Elsevier

The Lancet

Volume 361, Issue 9359, 1 March 2003, Pages 763-773
The Lancet

Seminar
Measles: not just another viral exanthem

https://doi.org/10.1016/S0140-6736(03)12661-XGet rights and content

Summary

Measles is the most frequent cause of vaccine-preventable childhood deaths. Infants younger than the recommended age for vaccination are susceptible to the disease, and in developing countries they have a high risk of complications and mortality. Vaccine coverage in excess of 95% interrupts endemic transmission of measles in many countries, but achievement of such coverage almost always requires coordinated supplementary mass vaccination campaigns. There are substantial health gains if countries improve measles vaccine coverage, irrespective of whether or not high coverage is achieved; these gains include much lower measles complication and case fatality rates, long-term interepidemic duration, and possibly non-specific improvements in survival of children. Investigation into the cost-effectiveness of different strategies for measles control, including mass campaigns, two-dose schedules, and young-infant doses, would help countries to formulate control policies appropriate to their setting. Pneumonia is the most common fatal complication associated with measles, and at least 50% of measles-related pneumonias are due to bacterial superinfection. WHO has developed standard case management programmes for measles, but there are several unresolved clinical issues, including optimum indications for antibiotic treatment, the importance of intravenous immunoglobulin, the role of viral coinfection, and the risk of tuberculosis after measles. The priority in worldwide efforts to control measles is to lend support to poor countries, helping them to increase vaccine coverage and sustain improvements to vaccination infrastructure, and to address technical issues with respect to optimum vaccination schedules. Measles represents a specific challenge, whereby partnerships between high-income and developing nations would reduce child mortality in developing countries; such partnerships are not without incentive for high-income countries, since without them imported measles cannot be prevented.

Section snippets

Virology

Measles virus is a spherical, enveloped, single-stranded RNA virus belonging to the genus Morbillivirus in the family paramyxoviridae.3 The virion is composed of six structural proteins, three of which form the viral envelope and three the ribonucleoprotein core. The nucleoprotein is the major component of the ribonucleoprotein core, the other two parts being the large protein and the phosphoprotein. The large protein contains the enzyme RNA polymerase, which catalyses the transcription and

Pathophysiology and immunology

Measles infection is acquired via the respiratory tract, and occasionally through the conjunctivae. Virions enter the local lymphatic system, either free or associated with macrophages, and are transported to the regional lymph nodes where they multiply before reaching the reticuloendothelial system. The reticuloendothelial infection is followed by a second viraemia through which the skin and the respiratory tract become infected and the disease is manifest after an incubation of 10–12 days.

Measles in young infants

In developing countries, measles is characterised by high incidence and mortality in infants younger than 9 months who are too young to have been vaccinated against the disease, according to the schedule recommended by WHO.51, 52, 53, 54 Infants have a higher risk of mortality and multisystem involvement than older children.50, 55 Young infants are more likely to be secondary cases of measles within a household than index cases, and case fatality when measles is acquired within a household is

Clinical issues

WHO has published standardised primary and first-level referral hospital case-management programmes for measles, which include recommendations on treatment and supportive care in outpatient and inpatient health facilities.86, 87 In the integrated guidelines for the primary-care management of the sick child (IMCI) in developing countries, a child is classed as having measles if he or she has a generalised rash and one of the following: cough, running nose, or red eyes. Children with measles are

Control and outbreak prevention or eradication

The fight against measles can be divided into three battles: control, outbreak prevention, and eradication. These battles can be waged at different times in different places, according to needs and resources.

The aim of control is to reduce the occurrence of measles and any associated deaths. As vaccination coverage increases, the epidemiology of the disease changes substantially and in a complex way, providing great advantages for communities even if target levels for elimination are not

Conclusion

Measles is a challenge for all countries. Effort needs to be put into sustaining the infrastructure necessary for vaccine delivery in low-income countries, as well as into development of novel vaccines and addressing technical questions about elimination schedules. Further research is necessary to address many public health and clinical issues relating to measles (panel 2). Measles represents a specific opportunity for high-income countries to contribute to the health and survival of children

Search strategy

We searched PubMed with the terms: measles, measles vaccine, measles pneumonia, measles and bacteria, measles and secondary infection, measles and control, measles and elimination, measles and young infants, and measles and tuberculosis. The Cochrane database was searched for reviews of measles. We also did an internet search on measles control or elimination, looking for reports of national strategies for measles control, and a search of the WHO website. Many other references were found in the

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