The Re-emergence of Measles in Children in Bangladesh: A Review of Outbreak Patterns and Updated Management

Sayeeda Anwar^1*, Masuma Khan², Afsana Mukti², Dipa saha², Sudipta Roy², Fatema Farzana³

¹Professor and Head, Department of Paediatrics, Ad-din Women's Medical College, Dhaka, Bangladesh

²Associate Professor, Department of Paediatrics, Ad-din Women's Medical College, Dhaka, Bangladesh

³Junior Consultant, Department of Paediatrics, Dinajpur Medical College Hospital, Dinajpur, Bangladesh

^*Corresponding Author: Dr. Sayeeda Anwar, Professor and Head, Department of Paediatrics, Ad-din Women's Medical College, Dhaka, Bangladesh.

Received: 15 April 2026; Accepted: 08 July 2026; Published: 20 July 2026

1. Introduction

Measles remains a major global public health concern despite the availability of a safe and highly effective vaccine. As one of the most contagious human infections, even minor declines in population immunity can quickly lead to new outbreaks, especially in children. From 2000 to 2023, measles vaccination prevented an estimated 60.3 million deaths, yet progress has stalled. In 2023, first-dose vaccine coverage stayed at 83%, cases rose by about 20% compared to 2022, and the number of countries with major outbreaks increased from 36 to 57 [1]. Together, these trends highlight measles as an indicator of weaknesses in immunization systems and an ongoing risk to child survival, particularly where two-dose coverage is inadequate [1,2].

The burden of measles is concentrated in low- and middle-income countries, where under-vaccination, crowding, malnutrition, and delayed access to care often coexist. A recent systematic review of the early impact of COVID-19 in these countries found that first-dose measles vaccine coverage fell by a median of 23.3%. Second-dose coverage dropped by 48.2% during disruption periods [2]. The review highlighted that most unvaccinated children live in lower-resource settings. This helps explain the pronounced measles resurgence [2]. Children under five, especially those too young for the first scheduled dose, are most vulnerable. This is due to severe outcomes in this group and to amplified risk from undernutrition, vitamin A deficiency, poor access to health services, and low immunization coverage [3]. In a Bangladeshi study of under-five measles cases, the majority were younger than 9 months. Pneumonia and diarrhea were common complications, underscoring the combined effect of biological susceptibility and delayed vaccine protection [4].

Bangladesh has made notable progress in measles control through the Expanded Programme on Immunization and supplementary immunization activities, but recent evidence shows this progress is fragile. In 2016, a national report documented 21 outbreaks and 972 confirmed measles cases, demonstrating persistent transmission in susceptible pockets [5]. More recent Demographic and Health Survey data indicate that full basic vaccination coverage improved to 88%–89%, but maternal education, media exposure, geography, and household conditions remained key determinants [6,7]. However, national averages may hide local immunity gaps. Hospital studies from Chattogram underscore this: during the 2019-2020 upsurge, 67.6% of affected children were under one year old and 80% were unvaccinated; another facility-based study found 69% had incomplete or no vaccination and just 31% completed two doses [8,9]. These findings indicate that measles re-emergence in Bangladesh results more from delayed vaccination, missed children, and clusters of under-immunized infants and young children than vaccine failure.

A review is needed now because the post-pandemic global resurgence of measles coincides with renewed evidence of pediatric susceptibility in Bangladesh, while the available literature remains scattered across surveillance reports, national vaccination analyses, and single-centre hospital studies [1,2,5-9]. There is also a practical need to bring epidemiologic patterns together with updated clinical and public health priorities, as measles in Bangladeshi children carries not only risks of preventable complications and deaths but also substantial family and health-system costs [3,10] A contemporary narrative synthesis can therefore help clarify who is most at risk, where immunity gaps remain, and how outbreak response and case management should be updated in the current context. This review examines the re-emergence of measles among children in Bangladesh, with particular emphasis on outbreak patterns, determinants of susceptibility, and updated approaches to management and prevention.

