He pointed at the curve where my mass should be.
The skinny line wherein the whole of my being should fit--
based on what a man in a lab coat said once.
He dashed a tiny spec above it, where I was.
Out of line.
Not fitting in.
Against the rules.
I counted the tiny squares that separated me from my belonging...
… one... two... three...
Three squares from worthiness.
Three squares wrong.
Three squares from deserving love.
Three squares from good enough.
I stared at that dot a man drew for me and discovered brokenness.
I was five.

youre in a too-small bed in pediatrics
all sticky plasters and twitching toes
stuffed full of wires, pink to the bone
hollow and soft, impossibly close

youre a skinned hare, still running
eyes drippy with moon milk so fresh
teeth carved from wax and every orifice
a wound; every love, from the flesh

so now the sun rises on a sea of all-pale
im holding your hand, waiting to flower
you let down your hair--i know its gone thin
but dear deer, ill still try your tower

we're wasting away in symmetrical styles
one from the heart; another from the head
ill leave it to you to figure which is literal
ill leave it to you to see my blood be bled
(its too much for me, now: all i can consider
are the slow and subtle pains of sharing your bed.)

Patience became elusive,
The ending became conclusive.
Comedic flair held in the glow of a ****
Narcotic remedies picked up in a rut

Pediatrics pause as the womb grows thin
Bubble bursts at the point of a pin.
Hollow transparency left in the delivery room
Building up a two foot tomb

Gums rubbed sore
Caked ***** on the floor
Left to sleep outside in the snow
Basking in her pin pricked paradise and lonesome woe

I like to gamble
I play blackjack on my phone sometimes
It’s easy that’s why I like it
Not many rules but still a game of chance
But I’m 15
So it’s sort of illegal for me to gamble
only by 3 years
But when I was ***** I was 13
So the age of consent 3 years away
All the same
I like to gamble
Sometimes I’ll stay home from school
With no rhyme or reason
Just depression of the season
But I won’t text any of my friends
for the first few classes of the day
That way I can see their responses
And see if they wonder if I’m ok
My mom doesn’t ask question
Just a tear or two
And new hairdo
Doesn’t seem to grab her attention
I like to gamble
One time I dyed my hair red to black ombré
And came home with a belly button ring
It took her a week to notice the new color
And she still hasn’t noticed the metal
She hasn’t noticed the scars either
I like to gamble
Sometimes I’ll steal alcohol from the liquor cabinets of my home
And I’ll sneak out my window and into my friend's car
I like to gamble
Standing on the edge of a tall building
The wind blowing through my hair
And down my spine making me shiver
Wondering what would happen if I were to just move an inch
Wishing I would just move an inch
I like to gamble
But I’m not very good at it cards, money it’s all the same
Alcohol, death it’s just a game
Maybe if I quit it won’t save
And I could start a whole new level
Get rid of the pain
Because I like to gamble
with life and death
Because it’s worth as much as the money on my phone
Coins that you’ll never hear clang
It’s just a game
I like to gamble
Sometimes I won’t take my medicine
Just to see how much it changes
The feelings it exchanges
For depression
I don’t like taking it to friends houses
Because they can see me swallow my happiness
It’s not something I’m proud of
I like to gamble
One time I had a thought about poking a hole in a ******
That my boyfriend and I were about to use
Just to see if next month I would bleed
Just to see if a month from that day I would walk up to him
And say
Congratulations
A new pediatrics patient
I like to gamble
But I’ve played all my cards
I stare at the dealer
Like I’m staring at the stars
In wonder and awe
Confused and deranged
Isn’t it strange
How a game holds so much sway
But the only thing I don’t like about the game
Is the steep price I have to pay

Today marks fourth anniversary of tragic deaths
an aching breaking heart – mine
remembers four extinguished breaths.

(dashed – not while riding off
in a white horse open sleigh,
but upon learning untimely demise
regarding prosperous family, whose small
plane crashed August 8, 2019.

They lived ~ three doors down from us
farther than one can toss a Buffalo nickelback.)

The victims included;
Jasbir Khurana, 60
(a professor of pathology
and laboratory medicine
at Temple University's
Lewis Katz School of Medicine);
Divya Khurana, 54 (a professor
of pediatrics and neurology
at the Drexel University
College of Medicine,
specializing in pediatrics, sleep) ;
and the couple's youngest daughter
Kiran Khurana 19 years old.

No words can assuage the deep sorrow,
this once upon a time neighbor
(I lived at 1148 Greentree Lane) experienced
disbelief, numbness, shock...
attendant by an irreparable loss of beloved,
and vacillated how to communicate
heartfelt (I cannot ex spleen) sympathy,
where words superfluous,
yet... if for that challenge alone,
an affinity with language

spurred impulse to focus upon
bountiness of joie de vivre
imbibed years gone by,
when every now and
again chance encounters
found yours truly (me)
in delightful company
regarding persons whose presence
imbued benevolence, kindness, warmth...
facilitating emotional philanthropy

influenced long term positive memories
to one experienced being
outcast, ostracized, offensive...
courtesy unfortunate series
of circumstances beyond my control,
which voiced unwelcome tension
sabotaged reaching quality politeness
displeased at unfriendly reactions
reflexively, maliciously, impetuously...
did little or no justice

toward conflict resolution
which altercations nearly,
quickly did segway profoundly
into unpleasant standoffs,
yes bias, bigotry, bitterness
begat bisel meshuga
acutely aware I loathe
uncouth actions regarding myself
and strive to remain
affable, cordial, friendly...,

hence an object lesson,
(albeit ex post facto)
to abide by my inner integrity,
ethos, dogma politesse...,
especially when pitted against
unsavory electric acid kool aid test
tis then urgently vital to remain
steadfast, and figuratively
turn the other cheek
particularly when populace

under severe duress
re: instigated by pathologically
belligerent, ill mannered, rude...
former president whose
set abhorrent precedence,
whereby people of nation follow suit,
yet this nonconformist only hopes
to affect positive within
webbed wide world at large.

