ever had your stomach pumped?

they handle this differently now, but when the doctors, nurses, and staff working in the ER would get a patient who swallowed an entire bottle of ****** with a ***** chaser; or a new mother's young son swallowing her bottle of sertaline, they would get to work. one hand activated charcoal, the other hand with a large suction tube.

activated charcoal is what neutralizes the bottle of ****** or the bottle of Zoloft. the charcoal can absorb **** near anything. it pulls out stains and poisons, neutralizing and absorbing.

this is where the tube comes in. the charcoal is harmless on its own, but the ER staff is in a hurry to console (get rid of) the screaming mother; to move the seventeen year old girl with the ****** ***** chaser to the psychiatric unit, and continue their night.

insert the long tube to suction the charcoal out of the stomachs of the two children. this is often haphazardly shoved down the back of the throat, down the esophagus, reaching the stomach. flip the switch, undo what peristalsis cannot. it's not pleasant. gagging, rough, foul, I've been told.

the body is working in reverse order. vomiting may be easier. the suction tube is fighting the natural flow of the body. the esophagus is attempting to push everything down down down, and the tube is fighting back.

I am the activated charcoal found in every ER across the globe. I absorb the poisons that human beings put into​ their bodies.

I can pass someone on the street, and my activated charcoal soul absorbs the negativity, the poison, the hatred, the emotional chaos from that individual.

I often wonder if the person feels lighter, noting the absence of the venom that once crippled them. I never ask. I just keep my gaze down and ignore the tempest ensnared within my activated charcoal lint trap.

there are others like me. activated charcoal hearts, lint trap souls.

The moon in the sky, is the home of father time
and the sun is where mother nature is confined
she sleeps while he shines
when she's awake, he hides

He floats in the night like a bird of prey
peering through the trees to the ground to watch the mice play
giving light to us human-beings that stay up this late
to see the beauty that darkness creates

She rises up from the horizon like a spotlight
shining fuel onto every inch of life
neutralizing the temperature, setting the equilibrium right
just as us humans used wind to fly kites
the love letters from the sun to the moon take flight
every once in a while their paths will cross
and here on earth our light is barely lost
enough to illuminate the two lovers as they take their clothes off

it bothers me that
arpeggiated piano
still incites in me
[saudade(for you)] on
these empty evenings;
and it bothers me that
this silly irish girl
feels the same way
i do, and that your
sister shares a name
rooted in gaelic, just
like her; and now i
might be grasping
at straws, but never
have i told a bigger
truth than when i
say i find the most
arbitrary ways to
remind myself of
you, or accurately,
the lacking thereof.

and it bothers me that
the only seeming cure
is to purge (myself) of
you with [ballads sung
by sobbing ivory keys],
like [baking soda] to a
(bee sting), drawing
out the venom drops
of your last acidic kisses,
and neutralizing them
in the stark alkalinity
of these spare words,
little more than dimes
dropped into the tin
cup or upturned hat
of the beggar i have
become.

After wandering into a field I had fantasized all my basic life
        I waded into fading pH pools
Looking through a flower, I fleetingly saw you
        Trapped between petals and figments, peering back at me
Caught off guard and slipping into the arena of my past
I wished, I remembered, and then I corroded
With a neutralizing epiphany,
        I realized you were content to stay.

There is comfort with you, the softness of you, hair, eyes, smile, hands, counteract my hard edges. Neutralizing. My acidity becomes neutral as you trace the angels of the spine and hip bones. Our chemistry creating the ultimate balance. Locking eyes ignites chemicals below the stomach bubbling in my throat and chest. Soft lines of fingers, juxtaposed against my fumbling appendages. The quiet of your voice colliding with the raucousness of my own. The basic collision of differences creating the uncontrollable, but inevitable reaction. But within the difference lies the similarity, the melody of voices vocalizing literature. The magnetic pull compelling our bodies to become one. The warmth of flawed bodies tangled together in a twin bed. The resentfulness towards hatred and hypocrisy, the inclination towards love and understanding. The creation of something inexplicable, something unknown, unexpected, something that has redefined beauty.

My disease can shock and offend , pull a rotten apple from the tree of life itself , a black hole neutralizing star light , an unheard cry in the middle of night . Gifted hands tied by the poisonous vine of censorship , melancholy days , a wind racked ship set adrift . A tiny wisp of flame in the path of a storm , unsettling voices from sources unknown . The riddle of two clenched fist , one holding a diamond . A motherless son with no one to guide him . Drugs that manage hopelessness , ripe berries surrounded by brambles , dark days to oneself , seedling drowned in a glass of water .

