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Measles and Primary Health Care

MEASLES continues to excite worldwide interest andconcern because it should be preventable; yet, NorthAmerica apart, the ability of most countries to controlthe disease does not seem to improve. With protein-energy malnutrition and diarrhoeal disease, measlesremains one of the biggest killers in poor countries, andthe figure of 900 000 deaths annually cited five yearsago by Walsh and Warren’ is unlikely to have alteredtoday. In many countries the case fatality rate of youngchildren is 1(}-20%,2 compared with about 0 02% inBritain,3 and the reason is far from clear. The dominantrole of malnutrition as a contributor to mortality inmeasles is increasingly doubted,4,5 and explanations arebeing sought more in the intensity of the infecting doseand the younger age group of children at risk. Anearlier editoria16 commented on Loening andCoovadia’s data7 indicating a positive correlationbetween population density and the percentage ofmeasles patients aged 8 months or less-A factor that has-been little analysed is the relation between healthfacilities and the death rate from measles. Most studiesassess mortality in hospital, where the cases presentingare likely to be late and complicated. In one of the fewpublished primary-care studies, Drew and Bauhaun8reported a mortality rate of only 2% for measles in arefugee camp after provision of simple managementprotocols to paramedical workers.What are the implications of these observations for

measles control? Most commentators have pinnedtheir hopes on vaccination, though there is

disagreement over whether eradication is achievable

1. Walsh JA, Warren KS. Selective primary care: An interim strategy for disease control indeveloping countries. N Engl J Med 1979; 301: 967-74.

2. McGregor IA. Measles and child mortality in The Gambia. W Afr Med J 1964, 13:251-56.

3. Williams G. Measles and rubella. In: Ball AP, ed. Notes on infectious diseases.Edinburgh: Churchill Livingstone, 1982.

4. Aaby P, Bukh J, Lisse IM, Smith AJ. Measles mortality, state of nutrition and familystructure: a community study from Guinea-Bissau. J Inf Dis 1983; 147: 693-701.

5. Smedman L, Lindeberg A, Jeppsson O, Zetterstrom R. Measles mortality andmalnutrition. Lancet 1983; ii: 695.

6. Editorial. Measles mortality and malnutrition. Lancet 1983, ii: 661.7. Loening WEK, Coovadia HM. Age-specific recurrence rates of measles in urban, peri-

urban, and rural environments: implications for time of vaccination. Lancet 1983; ii:324-26

8. Drew D, Bauhaun M Effective deployment of refugee health workers in epidemicmeasles. Trop Doctor 1982; 12: 132-33.

worldwide in the near future.9,10 Argument alsocontinues over the optimum age of immunisation, 11,12the target population for immunisation, 13 the

practicalities of the cold chain, and even over thecost/benefit ratio of vaccination in the rural areas of a

developing country.14 The current World Health

Organisation advice"-a single vaccine dose to be

given at 9 months of age-has been justified by a recentstudy from Cameroon15 which showed a decrease inmeasles of 44% in children of all ages and 64% inchildren under 9 months after such a policy wasinstituted. An aerosol human diploid-cell vaccinewhich achieved 96% seroconversion in 39 children

aged 4-6 months,16 and the likely advent of a heat-stable vaccine,17 promise better protection of infantsand young children; but British experience of

persisting low immunisation rates 18 despite the

availability of an effective vaccine, a well maintainedcold chain, and an extensive health infrastructureshows that a massive extension of vaccine coverage in

developing countries will be no easy task.Whilst work must continue on improving

immunisation rates by all means possible, perhapsother strategies of control are desirable. Can improvedmedical care at primary level alleviate the effectsof measles, by cutting death rates and by reducingthe devastating morbidity from blindness andmalnutrition? The answers must be conjectural butthe low mortality obtained in the small series of Drewand Bauhauns may be a pointer. Deaths frommeasles are due to diarrhoea and dehydration,bronchopneumonia and laryngotracheitis, encephalitis,and overwhelming viraemia. The major late com-plications are malnutrition and blindness or severe eyedamage. What has secondary prevention by the

primary care worker to offer in reducing deaths andcomplications? Diarrhoeal deaths are eminentlypreventable by oral rehydration; and nutritional

support, both by early introduction of high caloriefeeds19 and by use of locally available calorific

rehydration mixtures,2o should be a corollary. Whenmeasles diarrhoea is associated with prolongedstomatitis and protein-losing enteropathy specificnutritional support is needed. Early use of antibiotics