"Send in The Clowns"
Linda Ronstadt sang on as mother wept
I was quite young
I become bruised by her drunken and stabbing snake's tongue
I worked long nights as a teen
Avoiding the hell that ruined my youth that forced me into a man's role
I raised my mother like a daughter as my dad worked.
He was blind to her unplanned brutality.
Her life almost ended many times due to drunk stunts
I rushed to the phone as the pediatrics asked questions
over scars and ****** wounds she forced into my arms.
Blows that winded me and were blunt.
Bad boys homes
Escapes from her terror as she took in the poison.
As she waked sober. She was quite a charm.
A loving soul mixed with dealers and her boyfriend pimps
I was fearing the smile of the circus until I immersed into insanity.
Changing schools like underwear
Sitting in therapy. Not uttering a word.
The shrink wasted time, lifting her skirts, and left me empty and broken there.
I was afraid of the tornado of "Mommy Dearest"
as the volcano of tame-less  evil.
The drink rotted her brain and body.
She would break as I was thrown through a window sill.
"Mommy please stop this pain."
Years and years the storms rolled on.
I road the roller coaster to car crashes and ****** fights.
A storm crushed family left in blood stained tears.
I stay strong and helped lift them up.
Their "rock of loyalty"
Their "Honey" in a broken cup.
Her sins felt like my own
Now I held the same drink from which it came.
Insanity in ***** and wasted years.
Now the pain's voices I've endured
They can sing and close me up.
But strength and a true heart can never be tamed
Even on through the words of blame.
I can laugh at the vary likeness of the clown I had feared.
Clowns stay happy without meaning.
I am the one you see walking tall, still.
See him write, sing, and create.
For true wisdom and beauty are not bought or given.
They are not even just a beauty that is enjoyed skin deep.
This strength prevented me from drowning in fears waters
which were ,then, way too deep.

HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to us e
M-M-R II safely and effectively. See full prescribing information
for M-M-R II.
M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live)
Suspension for subcutaneous injection
Initial U.S. Approv al: 1978
-------------------------------INDICATIONS AND USAGE-------------------------------
M-M-R II is a vaccine indicated for active immunization for the
prevention of measles, mumps, and rubella in individuals 12 months of
age and older. (1)
-------------------------- DOSAGE AND ADMINISTRATION--------------------------
Administer a 0.5-mL dose of M-M-R II subcutaneously. (2.1)
• The first dose is administered at 12 to 15 months of age. (2.1)
• The second dose is administered at 4 to 6 years of age. (2.1)
------------------------DOSAGE FORMS AND STRENGTHS -----------------------
Suspension for injection (0.5-mL dose) supplied as a lyophilized
vaccine to be reconstituted using accompanying sterile diluent. (3)
---------------------------------- CONTRAINDICATIONS ----------------------------------
• Hypersensitivity to any componentof the vaccine. (4.1)
• Immunosuppression. (4.2)
• Moderate or severe febrile illness. (4.3)
• Active untreated tuberculosis. (4.4)
• Pregnancy. (4.5, 8.1)
-------------------------- WARNINGS AND PRECAUTIONS --------------------------
• Use caution when administering M-M-R II to individuals with a
history of febrile seizures. (5.1)
• Use caution when administering M-M-R II to individuals with
anaphylaxis or immediate hypersensitivity following egg ingestion.
(5.2)
• Use caution when administering M-M-R II to individuals with a
history of thrombocytopenia. (5.3)
• Immune Globulins (IG) and other blood products should not be
given concurrently with M-M-R II. (5.4, 7.2)
----------------------------------ADVERSE REACTIONS----------------------------------
See full prescribing information for adverse reactions occurring duri ng
clinical trialsor the post-marketing period. (6)
To report SUSPECTED ADVERSE REACTIONS, contact Merck
Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-8 7 7 -
888-4231 or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.
-----------------------------------DRUG INTERACTIONS----------------------------------
• Administration of immune globulins and other blood products
concurrently with M-M-R II vaccine may interfere with the
expected immune response. (7.2)
• M-M-R II vaccination may result in a temporary depression of
purified protein derivative (PPD) tuberculin skin sensitivity. (7.3)
-------------------------- USE IN SPECIFIC POPULATIONS--------------------------
• Pregnancy: Do not administer M-M-R II to females who are
pregnant. Pregnancy should be avoided for 1 month following
vaccination with M-M-R II. (4.5, 8.1, 17)
See 17 for PATIENT COUNSELING INFORMATION and FDA
approv ed patient labeling.
Rev ised: 06/2020
FULL PRESCRIBING INFORMATION: CONTENTS
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Dose and Schedule
2.2 Preparation andAdministration
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
4.1 Hypersensitivity
4.2 Immunosuppression
4.3 Moderate or Severe Febrile Illness
4.4 Active Untreated Tuberculosis
4.5 Pregnancy
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
5.2 Hypersensitivity to Eggs
5.3 Thrombocytopenia
5.4 Immune Globulins and Transfusions
6 ADVERSE REACTIONS
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
7.2 Immune Globulinsand Transfusions
7.3 Tuberculin Skin Testing
7.4 Use with Other Live Viral Vaccines
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
8.2 Lactation
8.4 Pediatric Use
8.5 Geriatric Use
11 DESCRIPTION
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.6 Persistence of Antibody Responses After Vaccination
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
14 CLINICAL STUDIES
14.1 Clinical Efficacy
14.2 Immunogenicity
15 REFERENCES
16 HOW SUPPLIED/STORAGE AND HANDLING
17 PATIENT COUNSELING INFORMATION
Sections or subsections omitted from the full prescribing info rma tion
are not listed.
2
FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
M-M-R® II is a vaccine indicated for active immunization for the prevention of measles, mumps, and
rubella in individuals 12 months of age and older.
2 DOSAGE AND ADMINISTRATION
For subcutaneous use only.
2.1 Dose and Schedule
Each 0.5 mL dose is administered subcutaneously.
The first dose is administered at 12 to 15 months of age. A second dose is administered at 4 to 6
years of age.
The second dose may be administered prior to 4 years of age, provided that there is a minimum
interval of one month between the doses of measles, mumps and rubella virus vaccine, live {1-2}.
Children who received an initial dose of measles, mumps and rubella vaccine prior to their first
birthday should receive additional doses of vaccine at 12-15 months of age and at 4-6 years of age to
complete the vaccination series [see Clinical Studies (14.2)].
For post-exposure prophylaxis for measles, administer a dose of M-M-R II vaccine within 72 hours
after exposure.
2.2 Preparation and Administration
Use a sterile syringe free of preservatives, antiseptics, and detergents for each injection and/or
reconstitution of the vaccine because these substances may inactivate the live virus vaccine. To
reconstitute, use only the diluent supplied with the vaccine since it is free of preservatives or other
antiviral substances which might inactivate the vaccine.
Withdraw the entire volume of the supplied diluent from its vial and inject into lyophilized vaccine vial.
Agitate to dissolve completely. Discard if the lyophilized vaccine cannot be dissolved.
Withdraw the entire volume of the reconstituted vaccine and inject subcutaneously into the outer
aspect of the upper arm (deltoid region) or into the higher anterolateral area of the thigh.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to
administration, whenever solution and container permit. Visually inspect the vaccine before and after