Whatever civil stuff there is to oppose evil, in terms of removing an agent of evil from a position of significant power, it's nigh on ineffective. Partly because people, being ones putting all that civil stuff into practice, are corruptible. Imagine someone [further - TP (that person)] in a position of power being accused of some wrongdoing. Yes, if TP's an expendable part of a corrupt system they belong to, they may end up in prison. But what if TP isn't & have more than enough money for a bribe & connections big enough to end up with the case against them being dropped or not even initiated (in other words, untouchable)? And let's say a wrongdoing committed by TP is grave (just like a place deserved by villains such as autocrats to be put in). Such as sentencing a dissident to prison, thus making them a political prisoner, or usage of physical tortures, or even being a leader of an authoritarian regime waging an unjustified aggressive war, what's then? What are remaining options? Evil understands only the language of force & threats. And in comics, there's a type of individuals to punish such agents of evil: VIGILANTES.

Yes, vigilantes operate above the law, but they're above the law either when the rule of law is broken, or in cases when there isn't enough evidence to put a criminal into prison. And by vigilantes, I don't mean the "civil" type like the Batman bringing criminals to justice by neutralizing them unlethally so they can be handed over to law enforcement agents (though, it's worth noting that the Dark Knight strikes terror into criminals, at least into ones operating where he operates). I mean the type like Jason "Red Hood" Todd, Francis "Punisher" Castle, or V disposing of agents of evil as if they were weeds, which they are. Some may deem such individuals as criminals, if more precisely, murderers, but to me & ones like-minded, they're, first of all, society purgers. Necessary antiheroes, if you will.

It's understandable why there's no or nigh on zero such individuals in the real world. For there's little of those having nothing or nigh on nothing to lose & even less of those belonging to this type & being/willing to become expert assassins at the same time. As for professional killers present in the world, as far as I understand, most of them work for the underworld & have no or little principles. I wish there's a whole squad of those vigilantes/society purgers in the world targetting the most powerful ones among agents of authoritarian regimes & members of the underworld. For all those power-corrupted ******* understand only the language of force & threats, as it seems to me, &, as Rorschach from "Watchmen" said, evil must be punished. Of course, the problem is not that there are corrupt people committing wrongdoings, the problem is that there are corrupt ideas hosted by these or other people. But since there's no way to destroy an idea, especially in today's digitalized world, all there's that can be done is to make so that wrongdoing hosts of corrupt ideas are either stripped of power somehow, or isolated from the rest of society, if realization of either one is possible. If not, then liquidation of those hosts.

As Vladimir Makarov from "Call Of Duty: Modern Warfare III" (2023) said, the wicked prosper, they always will. The harsh reality is that this world's so terrible it could use having antiheroic vigilantes being lesser evil to fight villains being greater one.

Don't get it wrong, I neither support nor mean to glorify violence. My only intention is to justify usage of it towards wrongdoers in positions of power, in particular, towards, as I've said, the most powerful ones among agents of authoritarian regimes & members of the underworld.

The day has arrived.
The cold wind whistle, the land is bare and everything feels contrived.
A girl broken, fragile as a leaf in fall.
Damaged but promised.

Borded and no place to go.
Lonely, defeated and feeling so low.
The clouds are telling  a similar story.
Laying out a laundry list of woes.

The air is rich and fragrant.
A crooked little smile on her face.
She can't help herself as the sun fills her with grace.

Venturing out for the first time.
Load music, beautiful people everywhere.
Surrounded by all her partners in crime.
Spinning, dancing with laughter completely unaware.

He's at least 10 years younger.
An unusual flutter.
So beautiful, so strong and hard
He wants her but her bodyguards say no.

But she follows her heart.
Anticipation almost parelizing.
That first touch neutralizing.
Fast and furious, slow passionate.
Completely off the charts.

Behind doors and on roof tops.
Everywhere anytime, non stop.
Her innocent excitement increases.
A new cocktail of chemicals releases.
Lust, sweet delectable lust.
So happy and content

New attitude, a new her

Forever remembered

Language can be used to unify
representing our cultural groupings
of religion,
caste,
region

Language is power,
the power to name
It is the most potent instrument of culture

Language is sweet tongued
riddles in speech
beautifully balanced rhythm
in original language
A widespread...language game

A game with hidden rules:
indigenous structures and rhythms
referring by analogy to something else
with hidden meanings which must be searched for

Take our language away and
We have fallen apart
A foreign tongue will send tremors of fear into every heart
“Oh Lord, save Thy people”
The great Evil has come:
Language of the small and elite
the petty-bourgeoisie readership

It has established a kind of presence
It has created its own momentum.
It doesn’t go anywhere.
There’s nothing you can do with it to make it sing.
It’s heavy. It’s wooden.