2. Methods

This article was prepared as a narrative review to summarize evidence on the re-emergence of measles in children in Bangladesh. It focuses on outbreak patterns, contributing factors, and updated management. A narrative approach was chosen because the literature includes diverse sources, including surveillance reports, outbreak investigations, hospital-based studies, analyses of vaccination coverage, and guideline documents.

A structured literature search was conducted in PubMed, Google Scholar, Scopus, and BanglaJOL. We also included open-access reports from the World Health Organization, UNICEF, and Government of Bangladesh. The search covered publications from January 2010 to March 2026. Search terms included measles, children, pediatric, Bangladesh, outbreak, vaccination, immunization coverage, complications, management, vitamin A, and surveillance. Reference lists of selected articles were also manually screened.

Eligible sources included open-access, English-language, peer-reviewed original articles, outbreak investigations, epidemiological studies, hospital-based pediatric studies, vaccination coverage analyses, and relevant guideline-based reports related to measles in children. Bangladesh-specific studies were prioritized. Selected regional and global references were included where necessary for context and updated management. Articles focusing only on adults, unrelated diseases, duplicate reports, editorials, conference abstracts without full text, and studies lacking sufficient relevance were excluded.

Data from the included literature were reviewed and organized under major thematic domains: global importance of measles, burden in low- and middle-income countries, vulnerability of children, measles epidemiology in Bangladesh, outbreak patterns, contributory risk factors, clinical manifestations and complications, diagnosis, updated management, and prevention strategies. Information was synthesized descriptively rather than statistically. Special emphasis was placed on the consistency of findings across studies, public health relevance, and applicability to the Bangladeshi pediatric context. As this was a review of previously published literature, the authors did not undertake direct patient enrollment, and ethical approval was therefore not required.

3. Results

The selected studies indicate that Bangladesh’s measles problem is no longer simply one of low national coverage, but of clustered susceptibility, especially among infants, delayed or incomplete vaccine recipients, and displaced populations (Table 1).

Table 1: Summary of selected studies on measles outbreaks in Bangladesh.

Bangladesh studies on vaccination coverage and outbreak epidemiology point repeatedly to educational inequity, wealth-related disadvantage, geographic disparity, delayed completion of measles vaccination, and vulnerability in displaced populations as the main conditions allowing re-emergence (Table 2).

Table 2: Risk factors associated with measles re-emergence in children in Bangladesh.

Current guidance remains centered on supportive care, early vitamin A, treatment of bacterial complications when present, and strict isolation, while post-exposure prophylaxis is critical for susceptible contacts during outbreak response (Table 3).

Table 3: Updated management of measles in children.

4. Discussion

The reviewed evidence demonstrates that the re-emergence of measles among Bangladeshi children should be attributed not to a failure of vaccination as a concept, but to the inability to maintain consistently high, timely, and equitable immunity across all subpopulations. Globally, measles control has become increasingly fragile following the COVID-19 period, as first-dose coverage remains below the threshold required to interrupt transmission and the number of countries experiencing large or disruptive outbreaks has risen [2,14]. This global reversal is also evident within the WHO South-East Asia Region, where elimination efforts have achieved significant progress, yet the region remains off track because high national averages continue to obscure subnational pockets of susceptibility [15]. Bangladesh, therefore, exemplifies a broader regional and global trend: measles resurges wherever immunity gaps accumulate more rapidly than health systems can identify and address them.

Despite these challenges, Bangladesh has achieved considerable progress over the past two decades. Early national initiatives, such as supplementary immunization activities and the introduction of a second measles-containing dose, significantly reduced incidence and enhanced population-level protection [5]. However, current evidence indicates that this progress has plateaued at a level insufficient to control a virus as highly transmissible as measles. Nationally representative analyses consistently demonstrate that while childhood vaccination coverage has improved over time, it remains uneven across administrative divisions and social groups. Factors such as maternal education, household wealth, media exposure, antenatal care utilization, family size, place of residence, and possession of vaccination cards all influence completion of the vaccination schedule [6,7,16,17]. Consequently, the primary epidemiologic challenge in Bangladesh is now less about low national coverage and more about incomplete coverage, delayed dosing, dropout, invalid doses, and inequities between communities. For a disease that typically requires at least 95% two-dose coverage in every district, this “near-success” remains epidemiologically unstable [6,7,15].