reconstitution prior to administration. Before reconstitution, the lyophilized vaccine is a light yellow
compact crystalline plug, when reconstituted, is a clear yellow liquid. Discard if particulate matter or
discoloration are observed in the reconstituted vaccine.
To minimize loss of potency, administer M-M-R II as soon as possible after reconstitution. If not used
immediately, the reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from
light, for up to 8 hours. Discard reconstituted vaccine if it is not used within 8 hours.
3 DOSAGE FORMS AND STRENGTHS
M-M-R II vaccine is a suspension for injection supplied as a single dose vial of lyophilized vaccine to
be reconstituted using the accompanying sterile diluent [see Dosage and Administration (2.2) and How
Supplied/Storage and Handling (16)]. A single dose after reconstitution is 0.5 mL.
4 CONTRAINDICATIONS
4.1 Hypersensitivity
Do not administer M-M-R II vaccine to individuals with a history of hypersensitivity to any component
of the vaccine (including gelatin) {3} or who have experienced a hypersensitivity reaction following
administration of a previous dose of M-M-R II vaccine or any other measles, mumps and rubellacontaining vaccine. Do not administer M-M-R II vaccine to individuals with a history of anaphylaxis to
neomycin [see Description (11)].
4.2 Immunosuppression
Do not administer M-M-R II vaccine to individuals who are immunodeficient or immunosuppressed due
to disease or medical therapy. Measles inclusion body encephalitis {4} (MIBE), pneumonitis {5} and death
as a direct consequence of disseminated measles vaccine virus infection have been reported in
3
immunocompromised individuals inadvertently vaccinated with measles-containing vaccine. In this
population, disseminated mumps and rubella vaccine virus infection have also been reported.
Do not administer M-M-R II to individuals with a family history of congenital or hereditary
immunodeficiency, until the immune competence of the potential vaccine recipient is demonstrated.
4.3 Moderate or Severe Febrile Illness
Do not administer M-M-R II vaccine to individuals with an active febrile illness with fever >101.3F
(>38.5C).
4.4 Active Untreated Tuberculosis
Do not administer M-M-R II vaccine to individuals with active untreated tuberculosis (TB).
4.5 Pregnancy
Do not administer M-M-R II to individuals who are pregnant or who are planning on becoming
pregnant within the next month [see Use in Specific Populations (8.1) and Patient Counseling Information
(17)].
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
There is a risk of fever and associated febrile seizure in the first 2 weeks following immunization with
M-M-R II vaccine. For children who have experienced a previous febrile seizure (from any cause) and
those with a family history of febrile seizures there is a small increase in risk of febrile seizure following
receipt of M-M-R II vaccine [see Adverse Reactions (6)].
5.2 Hypersensitivity to Eggs
Individuals with a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives,
swelling of the mouth and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion
may be at an enhanced risk of immediate-type hypersensitivity reactions after receiving M-M-R II vaccine
.The potential risks and known benefits should be evaluated before considering vaccination in these
individuals.
5.3 Thrombocytopenia
Transient thrombocytopenia has been reported within 4-6 weeks following vaccination with measles,
mumps and rubella vaccine. Carefully evaluate the potential risk and benefit of vaccination in children
with thrombocytopenia or in those who experienced thrombocytopenia after vaccination with a previous
dose of measles, mumps, and rubella vaccine {6-8} [see Adverse Reactions (6)].
5.4 Immune Globulins and Transfusions
Immune Globulins (IG) and other blood products should not be given concurrently with M-M-R II [see
Drug Interactions (7.2)]. These products may contain antibodies that interfere with vaccine virus
replication and decrease the expected immune response.
The ACIP has specific recommendations for intervals between administration of antibody containing
products and live virus vaccines.
6 ADVERSE REACTIONS
The following adverse reactions include those identified during clinical trials or reported during postapproval use of M-M-R II vaccine or its individual components.
Body as a Whole
Panniculitis; atypical measles; fever; syncope; headache; dizziness; malaise; irritability.
Cardiovascular System
Vasculitis.
Digestive System
Pancreatitis; diarrhea; vomiting; parotitis; nausea.
Hematologic and Lymphatic Systems
Thrombocytopenia; purpura; regional lymphadenopathy; leukocytosis.
Immune System
Anaphylaxis, anaphylactoid reactions, angioedema (including peripheral or ****** edema) and
bronchial spasm.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
4
Nervous System
Encephalitis; encephalopathy; measles inclusion body encephalitis (MIBE) subacute sclerosing
panencephalitis (SSPE); Guillain-Barré Syndrome (GBS); acute disseminated encephalomyelitis (ADEM);
transverse myelitis; febrile convulsions; afebrile convulsions or seizures; ataxia; polyneuritis;
polyneuropathy; ocular palsies; paresthesia.
Respiratory System
Pneumonia; pneumonitis; sore throat; cough; rhinitis.
Skin
Stevens-Johnson syndrome; acute hemorrhagic edema of infancy; Henoch-Schönlein purpura;
erythema multiforme; urticaria; rash; measles-like rash; pruritus; injection site reactions (pain, erythema,
swelling and vesiculation).
Special Senses — Ear
Nerve deafness; otitis media.
Special Senses — Eye
Retinitis; optic neuritis; papillitis; conjunctivitis.
Urogenital System
Epididymitis; orchitis.
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
M-M-R II vaccine should not be administered to individuals receiving immunosuppressive therapy,
including high dose corticosteroids. Vaccination with M-M-R II vaccine can result in disseminated disease
due to measles vaccine in individuals on immunosuppressive drugs [see Contraindications (4.2)].
