Differences in female-male mortality after high-titre measles vaccine and association with subsequent vaccination with diphtheria-tetanus-pertussis and inactivated poliovirus: reanalysis of West African studies

Lancet. 2003 Jun 28;361(9376):2183-8. doi: 10.1016/S0140-6736(03)13771-3.


Background: Females given high-titre measles vaccine (HTMV) have high mortality; diphtheria-tetanus-pertussis (DTP) vaccination might be associated with increased female mortality. We aimed to assess whether DTP or inactivated poliovirus (IPV) administered after HTMV was associated with increased female-male mortality ratio.

Methods: In three trials from West Africa, 2000 children were randomised to HTMV or control vaccine at 4-5 months of age; a second vaccination was given at age 9-10 months (standard measles vaccine). Children in high-titre groups were given IPV or DTP-IPV. Another 944 children received HTMV as routine vaccination in Senegal.

Findings: When we compared high-titre and control groups, no difference in mortality between the first and the second vaccination was noted. After the second vaccination, the female-male mortality ratio was 1.84 (95% CI 1.19-2.84) in children in the high-titre groups who received DTP-IPV or IPV, and 0.59 (0.34-1.04) in controls who received standard measles vaccine (p=0.007). Children who received HTMV but no additional DTP-IPV or IPV had a female-male mortality ratio of 0.83 (0.41-1.67). This ratio was 2.22 (1.04-4.71) for children who received DTP-IPV after routine HTMV and 1.00 (0.68-1.47) for those who did not. When we combined the results from all trials, the female-male mortality ratio was 1.93 (1.33-2.81) for those who received DTP or IPV after HTMV, and 0.96 (0.69-1.34) for those who did not (p=0.006).

Interpretation: A change in sequence of vaccinations, rather than HTMV itself, may have been the cause of increased female mortality in these trials.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cause of Death
  • Diphtheria-Tetanus-Pertussis Vaccine / administration & dosage*
  • Female
  • Gambia / epidemiology
  • Guinea-Bissau / epidemiology
  • Humans
  • Immunization Schedule
  • Infant
  • Male
  • Measles / mortality*
  • Measles / prevention & control*
  • Measles Vaccine / administration & dosage*
  • Poliovirus Vaccine, Inactivated / administration & dosage*
  • Randomized Controlled Trials as Topic
  • Research Design
  • Senegal / epidemiology
  • Sex Factors
  • Sex Ratio


  • Diphtheria-Tetanus-Pertussis Vaccine
  • Measles Vaccine
  • Poliovirus Vaccine, Inactivated