Measles is caused by a virus, which belongs to a family of virus known as paramyxoviridae. These viruses are enveloped in two layers of lipid, which make it fragile to heat, acidity or causticity and sunlight but because of non-segmented genome, it is relatively more stable than its cousin influenza virus, orthomyxoviridae. This also incidentally helps to develop a stable and long-lasting vaccine, unlike that for influenza. The bilayer of lipid in the viral envelope is derived from the host human cell while exiting the host cell, after multiplication within. These lipid layers help the virus to evade human immune actions against it while docking on a human cell since the host immune system does not identify it as an external and harmful body.
The virus also has a fusion protein, which additionally helps the virus to fuse with the host cell membrane at ease and in cell-to-cell spread. The three other familiar diseases that are caused in Bangladesh by the paramyxoviridae are mumps, respiratory syncytial virus and nipah virus. These viruses are spread through droplets through the respiratory tract of the infected person, like Coronavirus, or SARS-CoV-2. Some paramyxoviridae also cause severe animal infection although humans are the only known hosts of the measles virus.
Clinical features
Measles identification begins with the Koplik spot, known as its pathognomonic sign. These are small, bluish-white papules on an erythematous base that grow inside the cheeks. They typically appear one to two days before the widespread maculopapular rash and last for two to three days, often disappearing as rash peaks. The symptoms are high fever, often above 104°F, followed by cough, runny nose and conjunctivitis. A red blotchy rash appears about four days after the start of the fever, beginning at the hairline, then on the face and the upper neck and proceeding downward and outwards to hands and feet. After five to six days, the rash fades in the same order as it appears. Serious complications of measles include diarrhoea, otitis media, pneumonia, encephalitis, subacute sclerosing panencephalitis, which is inflammation of the whole brain, and death. The treatment is symptom based only as there is no specific treatment for measles.
The incubation period for measles is typically 10 to 12 days, ranging from 7 to 18 days after an exposure to the virus. In some cases, rash may appear even up to 21 days post exposure. However, measles is infectious four days before and four days after the onset of rash. This period of communicability has epidemiological implication, ie the virus may spread from an infected but apparently healthy person unwittingly to people, in general, before the infected person shows signs of sickness. Measles is the most infectious of all the known human diseases, next one being chickenpox. Its R0, ie basic reproduction number, which means how many secondary cases a disease is transmitted to by a primary infected case, in virgin natural environment and conditions, ie when there is no vaccination programme and when there are no immune people on a location, is 12 to 18. R0 is 10–12 for chickenpox and up to 6 in Covid-19. The percentage of people who are to be vaccinated for preventing the occurrence of the disease when R0 is 18 is given by 1– 1/R0–95 per cent of eligible people. If it is less than 95 per cent, about 90 per cent of the people who have not been vaccinated and are exposed to someone with measles will become infected. People infected with measles usually manifest the clinical features, ie no hidden measles.
Infected people can spread measles by coughing, sneezing, talking or even through breathing. Measles virus can live up to two hours in the air where the infected person coughed or sneezed. If other people breathe the contaminated air or touch the infected surface, then touch their eyes, the nose or the mouth, they can become infected. Spread of measles is more common within households, daycare centres and schools.
Some other epidemiological features must also be examined and considered at this point. First, pathogens which are too transmissible are less virulent. The case fatality of measles, in general, is 1 to 3 per 1,000 infected cases. Second, the earlier policy of vaccinating children against measles was at the age of nine months of age in Bangladesh. It was decided with the understanding that maternal immunity can protect an infant up to six months of age. But we forgot that in Bangladesh, the breastfeeding rate started falling since 2011 and now it is barely 50 per cent. So, babies were not protected by their mothers. On the top of that, the measles vaccination rate was 59 per cent in 2025.
Third, about a third of the vaccinated were also infected with the virus. It begs a question as to whether the vaccine given itself was efficacious enough for sero-conversion to impart immunity. This could be among many other reasons because a lackadaisical vaccine performance such as not maintaining cold chain properly, especially in warn weather, might destroy a live virus, already attenuated for vaccination. This also indicates that we need to assess if sero-conversion is long-lasting, usually life-long in case of measles and its vaccination. Fourth, measles is a springtime disease. The surveillance system of the country should have been agile at this time of the year to pick the cases for early warning. Fifth, it is also likely that all those children who are identified as cases of measles may not be actually measles. Some enterovirus, eg Coxsackie and ECHO also cause rash and so does another group of virus, Parvovirus. It may, therefore, be possible that not all currently reported deaths are from measles.
Sixth, malnutrition, which is widespread in Bangladesh despite some amelioration, also reduces the strength of an at-risk person to mount immunity since immunity is protein-based while growing children suffer inordinately more from protein deficiency. Along with this, the deficiency of Vitamin A and D, which need dietary fat for their absorption, transportation and storage also reduces people’s capacity to prevent serious effects and impacts of a disease in general.
