SYMPOSIUM

Niger J Paed 2012; 39 (3):144 -148

Abdulkarim A

Johnson A

Yahaya-Kongoila S

Mohammed SS

Measles: the past, the present and the

future

DOI:http://dx.doi.org/10.4314/njp.v39i3,12

Accepted : 27th February 2012

Abstract Measles is one of the viduals with a potential for epidem-

most infectious diseases known to ics. The history, aetiopathogenesis,

affect man. It spreads rapidly from clinical features (including compli-

an index case to many susceptible cations), diagnostic tools, treatment

individuals resulting in cycles of and prevention are discussed in this

epidemics in different parts of the article. The most important steps to

world especially in the African con- prevent measles cases and deaths

tinent. The contribution of measles would be to institutionalize the two

to childhood mortality and morbid- dose measles vaccine regime; give

ity remains high because it gives supplemental Vitamin A; strengthen

rise to complications such as pneu- health systems to be able to ade-

monia, malnutrition and blindness. quately deliver the vaccine and sup-

Measles vaccine is known to be plement, carry out surveillance and

efficacious and effective; however offer treatment for cases. There is

appearance of epidemics in parts of no doubt that global partnerships

Europe and the USA in recent times remain relevant in order to consoli-

underscores the fact that low vac- date and accelerate prevention of

cine uptake will always leave a measles, thus, they must continue to

large number of susceptible indi- be supported.

Abdulkarim A⁽

)

Johnson A, Yahaya-Kongoila S

Mohammed SS

Department of Paediatrics and

Child Health,

University of Ilorin Teaching

Hospital,

Ilorin, Nigeria

(

mainly in Venezuela, Mexico, and the United States)

Fig 1– 5)

Introduction

Reports of measles go back to at least 700BC. However,

the first scientific description of the disease and its dis-

tinction from smallpox attributed to the Muslim physi-

cian Ibn Razi(Rhazes) 860-932 who published a book

entitled "Smallpox and Measles" (in Arabic: Kitab fi al-

jadari wa-al-hasbah).

Fig 1

The Facts

Measles remains a leading cause of death among young

children globally, despite the availability of a safe and

effective vaccine. An estimated 197 000 people died

from measles in 2007, mostly children under the age of

five. In developing countries, measles affects 30 million

children a year and causes 1 million deaths. Measles

causes 15,000-60,000 cases of blindness per year. Ap-

proximately 30 million measles cases are reported annu-

ally. Most reported cases are from Africa. In 1998, the

cases of measles per 100,000 total population reported

to the World Health Organization was 1.6 in the Ameri-

cas, 8.2 in Europe, 11.1 in the Eastern Mediterranean

region, 4.2 in South East Asia, 5.0 in the Western Pa-

cific region, and 61.7 in Africa. Only 187 confirmed

cases were reported in the Western Hemisphere

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livirus Morbilliviruses, like other paramyxoviruses, are

enveloped, single-stranded, negative-sense RNA vi-

ruses. The measles virus is a spherical, non segmented,

single-stranded RNA virus in the Morbillivirus family,

closely related to the rinderpest and canine distemper

viruses. It contains six structural proteins, three that are

complexed to the RNA and three that are associated with

the viral membrane envelope. The F (fusion) protein is

responsible for fusion of virus and host cell membranes,

viral penetration and hemolysis. The H (hemagglutinin)

protein is responsible for adsorption of the virus to

cells. There is only one serotype of Measles virus and

no subtypes have yet been recognized

Fig 2 : Nigerian incidence series over 10 years (Source: WHO)

Pathogenesis

The essential lesion of measles is found in the skin, con-

junctivae, and mucous membranes of nasopharynx,

bronchi, and intestinal tract. Serous exudate and prolif-

eration of mononuclear cells and a few polymorphonu-

clear cells occur around the capillaries. Hyperplasia of

lymphoid tissue usually occurs particularly in the appen-

dix. The pathologic lesion is the Warthin-Finkeldey

giant cell. These are multinucleated reticuloendothelial

giant cells of up to 100 micrometers in diameter.

In the skin, this reaction can be noted around the seba-

ceous glands and hair follicles. Koplik spots consist of

serous exudate and proliferation of endothelial cells

similar to those seen in the skin lesions.

