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Measles in Nigerian children
TROPICAL PEDIATRICS
Measles in Nigerian children The clinical patterns o[ measles in the developing country o[ Nigeria are contrasted with those in the economically developed countries o[ Europe and North America. The areas o[ difference lie in the epidemiology, the age incidence, and particularly in the severity o[ the disease as mani[ested by the phenomenal morbidity and mortality rates in Nigeria. Malnutrition, aided and abetted by a number o[ "iatrogenic" complications, is the most important single [actor which determines the outcome o[ the disease.
M. I. Ogbeide, M.B. (Lond.) M.R.C.P.ED. LAGOS,
NIGERIA
is essentially a d i s e a s e o f early childhood, the majority of children in crowded communities (developed or underdeveloped) having had it by the age of 5 years. In developing countries, measles is still a very serious disease, 1-3 constituting a major and urgent public health problem? Although the basic clinical features of measles are the same everywhere, they are generally much more pronounced in the developing countries, resembling those seen in Europe in the early part of the present century2 This paper is devoted principally to those aspects of measles in which the character of the disease in Nigeria differs significantly from that in the economically advanced countries. In addition, a description is given of certain "iatrogenic" complications which tend to aggravate the disease. M EAS L E S
EPIDEMIOLOGY Nigerian measles is an endemic disease, no month of the year being free of it. This observation is in agreement with those of
Morleys in Ilesha in the Western Region of Nigeria. However, at certain periods of the year, commonly during March and April, just prior to the rainy season, and October and November, immediately following the rainy season, the disease often assumes epidemic proportions, occurring in severe forms and spreading rapidly. Gans and co-workers 2 and Morley 3 stressed the late dry season (period prior to the rainy season) as the epidemic period. Morley suggests that this is the time of year when the people of Ilesha leave their farms and return home for annual festivities, thus increasing the chances for spread of the disease (and also affording mothers an opportunity to take their children to the hospital). However, neither writer described the end-of-the-rains peak period of September, October, or November (depending on whether the dry season is early or late). It is clear therefore that the disease in Nigeria does not occur with the familiar biennial periodicity seen in Europe or North America. Vol. 71, No. 5, pp. 737-741
738
Ogbeide
The ]ournal of Pediatrics November 1967
AGE INCIDENCE
Some immunity to measles is transmitted from the mother to. her infant prenatally, but such immunity has generally disappeared by one year after birth. I n economically advanced countries it is relatively u n c o m m o n for measles to occur during the first year of life, and still more u n c o m m o n for it to occur before the age of 6 months. In Nigeria, however, about a third of the cases occur in the first year of life, some as early as 4 months of age. This is of great practical significance in regard to measles vaccination in developing countries: although the Council on Drug-s of the American Medical Association ~ has recommended that neither the Edmonston B nor the further attenuated Schwarz measles vaccines should be given to. children less than 12 months of age (because residual maternal antibodies may interfere with satisfactory immunological response), such interference may be expected to. be less of a problem in the developing countries.
Fig. 1. Early stage of cancrum otis in convalescent measles in an 18-month-old girl. Note the central core of necrotic tissue (slough), with cellulitis of the face and periorbital edema involving the left eye, and, to a lesser extent, the right eye as well.
MORBIDITY
It is d e a r therefore that in Nigeria measles occurs in the age group which is particuIarly liable to complications and in which such complications are often very severe. With a complication rate of up to 44.5 per cent, * m u c h morbidity arises from respiratory infections and gastrointestinal disorders, both of which are conditions that often precipitate or accentuate protein-calorie malnutrition, ophthalmitis, stomatitis, middle ear infection, and involvement of the central nervous system such as restlessness, drowsiness, muscle twitching, "febrile convulsions," and frank measles encephalitis. Consequently, a considerable number of survivors have permanent sequelae in the form of suppurative lung lesions such as empyema and bronchiectasis, blindness, hideous facial disfigurement resulting from cancrum oris (Fig. 1), deafness, mental retardation, and nerve palsies. Bronchopneumonia is by far the commonest single complication, occurring in up to 80 per cent of the admitted cases, 98 per cent of them under the age of 4 years/
Fig. 2. Measles encephalitis in a 5-month-old boy. Note, also, the severe stomatitis.
