Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Measles, mumps, and rubella immunization in infants, children, and adolescents

Jan E Drutz, MD
Section Editors
Teresa K Duryea, MD
Morven S Edwards, MD
Deputy Editor
Mary M Torchia, MD


Childhood and adolescent immunizations are one of the most effective means of preventing serious illness. Combination measles, mumps, and rubella (MMR) immunization in infants, children, and adolescents will be discussed here, focusing on routine immunization of children in the United States. Our recommendations are consistent with those of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians.

MMR immunization in adults is discussed separately. (See "Measles, mumps, and rubella immunization in adults".)


The measles virus causes an acute infection characterized by fever, cough, coryza, conjunctivitis, rash (picture 1A-B), and enanthem (picture 2) that may be followed by severe complications, including encephalitis. (See "Measles: Clinical manifestations, diagnosis, treatment, and prevention".)

The mumps virus causes an acute viral syndrome with parotid swelling (picture 3). Mumps infection usually is self-limited, but may be associated with complications, including orchitis and oophoritis, aseptic meningitis, and encephalitis. (See "Mumps", section on 'Clinical manifestations'.)

The rubella virus causes German measles, a generally mild infection with a characteristic rash (picture 4) that can affect both children and adults. However, rubella infection can cause significant birth defects (eg, hearing loss; cataracts (picture 5); cardiac disease; and neurodevelopmental effects, including intellectual disability and autism) if it occurs early in fetal life. (See "Rubella", section on 'Clinical manifestations' and "Rubella in pregnancy" and "Congenital rubella syndrome: Clinical features and diagnosis", section on 'Clinical features'.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Feb 2017. | This topic last updated: Wed Mar 22 00:00:00 GMT+00:00 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  2. Centers for Disease Control and Prevention. Q & As about monovalent M-M-R vaccines. Available at: www.cdc.gov/vaccines/vac-gen/shortages/mmr-faq-12-17-08.htm (Accessed on May 05, 2015).
  3. Low N, Bavdekar A, Jeyaseelan L, et al. A randomized, controlled trial of an aerosolized vaccine against measles. N Engl J Med 2015; 372:1519.
  4. Committee on Infectious Diseases. Policy statement—Prevention of varicella: update of recommendations for use of quadrivalent and monovalent varicella vaccines in children. Pediatrics 2011; 128:630.
  5. ProQuad measles, mumps, rubella, and varicella virus vaccine for subcutaneous injection. US Food & Drug (FDA) approved product information. Revised March 2014. US National Library of Medicine. Available at: www.dailymed.nlm.nih.gov (Accessed on May 06, 2015).
  6. Barlow WE, Davis RL, Glasser JW, et al. The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. N Engl J Med 2001; 345:656.
  7. Farrington P, Pugh S, Colville A, et al. A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines. Lancet 1995; 345:567.
  8. Jacobsen SJ, Ackerson BK, Sy LS, et al. Observational safety study of febrile convulsion following first dose MMRV vaccination in a managed care setting. Vaccine 2009; 27:4656.
  9. Klein NP, Fireman B, Yih WK, et al. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures. Pediatrics 2010; 126:e1.
  10. MacDonald SE, Dover DC, Simmonds KA, Svenson LW. Risk of febrile seizures after first dose of measles-mumps-rubella-varicella vaccine: a population-based cohort study. CMAJ 2014; 186:824.
  11. Klein NP, Lewis E, Baxter R, et al. Measles-containing vaccines and febrile seizures in children age 4 to 6 years. Pediatrics 2012; 129:809.
  12. Centers for Disease Control and Prevention. Varicella. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S, (Eds). Public Health Foundation, Washington, DC 2015. http://www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on July 09, 2015).
  13. Redd SC, King GE, Heath JL, et al. Comparison of vaccination with measles-mumps-rubella vaccine at 9, 12, and 15 months of age. J Infect Dis 2004; 189 Suppl 1:S116.
  14. LeBaron CW, Beeler J, Sullivan BJ, et al. Persistence of measles antibodies after 2 doses of measles vaccine in a postelimination environment. Arch Pediatr Adolesc Med 2007; 161:294.
  15. Davidkin I, Jokinen S, Broman M, et al. Persistence of measles, mumps, and rubella antibodies in an MMR-vaccinated cohort: a 20-year follow-up. J Infect Dis 2008; 197:950.