Fig 3 : A 5-year measles admission in EPU, UITH

Transmission

Measles is spread through respiration (contact with flu-

ids from an infected person's nose and mouth, either

directly or through aerosol transmission), and is highly

contagious—90% of people without immunity sharing a

house with an infected person will catch it. The infection

has an average incubation period of 14 days (range 6-19

days). Infectivity lasts from 2-4 days prior to 2-5 days

following the onset of the rash. Replication occurs in

nasopharynx and regional lymph nodes. Primary virae-

mia occurs 2-3 days after exposure while secondary

viremia occurs 5-7 days after exposure with spread to

tissues.

Fig 4: EPU admission in the last 5 months (as at 7th March,

2

011)

Clinical Features

Incubation period ranges from 6-19 days. It has a pro-

dromal period which presents with stepwise increase in

0

fever to 39.4 C or higher, cough, coryza, conjunctivitis

and Koplik spots (rash on mucous membranes).

The rash occurs 2-4 days after prodrome and 14 days

after exposure. It is maculopapular and later become

confluent beginning on face and head. It persists 5-6

days and fades in order of appearance. Patients are con-

tagious from 1-2 days before onset of symp-

toms. Healthy children are also contagious during the

period from 3-5 days before the appearance of the rash

to 4 days after the onset of rash. On the other hand, im-

munocompromised individuals can be contagious during

the entire duration of the illness.

Fig 5: Deaths from Measles admitted in EPU over 5 years

Measles

It is an infection of the respiratory system caused by a

virus, specifically Paramyxoviruses of the genus Morbil-

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feet and spreads centrally. The rash is most prominent in

the body creases and may be macular, hemorrhagic

vesicles, petechial, or urticarial. Complications may

include pneumonia, pleural effusion, hilar lymphade-

nopathy, Hepatosplenomegaly, hyperesthesia, or pares-

thesia. Atypical measles occurs in individuals who were

previously immunized with the killed measles vaccine

between 1963 and 1967 and who have incomplete im-

munity.

Subacute sclerosing panencephalitis (SSPE)

Risk factors for infection

It is a neurodegenerative disease caused by persistent

infection of the brain by an altered form of the measles

virus. Neither the biology underlying the viral persis-

tence nor the triggering mechanism for viral reactivation

is well understood. In most cases, infected children re-

main symptom-free for 6-15 years after acute measles

infection. Subacute sclerosing panencephalitis (SSPE) is

rare chronic, progressive encephalitis that affects pri-

marily children and young adults, caused by a persistent

infection of immune resistant measles virus (which can

be a result of a mutation of the virus itself). 1 in 100,000

people infected with measles develop SSPE. SSPE is

Risk of infection is increased among children with im-

munodeficiency due to HIV or acquired immunodefi-

ciency syndrome (AIDS), leukemia, alkylating agents,

or corticosteroid therapy, regardless of immunization

status. Also those that travel to areas where measles is

endemic or contact with travellers to endemic areas,

infants who lose passive antibody prior to the age of

routine immunization, children with malnutrition, under-

lying immunodeficiency and vitamin A deficiency are at

increased risk of contacting measles.

'

tion if treatment is started at an early stage.

incurable' but the condition can be managed by medica-

Mortality Rate in Measles

The mortality rate associated with uncomplicated mea-

sles in immunocompetent, well nourished children is

low but is much higher in malnutrition (marked in Afri-

can children), in immunocompromised, and to lesser

extent with age.

Clinical Presentation of SSPE

Characterized by a history of primary measles infection

usually before the age of 2 years, followed by several

asymptomatic years (6–15 on average), and then grad-

ual, progressive psycho neurological deterioration, con-

sisting of personality change, seizures, myoclonus,

ataxia, photosensitivity, ocular abnormalities, spasticity,

and coma.

1

4

. Entry

. Exit

Diagnosis of Measles

3

. Diseases

SSPE

2

. Spread

Encephalitis

Rash

Otitis media

Pneumonia

Most cases of Measles are diagnosed clinically, usually

in patient’s home or in General practice. Direct Vi-

rological confirmation is difficult in most of the devel-

oping countries.

Diagnosis by Microscopy

Production of multinucleate giant cells with inclusion

bodies is path gnomonic for measles. During the prodro-

mal phase, such cells are detectable in the NPS

Prominent features in Measles

Modified Measles

(

nasopharyngeal secretions). This is more rapid and

practical than virus isolation.

Modified measles occurs in children who have received

serum immunoglobulin after their exposure to measles.

The measles symptom complex may still occur, but the

incubation period is as long as 21 days, with the same

symptoms as measles but milder.

