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Severe measles, vitamin A deficiency, and the Roma community in Europe.

To the Editor: The Roma community in Europe is a subgroup of the Romani people, whose origins are in northern India and who have been known in English-speaking countries as "gypsies." Measles outbreaks, including severe cases, were reported in the European Roma community during 2008-2010 (1,2). We describe the potential roles of malnutrition and vitamin A deficiency as risk factors for severe measles in adults from this community.

In Europe, >25,000 cases of measles, more than half of which occurred in France, were reported during a 2011 outbreak (3). The exact proportion of measles cases occurring among the Roma community in France during the outbreak are not available (2). Measles epidemiology has changed; the disease now mainly affects children <1 year old and young adults, the latter of whom are mostly unvaccinated or have unknown vaccination status (2,4). Roma people in Europe experience some of the worst health conditions in the industrialized world: they live in overcrowded conditions and have limited access to prevention programs and to healthcare services (2,5). In such populations, deficiencies of vitamins, such as A, C, and E, have been reported (6). Vitamin A deficiency has been associated with severe cases of measles in children in developing countries (7,8). To date, we did not find published data associating vitamin A deficiency with severe measles among adults. We describe 6 adults from the Roma community in Marseille, France, who had measles and low levels of vitamin A; 2 of these persons had severe measles.

Case-patients 1 and 2 were men who were 21 and 25 years of age, respectively. They were admitted to North Hospital, Marseille, France, with typical signs of measles (fever, cough, and maculopapular rash). They had no medical history of serious illness, including no immunocompromising conditions, and no history of measles vaccination. For both patients, the diagnosis of measles was confirmed by the results of PCR performed on pharyngeal and urinary samples. In case-patient 1, acute meningoencephalitis developed, and he was transferred to the intensive care unit for 3 days. During his stay, the patient was found to have active viral hepatitis B. Case-patient 2 had the following signs and symptoms: abdominal pain and vomiting, severe hepatitis (serum transaminases level 10x higher than the upper reference limit; total bilirubin within reference range), and keratitis. Other causes of viral or bacterial hepatitis were ruled out by serologic testing, and the patient did not frequently drink alcohol.

Case-patients 1 and 2 had vitamin A deficiency with values of 0.31 mg/L and 0.2 mg/L, respectively, (reference range 0.5-0.8 mg/L). We measured vitamin A levels in blood samples from the next 4 consecutive hospitalized patients with measles, all of whom were from the Roma community. They did not have complications of measles, but were hospitalized for infection-control reasons. All 4 patients had low levels of vitamin A (0.16-0.34 mg/L) (Table). In case-patient 4, the blood level of retinol-binding protein was 0.026 g/L (normal range 0.02-0.05 g/L), confirming vitamin A deficiency. Vitamin A supplementation was administered intramuscularly as recommended by the World Health Organization (200,000 IU followed by a second dose the next day) to each patient (8). The 6 patients progressed to recovery. Low levels of vitamin A (0.36-0.46 mg/L) were also found for 2 other patients from the Roma community who did not have measles (Table).

Serum vitamin A concentrations do not always reflect total vitamin A stores (9). In severe protein--calorie malnutrition, and during intercurrent infection, serum retinol levels could be artificially low in relation to a decrease in retinol-binding protein level (9). However, the diagnosis of vitamin A deficiency is usually supported by low levels of serum vitamin A and levels of retinol-binding protein within the reference range as described for at least 1 of the case-patients reported here.

Vitamin A deficiency affects the severity of illness and the rate of deaths associated with measles, and it is known to induce severe measles-related complications in children, delaying recovery and promoting xerophthalmia, corneal ulcer, and blindness (7,8,10). Acute measles precipitates vitamin A deficiency by depleting vitamin A stores and increasing its utilization, leading to more severe ocular injury (7,8). Vitamin A supplementation given to children with measles has been associated with better outcomes (7,8). Although it is too early to associate vitamin A deficiency with severe measles in adult patients, such an association is possible. Adults with low levels of vitamin A but not infected with measles could be at higher risk for more severe disease if they become infected with the virus.