  16. Markowitz LE, Albrecht P, Orenstein WA, et al. Persistence of measles antibody after revaccination. J Infect Dis 1992; 166:205.
  17. Ward BJ, Boulianne N, Ratnam S, et al. Cellular immunity in measles vaccine failure: demonstration of measles antigen-specific lymphoproliferative responses despite limited serum antibody production after revaccination. J Infect Dis 1995; 172:1591.
  18. LeBaron CW, Forghani B, Matter L, et al. Persistence of rubella antibodies after 2 doses of measles-mumps-rubella vaccine. J Infect Dis 2009; 200:888.
  19. Hillary IB, Griffith AH. Persistence of rubella antibodies 15 years after subcutaneous administration of Wistar 27/3 strain live attenuated rubella virus vaccine. Vaccine 1984; 2:274.
  20. Christenson B, Böttiger M. Long-term follow-up study of rubella antibodies in naturally immune and vaccinated young adults. Vaccine 1994; 12:41.
  21. LeBaron CW, Forghani B, Beck C, et al. Persistence of mumps antibodies after 2 doses of measles-mumps-rubella vaccine. J Infect Dis 2009; 199:552.
  22. Gothefors L, Bergström E, Backman M. Immunogenicity and reactogenicity of a new measles, mumps and rubella vaccine when administered as a second dose at 12 y of age. Scand J Infect Dis 2001; 33:545.
  23. Broliden K, Abreu ER, Arneborn M, Böttiger M. Immunity to mumps before and after MMR vaccination at 12 years of age in the first generation offered the two-dose immunization programme. Vaccine 1998; 16:323.
  24. Rodgers DV, Gindler JS, Atkinson WL, Markowitz LE. High attack rates and case fatality during a measles outbreak in groups with religious exemption to vaccination. Pediatr Infect Dis J 1993; 12:288.
  25. Centers for Disease Control (CDC). Measles outbreak--New York City, 1990-1991. MMWR Morb Mortal Wkly Rep 1991; 40:305.
  26. Centers for Disease Control (CDC). Measles outbreak--Washington, 1989: failure of delayed postexposure prophylaxis with vaccine. MMWR Morb Mortal Wkly Rep 1990; 39:617.
  27. Centers for Disease Control (CDC). Update: measles outbreak--Chicago, 1989. MMWR Morb Mortal Wkly Rep 1990; 39:317.
  28. Rowhani-Rahbar A, Fireman B, Lewis E, et al. Effect of age on the risk of Fever and seizures following immunization with measles-containing vaccines in children. JAMA Pediatr 2013; 167:1111.
  29. Hambidge SJ, Newcomer SR, Narwaney KJ, et al. Timely versus delayed early childhood vaccination and seizures. Pediatrics 2014; 133:e1492.
  30. Watson JC, Pearson JA, Markowitz LE, et al. An evaluation of measles revaccination among school-entry-aged children. Pediatrics 1996; 97:613.
  31. Davis RL, Marcuse E, Black S, et al. MMR2 immunization at 4 to 5 years and 10 to 12 years of age: a comparison of adverse clinical events after immunization in the Vaccine Safety Datalink project. The Vaccine Safety Datalink Team. Pediatrics 1997; 100:767.
  32. Fiebelkorn AP, Coleman LA, Belongia EA, et al. Measles Virus Neutralizing Antibody Response, Cell-Mediated Immunity, and Immunoglobulin G Antibody Avidity Before and After Receipt of a Third Dose of Measles, Mumps, and Rubella Vaccine in Young Adults. J Infect Dis 2016; 213:1115.
  33. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev 2012; :CD004407.
  34. Centers for Disease Control and Prevention (CDC). Elimination of rubella and congenital rubella syndrome--United States, 1969-2004. MMWR Morb Mortal Wkly Rep 2005; 54:279.
  35. Pan American Health Organization. Americas region is declared the world's first to eliminate rubella. Available at: www.paho.org/hq/index.php?option=com_content&view=article&id=10798&Itemid=1926&lang=en (Accessed on May 01, 2015).
  36. Centers for Disease Control and Prevention (CDC). Three cases of congenital rubella syndrome in the postelimination era--Maryland, Alabama, and Illinois, 2012. MMWR Morb Mortal Wkly Rep 2013; 62:226.
  37. Centers for Disease Control and Prevention (CDC). Brief report: Imported case of congenital rubella syndrome--New Hampshire, 2005. MMWR Morb Mortal Wkly Rep 2005; 54:1160.