T h o u g h it used to be taught, and it is probably still the case in the advanced countries, that encephalitis is a more c o m m o n complication in older children, measles encephalitis is not at all u n c o m m o n even in the infant under one year of age in Nigeria
(Fig. 2). "IATROGENIC"
COMPLICATIONS
T h e group of complications which may be termed "iatrogenic" are not confined to measles and may be present in any child who is ill with fever and febrile convulsions. T h e offending "physician" here, however, is not
Volume 71 Number 5
the ordinary qualified registered medical practitioner, but usually the local medicineman or the child's parent, relative, or wellmeaning neighbor. Certain measures based on tradition, ignorance, and misconceptions are carried out in the treatment of measles and convulsions and have the effect of aggravating these conditions. Conjunctivitis. Varying degrees of involvement of the conjunctivas are common in measles, and often constitute a useful adjunct to the diagnosis of the disease during the prodromal phase. However, worsening of the usual conjunctivitis is caused by the application of such agents as red pepper (Capsicum minimum) to the child's eyes. It is believed that the child who is unconscious and convulsing is in deep sleep, and that a sufficiently painful stimulus such as the smarting effect of red pepper in the eyes will rouse him. Sometimes, drops of local "palm-wine" are applied. Hyperpyrexia. Heat is believed to have a similar rousing effect, and it is usual to place a convulsing child in a room with all doors and windows shut and to start a big fire. The effect is to eliminate the natural processes of body cooling by evaporation of perspiration and movements of convection currents. The child's temperature is thereby kept at high levels for long hours, with perpetuation of the convulsions and consequent cerebral damage. Dehydration. It is a common practice to administer a purgative to the child with measles because it is believed that, unless this is done, the measles rash will tend to be "locked up" in the child's body and fail to erupt, which would be a bad thing. The disastrous effect of such a measure on the already dehydrated child is obvious. Ulcerations of the skin. Ordinarily, desquamation of the skin is a more prominent feature of convalescent measles in Nigerian children than in children of the advanced countries, and this may be a further indication of some deficiency, possibly related to vitamin A. However, this is often made worse by the topical application of some traditional concoctions, employing local "illicit gin" as
Measles in Nigeria 7 3 9
the medium, which give rise to severe blisters of large areas of the skin. When such skin lesions are associated with the concomitant conjunctivitis, stomatitis, and sometimes also vulvitis or urethritis, a picture practically indistinguishable from erythema multiforme exudativum (Stevens-Johnson syndrome) may be produced. The consequent loss of body liquids in a child already gravely ill with toxemia and dehydration renders this complication particularly lethal. Burns. Another common procedure employed in trying to rouse the unconscious child in convulsions is to submerge the feet and buttocks in boiling water, resulting often in severe burns. Poisoning by cow's urine. A product of fermentation in cow's urine is used traditionally both in the treatment of a n established convulsion and for prophylaxis against it in the febrile and restIess child. The composition of this product appears to. vary somewhat from one medicine-man to another, but it is now felt that its clinical effects cannot be ascribed to cow's urine per se, the urine probably being a vehicle for other ingredients. The high level of nicotine content confirms the suspicion that tobacco leaves, in addition to some others, are used in its preparation. Sometimes comphor is added by the more sophisticated medicine-men. However, whatever may be the exact composition of this product, its characteristic penetrating, nauseating odor is an unmistakable sign. Large quantities of this potent cerebral depressant are administered, and the more the child takes, the more he is given. Consequently, many such children are left in coma or semi-coma for days after the cessation of the convulsions, and eventually die. Because of the frequency of its use, the assessment of the exact incidence of true encephalitis as a complication of measles is difficult. The preparation is also rubbed on the child's body and may pIay some part in the pathogenesis of ulcerations of the skin. Furthermore, an attempt to "force-feed" this preparation to the unconscious child frequently leads to inhalation pneumonia with its attendant disastrous consequences.