We conclude that all adults who have measles should be assessed for vitamin A and retinol-binding protein levels and should be considered for vitamin A supplementation, as are children (8). A prospective case-control study assessing vitamin A deficiency in the Roma adult community is necessary to assess its consequences on measles outcome. Aside from preventing complications among the Roma people, improving vaccine coverage in this nomadic population is crucial for reducing measles virus circulation among the general population.


We are grateful to Merhaj Vikram for editing the article.

Clea Melenotte, Philippe Brouqui, and Elisabeth Botelho-Nevers

Author affiliation: Aix Marseille Universite, Faculte de Medecine, Marseille, France



(1.) Mankertz A, Mihneva Z, Gold H, Baumgarte S, Baillot A, Helble R, et al. Spread of measles virus D4-Hamburg, Europe, 2008-2011. Emerg Infect Dis. 2011;17:1396-401.

(2.) Muscat M. Who gets measles in Europe? J Infect Dis. 2011;204(Suppl 1):S353-65.

(3.) Centers for Disease Control and Prevention. Increased transmission and outbreaks of measles-European Region, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1605-10.

(4.) Cottrell S, Roberts RJ. Measles outbreak in Europe. BMJ. 2011;342:d3724. http://

(5.) Masseria C, Mladovsky P, Hernandez-Quevedo C. The socio-economic determinants of the health status of Roma in comparison with non-Roma in Bulgaria, Hungary and Romania. Eur J Public Health. 2010;20:549-54. http://

(6.) Dejmek J, Ginter E, Solansky I, Podrazilova K, Stavkova Z, Benes I, et al. Vitamin C, E and A levels in maternal and fetal blood for Czech and Gypsy ethnic groups in the Czech Republic. Int J Vitam Nutr Res. 2002;72:183-90. http://dx.doi. org/10.1024/0300-9831.72.3.183

(7.) Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. N Engl J Med. 1990;323:160-4. http://dx.doi. org/10.1056/NEJM199007193230304

(8.) Measles vaccines: WHO position paper. Wkly Epidemiol Rec. 2009;84:349-60.

(9.) de Pee S, Dary O. Biochemical indicators of vitamin A deficiency: serum retinol and serum retinol binding protein. J Nutr. 2002;132(Suppl):2895S-901S.

(10.) Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004;189(Suppl 1):S4-16. http://

Address for correspondence: Elisabeth Botelho-Nevers, Service de Maladies Infectieuses et Tropicales, IHU Mediterranee Infection, URMITE, Aix Marseille Universite, Faculte de Medecine, 27 Boulevard Jean Moulin, 13005 Marseille, France; email:
Table. Characteristics of 6 measles case-patients and 2 control
patients with vitamin A deficiency, Roma community, France *

                  Age, y/      Signs and              Defining
Participant         sex         symptoms           characteristics

Case-patient 1     21/M      Rash, meningo-     Positive PCR results
                              encephalitis       for pharyngeal and
                                                   urinary samples
Case-patient 2     25/M     Rash, hepatitis,   Positive PCR result for
                               keratitis       pharyngeal and urinary
Case-patient 3     26/M           Rash         Positive PCR result for
                                                  pharyngeal sample
Case-patient 4     22/M           Rash         Positive PCR for result
                                                 urinary, nasal, and
                                                 pharyngeal samples;
                                               Positive serologic test
Case-patient 5     15/M           Rash           Positive PCR result
                                                  for nasal sample
Case-patient 6     17/M     Rash, hepatitis,       Clinical signs
                              Koplik spots
Control 1          34/F           None                   NA
Control 2          12/M           None                   NA

                  level, mg/L)                 No. days in
Participant        ([dagger])      Outcome       hospital

Case-patient 1        0.31        Recovered         12

Case-patient 2        0.20        Recovered         4

Case-patient 3        0.27        Recovered         2

Case-patient 4        0.27        Recovered         3

Case-patient 5        0.16        Recovered         1

Case-patient 6        0.34        Recovered         2

Control 1             0.46            NA            NA
Control 2             0.36            NA            NA

* Control participants did not have measles. NA, not applicable.

([dagger]) Reference range 0.5-0.8 mg/L.
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Article Details
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Title Annotation:LETTERS
Author:Melenotte, Clea; Brouqui, Philippe; Botelho-Nevers, Elisabeth
Publication:Emerging Infectious Diseases
Article Type:Letter to the editor
Geographic Code:4E
Date:Sep 1, 2012
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