Measles remains a leading cause of childhood
morbidity and mortality in developing countries, with fatality rates in
hospitalised children often exceeding 10%.(1) Most deaths
follow complications such as pneumonia, croup, and diarrhoea and are
often associated with malnutrition. Reducing the severity of disease
through appropriate management should thus be a priority. What is
surprising and rather disturbing, however, is the lack of published
scientific information on issues that are central to developing a sound
basis for managing measles. A recent review of clinical problems
associated with measles has highlighted the paucity of data on risk
factors, aetiology, natural course, and management (except vitamin A)
of the common complications of measles.(2) The problems with
prophylactic antibiotic trials are discussed by Shann in this week's
BMJ.(3)
Nevertheless, on the basis of the available data, the World
Health Organisation's Expanded Programme on Immunisation has developed
a policy document on integrated management of measles to help health
workers in developing countries to reduce the severity of
measles.(4) The basic principles are outlined in the
box.
| Basic principles of management |
| Anticipate complications in high risk groups
Admit severely ill children to hospital
Give paracetamol if temperature exceeds 39|SDC
Treat with high dose vitamin A
Encourage breast feeding
Provide nutritional support to all children
Treat eyes promptly to prevent blindness
Use antibiotics only for clear indications
Give oral rehydration solution for diarrhoea
Treat multiple complications at the same time
Monitor growth regularly |
Severe disease should be anticipated if the child is from a high
risk area (for example, areas with vitamin A deficiency, poor
socioeconomic status, or low immunisation coverage) or from a high risk
group (for example, young infants, immunocompromised children
(including those with HIV or AIDS), migrants,
refugees, or those with severe malnutrition).(4) Even though
hospital resources are limited in many developing countries, children
with severe pneumonia, dehydration, croup, malnutrition, or
neurological complications must be admitted to hospital for treatment.
Vitamin A deficiency is a recognised risk factor for severe
measles.(5) In hospital based studies, treatment with high
dose vitamin A significantly reduced morbidity and
mortality.(6) Large community based intervention trials
evaluating the effect of vitamin A prophylaxis on overall childhood
mortality have also shown a reduction in mortality from
measles.(7)
Measles is an extremely catabolic event associated with reduced intake
of food, increased gastrointestinal losses, and rapid weight
loss.(8) Breast feeding should be encouraged to provide
nutritional support and should be continued even if the infant has
diarrhoea. If the child refuses feeds a nasogastric tube should be
passed and additional fluids given to prevent or treat dehydration. If
dysentery is present an appropriate antibiotic should be given for
shigella infection.
Severe mouth ulceration, usually a consequence of secondary herpes
infection, contributes to reduced fluid and food intake. Regular mouth
washes with clean water should be used, and 1% gentian violet should
be applied to mouth lesions. Secondary eye infections should be
prevented by regular cleansing of eyes with water and the application
of tetracycline eye ointment. If there is any evidence of
xerophthalmia, clinicians should ensure that the child has received the
two doses of vitamin A as part of the treatent for measles. A third
dose of vitamin A is recommended four to six weeks later. A protective
eye pad will help to prevent secondary infection. Severe pneumonia and
otitis media should be treated with an appropriate antibiotic and a
bronchodilator if there is wheezing. Inhaled oxygen is mandatory if
there is clinical evidence of severe pneumonia. Children with severe
stridor must be referred to a hospital with facilities for airway
intervention. Nebulised adrenaline may also be useful.
One of the controversies regarding management of measles is the use of
prophylactic antibiotics.(2)(3) The argument for such a
strategy is the high risk of secondary bacterial infections and
consequent mortality. On the other hand, routine use of antibiotics is
costly and may result in unnecessary complications such as antibiotic
associated diarrhoea, severe drug reactions, and the emergence of drug
resistant organisms. In this week's BMJ, a
meta-analysis of five randomised controlled clinical trials done
between 1939 and 1954 indicate that prophylactic antibiotics were not
beneficial in reducing mortality (p 334).(3) Even though no
well conducted placebo controlled clinical trials have been done in
developing countries, two studies suggested that prophylactic
antibiotics may be useful. An outpatient study from India in 1967 found
that, of 80 children with measles who were given placebo, 11 developed
important radiological features of pneumonia, compared with none of the
78 children treated prophylactically with tetracycline.(9) A
descriptive study from Senegal reported that routine treatment with
cotrimoxazole in children younger than 3 years may have been
associated with a reduction of respiratory complications and
mortality.(10)
Even though controlled clinical trials to evaluate the efficacy of
prophylactic antibiotics may be difficult to do,(2) a recent
WHO report on clinical research on measles treatments has identified
this as a research priority.(11) Until the issue is resolved
it must be emphasised that antibiotics should be given only if there is
a specific indication such as pneumonia, otitis media, or dysentery.
Prophylactic antibiotics may be justifiable in children who are at an
additional risk of secondary bacterial infections, such as those with
severe malnutrition, AIDS, or xerophthalmia. Finally, it should be
remembered that measles is preventable by immunisation and that,
ultimately, the control of measles depends on obtaining and maintaining
a measles vaccine coverage that is in excess of 90%.
Greg Hussey
Associate professor
Department of Paediatrics and Child Health,
University of Cape Town,
Rondebosch,
Cape Town,
South Africa
References
1 Morley D. Severe measles in the tropics: I.
BMJ 1969;i:297-300.
2 Hussey G D, Clements C J. Clinical problems in measles case
management. Ann Trop Ped (in press).
3 Shann F. Prophylactic antibiotics for children with measles: a
meta-analysis. BMJ 1997;314:334-6.
4 World Health Organisation. Case management of
measles - a policy document. Geneva: WHO, 1996.
5 Butler J C, Havens P L, Sowell A L, Huff D L, Peterson D E, Day S E,
et al. Measles severity and serum retinol (vitamin A)
concentration among children in the United States.
Pediatrics 1993;91:1176-81.
6 Hussey G D, Klein M A. A randomised controlled trial of vitamin
A in children with severe measles. N Engl J Med
1990;323:160-4.
7 Beaton G H, Martorell R, L'Abbe K, Edmonston B, McCabe G, Ross
AC, et al. Effectiveness of vitamin A supplementation in
the control of young child morbidity and mortality in developing
countries. Final report to CIDA. Toronto: University of
Toronto, 1992.
8 Dossetor J F B, Whittle H C. Protein-losing enteropathy and
malabsorption in acute measles enteritis. BMJ
1975;ii:592-3.
9 Prasad R, Marthur G P, Trehan O P, Mehrotra M L, Dayal R S. A
clinical and radiological study of measles. Indian
Pediatr 1967;4:243-50.
10 Samb B, Simondon F, Aaby P, Whittle H, Seck A W M C. Prophylactic
use of antibiotics and reduced case fatality in measles infection.
Pediatr Infect Dis J 1995;14:695-6.
11 World Health Organisation. Clinical research on
treatment of measles: report of a meeting. Geneva: WHO,
1995.
