5.13 MEASLES

Basic facts

· Measles is a highly communicable viral infection spread via respiratory droplets from person to person.

· It is a severe disease caused by the rubeola virus, which damages epithelial surfaces and the immune system.

· Measles can increase susceptibility to other infectious agents such as pneumococcus, Haemophilus influenzae and Staphylococcus aureus.

· It can lead to or exacerbate vitamin A deficiency, thus increasing the risk of xerophthalmia, blindness and premature death.

· The most vulnerable are children between the ages of 9 months and 5 years in developing countries, but this depends on immunization coverage rates.

· Deaths are mostly due to complications such as pneumonia, croup and diarrhoea and are frequently associated with malnutrition.

Natural history

· The incubation period is usually 10-12 days from exposure to onset of fever.

· Initial symptoms and signs are high fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa).

· A characteristic erythematous (red) maculopapular (blotchy) rash appears on the third to seventh day, commencing behind the ears and on the hairline and then spreading to the rest of the body.

· The temperature subsides after 3-4 days and the rash fades after 5-6 days.

· Measles is highly infectious from the start of the prodromal period until approximately 4-5 days after the rash appears.

· Case fatality rates are estimated at 3-5% in developing countries, but may reach as high as 10-30% in displaced populations.

Complications

· Some 5-10% of patients develop complications.

· Complications occurring in the first week of the illness, such as croup, diarrhoea and pneumonia, are usually due to the effects of the measles virus and are rarely life-threatening.

· Later complications are usually due to secondary viral or bacterial infections. Post-measles pneumonia, diarrhoea and croup are the most common life-threatening complications (see Table 5.11).

Table 5.11. Complications of measles

Pneumonia	Usually severe, frequent bacterial superinfection
Diarrhoea	Caused either by the virus or by a secondary infection e.g. Shigella
Malnutrition	Precipitated by anorexia, stomatitis, fever, vomiting, diarrhoea and other complications
Stomatitis	Compromises sucking and eating
Vitamin A deficiency	Keratoconjunctivitis; measles increases the need for vitamin A and often precipitates xerophthalmia and/or blindness due to scarring
Encephalitis	Acute measles encephalitis occurs in approximately 1 in 1000 infected children, typically during convalescence
	NB: the most common neurological manifestation of measles infection is febrile convulsions
Otitis media	This is a common complication of measles: the ear is painful and hearing is reduced
Croup	Laryngotracheobronchytis causing airway obtruction

Case management

A history should be taken from the mother and the child should be examined for the signs and symptoms set out in Table 5.12.

Table 5.12. Symptoms and signs indicating measles

Symptoms	Signs
Ability to take feeds or fluids Cough and difficult breathing Diarrhoea or blood in stools Sore mouth, eyes or ears	Nutritional status Breathing rate, chest indrawing, stridor Dehydration and fever Mouth ulcers, sore and discharging ears and eyes, Bitot's spots* Level of consciousness

* Bitot's spots are superficial, foamy gray or white, irregularly shaped patches, which appear on the conjunctiva (or white) of the eyeball. They are due to severe vitamin A deficiency.

Case management of uncomplicated measles: health centre

Most children will have uncomplicated measles and require supportive care as an outpatient. Good supportive care can improve a child's outcome. Isolation of patients with measles is not indicated in emergency situations. All children with measles in these settings should have their nutritional status monitored and be enrolled in a selective feeding programme if necessary.

· The child should be nursed in a shaded and well ventilated area, as this is generally more comfortable for the child. Sunlight can be painful for the eyes and a cool environment can keep the temperature down:

· Control the fever by tepid sponging and administration of paracetamol.

· Keep the patient well hydrated; treat diarrhoea with oral rehydration salts.

· Observe the patient closely for complications.

· Give prophylaxis against xerophthalmia: vitamin A on days 1 and 2 (see Table 5.13).

Table 5.13. Dosages of vitamin A in measles treatment regimens

Age	Immediately on diagnosis	Following day
Infants < 6 months	50 000 IU	50 000 IU
Infants 6-11 months	100 000 IU	100 000 IU
Children > 11 months	200 000 IU	200 000 IU

· Maintain an adequate protein-calorie intake: inform mothers of the importance of frequent small meals.

· Continue breastfeeding.

· Provide supplementary feeding if available. The diet must be soft with a high calorie density, so small portions go a long way. Protein, unless in the form of egg, is unlikely to be eaten (remember the child has a sore mouth and poor appetite).

· Do not admit patients to general feeding centres until after the infectious period.

· If there are large numbers of cases it may be necessary to set up a small unit for children with measles, as they and their mothers need a lot of supportive care.

· Use antimicrobials only when indicated.

· Undertake active case-finding during the epidemic, if practical (home visits).

Case management of complicated measles: health centre/hospital

· Control fever, provide nutritional support and ensure two doses of vitamin A have been given (as for uncomplicated measles).

· If there is vitamin A eye disease, a third dose must be given four weeks later.

· Antimicrobials should not be given routinely.

· Indications for antibiotic therapy are of two types: (a) documented complications such as pneumonia, otitis media and dysentery; and (b) children at significant risk of secondary bacterial infection (e.g. severe malnutrition, HIV infection or xerophthalmia). A broad-spectrum antibiotic such as ampicillin or co-trimoxazole should be used.

· In case of cough and rapid breathing (40 breaths per minute or more if over 1 year of age; 50 breaths per minute if less than 1 year) give an antibiotic such as ampicillin, amoxycillin or co-trimoxazole. If the child's condition does not improve after 24-48 hours, change the antibiotic to an anti-staphylococcal drug such as cloxacillin or chloramphenicol.

· If there are three or more loose or watery stools in 24 hours, assess if there is associated dehydration. If there is blood in the stool, the child has dysentery. The commonest cause of dysentery is Shigella spp. (see Section 5.2 for details of managing cases of shigellosis).

· The major eye problems associated with measles are measles conjunctivitis, or keratitis with ensuing corneal damage due to vitamin A deficiency. The mere observation of red and watery eyes without other complications does not justify specific treatment. Sticky eyes or pus in the eyes is due to secondary bacterial infection: clean the eye at least three times a day with cooled boiled water, using cotton wool or a clean cloth. Use tetracycline ointment three times a day for 7 days.

IMPORTANT. NEVER use steroid eye ointments.

Prevention and control measures

See Section 2.6.5.

IMPORTANT. While this section details the diagnosis and case management of measles, immunization remains the most important strategy for measles control. Measles immunization campaigns are one of the highest priorities in emergency situations.

Further reading

Conduite à tenir en cas d'épidémie de rougeole. Paris, Médecins sans Frontières, 1996.

Toole MJ. Measles prevention and control in emergency settings. Bulletin of the World Health Organization, 1989, 67:381-388.

Treating measles in children. Geneva, World Health Organization, 1997 (document WHO/EPI/TRAM/97.02).