A strategy of language manipulation
The darkness drops again

Translation is a battleground,
mere anarchy loosened upon the world
The neutralizing alternative
interlanguage,
mimicking
A gaze blank and pitiless as the sun

Take our language and our center cannot hold
Things fall apart.

Or construct the lens through which understanding takes place:
What is it in your dialect?
The result is incredible.

There are scars opening
Ones I knew were still there
Though the love kept blossoming
And my immunity was holding up.
Though now these scars are bubbling up,
The blood beneath the skin is acting up.
It's ready to be cleansed.

And I feel high now still, and
Below, on lower limbs I feel
The air touching my skin.
I feel breezes of time
Opening. Portals being defined
And this time, I see.

This time around I can see fine
Clearly aware of the cycles repeat.
The rebirth of lessons missed.
Deep explorations of my depths.
This time I trust me.
Then I had yet to see.

Then the basics had to be
Founded.
The base was weak.
The little girl me was hurt early.
Early captures of my vulnerability.
Fear implanted then.
Here is where by breakthrough began
At the edge of free.
Lessons to learn in the sand, in the dirt.
In the breakdown of life.
As the death is settled in,
These truths I stand in.
Balance of fear and love.

Habits still to be shut,
Neural paths to be re-spun.
Neutrons path to be felt.
Neutralizing these low vibing memories,
The ones that I alone live through.  
Tearing open these scars,
Clean the blood. Rinse generational
Wounds of appendages and organs
And hearts. Cleanse us.
Bring the healing energy down.
Mend the scars.  Create new
Warrior Marks.

The love of my life runs through my veins
It can't be a lie that makes me feel safe
All the jewels of emotions come into the phrase
Neutralizing stabilised thoughts for a place
Concluding I hope to get my precious gains


The Brain and Heart are my soul locators
Giving me purpose to live and aware
Following into happiness of my favorite sphere
Inside the self loving treatment of geared individuals


I dig into my thoughts of shallow waters
Growling into the fact of curious matter
I am no more the master to my beloved grandeur
I lost hope into the Truth of love for my serious self desire.

It's clear that I have lost friends
That's what fire in your soul and the resulting fearlessness brings
I don't have a lot of intelligent open minded people rifling through my works or giving them the attending  or attention they deserve. They might overlook the irony sarcasm, wit or inherent fairness that is so carefully crafted into endless themes. Sometimes a social leveler, others a defensive maneuver of a wounded animal or all out aggressive neutralizing campaign. Regardless, I never wrote for any of them, I wrote for me.
They were just lucky I let them see.

- The SS

a web without the print of a creator but instead diagrammatic self evident unfurling stretches in omnidirectional transcendent space crosshatching perpetual fall buoyed by synthetic leaves which provide penultimate impact fluxes to the brain surplusing centripetal stirring while acidic gut indicates the mind has been hijacked by racing network graphics smuggling a chromatic spectrum of strict empiricism that manifests hieroglyphs with junk dna and superfluous deep web code revealing repetition indistinguishable from the loaded traces phase injected to give an illusion of random chance luring emaciated counter adepts to insert all ten fingers in this muck and gaze in its vacant form with eyes now containing double lizard lid seamlessly surgically added while anesthetized in computer god robot operating cabinet hidden behind the gut film of all womb corrals by overlords crowding the sky with shadow mask while will beaming psywaves and psyops to the planet held frozen asserting infinity a zero sum game or infinity a desire sink atomizing discipline to dust blown till even dispersal that settles as the desert of us where ancient cathedral rubble can be picked up without knowing though covering it is graffiti in slang that too is long outdated yet untouched immaculate stands the pyramid where atop the eye burns as infernal chaser back of darkness our primordial creeping from we forget due to whippings under omnipresent dominion as our birth origin and impious realm of ambiguous nondual reciprocity which angered the envious great liar who then swindled the good will of man for instantiation of a fake godhead as virus from infinite space beyond the punched out skyshell by saying “this is everything” signaling intuitors who lack the bandwidth necessary for computing a safe closed circuit to boot load non sequiturs corrupting their internal hall of mirrors by neutralizing all quotients with zero triggering an attempt to apotheose by the lobotomy spike wielding free radical poised to strike once the asymptotically approaching monad of dark energy has arrived and the mantra of hologram reality is hammered into zygote protoconsciousness through fritolay derived nutrients with de as prefix marking eschaton having cropped up like small flames across the plain of man reducing form to powdered grey concentrated potential.