  38. Zipprich J, Winter K, Hacker J, et al. Measles outbreak--California, December 2014-February 2015. MMWR Morb Mortal Wkly Rep 2015; 64:153.
  39. Gahr P, DeVries AS, Wallace G, et al. An outbreak of measles in an undervaccinated community. Pediatrics 2014; 134:e220.
  40. Centers for Disease Control and Prevention (CDC). Notes from the field: measles outbreak among members of a religious community - Brooklyn, New York, March-June 2013. MMWR Morb Mortal Wkly Rep 2013; 62:752.
  41. Fiebelkorn AP, Redd SB, Gastañaduy PA, et al. A Comparison of Postelimination Measles Epidemiology in the United States, 2009-2014 Versus 2001-2008. J Pediatric Infect Dis Soc 2015.
  42. Holt EA, Boulos R, Halsey NA, et al. Childhood survival in Haiti: protective effect of measles vaccination. Pediatrics 1990; 85:188.
  43. Kabir Z, Long J, Reddaiah VP, et al. Non-specific effect of measles vaccination on overall child mortality in an area of rural India with high vaccination coverage: a population-based case-control study. Bull World Health Organ 2003; 81:244.
  44. Koenig MA, Khan MA, Wojtyniak B, et al. Impact of measles vaccination on childhood mortality in rural Bangladesh. Bull World Health Organ 1990; 68:441.
  45. Clemens JD, Stanton BF, Chakraborty J, et al. Measles vaccination and childhood mortality in rural Bangladesh. Am J Epidemiol 1988; 128:1330.
  46. Desgrées du Loû A, Pison G, Aaby P. Role of immunizations in the recent decline in childhood mortality and the changes in the female/male mortality ratio in rural Senegal. Am J Epidemiol 1995; 142:643.
  47. Fisker AB, Rodrigues A, Martins C, et al. Reduced All-cause Child Mortality After General Measles Vaccination Campaign in Rural Guinea-Bissau. Pediatr Infect Dis J 2015; 34:1369.
  48. Mina MJ, Metcalf CJ, de Swart RL, et al. Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Science 2015; 348:694.
  49. de Vries RD, de Swart RL. Measles immune suppression: functional impairment or numbers game? PLoS Pathog 2014; 10:e1004482.
  50. American Academy of Pediatrics. Measles. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.535.
  51. van der Maas NA, Woudenberg T, Hahné SJ, de Melker HE. Tolerability of Early Measles-Mumps-Rubella Vaccination in Infants Aged 6-14 Months During a Measles Outbreak in The Netherlands in 2013-2014. J Infect Dis 2016; 213:1466.
  52. Hutchins SS, Dezayas A, Le Blond K, et al. Evaluation of an early two-dose measles vaccination schedule. Am J Epidemiol 2001; 154:1064.
  53. Woo EJ, Winiecki SK, Arya D, Beeler J. Adverse Events After MMR or MMRV Vaccine in Infants Under Nine Months Old. Pediatr Infect Dis J 2016; 35:e253.
  54. Centers for Disease Control and Prevention. Mumps. In: Manual for the Surveillance of Vaccine-Prevantable Diseases. Atlanta, GA, October 2012. Available at: www.cdc.gov/vaccines/pubs/surv-manual/chpt09-mumps.html (Accessed on May 05, 2015).
  55. Albertson JP, Clegg WJ, Reid HD, et al. Mumps Outbreak at a University and Recommendation for a Third Dose of Measles-Mumps-Rubella Vaccine - Illinois, 2015-2016. MMWR Morb Mortal Wkly Rep 2016; 65:731.
  56. Ogbuanu IU, Kutty PK, Hudson JM, et al. Impact of a third dose of measles-mumps-rubella vaccine on a mumps outbreak. Pediatrics 2012; 130:e1567.
  57. Lejeune A, Martin L, Santibanez S, et al. Postexposure prophylaxis with intravenous immunoglobulin G prevents infants from getting measles. Acta Paediatr 2017; 106:174.
  58. Centers for Disease Control and Prevention. Mumps In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S, (Eds). Public Health Foundation, Washington, DC 2015. http://www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on November 25, 2016).
  59. Centers for Disease Control and Prevention. Rubella. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S, (Eds). Public Health Foundation, Washington, DC 2015. http://www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on November 25, 2016).