7.2 Immune Globulinsand Transfusions
Administration of immune globulins and other blood products concurrently with M-M-R II vaccine may
interfere with the expected immune response {9-11} [see Warnings and Precautions (5.4)]. The ACIP has
specific recommendations for intervals between administration of antibody containing products and live
virus vaccines.
7.3 Tuberculin Skin Testing
It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually
may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin skin test with
tuberculin purified protein derivative (PPD) is to be done, it should be administered before, simultaneously
with, or at least 4 to 6 weeks after vaccination with M-M-R II vaccine.
7.4 Use with Other Live Viral Vaccines
M-M-R II vaccine can be administered concurrently with other live viral vaccines. If not given
concurrently, M-M-R II vaccine should be given one month before or one month after administration of
other live viral vaccines to avoid potential for immune interference.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
M-M-R II vaccine is contraindicated for use in pregnant women because infection during pregnancy
with the wild-type viruses has been associated with maternal and fetal adverse outcomes.
Increased rates of spontaneous abortion, stillbirth, premature delivery and congenital defects have
been observed following infection with wild-type measles during pregnancy. {12,13} Wild-type mumps
infection during the first trimester of pregnancy may increase the rate of spontaneous abortion.
Infection with wild-type rubella during pregnancy can lead to miscarriage or stillbirth. If rubella infection
occurs during the first trimester of pregnancy, it can result in severe congenital defects, Congenital
Rubella Syndrome (CRS). Congenital rubella syndrome in the infant includes but is not limited to eye
manifestations (cataracts, glaucoma, retinitis), congenital heart defects, hearing loss, microcephaly, and
intellectual disabilities. M-M-R II vaccine contains live attenuated measles, mumps and rubella viruses. It
is not known whether M-M-R II vaccine can cause fetal harm when administered to pregnant woman.
There are no adequate and well-controlled studies of M-M-R II vaccine administration to pregnant
women.
5
All pregnancies have a risk of birth defect, loss or other adverse outcomes. In the US general
population, the estimated background risk of major birth defects and miscarriage in clinically recognized
pregnancies is 2% to 4% and 15% to 20%, respectively.
Available data suggest the rates of major birth defects and miscarriage in women who received
M-M-R II vaccine within 30 days prior to pregnancy or during pregnancy are consistent with estimated
background rates (see Data).
Data
Human Data
A cumulative assessment of post-marketing reports for M-M-R II vaccine from licensure 01 April 1978
through 31 December 2018, identified 796 reports of inadvertent administration of M-M-R II vaccine
occurring 30 days before or at any time during pregnancy with known pregnancy outcomes. Of the
prospectively followed pregnancies for whom the timing of M-M-R II vaccination was known, 425 women
received M-M-R II vaccine during the 30 days prior to conception through the second trimester. The
outcomes for these 425 prospectively followed pregnancies included 16 infants with major birth defects, 4
cases of fetal death and 50 cases of miscarriage. No abnormalities compatible with congenital rubella
syndrome have been identified in patients who received M-M-R II vaccine. Rubella vaccine viruses can
cross the placenta, leading to asymptomatic infection of the fetus. Mumps vaccine virus has also been
shown to infect the placenta {14}, but there is no evidence that it causes congenital malformations or
disease in the fetus or infant .
The CDC established the Vaccine in Pregnancy registry (1971-1989) of women who had received
rubella vaccines within 3 months before or after conception. Data on 1221 inadvertently vaccinated
pregnant women demonstrated no evidence of an increase in fetal abnormalities or cases of Congenital
Rubella Syndrome (CRS) in the enrolled women {15}.
8.2 Lactation
Risk Summary
It is not known whether measles or mumps vaccine virus is secreted in human milk. Studies have
shown that lactatingpostpartum women vaccinated with live attenuated rubella vaccine may secrete the
virus in breast milk and transmit it to breast-fed infants.{16,17} In the breast-fed infants with serological
evidence of rubella virus vaccine strain antibodies, none exhibited severe disease; however, one
exhibited mild clinical illness typical of acquired rubella.{18,19}
The developmental and health benefits of breastfeeding should be considered along with the mother’s
clinical need for M-M-R II, and any potential adverse effects on the breastfed child from M-M-R II or from
the underlying maternal condition. For preventive vaccines, the underlying maternal condition is
susceptibility to disease prevented by the vaccine.
8.4 Pediatric Use
M-M-R II vaccine is not approved for individuals less than 12 months of age. Safety and effectiveness
of measles vaccine in infants below the age of 6 months have not been established [see Clinical Studies
(14)]. Safety and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have
not been established.
8.5 Geriatric Use
Clinical studies of M-M-R II did not include sufficient numbers of seronegative subjects aged 65 and
over to determine whether they respond differently from younger subjects.
11 Description
M-M-R II vaccine is a sterile lyophilized preparation of (1) Measles Virus Vaccine Live, an attenuated
line of measles virus, derived from Enders' attenuated Edmonston strain and propagated in chick embryo
cell culture; (2) Mumps Virus Vaccine Live, the Jeryl Lynn™ (B level) strain of mumps virus propagated in
chick embryo cell culture; and (3) Rubella Virus Vaccine Live, the Wistar RA 27/3 strain of live attenuated
rubella virus propagated in WI-38 human diploid lung fibroblasts. {20,21} The cells, virus pools,