Diagnosis with Immunofluorescence

Direct and indirect immunofluorescence has been used

extensively to demonstrate MV antigens in cells from

NPS specimens. This technique can also be applied to

the urine as such cells may be present in the urine 2 to 5

days after the appearance of the rash.

Atypical Measles

When exposed to the measles virus, a mild or nonexis-

tent prodrome of fever, headache, abdominal pain, and

myalgias precedes a rash that begins on the hands and

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Diagnosis by Viral Isolation

Treatment options in Developing Countries

Measles virus can be isolated from a variety of sources,

e.g. throat or conjunctival washings, sputum, urinary

sediment cells and lymphocytes. Primary human kidney

All children in developing countries diagnosed with

measles should receive two doses of vitamin A

supplements, given 24 hours apart. This can help pre-

vent eye damage and blindness. Vitamin A supplements

have been shown to reduce the number of deaths from

measles by 50%.

(

HEK) cells are the best, although primary monkey kid-

ney can be used as well. Continuous cell lines such as

Vero cells can also be used although they are not as effi-

cient as primary cell lines.

Vaccination

Diagnosis by Serology

The Vaccines are live attenuated containing Edmonston

B or Schwartz strains which will give seroconversion

rate of 90%. The immunity produced may be lifelong.

Diagnosis of measles infection can be made if the anti-

body titres rise by 4 fold between the acute and the con-

valescent phase or if measles-specific IgM is found. The

methods that can be used include HAI, CF, neutraliza-

tion and ELISA tests.

Changing trends for a Booster Dose

In 2007, about 82% of the world's children received one

dose of measles vaccine by their first birthday through

routine health services, up from 72% in 2000. (Two

doses of the vaccine are recommended to ensure immu-

nity, as it has been found that about 15% of vaccinated

children fail to develop immunity from the first dose).

Differential diagnosis of measles

1

2

3

. Rubella

. Scarlet fever

. Infectious mononucleosis, erythema infectiosum,

echovirus and coxsackievirus infections

4

.

Drug rashes (eg, from phenobarbital

or sulfonamides

Two doses of Measles Vaccine

Continued progress depends on ensuring that all chil-

dren receive two doses of measles vaccine including one

dose by their first birthday, strengthening disease sur-

veillance systems, and providing effective treatment for

measles. However, in Nigeria, this two-dose vaccine

policy has not yet been adopted.

How to distinguish measles from some other conditions

•

Rubella: A recognizable prodrome is absent, fever

and other constitutional symptoms are absent or less

severe, postauricular and suboccipital lymph nodes

are enlarged (and usually tender), and duration is

short.

Roseola infantum: The rash resembles that of mea-

sles, but it seldom occurs in children > 3 yr. Initial

temperature is usually high, Koplik's spots and mal-

aise are absent, and defervescence and rash occur

simultaneously.

Global Initiatives

The Measles Initiative - a collaborative effort of WHO,

UNICEF, the American Red Cross, the United States

Centres for Disease Control and Prevention, and the

United Nations Foundation - and other public and pri-

vate partners play key roles in advancing the global

measles strategy

Drug rashes: A drug rash often resembles the mea-

sles rash, but a prodrome is absent, there is no

cephalocaudal progression or cough, and there is

usually a history of recent drug exposure

WHO and UNICEF are collaborating to ensure;

•

Strong routine immunization: for children by

their first birthday.

A 'second opportunity' for measles immuniza-

tion through mass vaccination campaigns, to ensure

that all children receive at least one dose.

Effective surveillance in all countries to quickly

recognize and respond to measles outbreaks.

Better treatment of measles cases, to include

vitamin A supplements, antibiotics if needed, and

supportive care that prevents complications.

Complications

Some complications include; pneumonia, croup, pneu-

mothorax, bacterial superinfection, acute thrombocyto-

penic purpura, post-measles anergy, encephalitis,

subacute sclerosing panencephalitis and atypical measles

syndrome

•

Treatment

Severe complications from measles can be avoided

though supportive care that ensures good nutrition, ade-

quate fluid intake and treatment of dehydration with

WHO-recommended oral rehydration solution (to re-

place fluids and other essential elements lost from diar-

rhoea or vomiting). Antibiotics should be prescribed to

treat eye and ear infections, and pneumonia.

Acknowledgement

Reproduced with kind permission of the department of

Paediatrics and Child Health of the University of Ilorin

Teaching Hospital, Ilorin Nigeria owners of the Ilorin

Paediatric Digest 2011.

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2

004 Elsevier.