“Count your children after the measles has passed.”—Arabic Proverb

Measles is a major cause of childhood morbidity and mortality worldwide. Case fatality rates of 5% to 25% are common in developing countries in contrast to the less than 1% case fatality rate in the United States during the epidemic of 1989 to 1990. In the developing world,epidemiologic factors associated with severe measles include younger age,overcrowding, poor access to care, pre-existing medical conditions, and malnutrition. Because these factors frequently coexist in the developing world, the relative contribution of each to measles morbidity is unclear. However, malnutrition has been implicated most markedly and repeatedly.

It had been suspected that malnutrition increased the morbidity and mortality of childhood measles as early as 1885 by Drinkwater, who investigated an epidemic in Sunderland, England, that had an unusually high case fatality rate of 10%. He attributed this finding to “semi-starvation among the poor.”Drink-water’s hunch has...

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