recombinant human serum albumin and fetal bovine serum used in manufacturing are tested and
determined to be free of adventitious agents.
After reconstitution, each 0.5 mL dose contains not less than 3.0 log10 TCID50 (tissue culture infectious
doses) of measles virus; 4.1 log10 TCID50 of mumps virus; and 3.0 log10 TCID50 of rubella virus.
Each dose is calculated to contain sorbitol (14.5 mg), sucrose(1.9 mg), hydrolyzed gelatin (14.5 mg),
recombinant human albumin (≤0.3 mg), fetal bovine serum (<1 ppm), approximately 25 mcg of neomycin
and other buffer and media ingredients. The product contains no preservative.
6
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
M-M-R II vaccination induces antibodies to measles, mumps, and rubella associated with protection
which can be measured by neutralization assays, hemagglutination-inhibition (HI) assays, or enzyme
linked immunosorbent assay (ELISA) tests. Results from efficacy studies or effectivenes s studies that
were previously conducted for the component vaccines of M-M-R II were used to define levels of serum
antibodies that correlated with protection against measles, mumps, and rubella [see Clinical Studies (14)].
12.6 Persistence of Antibody Responses After Vaccination
Neutralizing and ELISA antibodies to measles, mumps, and rubella viruses are still detectable in 95-
100%, 74-91%, and 90-100% of individuals respectively, 11 to 13 years after primary vaccination. {22-28}
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
M-M-R II vaccine has not been evaluated for carcinogenic or mutagenic potential or impairment of
fertility.
14 CLINICAL STUDIES
14.1 Clinical Efficacy
Efficacy of measles, mumps, and rubella vaccines was established in a series of double-blind
controlled trials. {29-34} These studies also established that seroconversion in response to vaccination
against measles, mumps and rubella paralleled protection. {35-38}
14.2 Immunogenicity
Clinical studies enrolling 284 triple seronegative children, 11 months to 7 years of age, demonstrated
that M-M-R II vaccine is immunogenic. In these studies, a single injection of the vaccine induced measles
HI antibodies in 95%, mumps neutralizing antibodies in 96%, and rubella HI antibodies in 99% of
susceptible individuals.
A study of 6-month-old and 15-month-old infants born to mothers vaccinated with a measles vaccine in
childhood, demonstrated that, following infant and toddler vaccination with Measles Virus Vaccine, Live
(previously US-licensed, manufactured by Merck), 74% of the 6-month-old infants developed detectable
neutralizing antibody titers while 100% of the 15-month-old infants vaccinated with Measles Virus
Vaccine, Live or M-M-R II vaccine developed neutralizing antibodies {39}. When the 6-month-old infants
of immunized mothers were revaccinated at 15 months with M-M-R II vaccine, they developed antibody
titers similar to those of toddlers who were vaccinated previously at 15-months of age.
15 REFERENCES
1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices, MMWR
43(RR-1): 1-38, January 28, 1994.
2. Measles, Mumps, and Rubella — Vaccine Use and Strategies for Elimination of Measles, Rubella, a n d Co n g e nita l Ru b e lla
Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practice s (ACIP), M M WR
47(RR-8): May 22, 1998.
3. Kelso, J.M.; Jones, R.T.; Yunginger, J.W.: Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gel atin , J.
Allergy Clin. Immunol. 91: 867-872, 1993.
4. Bitnum, A.; et al: Measles Inclusion Body Encephalitis Caused by the Vaccine Strain of Measles Virus. Cl i n . In fect. Di s. 2 9 :
855-861, 1999.
5. Angel, J.B.; et al: Vaccine Associated Measles Pneumonitis in an Adult with AIDS. Annals of Internal Medicine, 129: 1 0 4 -1 06 ,
1998.
6. Cecinati V, et al. Vaccine administration and the development of immune thrombocyto pe ni c p urp u ra i n ch i ld re n. Hu m an
Vaccines & Immunotherapeutics 9:5, 2013.
7. Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic Purpura after Measles-Mumps-Rubella Vaccination: A Systematic
Review of the Literature and Guidance for Management. J Ped 156(4): 2010.
8. Andrews N, Stowe J, Miller E, Svanstrom H, Johansen K, Bonhoeffer J, et al. A collaborative approach to investigating th e ri sk
of thrombocytopenic purpura after measles-mumps-rubella vaccination in England and Denmark. Vaccine. 2012;30:3042‐6.
9. Rubella Prevention: Recommendation of the Immunization Practices Advisory Committee (ACIP), MM WR 3 9 (RR-1 5 ): 1 -1 8 ,
November 23, 1990.
7
10. Peter, G.; et al (eds): Report of the Committee on Infectious Diseases, Twenty-fourth Edition, American Academy of Pediatri cs,
344-357, 1997.
11. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP), MMWR 38(S-9): 5-22,
December 29, 1989.
12. Eberhart-Phillips, J.E.; et al: Measles in pregnancy: a descriptive study of 58 cases. Obstetrics and Gynecology, 82(5): 797-801,
November 1993.
13. Jespersen, C.S.; et al: Measles as a cause of fetal defects: A retrospective study of ten measles epidemics in Greenland. Acta
Paediatr Scand. 66: 367-372, May 1977.
14. Yamauchi T, Wilson C, Geme JW Jr. Transmission of live, attenuated mumps virus to the hu m a n p l ace n ta . N En g l J M e d .
1974;290(13):710‐712.
15. Rubella Vaccination during Pregnancy —United States, 1971-1988. JAMA. 1989;261(23):3374–3383.
16. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. II.
Maternal-neonatal interactions, J. Infect. Dis. 145: 661-666,1982.
17. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. I.
Development and characterization of specific immunologic reactivity in breast milk, J. Infect. Dis. 145: 654-660, 1982.
18. Landes, R.D.; Bass, J.W.; Millunchick, E.W.; Oetgen, W.J.: Neonatal rubella following postpartum maternal i mm un izatio n , J.
Pediatr. 97: 465-467, 1980.
19. Lerman, S.J.: Neonatal rubella following postpartum maternal immunization, J. Pediatr. 98: 668, 1981. (Letter)
