|Year : 2016 | Volume
| Issue : 1 | Page : 1-4
Clinical findings and outcome of measles outbreak in an African city
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Kano State, Nigeria
|Date of Web Publication||29-Feb-2016|
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano State
Source of Support: None, Conflict of Interest: None
Background: Measles still poses a big heath threat in Nigeria. Of concern is the increasing cases of parental/caregiver's refusals of vaccine acceptance which will further worsen efforts to curtail this menace. Measles may cause complication warranting admission. Therefore, this study reviewed common indications for measles admission during the 2013 outbreak. This should serve as a guide on their common presentation and ensure adequate preparation for future outbreaks while efforts are geared toward eradication. Materials and Methods: This research is a retrospective and epidemiological study. Medical records of all cases of measles were reviewed during January-May 2013 and were analyzed, and relevant information were extracted. Results: There were 176 cases of measles; however, 8 files had incomplete data and were excluded from relevant analysis. There were 108 males and 60 females with male-to-female ratio of 1.8:1. Out of all the subjects, 60.7% were not immunized, and only 18.5% had complete immunization. Half of the subjects had bronchopneumonia alone; bronchopneumonia with diarrhea disease was present in 26.2%, while the least recorded case was convulsion with diarrhea disease. Eighty-one percent of the subjects were discharged without complications, only 9 (7.4%) of the 122 well-nourished subjects had complications and 12 (63.4%) subjects with marasmus had most complications and 11 (6.5%) deaths were recorded mostly among the malnourished children. Conclusion: Measles is a health concern in Nigeria; many children are still not vaccinated despite availability of vaccines, and bronchopneumonia and diarrhea diseases are common indications for admission.
Keywords: Admission, complication, immunization, measles, morbidity, mortality, outcome
|How to cite this article:|
Aliyu I. Clinical findings and outcome of measles outbreak in an African city. Sifa Med J 2016;3:1-4
| Introduction|| |
Measles still remains a major health problem in the tropics and subtropics despite the availability of potent vaccines; it is estimated that measles was responsible for 122,000 deaths globally in 2012 and most of these occurred in children, mostly less than 5-year olds, and in developing countries. 
However, about 1 billion doses of the measles vaccine has been administered to children since 2000 globally,  but cases are still recorded in children who were vaccinated, and this is often attributed to poor maintenance of the cold chain, decreasing herd immunity, and possibly wild virus strain. However, this is worrisome because it contributes to this alarming concern of parents/caregivers refusal of vaccination of their wards; and if this trend should persist, the tendency of re-emergency of earlier controlled vaccine-preventable diseases is heightened.
Measles has both short- and long-term complications that are preventable; therefore, efforts should be channeled toward prevention through vaccination.
This communication therefore seeks to determine the common indications for measles admission and their outcome in our health facility during the 2013 outbreak; which will ensure adequate preparation of health-care facilities to manage future occurrence.
| Materials and Methods|| |
This was a retrospective review of cases of measles seen during the January to May 2013 outbreak of the epidemic. Records of children admitted for measles at Emergency Paediatric Unit of Aminu Kano Teaching Hospital (aged 0-12 years) were reviewed, and relevant information such as age, sex, immunization status, anthropometry, clinical presentation, complication, and outcome were extracted and entered into a pro forma. Ethical approval was obtained from the Ethics Committee of Aminu Kano Teaching Hospital. All clinical cases of measles except for those with incomplete clinical records were included for the relevant analysis.
The case definition was based on case classification system as adopted by the Council of State and Territorial Epidemiologist. , Case definition of measles is generalized macula-papular rash lasting for >3 days, temperature of >38.3 ° C, and any one of the following: Cough, coryza, or conjunctivitis. , increasing incidence of measles increases the performance of this case definition. The socioeconomic class of the parents were determined using parameters established by Oyedeji,  which is a summation of the educational qualification of both parents. There were 176 recorded cases of measles out of a total of 1,241 admissions during the study period. However, 8 files had incomplete information and were excluded from the relevant analysis.
