Reevaluating vitamin A for measles management in high-income settings

As of June 24, 2025, a total of 1227 confirmed measles cases were reported across the United States—a concerning development given that the country achieved measles elimination in 2000.¹ This resurgence of a vaccine-preventable illness has renewed attention to clinical management strategies, including vitamin A supplementation. While U.S. public health authorities—including the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the National Foundation for Infectious Diseases (NFID)— recommend routine vitamin A supplementation for all children with measles, we present evidence challenging this universal approach. Instead, we propose a targeted strategy focused on high-risk subgroups, given the low prevalence of vitamin A deficiency and the potential risks of toxicity in the U.S. context.

Clinical overview of measles

Measles is a highly contagious viral illness characterized by a prodrome of fever, cough, coryza, and conjunctivitis, followed by a maculopapular rash. The incubation period averages 10–14 days, and infected individuals are contagious from 4 days before to 4 days after rash onset.^1,2 Complications are common, especially in young children: approximately 1 in 20 develop pneumonia, 1 in 1000 develop encephalitis, and 1–3 in 1000 die from the disease.^1,3

Supportive care remains the standard, as no antiviral treatment is available.³ Providers should follow airborne precautions, monitor for clinical deterioration, and remain vigilant for secondary infections. Early recognition and prompt referral for escalating symptoms are essential to reducing morbidity and mortality.

Global context: vitamin A and measles mortality

In countries where vitamin A deficiency is prevalent, measles case-fatality rates can exceed 30%.² Vitamin A deficiency is associated with delayed recovery and increased risk of post-measles complications. During febrile illnesses such as measles, retinol is lost through increased urinary excretion, further depleting stores.⁴ In these settings, vitamin A supplementation has been shown to reduce both overall and pneumonia-specific mortality.⁵ Importantly, vitamin A does not prevent measles.¹

In contrast, vitamin A deficiency is rare in the U.S. (<1%) due in part to widespread food fortification and supplement use. National Health and Nutrition Examination Survey (NHANES) data show that up to 72% of children aged 2–8 years who take supplements exceed the Tolerable Upper Intake Level (UL) for preformed vitamin A.⁶

Despite this, the CDC,¹ AAP,³ and NFID⁷ continue to recommend vitamin A supplementation as part of supportive management for all children with measles. This approach is largely based on evidence from low- and middle-income countries (LMICs) with unclear applicability in high-income settings. A recent prospective controlled cohort study in Italy found no benefit of vitamin A supplementation on fever duration, hospitalization, or complication rates among children hospitalized with measles.⁸

Revisiting vitamin A use in the U.S. context

We propose for a shift from universal to selective vitamin A use in children with measles who at higher risk of complications or deficiency. High-risk groups include: hospitalized children with severe measles, children with clinical signs of vitamin A deficiency, malnourished children, immunocompromised children, or children under 2 years of age.^2,5,7

Vitamin A should be administered under medical supervision, as improper dosing may result in toxicity. Although dosing guidelines differ slightly across CDC, AAP and World Health Organization recommendations,1, 2, 3 the standard regimen includes two oral doses, given immediately upon measles diagnosis, and repeated the next day:

• •50,000 IU (15,000 RAE) for infants <6 months
• •100,000 IU (30,000 RAE) for infants 6–11 months
• •200,000 IU (60,000 RAE) IU for children ≥12 months

A third dose may be considered 4–6 weeks later if ocular signs of vitamin A deficiency (e.g., Bitot's spots) are present.²

Risks of vitamin A supplementation

Toxicity can result from excessive or prolonged use of preformed (active) vitamin A, such as from supplements or cod liver oil. Acute toxicity symptoms include nausea, vomiting, fatigue, and lightheadedness and can progress to liver failure, skin desquamation, and increased intracranial pressure (e.g., bulging fontanelles, headache, blurred vision).⁹ Chronic toxicity may lead to osteoporosis, premature epiphyseal closure, hepatoxicity, pseudotumor cerebri, or teratogenic effects, including spontaneous abortion and severe birth defects. Pregnant women, who are themselves at increased risk for measles complications, should avoid high doses of vitamin A due to the risk of severe fetal malformations.

Unlike preformed vitamin A, provitamin A carotenoids (e.g., beta-carotene found in plant-based foods) are considered safe, as the body regulates their conversion to active vitamin A, minimizing toxicity risk. High beta-carotene intake may cause benign and reversible carotenodermia (yellow-orange skin discoloration). Families can support vitamin A status through a diet rich in carotenoids-found in leafy greens, orange and yellow vegetables, and fruits (e.g., carrots, squash, spinach and sweet potatoes), which are easily prepared as purees for young children.

In LMICs, growing evidence suggests that overlapping vitamin A interventions (e.g., supplementation plus food fortification) may lead to excessive intakes and potential toxicity.¹⁰ More research is needed to inform policy transitions from universal to targeted supplementation approaches in such settings.

Conclusion

Vitamin A supplementation can be lifesaving for children with measles in settings where vitamin A deficiency is prevalent. However, in the United States, where deficiency is rare and excessive intake is more common, universal supplementation may offer little benefit and may cause harm. We urge public health agencies to critically review the current evidence and revise their recommendations to reflect a targeted, risk-based approach to vitamin A supplementation. Greater transparency and documentation across diverse high-income countries currently experiencing measles outbreaks would help inform more nuanced, evidence-based guidance. As the 2025 measles outbreak unfolds, clinicians must balance the urgency of response with the strength of available evidence. Above all, measles vaccination remains the most effective and essential tool for preventing measles and its complications (Box 1).

Box 1. What clinicians should know about vitamin A and measles.

• • Administration of measles-containing vaccines remains the most effective strategy to prevent measles and its complications.
• •There is no approved antiviral treatment for measles; care is supportive, focusing on hydration, fever management, and treatment of complications such as pneumonia or bacterial coinfections.
• •In the U.S., routine vitamin A supplementation for all measles cases is not recommended due to limited evidence of benefit, low prevalence of deficiency, and risk of toxicity.
• •Targeted vitamin A supplementation may be appropriate for high-risk groups, including hospitalized children, infants, those with malnutrition or immunosuppression, and those with clinical signs of deficiency- but should be administered only under medical supervision.

Contributors

PSS- conceptualisation, writing of original draft; NFK- reviewing and editing; SAT- reviewing and editing.

Declaration of interests

PSS reports serving on the American Academy of Pediatrics Committee on Nutrition, during the conduct of the submitted work. SAT declares consulting fees from Particles for Humanity and Givewell. We declare no other competing interests.