  60. Nelson GE, Aguon A, Valencia E, et al. Epidemiology of a mumps outbreak in a highly vaccinated island population and use of a third dose of measles-mumps-rubella vaccine for outbreak control--Guam 2009 to 2010. Pediatr Infect Dis J 2013; 32:374.
  61. Date AA, Kyaw MH, Rue AM, et al. Long-term persistence of mumps antibody after receipt of 2 measles-mumps-rubella (MMR) vaccinations and antibody response after a third MMR vaccination among a university population. J Infect Dis 2008; 197:1662.
  62. Patel MK, Gacic-Dobo M, Strebel PM, et al. Progress Toward Regional Measles Elimination - Worldwide, 2000-2015. MMWR Morb Mortal Wkly Rep 2016; 65:1228.
  63. National Center for Immunization and Respiratory Diseases. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011; 60:1.
  64. Knuf M, Zepp F, Meyer CU, et al. Safety, immunogenicity and immediate pain of intramuscular versus subcutaneous administration of a measles-mumps-rubella-varicella vaccine to children aged 11-21 months. Eur J Pediatr 2010; 169:925.
  65. Cassidy WM, Jones G, Williams K, et al. Safety and immunogenicity of concomitant versus nonconcomitant administration of hepatitis B, tetanus-diphtheria, and measles-mumps-rubella vaccines in healthy eleven- to twelve-year-olds. J Adolesc Health 2005; 36:187.
  66. Gasparini R, Tregnaghi M, Keshavan P, et al. Safety and Immunogenicity of a Quadrivalent Meningococcal Conjugate Vaccine and Commonly Administered Vaccines After Coadministration. Pediatr Infect Dis J 2016; 35:81.
  69. Verstraeten T, Jumaan AO, Mullooly JP, et al. A retrospective cohort study of the association of varicella vaccine failure with asthma, steroid use, age at vaccination, and measles-mumps-rubella vaccination. Pediatrics 2003; 112:e98.
  70. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  71. Poon TP, Tchertkoff V, Win H. Subacute measles encephalitis with AIDS diagnosed by fine needle aspiration biopsy. A case report. Acta Cytol 1998; 42:729.
  72. Bitnun A, Shannon P, Durward A, et al. Measles inclusion-body encephalitis caused by the vaccine strain of measles virus. Clin Infect Dis 1999; 29:855.
  73. Baram TZ, Gonzalez-Gomez I, Xie ZD, et al. Subacute sclerosing panencephalitis in an infant: diagnostic role of viral genome analysis. Ann Neurol 1994; 36:103.
  74. Centers for Disease Control and Prevention (CDC). Measles pneumonitis following measles-mumps-rubella vaccination of a patient with HIV infection, 1993. MMWR Morb Mortal Wkly Rep 1996; 45:603.
  75. Derryck A, LaRussa P, Steinberg S, et al. Varicella and zoster in children with human immunodeficiency virus infection. Pediatr Infect Dis J 1998; 17:931.
  76. Department of Health and Human Services. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Available at: aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf (Accessed on November 20, 2013).
  77. Siber GR, Werner BG, Halsey NA, et al. Interference of immune globulin with measles and rubella immunization. J Pediatr 1993; 122:204.
  78. American Academy of Pediatrics. Active immunization of people who recently received immune globulin and other blood products. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.38.
  79. King GE, Markowitz LE, Heath J, et al. Antibody response to measles-mumps-rubella vaccine of children with mild illness at the time of vaccination. JAMA 1996; 275:704.
  80. Dennehy PH, Saracen CL, Peter G. Seroconversion rates to combined measles-mumps-rubella-varicella vaccine of children with upper respiratory tract infection. Pediatrics 1994; 94:514.
  81. Ratnam S, West R, Gadag V. Measles and rubella antibody response after measles-mumps-rubella vaccination in children with afebrile upper respiratory tract infection. J Pediatr 1995; 127:432.
  82. Farizo KM, Stehr-Green PA, Markowitz LE, Patriarca PA. Vaccination levels and missed opportunities for measles vaccination: a record audit in a public pediatric clinic. Pediatrics 1992; 89:589.
  83. Brickman HF, Beaudry PH, Marks MI. The timing of tuberculin tests in relation to immunization with live viral vaccines. Pediatrics 1975; 55:392.
  84. Siberry GK, Patel K, Bellini WJ, et al. Immunity to Measles, Mumps, and Rubella in US Children With Perinatal HIV Infection or Perinatal HIV Exposure Without Infection. Clin Infect Dis 2015; 61:988.