Statistical Package for the Social Sciences (SPSS) (for Windows, version 19) (SPSS-Inc., Chicago, US) software was used for the analysis. Mean, standard deviation, and frequency distribution of variables were determined, and chi-square test for judging significance was explored with P value <0.05 quoted as being statistically significant.
| Results|| |
This study included 168 cases. There were 108 males and 60 females with male-to-female ratio of 1.8:1. The mean age of the study group was 25.11 ± 18.0 months, with a range of 5-120 months [Figure 1]. [Table 1] shows that 60.7% of the subjects were not immunized, 20.8% had incomplete immunization, while only 18.5% had complete immunization including that for measles.
[Figure 2] showed that the month of April recorded 68 cases (38.0%), this was the highest admission for measles; March had 58 cases (33.0%); May had 28 cases (16.0%); February had 17 cases (10.0%); while January recorded 5 cases (3.0%).
One hundred and twenty-two (72.6%) of the subjects were well nourished according to Wellcome classification; 26 were underweight (15.5%), 19 had marasmus (11.3%); while only 1 (0.6%) had marasmic kwashiorkor.
[Table 2] revealed that majority of the children belonged to the middle class; they had more cases of those not immunized and also those with incomplete vaccination history; however, this was not statistically significant when compared to those from the lower class (X2 = 1.310, df = 2, P = 0.520).
|Table 2: Immunization history of the subjects according to the social status of the parents |
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There were varieties of clinical presentations, some with mixture of diseases; however, bronchopneumonia (2 of these had air-leak syndrome) was the commonest indication for measles admission, followed by co-morbidity of diarrhea disease and bronchopneumonia, while convulsion was the least common [Table 3].
One hundred and forty-one (83.9%) of the subjects were discharged within 7 days of admission, 25 were discharged within 8-28 days (14.9%) while 2 subjects spent more than 28 days (1.2%).
[Table 4] showed that most of the subjects were discharged without complications (81.0%), while 11 (6.5%) deaths were recorded mostly among the malnourished children. Only 9 (7.4%) of the 122 well-nourished subjects had complications, 11 (42.3%) of those with underweight had complications while those with marasmus had most complications 12 (63.2%).
| Discussion|| |
Measles epidemic still occurs especially in sub-Saharan Africa and Asia; quite recently an outbreak was reported in the United States of America  despite the huge investment on measles vaccine. Common risk factors associated with measles infection include overcrowding especially amongst refugees and internally displaced persons,  malnutrition, vitamin A deficiency, immunodeficiency diseases, and non-immunization.  The risk factors identified in this report included malnutrition and non-vaccination of children; this is similar the findings reported by Etuk et al.  Most children from the middle-class families were nonvaccinated in this study, which is quite surprising; however, this may partly be due to higher patronage of the hospital by the middle-class families, as a result of cost of admission which may not be affordable to the lower class while those of the high social class patronize private hospitals, therefore there maybe disproportionate representation of the various social classes; however, this does not exclude the fact that vaccine acceptance by the educated parents as observed in middle and high social classes is also declining even in the developed countries for the fear of side-effects while some are concerned of possibility of vaccine ineffectiveness; therefore efforts at increasing vaccine acceptance should be made, it is clear that an earlier gain of increased , vaccine coverage has declined over the years.  Therefore, National Immunizations days for measles vaccination should be intensified and supplemented with vitamin A administration, while community-based surveillance programs on detection of malnutrition and measles should be strengthened.
More worrisome is increasing observation of measles in children who had been vaccinated, , this study documented a rate of vaccination of 18.5% that was higher than that documented in Sheppeard et al.  This is attributable to poor maintenance of vaccine cold chain though failure of the single dose vaccination program, which has been a subject of debate, may not be completely ruled out; this therefore necessitated the call for two-dose measles vaccination. ,
The peak age of measles in this report was 24 months similar to other reports; ,, however, 13 cases were recorded in children aged less than 9 months. There is argument on the concept of waning maternal antibody but clinicians often fail to ask if these young mothers were actually vaccinated or if they ever had natural measles infection as a child; hence it may not be surprising that these mothers never had measles protective antibody. Therefore, measles immunization should be individualized so that such at-risk children could be identified and vaccinated as early as possible. This can be possible if well-efficient child clinics are available.
Over the years, measles occur from the months of November to May; however, April and May recorded most cases in this study, while as per Etuk et al.  in Calabar most cases were reported in the month of February; the reason behind the peak periods is not clear.
