Editorials

Managing measles

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.

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 treatment 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 ^a

^a Department of Paediatrics and Child Health, University of Cape Town, Rondebosch, Cape Town, South Africa

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2. Hussey GD, Clements CJ. 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.
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11. World Health Organisation. Clinical research on treatment of measles: report of a meeting. Geneva: WHO, 1995.