C L MILLER. Deaths from measles in England and Wales, 1970-83. British Medical Journal, Vol 290, 9 February 1985

The annual number of deaths attributed to measles on death certificates fell from 39 in 1970 to 17 in 1983, but the ratio of deaths to measles notifications showed no declining trend over the period (table).

Deaths from measles in (a) previously normal and (b) previously abnormal persons, and deaths from Subacute sclerosing panencephalitis 1970-83
Year	Total measles deaths	Ratio/10,000 notifications	(a) Previously normal (No %)	(b) Previously abnormal	Subacute sclerosing panencephalitis
1970	39	1.3	24 (62)	15	5
1971	25	1.9	17 (68)	8	9
1972	29	2.0	18 (62)	11	15
1973	27	1.8	18 (67)	9	15
1974	19	1.7	12 (63)	7	12
1975	13	0.9	10 (77)	3	14
1976	11	2.0	4 (36)	7	15
1977	18	1.0	5 (28)	13	18
1978	13	1.0	6 (46)	7	15
1979	14	1.8	7 (50)	7	15
1980	23	1.6	8 (35)	15	12
1981	12	2.3	3 (25)	9	15
1982	10	1.1	3 (30)	7	13
1983	17	1.6	9 (50)	8	2
	270	1.5	144 (53)	126	175

Methods and results

To establish the age, primary cause of death, and proportion associated with previous abnormalities, copies of death certificates were obtained from the Office of Population Censuses and Surveys for 270 deaths from measles and 175 from subacute sclerosing panencephalitis over the period. Where information on death certificates was inadequate or ambiguous inquiries were made to the hospital or notifying doctor. No attempt was made to establish further clinical details, vaccination history, or social class.

The overall ratio of deaths to measles notifications was 1.5 per 10,000, but for children under 1 year it was 4.8 and for those aged 1-2 it was 2.3. Fifty-three per cent of the 270 deaths occurred in individuals with no pre-existing condition, and for these the proportion was highest (32/42) under 1 year and decreased with age. The converse was true for those previously abnormal: 31 of the 38 deaths over the age of 10 occurred in this group.

The most common primary cause of death at all ages was bronchopneumonia, followed by encephalitis and a combination of the two. In those previously normal 73% of deaths under the age of 2 and 45% from 2-9 were due to bronchopneumonia. Nearly twice as many children aged 2-9 died of encephalitis (28/78) than children under 2 (11/59). Other causes included toxaemia from measles (12), cerebral thrombosis, rupture of lung, acute pericarditis, adrenal failure, and disseminated intravascular coagulation.

The pre-existing conditions in the 126 previously abnormal individuals included cerebral palsy (24), men tar retardation (20), Down's syndrome (19) and various congenital abnormalities (22). There were nine children with immune deficiency or immunosuppression, and 19 aged 2-8 with lymphatic leukaemia, a number of them in remission.

Deaths from subacute sclerosing panencephalitis were few in 1970 and 1971, probably because it was not widely diagnosed before

the late 1960s and coding of the cause of death was still erratic. There was little change in the annual number of deaths in the next 10 years. The two deaths in 1983 probably reflect the smaller number of cases with onset in 1982-3 than in earlier years, but there were six deaths in the first half of 1984.Forty-one percent of deaths occurred between the ages of 10 and 14; this is in keeping with the median age of onset of 10 years, and the interval between onset and death of less than two years in 70% of cases.

Measles is widely considered a benign disease with a negligible mortality in developed countries. Certainly the number of deaths has fallen over the past 13 years, particularly in normal children; in the first four years 65% of deaths were in normal individuals compared with 35% in the last four year period. Nevertheless, over half the 270 deaths were in those with no pre-existing condition, and there has been no overall downward trend in the ratio of deaths to notifications. As in other studies, this ratio was highest in children under 1 year.^1,2 The increased ratio of deaths to notifications in adults which has been reported may well be due to the larger number of deaths in abnormal adults; in this study 16 were over 15 years compared with three (aged 16,20, and 94) in those previously normal.

Of those with pre-existing conditions, most were grossly physically or mentally abnormal or both. Nineteen deaths occurred in children with lymphatic leukaemia, however, some of them in remission. Since children with leukaemia are now living longer measles is an increasing danger to them, and a report from Japan of the successful vaccination against measles of children with acute lymphatic leukaemia in remission is of interest.

Clearly measles still carries a risk�not only of complications and subacute sclerosing panencephalitis but also of death�which is not confined to abnormal children.4 Vaccination has reduced the number of deaths, but 90% of deaths in those previously normal occurred in those over the age of 15 months, when vaccine is usually given. Protection of those under 1 year who are at greatest risk has up to now been complicated by the presence of maternal antibody. Recent reports of a vaccine produced in human diploid cells which has been given successfully at 4-6 months may be the answer.5

1 Babbott FL, Galbraith NS; McDonald JC, Shaw A, Zuckerman AJ. Deaths from measles in England and Wales in 1961. Monthly Bulletin of the Ministry of Health and Public Health Laboratory Service 1963; 22:167-75.

3 Torigoe S, Hirai S, Oitani K. et al. Application of live attenuated measles and mumps vaccines in children with acute leukemia. Biken J 1981; 24:147-51.

5 Whittle HC, Rowland MGM, Mann GF, et al. Immunisation of 4-6 month old Gambian infants with Edmonston-Zagreb measles vaccine. Lancet 1984;ii:834-7.