20. Plotkin, S.A.; Cornfeld, D.; Ingalls, T.H.: Studiesof immunization with living rubella virus: Trialsin children with a strain culture d
from an aborted fetus, Am. J. Dis. Child. 110: 381-389, 1965.
21. Plotkin, S.A.; Farquhar, J.; Katz, M.; Ingalls, T.H.: A new attenuated rubella virus grown in human fi bro b la sts: Evi d e n ce fo r
reduced nasopharyngeal excretion, Am. J. Epidemiol. 86: 468-477, 1967.
22. Weibel, R.E.; Carlson, A.J.; Villarejos, V.M.; Buynak, E.B.; McLean, A.A.; Hilleman, M.R.: Clinical and Labo ra tory Stu d ie s o f
Combined Live Measles, Mumps, and Rubella Vaccines Using the RA 27/3 Rubella Virus, Proc. So c. Exp . Bi ol. M e d. 1 6 5 :
323-326, 1980.
23. Watson, J.C.; Pearson, J.S.; Erdman, D.D.; et al: An Evaluation of Measles RevaccinationAmong School-Entry Age Ch i ld re n,
31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract #268, 143, 1991.
24. Unpublished data from the files of Merck Research Laboratories.
25. Davidkin, I.; Jokinen, S.; Broman, M. et al.: Persistence of Measles, Mumps, and Rubella Antibodies in a n M M R -Va ccina ted
Cohort: A 20-Year Follow-up, JID 197:950–6, April 2008.
26. LeBaron, W.; Beeler J.; Sullivan, B.; et al.: Persistence of Measles Antibodies After 2 Doses of Measles Vaccine in a
Postelimination Environment, Arch Pediatr Adolesc Med. 161:294-301, March 2007.
27. LeBaron, C.; Forghani, B.; Beck, C. et al.: Persistence of Mumps Antibodies after 2 Doses of Measles-Mumps-Rubella Vaccine,
JID 199:552– 60 , February 2009.
28. LeBaron, W.; Forghani, B.; Matter, L. et al.: Persistence of Rubella Antibodies after 2 Doses of Measles-Mumps-Rubella
Vaccine, JID 200:888–99, September 2009.
29. Hilleman, M.R.; Buynak, E.B.; Weibel, R.E.; et al: Development and Evaluation of the Moraten MeaslesVirusVa cci n e , JAM A
206(3): 587-590, 1968.
30. Weibel, R.E.; Stokes, J.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 3. Clinical and Serologic Aspects in a Fiel d
Evaluation,N. Engl. J. Med. 276: 245-251, 1967.
31. Hilleman, M.R.; Weibel, R.E.; Buynak, E.B.; et al:Live, Attenuated Mumps VirusVaccine 4. ProtectiveEfficacy as Measure d i n
a Field Evaluation, N. Engl. J. Med. 276: 252-258, 1967.
32. Cutts, F.T.; Henderson, R.H.; Clements, C.J.; et al: Principles of measles control, Bull WHO 69(1): 1-7, 1991.
33. Weibel, R.E.; Buynak, E.B.; Stokes, J.; et al: Evaluation Of Live Attenuated Mumps Virus Vaccine, Strain Jeryl Lynn, First
International Conference on VaccinesAgainst Viral and Rickettsial Diseases of Man, World Health Organization, No. 147, M a y
1967.
34. Leibhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; et al: Vaccination With RA 27/3 Rubella Vaccine, Am. J. Dis. Child. 123: 133-1 3 6,
February 1972.
35. Rosen, L.: Hemagglutination and Hemagglutination-Inhibition with Measles Virus, Virology 13: 139-141, January 1961.
36. Brown, G.C.; et al: Fluorescent-Antibody Marker for Vaccine-Induced Rubella Antibodies, Infection and Immunity 2(4): 360-363,
1970.
8
37. Buynak, E.B.; et al: Live Attenuated Mumps Virus Vaccine 1. Vaccine Development, Proceedings of the Society for
Experimental Biology and Medicine, 123: 768-775, 1966.
38. Hilleman M.R., Studies of Live Attenuated Measles Virus Vaccine in Man: II. Appraisal of Efficacy. Amer. J. o f Pu b l ic He a lth ,
52(2):44-56, 1962.
39. Johnson, C.E.; et al: Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles
Vaccine Era, Pediatrics, 93(6): 939-943, 1994.
16 HOW SUPPLIED/STORAGE AND HANDLING
No. 4681 ⎯ M-M-R II vaccine is supplied as follows:
(1) a box of 10 single-dose vials of lyophilized vaccine (package A), NDC 0006-4681-00
(2) a box of 10 vials of diluent (package B)
Exposure to light may inactivate the vaccine viruses.
Before reconstitution, refrigerate the lyophilized vaccine at 36°F to 46°F, (2°C to 8°C).
Store accompanying diluent in the refrigerator with the lyophilized vaccine or separately at room
temperature (68° to 77°F, 20° to 25°C). Do not freeze the diluent.
Administer M-M-R II vaccine as soon as possible after reconstitution. If not administered immediately,
reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from light, for up to 8
hours. Discard reconstituted vaccine if it is not used within 8 hours.
For information regarding the product or questions regarding storage conditions, call 1-800-
MERCK-90 (1-800-637-2590).
17 PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Patient Package Insert).
Discuss the following with the patient:
• Provide the required vaccine information to the patient, parent, or guardian.
• Inform the patient, parent, or guardian of the benefits and risks associated with vaccination.
• Question the patient, parent, or guardian about reactions to a previous dose of M-M-R II vaccine
or other measles-, mumps-, or rubella-containing vaccines.
• Question females of reproductive potential regarding the possibility of pregnancy. Inform female
patients to avoid pregnancy for 1 month following vaccination [see Contraindications (4.5) and
Use in Specific Populations (8.1)].
• Inform the patient, parent, or guardian that vaccination with M-M-R II may not offer 100%
protection from measles, mumps, and rubella infection.
• Instruct patients, parents, or guardians to report any adverse reactions to their health-care
provider. The U.S. Department of Health and Human Services has established a Vaccine
Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events
after the administration of any vaccine, including but not limited to the reporting of events required
by the National Childhood Vaccine Injury Act of 1986. For information or a copy of the vaccine
reporting form, call the VAERS toll-free number at 1-800-822-7967, or report online at
https://www.vaers.hhs.gov.
For patent information: www.merck.com/product/patent/home.html
Copyright © 1978-2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved.
uspi-v205c-i-2006r009
Product patents - Merck.com
merck.com
Product patents - Merck.com
Merck US has many products enjoying exclusive patent rights. Click here to access a full list of Merck US patents.

