By Dr. Goke Akinrogunde

I had an interesting conversation with a colleague, who works on the top with one of the bilateral health-related organisation in Nigeria on his take on the recent epidemic of an unknown febrile illness which broke out in a location in urban Lagos, claiming the lives of many children within few days. It remain scandalised that this sudden outbreak of an illness later confirmed to be Measles can occur in the most urban state in the country. This is especially so in a state which prides itself as having the highest penetration of routine immunization (against measles and its likes) in the country.

My friend, a public health physician by training, with wide knowledge base on childhood health conditions is a blunt but hidden talker (by reason of his engagement by the bilateral organisation and the diplomatic essence of a ‘careless talk but truthful observation’ on health). So for obvious reason, he requested that he can be heard but not be known.
I asked: what’s is your take on the killer fever disease, later confirmed to be Measles? I am referring to the Lagos incident
His reply: “I am embarrassed. Normally, Measles has a case definition and should have been top on their list. Fever with rash plus/minus conjunctivitis in a child should be considered measles in Nigeria until proven otherwise.
“But the real challenge is the poor herd immunity such an outbreak signifies in a state that prides itself as the center of excellence”. And I should add that this is quite worrisome especially for those of us parents whose children abode in Lagos.

In view of the aforementioned, we take another look at Measles; that troubling harsh rashes in children. Among all childhood illnesses, Measles is one highly infectious illness caused by a virus (the measles virus) that is commonly encountered every now and then. Viruses are very small microbes that are much smaller than bacteria and not affected by antibiotics.
The measles infection is spread by droplets from upper respiratory tract of infected patient 2-4 days before and 2-5 days after the rash first appears. The infection has a 1-2 week incubation period i.e. the period between the time of infection and the manifestation of the disease in an infected child.

Measles usually begins like a bad cold, the child then develops fever and a rash. The child always feels miserable and may be unwell for a week or so with a bad cough and a high temperature. Complications occur in some cases.
Worldwide measles is responsible for > 1 million deaths often due to complications arising from pneumonia and other chest infections as secondary bacterial infections.
Measles is much more serious than many people think. In fact, of all childhood infections, it is the one most likely to cause a serious complication called encephalitis, which is inflammation of the brain, sometimes resulting in brain damage.

It can also cause convulsions, ear infections, bronchitis and pneumonia, which can lead to long-term lung troubles. Each year a number of children die from measles. In developing countries, including Nigeria, it is a major cause of childhood death, particularly in the previously unvaccinated children.
Symptoms of Measles
The outcome of the disease varies from mild (usually the case in the well-fed child) to severe (usually in the malnourished or immunosuppressed patient). However, severe measles can occasionally present in a previously healthy child and particularly in young adults who have not been vaccinated or exposed to the virus naturally.
Prodrome
This is the disease course before the appearance of the rash, it last 2-4 days with persistent fever, runny nose, redness of the eyes (mild conjunctivitis), Koplik’s spots and diarrhoea. Koplik’s spots appear on the child’s mouth as small, red spots each with a white speck in the centre.

The summary of how the disease evolve and the symptoms of the illness is as follows:
Unremitting fever (high body temperature), sore eyes (conjunctivitis), and runny nose usually occur first.
Small white spots usually develop inside the mouth a day or so later.
A harsh dry cough is usual.
Poor appetite – going off food, tiredness, and aches and pains are usual.
Diarrhoea is common.
Vomiting is not unusual

A red blotchy rash normally develops about 3-4 days after the first symptoms.
The rash has the characteristic of both flattened – skin decolorizing and small pimples-like, what is medically referred to as maculopapulary rash. It usually starts on the head and neck, and spreads down the body. It takes 2-3 days to cover most of the body. The rash often turns a brownish colour and gradually fades over a few days. The rash may be accompanied with itching.
Affected children are usually quite unwell and miserable for 3-5 days.
After this, the fever tends to ease, and then the rash fades. The other symptoms gradually ease and go.

