Bulletin of the World Health Organization

Measles deaths in Nepal: estimating the national case–fatality ratio

Anand B Joshi, Elizabeth T Luman, Robin Nandy, Bal K Subedi, Jayantha BL Liyanage & Thomas F Wierzba

Volume 87, Number 6, June 2009, 456-465

Table 2. Risk factors for mortality among 4657 measles patients in selected districts of Nepal, September 2004 to January 2005a

Variable Cases
 Deaths
 Case–fatality ratio
 Multivariate analysisb
n Weighted %c n Weighted %c Weighted %d 95% CI Factor-levelP‑value aOR 95% CI Factor-level P‑value
Total 4657 64 1.1 0.5−2.3
Insecurity leveld 0.17 0.003
Moderate 2222 57.2 16 31.0 0.6 0.3−1.3 Referent
High 1693 32.8 27 51.8 1.7 0.4−6.6 1.8 0.5−6.2
Critical 742 10.0 21 17.1 1.9 0.9−3.7 15.8 3.4−73.4
Ecological zone 0.28 0.01
Himalayan mountains 377 6.4 4 5.9 1.0 0.6−1.8 3.7 1.0−13.6
Himalayan foothills 1769 50.8 20 19.3 0.4 0.1−1.3 Referent
Ganges plains 2511 42.8 40 74.8 1.9 0.8−4.7 11.9 2.6−55.3
Agee 0.02 < 0.001
< 1 years 301 6.3 8 20.6 3.5 0.8−14.2 21.2 1.9−233.7
1–4 years 1640 31.6 44 66.4 2.3 1.2−4.2 11.0 1.2−98.8
5–14 years 2461 56.4 11 11.2 0.2 0.1−0.6 1.0 0.1−11.5
15+ years 244 5.7 1 1.9 0.4 0.1−2.8 Referent
Vaccination status 0.02 < 0.001
Vaccinated 2387 51.8 14 25.1 0.5 0.2−1.2 Referent
Not vaccinated 2270 48.2 50 74.9 1.7 0.7−3.9 4.4 2.3−8.6
Cases in household and place in order of cases within household 0.05 < 0.001
1 case 1190 24.3 23 41.9 1.9 0.7−4.7 3.3 2.1−5.0
> 1 case in household, 1st case 1289 28.0 17 25.4 1.0 0.5−2.0 2.1 1.1−3.8
> 1 case in household, not 1st case 2178 47.7 24 32.7 0.7 0.3−1.7 Referent
Self-medication 0.11 0.04
Yes 672 12.0 15 23.4 2.1 1.0−4.3 2.7 1.1−7.0
No 3985 88.0 49 76.7 0.9 0.4−2.3 Referent
Vitamin A given during illness 0.03 < 0.001
Yes 2093 42.5 13 19.8 0.5 0.2−1.1 Referent
No 2654 57.5 51 80.2 1.5 0.7−3.3 4.0 2.4−6.6
Gender 0.09 0.04
Male 2284 49.5 25 39.4 0.9 0.4−2.0 Referent
Female 2378 50.5 39 60.6 1.3 0.6−2.8 1.7 1.0−2.7
Outbreak laboratory-confirmed 0.65 0.03
Yes 3499 84.9 46 88.9 1.1 0.5−2.7 3.4 1.2−9.8
No 1158 15.2 18 11.1 0.8 0.3−2.2 Referent
Development region 0.04
Eastern 857 25.3 1 1.8 0.1 0.0−0.8
Central 1018 13.8 8 12.4 1.0 0.6−1.6
Western 1105 38.2 8 18.7 0.5 0.2−1.6
Mid-western 1198 16.4 35 57.1 3.4 1.0−11.6
Far-western 479 6.3 12 15.0 2.6 1.8−3.6
Prevalence (%) of stunting (< 3SD) of preschool children in eco‑developmental region30 0.05
< 25 1664 51.4 6 12.0 0.3 0.1−0.8
≥ 25 2993 48.7 58 88.1 2.0 0.9−4.3
Ethnic group 0.36
Brahmin/Chhetri/Thakuri 2392 53.5 45 74.0 1.5 0.6−3.6
Newar/Tamang/Sherpa/Magar/Rai/Limbu/Chaudhary 1055 20.2 6 6.9 0.4 0.1−1.1
Muslim 396 6.6 5 4.1 1.0 0.2−4.1
Dalit 814 19.8 8 13.0 0.7 0.3−1.7
Household size 0.52
< 7 persons 2036 44.5 34 49.5 1.2 0.6−2.4
≥ 7 persons 2621 55.5 30 50.5 1.0 0.4−2.5
Treatment at health-care facility 0.31
Yes 1583 36.6 20 24.8 0.7 0.3−1.6
No 3074 63.4 44 75.2 1.3 0.5−3.0
Treatment with traditional medicine 0.32
Yes 1263 35.1 19 21.1 0.7 0.2−1.8
No 3394 64.9 45 78.9 1.3 0.6−3.1
Treatment by spiritual healers 0.11
Yes 334 6.6 12 14.9 2.4 1.2−6.4
No 4323 93.4 52 85.1 1.0 0.4−2.2

aOR, adjusted odds ratio; CI, confidence interval; n, unweighted sample size; SD, standard deviation.
a All results are weighted except for sample sizes.
b Reduced model based on standard backward elimination.
c All percents were weighted to adjust for the probability of selection at both sampling stages and for the sampling design.
d Level of insecurity based on United Nations official security phase designation from September 2002 to end of March 2004: “moderately insecure” were districts designated as either “phase I: warning” or “phase II: restricted” throughout the time period; “highly insecure” were districts sometimes designated as “phase III: relocation”; “critically insecure” were districts always designated as “phase III: relocation”.
e Eleven cases were excluded from the analysis of age groups and multivariate analysis due to lack of information on age at rash onset.