What is the role of Vitamin A (VA) supplementation in the management of measles?

Vitamin A Supplementation for Measles Management

All children with measles should receive vitamin A supplementation at a dose of 200,000 IU orally on days 1 and 2 for children over 12 months of age, and 100,000 IU for children under 12 months, to reduce mortality and complications. 1

Dosing and Administration Protocol

The recommended vitamin A supplementation protocol for measles cases is as follows:

• Standard dosing:

  • Children ≥12 months: 200,000 IU vitamin A orally on day 1 and day 2
  • Children <12 months: 100,000 IU vitamin A orally on day 1 and day 2 2, 1

• For complicated measles (pneumonia, otitis, croup, diarrhea with moderate/severe dehydration, or neurological problems):

  • Administer a second dose of vitamin A on day 2 2

• For children with eye symptoms of vitamin A deficiency (xerosis, Bitot's spots, keratomalacia, or corneal ulceration):

  • 200,000 IU oral vitamin A on day 1
  • 200,000 IU oral vitamin A on day 2
  • 200,000 IU oral vitamin A 1-4 weeks later
  • Children <12 months receive half doses (100,000 IU) 2

Evidence Supporting Vitamin A Supplementation

The evidence strongly supports vitamin A supplementation for measles:

• Vitamin A has been defined as an "anti-infective" vitamin, with deficiency being particularly problematic in measles cases 2
• Studies show that vitamin A supplementation in humans reduces morbidity and mortality in measles and measles-related pneumonia 2
• Meta-analysis demonstrates that two doses of 200,000 IU vitamin A given on consecutive days is associated with a 64% reduction in overall mortality (RR 0.36; 95% CI 0.14-0.82) and 67% reduction in pneumonia-specific mortality (RR 0.33; 95% CI 0.08-0.92) in hospitalized children 3
• The mortality reduction is even more pronounced in children under 2 years of age (83% reduction, RR 0.17; 95% CI 0.03-0.61) 3

Benefits Beyond Mortality Reduction

Vitamin A supplementation also provides additional benefits:

• 47% reduction in the incidence of croup (RR 0.53; 95% CI 0.29-0.89) 4
• 74% reduction in the incidence of otitis media (RR 0.26; 95% CI 0.05-0.92) in one study 4
• Significant decreases in the duration of diarrhea, pneumonia, hospital stay, and fever 4

Mechanism of Action

Vitamin A appears to work through multiple mechanisms:

• Boosting immune responses 5
• Maintaining integrity of epithelial surfaces that are rapidly destroyed during measles infection 5
• Modulating glycoproteins of lymphocyte membranes and supporting helper T-cell function 5

Important Clinical Considerations

• Vitamin A deficiency is common in measles patients: Studies have found that 50% of children with measles in the United States (95% CI: 28%-72%) were vitamin A deficient, indicating this is not just an issue in developing countries 6
• Single dose is insufficient: A single dose of 200,000 IU vitamin A was not associated with reduced mortality (RR 1.25; 95% CI 0.48-3.1), highlighting the importance of the two-dose regimen 3
• Undernutrition is not a contraindication: Undernourished or malnourished children should be prioritized for vaccination and vitamin A supplementation 2, 1

Integration with Overall Measles Management

Vitamin A supplementation should be part of a comprehensive approach to measles management that includes:

1. Appropriate supportive care
2. Oral rehydration therapy for diarrhea
3. Antibiotics for secondary bacterial infections (pneumonia, acute lower respiratory infections)
4. Nutritional support and monitoring 1

Pitfalls to Avoid

• Delaying vitamin A administration: Vitamin A should be given immediately upon diagnosis
• Using single-dose regimen: Two doses are significantly more effective than a single dose
• Overlooking vitamin A in developed countries: Vitamin A deficiency occurs in measles patients even in well-resourced settings
• Failing to repeat vitamin A in cases with eye symptoms: Additional doses are needed for patients with ocular manifestations of vitamin A deficiency