Bronchopneumonia remained the commonest indication for admission in this study that was similar to other reports ,, but contrasted with that of Akramuzzaman et al.  who reported chest infection in only 6% of cases of measles admission; however, 6 cases of measles croup were also documented and 2 of those with bronchopneumonia had air-leak syndrome. Most of the patients (81%) were successfully discharged without complication; however, post-measles malnutrition was the commonest complication. Out of the study subjects, 6.7% died; this was lower than the fatality rate of 7.8-56.5% as reported in previous studies. ,,, Interestingly, all the deaths were recorded in those with malnutrition. This further highlights the significance of protein energy malnutrition on the outcome of measles infection. 
| Conclusion|| |
Measles is still a huge health burden affecting even children younger than 9 months. Bronchopneumonia and diarrhea disease remain as common complications and indication for hospital admission as was reported earlier. Though most of the children were not vaccinated, yet infection in previously vaccinated children was recorded. Therefore, effective enlightenment campaign on its usefulness should be intensified.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Guris D, Harpaz R, Redd SB, Smith NJ, Papania MJ. Measles surveillance in the United States: An overview. J Infect Dis 2004;189(Suppl 1): S177-84.
Centers for Disease Control (CDC). Classification of measles cases and categorization of measles elimination programs. MMWR Morb Mortal Wkly Rep 1983;31:707-11.
Oyedeji GA. Socio-economic and cultural background of hospitalized children in Ilesha. Niger J Paed 1985;12:111-7.
Gastañaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, et al
.: Division of Viral Disease, National Center for Immunization and Respiratory Diseases, CDC. Measles - United States, January 1-May 23 2014. MMWR Morb Mortal Wkly Rep 2014;63:496-9.
Kouadio IK, Kamigaki T, Oshitani H. Measles outbreaks in displaced populations: A review of transmission, morbidity and mortality associated factors. BMC Int Health Hum Rights 2010;10:5.
Scheifele DW, Forbes CE. Prolonged giant cell excretion in severe African measles. Pediatrics 1972;50:867-73.
Etuk IS, Ekanem EE, Udo JJ. Comparative analysis of measles morbidity and mortality in Calabar during the expanded programme on immunization and the national programme on immunization eras. Niger J Paed 2003;30:81-5.
Ibia EO, Asindi AA. Measles in Nigerian children in Calabar during the era of expanded programme on immunization. Trop Geogr Med 1990;42:226-32.
Ekanem EE, Ochigbo SO, Kwagtsule JU. Unprecedented decline in measles morbidity and mortality in Calabar, south-eastern Nigeria. Trop Doct 2000;30:207-9.
Nkowane BM, Bart SW, Orenstein WA, Baltier M. Measles outbreak in a vaccinated school population: Epidemiology, chains of transmission and the role of vaccine failures. Am J Public Health 1987;77:434-8.
Lerman SJ, Gold E. Measles in children previously vaccinated against measles. JAMA 1971;216:1311-4.
Sheppeard V, Forssman B, Ferson MJ, Moreira C, Campbell-Lloyd S, Dwyer DE, et al
. Vaccine failures and vaccine effectiveness in children during measles outbreaks in New South Wales, March-May 2006. Commun Dis Intell Q Rep 2009;33:21-6.
Agumadu UN. Measles control in Nigeria. The case for a two-dose vaccine policy. Niger J Paed 2005;32:41-5.
Akramuzzaman SM, Cutts FT, Hossain MJ, Wahedi OK, Nahar N, Islam D, et al
. Measles vaccine effectiveness and risk factors for measles in Dhaka, Bangladesh. Bull World Health Organ 2002;80:776-82.
Onyiriuka AN. Clinical profile of children presenting with measles in a Nigerian secondary health-care institution. JIDI 2011;3:112-6.
Ibadin MO, Omoigberale AI. Current trend in childhood measles in Benin City, Nigeria. Sahel Med J 1998;1:6-9.
Ibrahim M, Jiya NM. Clinical presentation of measles in Sokoto, Nigeria. Sahel Med J 1999;2:104-7.
Onoja AB, Adeniji AJ, Faneye A. Measles complications in a Nigerian hospital setting. Clinical Reviews and Opinions 2013;5:18-23.
Moons P, Thallinger M, Cramond V. Subcutaneous emphysema, normally a rare complication of measles. Report of alarmingly high incidence in Somali refugee children. Medecins Sans Frontieres. Available from: http://epostersonline.s3.amazonaws.com/
. [Last accessed on 2013 Oct 12].
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]