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Int J Epidemiol. 1994 Jun;23(3):632-42.

Sex differences in measles mortality: a world review.

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Harvard School of Public Health, Department of Population and International Health, Boston, MA 02115.



In general females have a lower mortality than males at all ages. Excess female mortality has been documented in certain high mortality situations, in particular in South Asia. However, females may have a higher mortality for certain causes of death. One of the causes of death for which excess female mortality is suspected is measles.


Sex differences in measles mortality are investigated using all national data on causes of death published by WHO since 1950. An index of excess mortality is used: the geometric mean of the female sex ratios of age-specific deaths rates from measles, from age 0 to 44 years.


When pooled together, the results show an excess of female mortality from birth until age 50 years. The excess female mortality appears small at age 0-4 (+4.2%), larger at age 5-14 (+10.9%) and peaks during the female reproductive period, at age 15-44 (+42.6%). This pattern of excess female mortality occurs in all the major regions of the world: Europe, North and South America, Far-East Asia, the Middle East and South Asia. The only noticeable exceptions are the Philippines and Thailand. The validity of the finding is extensively reviewed. Emphasis lies on the statistical power to prove that sex differences in measles mortality do exist, on the critical analysis of a case study in England and Wales, on the comparison with the overall pattern of sex differences and on available data on sex differences in incidence. Possible explanations are reviewed.


Sex differences in measles mortality were examined among 78 countries and 1500 country years between 1950 and 1989; countries were classified by the regional pattern of mortality defined by Coale and Demeny or the UN. Some countries were assigned to the West regional pattern. Data were obtained from the World Health Organization (WHO) compilation, which excludes some large countries such as China, India, Pakistan, Bangladesh, Brazil, and most of tropical Africa. Morbidity data from WHO was also used and covered 23 countries for 356 country years by age and 17 countries for sex and limited age groups. Variables included the following: measles death rate (DR), incidence rate (INC), case fatality rate (CFR), relationship (DR/CFR), female sex ratio (FSR) for each of the preceding measures, and the variance in the logarithm of the estimated measures (VarLog). The results showed that age patterns of mortality declined markedly between aged 0-4 years and 45-49 years, and then increased thereafter. Measles mortality at age 85+ was as high as at age 15 years. At ages 0-4 years the measles DR was 166 per million persons years and at aged 5-9 years, 20 per million person years. The FSR was higher than 100 between ages 0 and 45-49 years, and below 100 after age 50 years, with a high degree of statistical significance. Female excess mortality appeared as early as aged 0-4 years (+4.2%) and 5-14 years (10.9%), but peaked at 25-29 years (88%). Excess female mortality was 42.6% at ages 15-44 years compared to males. The weighted geometric mean of death rates at ages 0-44 years was 105.5 with a confidence interval of 105.0 to 106.0. A comparison of observed with expected values of FSR in a West model life table showed excess female mortality of 39% at ages 0-4 years, 43% at 5-14 years, and 88% at 15-44 years; there were no differences between the observed and expected values after age 45 years. Regional variations showed excess female mortality of 3% in Europe, 6.2% in North America, 5.9% in Far East Asia, 4.3% in Latin America, and 20.9% in the Middle East. There was a range of FSR of 1.7% to 21.3% in the 5 regions, but values were particularly high in the Middle East. At ages 5-14 years, the range was 8/3% to 29.2%. A comparison of observed and expected values showed a range of 21-55% higher FSR values. Country-specific analysis showed some anomalies.

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