Often, I find myself thinking about all the people who I no longer speak to. I’m constantly lost in thought over every person who I will never see again.
I think about the best friend I had in preschool, the school nurse who made me a better person. I think about the two old women who were always waiting at the bus stop in front of my house. It’s not as if they died but it has been years since we’ve seen each other and I don’t know if we will ever meet again.

Sometimes I’ll watch T.V. and an old show will be on; a show that’s been off the air for years now. I like to watch the last season of those shows. It will occasionally take the audience back to a character that hasn’t been seen since the first season. Maybe it’ll even mention what they’ve been up to, who they are now.

When I was a kid, I used to think of my life in seasons. I used to keep an eye out for old friends. I used to find joy in running into a former algebra teacher. Or my brother’s childhood best friend. It felt like things were tying themselves up into a neat, little bow.

But I’m starting to think life doesn’t work that way.

I’m always looking for these people who I will probably never see again. I’ve gone on long walks, purely concentrated on remembering the last name of my favorite bus driver. I’m thinking about everyonet all day long.
I think about all the places I’ve been without realizing that I have been there for the last time. The pediatrics department of my doctors office. The Treasure Island hotel in Las Vegas that I have not stayed at since I was 7.

I think about all the moments in my life, big or small. that shaped the person I am today without even realizing they were those moments.

I’ve always had a bad perception of time. I’ve never been able to sit down somewhere and tell the difference between an hour passing by compared to five minutes.

But that perception is not limited to numbers on a clock. It is not just a matter of figuring out the time. It is a matter of staying in the right time.

I’m 22 but I was just eleven years old yesterday. I was walking home from school. It was 4 O’clock on a cloudy Friday. When I walked in the door, my brother was watching Family Guy and started to tell me about his day. Now that same brother has a wife and two children and lives eight hours away from me.

I’m 22 years old. I’m single, no children. The other day I was driving down the street and my mind jumped ahead to a day in the future where this car will no longer be around. The engine will be dead, the parts will be scrapped, and I’ll have two kids and a wife. I’ll be driving down the street with car seats in the backseat of my minivan. And I’ll see a Toyota Camry parked on a street somewhere.

I’ll think that today, right now, was such a long time ago.

Sometimes I look at my parents and I think about them in their twenties. I see them as the same age that I am. I wonder if we would have been friends.

I once picked up my niece while she was napping and carried her to bed. I laid her down, took her shoes off, and pulled a blanket up over her. I tried to picture her as a sixteen year old. I tried to picture this little person, who comes up and asks to open playdough, will still want to talk to me.
My nephew is only two. He’s a verbal late bloomer. I think about the times he will someday come home from school and tell me about his day. Or maybe he will be just as quiet as he is now.

I think I might be a time traveler. I’m always all over the place.

The other day I pulled off the freeway and onto the side of the road. I broke down into gasping sobs because my uncle had died. He passed away when I was 16. I think that was the first time I realized he was never coming home again.I think that was the first time I ever cried for him.  

Time is tricky. People say I have an old soul but maybe I just have old eyes. Maybe that’s why I’m stressing out on a mortgage bill that’s due on a house that I’m not even close to owning yet.
The other day, I had felt this deep sadness all day long. People kept asking me what was wrong but I thought it would have been silly to say that once, when I was 6 years old, my mother bought me a balloon at a park and it floated away and I’m still upset over it.

People aren’t like seasons. One day they’re here, the next they’re gone.
People aren’t like anything else around.
When it’s been sunny for awhile, I always know it will rain again, eventually. When I plant a tree, I know it’ll either grow. Or it’ll die. I won’t just look outside one day at a tree that has run away from home.
I don’t know if I’ll see certain people again.
I don’t know what has happened or what might happened.

Time has always been a tricky thing for me.

I try to make constants in my life.

Little anchors that let me know that this life is still my life.
Like when you see a silver car in a parking lot with a bunch of other silver cars, and you can still somehow recognize which one is your car.

I like to drink coffee. I always have.

It’s one of my constants. I drank coffee throughout my childhood and I drink coffee now.
I probably always will.
On the mornings when I shockingly have nothing to do, I like to make myself a big *** of coffee. It doesn’t matter if I’m at home or not. I’ve made coffee in hotel rooms, I’ve made coffee in ex lovers apartments. Even if it is not very good coffee.

My 8 year old hands hold onto the coffee mug, letting it’s warmth seep through my entire body. I’ll sit down, close to a window somewhere.
My 22 year old eyes taking in all the sites. I have drank coffee on windy fall mornings. I’ve drank coffee in a motel right next to the beach. I like to watch the waves hit the water. I like to watch joggers jog by the house.
I like to drink my coffee and look outside at my grandchildren playing in the backyard.

My one, true constant.

I’ll take a sip from that coffee, from whenever I am. And I’ll start to think about all the people I have seen for the last time.

And all the ones I have met to meet for the first time.

Dead, found guilty of political violence
(author's note - not rhyming violence with silence)
Sixteen feet beneath the topsoil
Rictus stretched atop the rot-foil

Human nature ugly design in punishment finds its reward
Otherwise a stapled piece of paper feels adored
Clunky funking clatter when we scatter to the wind
Die inside, before I stop your heart for which you've sinned

Clock stops. Electrical impulse.
Disturbing levels of pediatrics, thin pulse.
Elven clockwork dances round the center table, grand
Jesters laugh in octaves high as reaper shows its hand.

Violence, violet violence, a color rich and deep
Seems when under influence a secret it must keep
Strings, the pretty strings I pluck, I scratch them with a blade
Oh is that the killing joke, upon me it was played.

I am not a razor blade, a razor blade I'm not
Oh, but Mr. CEO thinks he's the one on top.
Die ASAP **** you're poem isn't go
Play along for long enough, and welcome to the show.

I am made of serpent flesh, my coils wrap tightly round.
This, you see, a snake den, is where me and kin are found.
Would I bite you? Yes, it's in my nature to do so.
Sink into the water, and be taken by the flow.

River grand and river wide, teach me how to turn the tide,
News and nuance unbeknownst, wither flowers in the growth
Death becomes the ego and the mind plays ***** tricks
Even in the end, it seems I'll never get my fix.

I'm a ******* pistol, or a rifle - I'm a gun.
See if you can figure out my idea of fun.
*******, *******, *******, die, you rude, pathetic ****
Wither in your carcass, it's the only place you fit.

Ay-Kay Forty-Seven says, "your sacrifice was bold"
Yea, that's fucken rich bro, but the story WE were told
Says you froze to death when winter's flurries took your life
****! Oh well, who's keeping score? This story isn't nice.