Orbited amongst supraorbited. Predetermined variance is your’s for refusal. Expression is accessible beyond the sense approved surface. Inevitable as it may seem. Vested physicality is greater. Remember the joy of your body, and smirk in the light.

like bringing a broom to a *******
romance...
great idea... considering that
you might be dealing with the dust
of an ex...

why are maine **** cats...
so ******* clingy?!
what's up with this breed
of domesticated bonsai tigers?
huh?!
        can someone explain to me
why they're so... so...
soppy & clingy?!

    ******'s on my bed... curled up
into a shape that best resembles
the xenomorph logo for the Alien
movie...
and i'm like...
              please just get me a
rottweiler...
      i want the jaw-snapper...
last thing i need is a girlfriend,
first things first...
         i need a dog...

something originating in
the Germanic eugenic breeding process...
a rottweiler,
but i'll settle for an Alsatian,
or a Doberman...

              like... it's itching me to
write this...
i don't want someone to have *** with...
i want something to wrestle with...
i can already tell you how i'd go
about neutralizing the snapper...

L...
     what?
                        Γ....
index and thumb finger...
extended... what do you get?
depends on your Copernican interpretation,
north is south, south is north,
north and south aren't really
either "north" or, "south...
  
   and you shove that shape into
the dog's mouth... right past all the teeth,
i ******* have to look this bit up...

you put pressure on the... ha ha...
hyopharyngeus of a dog...
  with a wedge...
akin to the L or gamma...
          shape between the protruding
extension of the space between
the index and the thumb fingers...
you lodge that, past all the teeth?
the dog starts choking...
or imitating choking...
a bit like putting on horse blinders
on horses to make them steer straight...

you shove that L into a dog's gob...
he begins with an unconscious
reaction of imitating swallowing
his tongue, his lasp...
i'm presuming that's how wolves
were tamed...

well...weren't the Huns who figured out
how to best ride a horse,
the barbarians who overcame the
Ancient civilized people with
the invention... known as the...
stirrup?!

        but that's how you tame a dog...
you L pressure the hyopharyngeus muscles
of a dog's gob...
   so it falls into a fit of choking
on its tongue... which it will not exactly
swallow...

   a bit like... a bit like what horses are
tamed by... the curb bit...
  god... i never fall asleep thinking about
having *** with two lesbians...
i'm thinking about wrestling with a rabid
German breed...
  
   what sort of loser requires 72 virgins...
i'm like the crazy cat lady on earth,
translated into heaven...
the crazy dog loner.

oh look... you didn't think that's how
you'd subdue a dog... shoving a massive
L shave of the hand down it's snout...
so that there's the either-side-of-the-snout
connection of the hyopharyngeus....
smile... smile *******...
let me see you choke.

You’re a heavy hitter
and I’m just a runner
afraid of getting tagged out
so I avoid the other players
and their neutralizing touch.
I don’t have a proper stance
hands drowning in my pockets
to avoid a strike zone
shoulders wide.

The force
field of romance
rebukes all contact
causing loneliness
limited to lying
low in the dirt
dour and hurt.

So I avoid your touch
to avoid your warmth
to avoid your essence
because I’ve learned enough lessons
to know on the other side of your silk skin
lies my skeleton.

My fingers will form barbs
that will cling to your hand
and sink into your skin
until you see my sin
is in holding on
and your presence is my prison
I’d commit crimes to remain in.

Your face is the Behemoth
that roams my mind.
Your words are the Leviathan
that swims through my blood.
God loves both of these creatures
despite their destructive force
He transposes that love into me
yet when I approach them
I am gnashed in the teeth
of a gargantuan beast.

Rosmarinus
Tender perennial plant
Love, and remembrance signified,
gift dignified,
antioxidants within this plant,
boosting your immune system,
blood circulation as part,
memory performance,
alertness green plant,
inhaling its aroma,
mood boosting persona,
neutralizing free radicals,
become a loner

© 2020  Carol Natasha Diviney