Measles control in developing and developed countries: the case for a two-dose policy

Bull World Health Organ. 1993;71(1):93-103.


Despite major reductions in the incidence of measles and its complications, measles control with a single dose of the currently used. Schwarz strain vaccine has failed to eradicate the disease in the developed countries. In developing countries an enormous toll of measles deaths and disability continues, despite considerable efforts and increasing immunization coverage. Empirical evidence from a number of countries suggests that a two-dose measles vaccination programme, by improving individual protection and heard immunity can make a major contribution to measles control and elimination of local circulation of the disease. Cost-benefit analysis also supports the two-dose schedule in terms of savings in health costs, and total costs to society. A two-dose measles vaccination programme is therefore an essential component of preventive health care in developing, as well as developed countries for the 1990s.

PIP: Measles incidence data were examined as reported in the US, Canada, the Netherlands, Finland, Sweden, the United Kingdom, Israel, the West Bank and Gaza, the Philippines, Malawi, and Nigeria. Data assembled by UNICEF on population, mortality, and immunization coverage were also examined. Recent literature on vaccine efficacy as well as cost-benefit studies were reviewed. Measles causes an estimated 1.4 million deaths annually, primarily in developing countries. Primary and secondary vaccine failures make absolute measles control a difficult objective. Even a 95% vaccination coverage of children up to 2 years of age is insufficient to fully control the disease. Some countries have adopted a two-dose policy: one dose in infancy and a booster, usually at school age. Evidence favors universal adoption of the two-dose schedule to achieve control of measles in both developed and developing countries. In the Quebec and Waterloo outbreaks in Canada in 1990 and 1991, large numbers of high-school and post-high-school students were ill with measles, despite universal immunization. Similarly, in the US, between 1985 and 1989, many epidemics were documented among highly immunized populations. The US has subsequently adopted a two-dose measles vaccination policy, while Canada continues with the one-dose policy. Favorable benefit-to-cost (B/C) ratios of the two-dose policy in Israel, the West Bank and Gaza, yielded measles incidence rates as low as 3.5/100,000 population and rates of 9/100,000, with only direct health services costs included. The ratio for the United Kingdom was found to be 38.6/1 health services alone, and 86.3/1 for society as a whole. For Italy, the B/C ratios were 20/1 and 53/1; and for Canada they were 17/1 and 8/1, respectively. During 1991, measles outbreaks occurred in Australia and New Zealand, with a resultant continuation of the one-dose policy in Australia, but adoption of a two-dose measles-mumps-rubella (MMR) policy in New Zealand. The two-dose policy was recently adopted in the United Kingdom in 1990, Saudi Arabia and Bahrain in 1991, and Papua New Guinea in 1992.

Publication types

  • Review

MeSH terms

  • Cost-Benefit Analysis
  • Developing Countries*
  • Europe
  • Health Expenditures
  • Humans
  • Immunization Schedule
  • Infant
  • Measles / economics
  • Measles / prevention & control*
  • Measles Vaccine / administration & dosage*
  • United States


  • Measles Vaccine