9 Hopkins DR, Koplan JP, Hinman AR, Lane JM The case for global measleseradication Lancet 1982; i: 1396-98.

10. Henderson DA. Global measles eradication. Lancet 1982, ii: 208.11 Expanded Programme for Immunisation. Programme statement. Geneva: WHO,

1976: 4

12 Schoeman C, van Niekerk CH. Measles vaccination-when to administer. S Afr Med J1984; 65: 232

13. Smith H Measles again. Br Med J 1980; 280: 766-67.14. Ponnighaus JM. The cost/benefit of measles immunisation: a study from Southern

Zambia. J Trop Med Hyg 1980; 83: 141-4915. Heymann DL, Murphy KR, Mayben GK, Guyer B, Foster SO. Measles control in

Yaounde justification of a one dose, nine month minimum age vaccination policy intropical Africa. Lancet 1983; ii: 1470-72

16. Sabin AB, Avechiga AF, Castro JF de, Sever JL, Madden DL, Shekarchi I, Albrecht P.Successful immunisation of children with and without maternal antibody byaerosolised measles vaccine JAMA 1983, 249: 2651-62.

17. Heyman DL, Nakano JH, Maben GK, Durand B. Field trial of a heat-stable measlesvaccine in Cameroon. Br Med J 1979, ii: 99-100.

18. Campbell AGM. Measles immunisation: Why have we failed? Arch Dis Child 1983; 58:3-5.

19. Hirschhorn N. Oral rehydration therapy for diarrhoea in children-a basic primer.Nutr Rev 1982, 40: 97-104

20. Hirschhorn N Enriched ORT. Diarrhoea Dialogue 1983, 15: 4.

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for preventing bacterial pneumonia and laryngealinfection is probably undesirable, though the issueneeds to be clarified by community-based studies.Weinstein showed in a hospital study nearly 30 yearsago2’ that bacterial infection was twice as common inmeasles children who had received an antibiotic beforeadmission as in those who had not. It would be better to

emphasise the early treatment of secondary infectionwhen it develops, but we do not know what clinicalsigns to look out for or which antibiotic to prescribe.Hospital research on these matters would be a welcomesymbol of interest in the dilemmas of primary care.The role of other supportive measures (includingnutrition) in reducing infective complications alsoneeds community testing. Good eye care in measles isvery important. Sauter22 has stressed the need for

thorough examination of the eyes in the measles child,who keeps the eyes shut and utters no complaint as thecornea melts away. He favours early administration of amassive oral dose (200 000 units) of vitamin A. Afterthe usual intramuscular injection of vitamin A

absorption is slow and unreliable, but theintramuscular preparation may be given by mouth if awater-miscible capsule is not available. Inna et al,23 inNigeria, report normal plasma vitamin Aconcentrations in children with post-measles cornealulceration, but this does not exclude a protective effect;they argue that measles infection may increase tissuerequirements for the vitamin.Could this kind of management be practised by

primary health workers at village level? Oral

rehydration, nutritional support, and eye care certainlyought to be feasible; vitamin A should be available inevery village. Isolation of measles children at villagelevel is also worth considering as a way of reducing theseverity of the epidemic and as a means of educatingvillagers in the germ theory of disease. At present,many rural populations know much about measles butcustoms surrounding the disease may still preventchildren from being brought for treatment at an earlystage, or may promote undesirable practices. Mothersin Ethiopia24 use an appeasement ceremony for "fairiesor hidden sisters who come to take the child".