An important finding from the Bangladeshi literature is that susceptibility to measles is clustered rather than randomly distributed. Recent studies on zero-dose and under-immunized children reveal that vulnerable populations are concentrated in hard-to-reach areas, including haor, coastal, hilly, and char regions, as well as urban slums and communities distant from Expanded Programme on Immunization (EPI) centers [18,19]. The Rohingya context introduces a humanitarian aspect to this pattern. While emergency campaigns in Cox’s Bazar achieved high levels of seroprotection among surveyed children and likely prevented numerous additional cases, the refugee setting underscores that crowding, displacement, disrupted routine services, and rapid population movement can rapidly facilitate explosive measles transmission [11,12]. Thus, the resurgence of measles in Bangladesh is best understood as the result of interactions between routine immunization gaps and high-risk environments where these gaps are intensified.

Clinical evidence aligns closely with epidemiologic findings. Hospital-based studies from Bangladesh indicate that measles cases disproportionately affect children under one year of age, particularly those younger than nine months. These children are either too young to receive the first routine dose or have experienced delayed vaccination after becoming eligible [8,4,9,20]. This pattern highlights a biologically and programmatically vulnerable period during which infants are exposed to intense community transmission before formal protection is established. Reported complications in Bangladeshi children, including pneumonia, diarrhea, and conjunctival involvement, are consistent with broader evidence that young age, malnutrition, crowding, and limited access to timely care increase the risk of severe outcomes and case fatality [3,4,8,9,20]. Therefore, the evidence indicates that outbreak control and case management are interdependent: delayed vaccination increases case numbers, and the same structural vulnerabilities that delay vaccination also exacerbate disease severity.

In comparison with neighboring countries, Bangladesh performs better than some at the national level but continues to face similar last-mile challenges. Recent registry-based analysis from Pakistan indicates that timely measles vaccination remains a significant issue even when nominal coverage is high, while evidence from India demonstrates that large-scale, campaign-based interventions can substantially reduce mortality [21,22]. These comparisons illustrate that Bangladesh is not unique in the factors driving measles resurgence: delayed vaccination, missed opportunities, social inequity, and subnational heterogeneity are persistent issues across South Asia [15,21,22]. The practical implication is that Bangladesh should not depend solely on national coverage indicators. Instead, emphasis should shift to district- and community-level microplanning, active defaulter tracing, rapid identification of zero-dose children, outreach in urban slums and hard-to-reach areas, enhanced case-based surveillance, and rigorous infection prevention in health facilities, particularly given previous documentation of nosocomial transmission during outbreaks [5,18,19].

5. Limitations of the Study:

As a narrative review, this study is potentially subject to selection bias. The limited availability of Bangladesh-specific evidence, along with the predominance of hospital-based and heterogeneous studies, may limit generalizability and hinder direct comparison.

6. Conclusion

Measles continues to pose a re-emerging public health threat among children in Bangladesh, despite significant improvements in immunization coverage. Recent evidence indicates that outbreaks are primarily driven by immunity gaps, delayed or incomplete vaccination, and increased vulnerability among infants and underserved populations. Enhancing timely administration of the two-dose vaccine, strengthening surveillance, improving outbreak response, and updating case management protocols are essential measures to reduce complications and advance measles control efforts among Bangladeshi children.

7. Recommendations

Routine measles immunization coverage should be strengthened with special attention to timely completion of the two-dose schedule. Targeted outreach is needed for zero-dose, under-immunized, hard-to-reach, and displaced children. Surveillance and rapid outbreak response should be improved to detect and contain cases early. Greater caregiver awareness, nutritional support, and availability of standard case management, including vitamin A supplementation, are also recommended. Further Bangladesh-specific studies are needed to monitor changing outbreak patterns and guide policy.

Funding:

No funding sources

Conflict of Interest:

None declared

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