  85. Berkelhamer S, Borock E, Elsen C, et al. Effect of highly active antiretroviral therapy on the serological response to additional measles vaccinations in human immunodeficiency virus-infected children. Clin Infect Dis 2001; 32:1090.
  86. Aurpibul L, Puthanakit T, Sirisanthana T, Sirisanthana V. Response to measles, mumps, and rubella revaccination in HIV-infected children with immune recovery after highly active antiretroviral therapy. Clin Infect Dis 2007; 45:637.
  87. Rowson K, Tan A, Donaghy S, et al. Measles reimmunization may not be effective in protecting HIV-infected children. Pediatr Infect Dis J 2015; 34:552.
  88. Kamboj M, Sepkowitz KA. Risk of transmission associated with live attenuated vaccines given to healthy persons caring for or residing with an immunocompromised patient. Infect Control Hosp Epidemiol 2007; 28:702.
  89. Nieminen U, Peltola H, Syrjälä MT, et al. Acute thrombocytopenic purpura following measles, mumps and rubella vaccination. A report on 23 patients. Acta Paediatr 1993; 82:267.
  90. Beeler J, Varricchio F, Wise R. Thrombocytopenia after immunization with measles vaccines: review of the vaccine adverse events reporting system (1990 to 1994). Pediatr Infect Dis J 1996; 15:88.
  91. Drachtman RA, Murphy S, Ettinger LJ. Exacerbation of chronic idiopathic thrombocytopenic purpura following measles-mumps-rubella immunization. Arch Pediatr Adolesc Med 1994; 148:326.
  92. Vlacha V, Forman EN, Miron D, Peter G. Recurrent thrombocytopenic purpura after repeated measles-mumps-rubella vaccination. Pediatrics 1996; 97:738.
  93. France EK, Glanz J, Xu S, et al. Risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children. Pediatrics 2008; 121:e687.
  94. Miller E, Waight P, Farrington CP, et al. Idiopathic thrombocytopenic purpura and MMR vaccine. Arch Dis Child 2001; 84:227.
  95. Stowe J, Kafatos G, Andrews N, Miller E. Idiopathic thrombocytopenic purpura and the second dose of MMR. Arch Dis Child 2008; 93:182.
  96. Vestergaard M, Hviid A, Madsen KM, et al. MMR vaccination and febrile seizures: evaluation of susceptible subgroups and long-term prognosis. JAMA 2004; 292:351.
  97. Berg AT, Shinnar S, Shapiro ED, et al. Risk factors for a first febrile seizure: a matched case-control study. Epilepsia 1995; 36:334.
  98. Kuter BJ, Brown M, Wiedmann RT, et al. Safety and Immunogenicity of M-M-RII (Combination Measles-Mumps-Rubella Vaccine) in Clinical Trials of Healthy Children Conducted Between 1988 and 2009. Pediatr Infect Dis J 2016; 35:1011.
  99. LeBaron CW, Bi D, Sullivan BJ, et al. Evaluation of potentially common adverse events associated with the first and second doses of measles-mumps-rubella vaccine. Pediatrics 2006; 118:1422.
  100. Ting CY, Tee NW, Thoon KC. Could a fever and rash after the measles, mumps and rubella vaccination indicate wild-type measles? Acta Paediatr 2015; 104:e232.
  101. American Academy of Pediatrics. Rubella. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.688.
  102. James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995; 332:1262.
  103. Beck SA, Williams LW, Shirrell MA, Burks AW. Egg hypersensitivity and measles-mumps-rubella vaccine administration. Pediatrics 1991; 88:913.
  104. O'Leary ST, Glanz JM, McClure DL, et al. The risk of immune thrombocytopenic purpura after vaccination in children and adolescents. Pediatrics 2012; 129:248.
  105. Klein NP, Lewis E, Fireman B, et al. Safety of measles-containing vaccines in 1-year-old children. Pediatrics 2015; 135:e321.
  106. Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic purpura after measles-mumps-rubella vaccination: a systematic review of the literature and guidance for management. J Pediatr 2010; 156:623.
  107. Ray P, Hayward J, Michelson D, et al. Encephalopathy after whole-cell pertussis or measles vaccination: lack of evidence for a causal association in a retrospective case-control study. Pediatr Infect Dis J 2006; 25:768.
  108. Chess S, Fernandez P, Korn S. Behavioral consequences of congenital rubella. J Pediatr 1978; 93:699.