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BMJ. Dec 16, 2006; 333(7581): 1234.
PMCID: PMC1702417

Measles in developing countries

Neal A Halsey, professor

Vitamin A and antibiotics prevent complications, but vaccination remains the priority

Widespread vaccination against measles and improvements in clinical care and socioeconomic status have reduced mortality due to measles in many countries.1 Nevertheless, measles remains an important cause of global morbidity and mortality, with case fatality rates as high as 9.7% in some African children with measles in recent years.1 2 Pneumonia, the most common cause of death due to measles, can be caused by the measles virus alone, secondary herpes simplex virus, adenoviruses, or bacterial infections.1 3 Factors contributing to increased rates of pneumonia and other complications in developing countries include young age at infection, crowding, and malnutrition, especially vitamin A deficiency.1 4

Antibiotics are often given to children with measles who do not have clinically apparent secondary bacterial infections, but evidence of benefit has been largely anecdotal. In this week's BMJ, a placebo randomised trial by Garly and colleagues supports the effectiveness of co-trimoxazole for preventing pneumonia and secondary bacterial conjunctivitis in children with measles in Guinea-Bissau.5 The trial found that children receiving co-trimoxazole were significantly less likely to develop pneumonia (odds ratio 0.08, 95% confidence interval 0 to 0.56), and had higher weight gain in the month after inclusion.

One limitation of the trial, however, is that the authors do not mention vitamin A therapy, which prevents pneumonia and mortality associated with measles.6 7 The World Health Organization recommends that all children with measles should receive vitamin A at the time of diagnosis and a second dose the next day (table 11).). Obviously, children with measles who have clinical signs of pneumonia should be treated with antibiotics; however, further studies need to determine whether antibiotics provide additional benefits to children who do not have clinical pneumonia and who receive vitamin A at the time of measles diagnosis.

Recommended vitamin A schedule for treatment of measles

Measles vaccination and vitamin A therapy are highly cost effective interventions for reducing mortality due to measles.7 Although measles vaccines have been available since 1963, hundreds of thousands of children still die from measles every year. Fortunately, new strategies are proving to be highly effective in Africa, including large scale community based supplemental immunisation campaigns, which effectively eliminated endemic transmission of measles in Latin America.9 These campaigns are being implemented in many African countries through the “measles initiative,” an effort coordinated by the American Red Cross, the Centers for Disease Control, Unicef, WHO, and the United Nations Foundation, and have resulted in dramatic declines in the incidence of measles.10 11

The 2010 WHO/Unicef goal to reduce global mortality due to measles by at least 90% from the 2000 estimates has an excellent chance of being met.11 12 Enthusiasm for declaring a goal for the global eradication of measles has been dampened by delays in meeting targets for polio eradication. Nevertheless, measles meets the criteria for diseases that could be eradicated.11 Some day, clinicians will no longer need to ponder the therapeutic options for children with measles. In the meantime, doctors caring for children everywhere should support local and global immunisation programmes and optimise care of children with measles using vitamin A and antibiotics when necessary.


Competing interests: NAH has received research grant support from GlaxoSmithKline, Sanofi Pasteur, and Merck, manufacturers of measles vaccines.


1. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis 2004;189:S4-16. [PubMed]
2. Nandy R, Handzel T, Zaneidou M, Biey J, Coddy RZ, Perry R, et al. Case-fatality rate during a measles outbreak in eastern Niger in 2003. Clin Infect Dis 2006;42:322-8. [PubMed]
3. Hussey GD, Clements CJ. Clinical problems in measles case management. Ann Trop Paediatr 1996;16:307-17. [PubMed]
4. Caulfield LE, de Onis M, Blossner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2004. l;80:193-8. [PubMed]
5. Garly ML, Balé C, Martins CL, Whittle HC, Nielsen J, Lisse IM, et al. Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ 2006. doi: 10.1136/bmj.38989.684178.AE [PMC free article] [PubMed]
6. Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. N Engl J Med 1990;323:160-4. [PubMed]
7. Edejer TT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries. BMJ 2005;331:1177. [PMC free article] [PubMed]
8. WHO, Unicef, United Nations Children's Fund. Global measles mortality reduction and regional elimination: strategic plan, 2001-2005. WHO/IVB/01.13Rev.1, September 2001:18. www.who.int/vaccines-documents/DocsPDF01/www573.pdf
9. De Quadros CA, Olive JM, Hersh BS, Strassburg MA, Henderson DA, Brandling-Bennett D, et al. Measles elimination in the Americas. Evolving strategies. JAMA 1996;275:224-9. [PubMed]
10. Hoekstra EJ, McFarland JW, Shaw C, Salama P. Reducing measles mortality, reducing child mortality. Lancet 2006;368:1050-2. [PubMed]
11. Asaria P, MacMahon E. Measles in the United Kingdom: can we eradicate it by 2010? BMJ 2006;333:890-5. [PMC free article] [PubMed]
12. WHO, Unicef. Joint statement: global plan for reducing measles mortality 2006-2010. WHO/IVB/0.5.11, January 2006. www.who.int/immunization_delivery/adc/measles/measles/en/index3.html.

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