What went wrong in management
THE expanded programme on immunisation administers measles vaccine in the form of measles, mumps and rubella at nine months of age and then a booster dose at 15 months of age. The EPI began in the country in 1979. The measles vaccination rate had been rising since then and in 2024, it reached 96 per cent, which is good enough for herd immunity. But the rate fell to 59 per cent in 2025. Why did it so so? Was there any dearth of measles vaccination? No, that was not the case. It was not the paucity of the vaccine. It was not a procurement, storage or transportation problem per se. But, the problem was somewhere else and to understand that we will have to go back. In fact, it was a management and logistical problem that came in many forms and facets and it involves a particular group of fringe level primary healthcare workers, health assistants, who have also been bestowed with the responsibility of vaccination.
The first issue was the indifference of policy-makers towards their legitimate demands. Considering their job load, which also includes home visits, health education in schools and communities, birth and death registration and performance recording and reporting online, their salary remained fixed at a level that is akin to that of the public sector drivers. They demanded technical allowance as their job includes technical know-how. They wanted travel allowance as they have to travel throughout a union’s perimeter. They needed money for the transportation of vaccine from the vaccine drop site. Porters carry the vaccines to the dropping site who are paid for this. These vaccine boxes are quite heavy and are transferred from one place to another with difficulty and in difficult terrain, it is it much more difficult to carry these boxes. Also in hard-to-reach areas, the carrying cost is considerable which the health assistants have to pay from their own paltry salary.
The salary of their supervisors, positions which some but not all of the health assistants are promoted to, are also on the same scale. One health assistant is supposed to attend 4,000 people in rural areas. This now stands at approximately 7,000. In actuality, this number may be higher for some health assistants because of the positions that remain vacant. This is a dire management issue as the vacancy is more than 20 per cent at any given time at the peripheral primary healthcare level. As a result of which some of the health assistants are ordered to cover adjacent vacant units, besides their own, without any additional remuneration, which in the hard-to-reach areas is a sort of punishment.
Further promotion of health assistants to upazila level as health inspectors gives them 14th grade of salary whereas family welfare visitors and midwives get salary at grade 11 and recently primary schoolteachers, who have the same educational background as health assistants, were given salary at grade 11. It is true that the latter are trained for 1.5 years to 3 years and health assistants are trained for three months and then occasionally for the sake of different programmes such as disease control, health education, etc. But, if they are not trained for longer period, it is not their fault. These needs and demands of health assistants have never given any ear ever since Bangladesh’s independence. In 2011 and 2023, community health care providers were recruited as stationary workers for community clinics while health assistants were mobile workers, travelling on bicycle, on foot or by boat.
Although I suggested giving preference to health assistants to select them as community health care providers, after I left for the regional office of the World Health Organisation in 2010, fresh graduates were selected as community health care providers and health assistants along with family welfare assistants, were ordered to provide care for two days a week from community clinics, where community health care providers sit for six days a week and everything in the community is in the hand of community health care providers. This hurt the feeling of the health assistants as well as their service tenure was much longer, at least senior by 20 years.
While we boast the awarding of the former prime minister as ‘vaccine hero,’ accorded by the Global Alliance for Vaccine Initiative, an organisation funded by bilateral and multilateral agencies and organisations, it was, nevertheless, due to the diligence of the toiling field workers of the health department. But, they did not get any mention, citation or appreciation for their hard work. Could it not be a bone of contention? Time after time, these health assistants were neglected and their pathetic working conditions were not looked into by anyone. Negligence by the policy level officials during the interim government was too much to bear by these hard working health assistants, like other health and family planning workers.
While demands were raised from nooks and corners of the country every day and everywhere by everybody, the health assistants also thought that real opportunity had come for them to raise their old demand and when no attention was given to their demand, they started to go slow with their prime job of vaccination. During this period, the planning adviser was contemplating to stop the operational plan-based development funding to project-based funding. While operational plans were stalled, projects did not see the light of the day and fund did not get released for procuring vaccines, medicine, machines, equipment and supplies; for replacement, repairs and maintenance; travel and transport; and operational cost from development budget. These broke the back of the camel as these were added to the already simmering disappointment of the vaccinators, the health assistants.
Recommendations
BESIDES solving the problems that are relevant to strengthening immunity and programme management, we need (1) an effective disease surveillance system for issuing early warning of an impending health problem. The health policy-makers have never prioritised disease surveillance as an important function. At one time, there were 37 operational plans and still surveillance has not been thought to be a priority. What Bangladesh needs is a strong surveillance system starting from sample collection skills at community level to the diagnosis of most common diseases at upazila level, some of which should as well be at union level. Surveillance needs to be conducted especially in summer, winter and rainy seasons to see seasonal effects on the incidence and prevalence of measles and immunity to it. (2) The national immunisation technical advisory croup formed during the interim government with 80 per cent members without any experience in national surveillance, vaccine management — vaccine procurement, financing, transportation and storage and administration — and the management of vaccine related human resources needs reform for timely and efficient advice to the government.
Dr Abu Muhammad Zakir Hussain is chairman of the Community Clinic Health Support Trust. He was a member of the health sector reform commission, director of Primary Health Care and Disease Control, regional adviser of environmental health and climate change of the World Health Organisation and staff consultant of the Asian Development Bank.