Most children are better within 7-10 days. An irritating cough may persist for several days after other symptoms have gone.
Some people mistake rashes caused by other viruses for measles. Measles is not just a mild red rash that soon goes. The measles virus causes an unpleasant, and sometimes serious, illness. The rash is just one part of this illness.
The child’s immune system makes antibodies during the infection. These fight off the virus and then provide lifelong immunity. It is therefore very rare to have more than one attack of measles in the lifetime of an individual.

Complications Of measles
The ‘usual’ and expected course of a measles attack enumerated above in terms of symptoms and signs may not be resolved after the estimated 7-10 days in a smaller percentage of children.
Other super-imposed infections like bacteria and fungi sometimes complicate the viral infection. This can results in much more serious and life-threatening illness. Some of these complications are mentioned below.

Otitis media – this is ear infection (of the so-called middle ear) that causes severe earache, it can come as a complication in measles. If otitis media is poorly treated, it can become a focus of infection for tetanus, which is a potential killer disease.
Febrile convulsion (fit) occurs in about 1 in 200 cases of measles, this can be alarming but full recovery is usual.
Infections of the airways such as bronchitis and croup are common. These are distressing but are not usually serious.
Pneumonia (lung infection) is a serious complication that sometimes develops. Typical symptoms include fast or difficult breathing, chest pains, and generally becoming more ill.

Brain inflammation (encephalitis) is a rare but very serious complication of measles. It occurs in about 1 in 5000 cases.
It is believed to be a neuroallergic process, which is saying that it is a kind of allergic reaction in the brain. It carries a 10-15% mortality rate with 25% children having permanent brain damage. It typically causes drowsiness, headache, and vomiting which starts about 7-10 days after the onset of the rash. Encephalitis may cause brain damage. Some children die from this complication.

Subacute sclerosing panencephalitis – occurs in 0.1-1.4/million children infected. It occurs 5-10 years after apparently normal measles, although it can occur at an early age, with disturbance in intellect and personality, behavioural disorders and worsening school work. This is followed by seizures, signs of Parkinson-like disease and finally decerebrate rigidity and death. This condition is untreatable..
Squint : this is a condition where the two eyes are not aligned; the condition is thought to be more common than usual in children who have had measles. This is thought to be due to the virus affectation of the nerve or muscles to the eye.
Complications are, however, more likely in children who are yet to get the measles vaccine, those with a poor immune system (such as those with leukaemia or HIV/AIDS), and in those who are malnourished. This is one reason why measles is still a major problem in poorer countries.

Treating Measles
Treatment is mainly supportive since the commonly available antibiotics do not kill the measles virus. Treatment is aimed towards easing the symptoms until the body’s immune system clears the infection.
This is achieved by following the protocol below:
Keep the child cool. Cold wet cloth wipe and cold showers help with keeping down the temperature.
The child is encouraged to drink a lots. Ice lollies/creams are a useful way of giving extra fluid and keeping cool.
Give Paracetamol liquid or suppositories (PANAGREEN) regularly to ease fever and aches and pains. Ibuprofen syrup is an alternative.
Cough remedies have little benefit on the cough.
Antibiotics do not kill the measles virus, and are not normally advised. They may be prescribed if a complication develops such as a ear infection or pneumonia. This is because in these complications bacteria may add to the infection (secondary bacterial infection). Antibiotics come handy in these complications.

When to visit the Hospital
In our environment, where there is little reserve for the sick child and where most hospitals are lacking in basic resuscitative facilities, it is better to report at the hospital early enough if the child has been having persisting fever few days running for immediate intervention, so as to avoid unaffordable complications.

Prevention
The only acclaimed preventive measure from being infected with the measles virus is via vaccination with the measles vaccines.
Measles immunisation is part of the routine immunisation programme in Nigeria. It is usually given to the infant at the age of nine month. However, any child that is yet to have the vaccine after the age of nine month should be taken to the appropriate health center immediately for vaccination.