Foodstuffs including popcorn, ’Coca-Cola’, and fruitare prepared as a gift for the fairies. However, childrenwith severe measles are not washed for 40 days.Primary health care workers would need to seek meansof integrating such traditional customs with moderncare. The broader background issues of overcrowding,family size, and equitable access to national resourcescan only be approached by socioeconomic reform,which should be closely allied to primary health care. Itwill be interesting to see whether measles mortality

21 Weinstein L Failure of chemotherapy to prevent the bacterial complications ofmeasles N Engl J Med 1955, 253: 679-83.

22 Sauter JJM. Why measles makes so many children blind. Trop Doctor 1982; 12:219-22.

23 Inna M, Duggan MB, West CE, Whittle HC, Kogbe OI, Sandford-Smith JH, Glover J.Post-measles corneal ulceration in children in N Nigeria role of vitamin A,malnutrition and measles. Ann Trop Pediatr 1983; 3: 181-91.

24. Barnabas G. Popcorn and fairies in the management of measles in Ethiopia Lancet1982, i: 450-51

declines in those countries which are reducingpopulation growth rates by a fairer distribution ofresources.25Immunisation may indeed be the key to the reduction

in the toll of measles deaths worldwide; but we may bechasing a chimera if we promote it as the solution, andneglect the value of primary-health-care measures inmeasles control.

Endocavitary Ablation for ArrhythmiaControl

SURGICAL interruption of atrioventricularconnections has proved a highly successful means ofcontrolling supraventricular arrhythmias. Re-entryatrioventricular tachychardias respond particularlywell, and the technique has been used also for atrialtachycardias. But the surgical approach with

thoracotomy and cardiopulmonary bypass is a majorundertaking; a non-surgical method, such as

endocavitary ablation, would be attractive if it offeredall the benefits with none of the drawbacks. In animals,complete atrioventricular conduction block has beensuccessfully accomplished without thoracotomy byelectrocauteryl of the atrioventricular node area and byinjection of formalin, but these techniques wereperformed with rigid needles and are unsuitable for usein man: trauma apart, they can induce ventricularfibrillation. Five years ago Vedel and co-workers3

reported the accidental production of complete heartblock by external cardioversion of ventricular

tachycardia during an electrophysiological study.They surmised that the shock had been delivered to theatrioventricular node by the His catheter. Thereupon,Gonzalez et al4 tried the method in dogs, and

successfully ablated the atrioventricular node withshocks of approximately 35 J. The cathode was aflexible wire electrode placed opposite the bundle ofHis and the anode was on the dog’s back. In 1982 twogroups5,6 independently reported successful ablation ofthe atrioventricular node in man, but the energyrequired was much greater, 200-500 J. Since thenthere has been ample evidence that endocardialablation of the atrioventricular node can be easily

25 Ratcliffe J Social justice and the demographic transition. In: Morley D, Rohde J,Williams G, eds. Practising health for all. Oxford Oxford University Press, 1983.

1. Brutsaert DC. Comparison of single and paired electrical heart stimulation on cardiachaemodynamics at rest and during exercise in dogs with atrio-ventricular heartblock. Arch Int Physiol 1966; 74: 9-20

2 Turina MI, Bobatai I, Wegman W. Production of chronic atrioventricular block indogs without thoracotomy. Cardiovasc Res 1968, 2: 389-93

3. Vedel J, Frank R, Fontaine G, Fournial JF, Grosgogeat Y. Bloc auriculo-ventriculaireintra-hisien definitif induit au cours d’une exploration endoventriculaire droiteArch Mal Coeur 1979; 72: 107-12.

4. Gonzalez R, Scheinman M, Margaretten W, Rubenstem M. Closed chest electrode-catheter technique for his bundle ablation in dogs. Am J Physiol 1981, 241:H283-87.

5. Gallagher JJ, Svenson RH, Kasell JH, et al. Catheter technique for closed chest ablationof the atrioventricular conduction system, a therapeutic alternative for the treatmentof refractory supraventricular tachycardia. N Engl J Med 1982; 306: 194-200

6 Scheinman MM, Morady F, Hess DS, Gonzalez R. Catheter-induced ablation of theatrioventricular junction to control refractory supraventricular arrhythmias. JAMA1982, 248: 85-95.