A cursory glance at the major changes in the recommendations for immunization by IAP 2014 [1] startled me and made me sit up and take notice. The committee recommends two doses of MMR at 9 and 15 months; no standalone measles dose at 9 months; and no MMR dose at 4-6 years of age. While there is no doubt about the need for two doses of MMR, it is their timing in the recommendation that is questionable.

There is indeed undeniable evidence that both mumps and rubella are also significant problems and this matter has been addressed beautifully in recent articles [1,2] and in the IAP Guidebook on Immunization 2013-14 [3]. Till the new recommendations became available, we were giving measles vaccine at 9 months and 2 doses of MMR at 15 months and 5 years. This schedule clearly combined the benefit of early protection against measles, coverage of all three diseases as recommended by WHO, and the very important issue of long term protection against mumps and rubella.

In the pre-vaccine era, mumps usually occurred primarily in young children between the age of 5 and 9 years [4]. It is most unusual to see mumps in children younger than below 5 years; so why the haste in completing both doses of mumps by 15 months? Outbreaks continue to occur even in highly vaccinated populations as a result of vaccine failure and also under vaccination of susceptible persons [5]. Also, though immunity appears to be long lasting, studies from the UK and the recent epidemic in the USA suggest that both antibody levels and vaccine effectiveness may decline, contributing to outbreaks mumps of in older vaccinated populations [4]. This is the basis of giving the second dose of mumps at 5 years, a practice followed all over the world. We must give mumps at 15 months and 5 years or face a massive outbreak of mumps in the older population due to waning immunity.

The case for rubella is equally interesting. Rubella vaccine should not be administered to infants younger than one year of age because persisting maternal antibodies may interfere with seroconversion [6]. Furthermore, a resurgence of rubella and congenital rubella syndrome in 1989-1991 forced the American authorities to introduce a second dose of rubella at 5 years. Once again the effort was to delay the second dose with aim of long lasting protection [7]. If our first dose of rubella vaccine at 9 months does not work and the second dose is given as early as 15 months, we may be staring at a massive outbreak of congenital rubella syndrome in the older population who has a waning immunity as seen in the West many years ago.

In a nutshell, the recommendations have been shortsighted in looking at the immediate seroconversion, and not at the long term immunity and consequences. In the private sector where families tend to follow the immunization schedule religiously, compliance becomes a relative nonissue. In this setting, should I not continue with measles vaccine at 9 months, and MMR at 15 months and 5 years?

1. Vashishtha VM, Choudhury P, Kalra A, Bose A, Thacker N, Yewale VN, et al. Indian Academy of Pediatrics (IAP) Recommended Immunization Schedule for children aged 0 through 18 years - India, 2014 and Updates on Immunizations. Indian Pediatr. 2014;51:785-804.

2. Vashishtha VM, Yewale VN, Bansal CP, Mehta PJ for Indian Academy of Pediatrics, Advisory Committee on Vaccines and Immunization Practices (ACVIP), IAP perspectives on measles and rubella elimination strategies. Indian Pediatr. 2014;51:719-22.

3. Chaudhary P, Vani S. Measles Mumps and Rubella Vaccines. In: Vashishta V, Choudhury P, Bansal C, Yewale V, Agarwal R, editors. IAP Guidebook on Immunization 2013-14. 2014 edition.Gwalior: National Publication House; 2014. p. 221-36.

4. Mason W. Mumps. In. Kliegman R, Stanton F,Schor N, Geme J, Berhman R, editors. Nelson Textbook of Pediatrics. 19th edition. Philadelphia: Saunders Elsevir; 2012. p. 1078-81.

5. Status Report on Progress towards Measles and Rubella Elimination. SAGE Working Group on Measles and Rubella (17 October 2013) Available from: http://www. who.int/immunization/sage/meetings/2013/november/ Status_Report_Measles_Rubella21Oct2013_FINAL.pdf Accessed on May 19, 2014.

6. Cherry J, Adachi K. Rubella Virus. In: Cherry J, Harrison G, Kaplan S, Steinbach W, Hotez P, editors. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. 7th edition. Philadelphia: Saunders Elsevir, 2014. p. 2222-3.