74 0
Ogbeide
The Journal of Pediatrics November 1967
MORTALITY
Hendrickse and Sherman 1 in the University Teaching Hospital at Ibadan noted an over-all mortality of 2.2 per cent; the rate was about 31 per cent, however, in cases which were severe enough to require intensive care in the emergency room or the wards. No reliable figures can be obtained for the over-all case mortality of measles in most of the less well-organized hospitals in Nigeria, but 20 to 30 per cent 8, 4, 7 of the patients admitted to the hospital die, and the disease accounts for 6.7 per cent of total hospital deaths? The results of a recent review of the 163 deaths from measles in an 80 bed children's hospital in Lagos between January, t963, and December, 1964, are recorded in Table I. A total of 161 (98.8 per cent) of the 163 deaths occurred in those under 4 years of age, with the greatest number of deaths for any single year occurring in the first year of life. DISCUSSION In most of the advanced countries, measles is a relatively minor childhood ailment. It has a low rate of complications, and encephalitis, which is the most dreaded, occurs only in about 1 per 1,000. The death rate is less than 2 per 10,000. 8' 9 Hendrickse's figure of 2.2 per cent (220 per 10,000) was based on cases in a university hospital, and, though they were unselected rather than referred because of their severity, they cannot be taken as representative of the general
Table I. Age distribution of 163 deaths in measles
]
A~e i 2 3 4 5
Total
No. 60 54 19 28 2 163
Death,; I Per cent 36.8 33.1 11.7 17.2 1.2 100.0
population, because they were privileged to have excellent hospital care, perhaps the best available in West Africa. In spite of this, the case mortality, rate was over 100 times than that for the United States or Great Britain. The corresponding figure for tile Federal Territory of Lagos in 1964 ~~ was about 6 per cent. (600 per 10,000) but this fell to 2.5 per cent. (250 per 10,000) in 1965,11 probably because of the influence of the Health Centers established in Lagos during that period. T h e absolute accuracy of these figures might be questionable, but the trend which they indicate would appear to be in no doubt. During a severe epidemic in a Nigerian village some 5 miles from the nearest dispensary, and 30 miles from the nearest cottage hospital, up to a quarter of the affected children may- die. 12 Why are morbidity and mortality rates for measles among Nigerian children so much higher than among children in the United States or Great Britain? By and large, the outcome of any disease is determined by the interaction between the virulence of the causative organism and the' resistance of the host. Virological studies indicate that there is only a single strain of measles virus. In this significant respect it is different from the viruses of smallpox and influenza, both of which have a number of different strains. It is therefore unlikely that virulence plays any part in the observed differences in the morbidity and mortality rates. When measles occurs in American or British children residing in Nigeria, the course of the disease is the same as that in the country of origin of such children; when it occurs in Nigerian children fi'om well-to-do families, again the result is almost uniformly favorable, with full recovery within a week of the appearance of the rash. When, however, the same disease occurs in children of the poorer classes in Nigm~a, a large number of them either succumb to the complicating conditions of bro.nchopneumonia and gastrointestinal disorders, or else die of protein-calorie malnutrition a few weeks later. Evidently-, therefor% the reason for this dif-
Volume 71 Number 5
ference is not genetic, racial, or climatic, but is due to a number of socioeconomic factors of which malnutrition is doubtless the most important. Factors other than nutrition, such as unsanitary conditions~ poor housing, and over-crowding, must play an important role in the development of bronchopneumonia which, although not confined to the poorer children, is unquestionably more c o m m o n a m o n g them. But while children of well-to-do families nearly always recover, and recover completely from the disease in a m u c h shorter time in hospital, children of the poorer class very often succumb to it. If they recover they do so only after a prolonged period of illness, and with a m u c h higher incidence of p e r m a n e n t sequelae in spite of the use of antibiotics and other forms of m o d e r n therapy? 2 CONCLUSIONS I n economically developed countries like the United States or Great Britain, where an adequate diet is within the means of the majority and a good nutritional state provides the first line of defense against disease in children, measles is a relatively minor childhood ailment. I n a developing country like Nigeria, on the other hand, where measles occurs among children whose general body resistance has already been depleted by malnutrition and other debilitating diseases, aided by peculiar "iatrogenic" complications, measles is a pernicious disease and an urgent public health problem. SUMMARY
Epidemiology, increased incidence at an early age, and the astounding severity of
Measles in Nigeria
74 1
measles account for its very high morbidity and mortality rate in Nigeria. T h o u g h a number of socioeconomic factors contribute to the complications, it is considered that malnutrition, aided by certain "iatrogenic" complications, is the most important factor in deciding the outcome of the disease. I am grateful to Dr. M. P. Otolorin, the Chief Medical Adviser to the Federal Military Government of Nigeria, for permission to publish this paper. REFERENCES
1. Hendrickse, R. G., and Sherman, P, M.: Morbidity and mortality from measles in children seen at University College Hospital, Ibadan, Arch. Gesamte Virusforsch. 16: 27, 1965. 2. Gans, B., Macnamara, F. N., Morley, D. C., Thompson, S. W., and Watt, A.: Some observations on the epidemiology of measles in West Africa, W. African M. J. 10: 253, 1961. 3. Morley, D. C.: Measles in Nigeria, Am. J. Dis. Child. 103: 230, 1962. 4. Ogbeide, M. I.: Curative paediatric needs for Lagos, W. African M. J. 15: 84, 1966. 5. Morley D. C.: The severe measles of West Africa, Proc. Roy. Sue. Med. 57: 846, 1964. 6. Report by the Council on Drugs of the American Medical Association, J. A. M. A. 194: 1237, 1965. 7. Gans, B.: Paediatric problems in Lagos, W. African M. J. 10: 33, 1961. 8. U. S. Weekly Morbidity and Mortality Report, January 15, 1966. 9. Miller, D. L.: Frequency of complications of measles, 1963, Brit. M. J. 2: 75, 1964. 10. Federation of Nigeria Reported Cases and Deaths from Notifiable Diseases by Regions, Lagos, 1964, Federal Ministry of Health. 11. Federation of Nigeria Reported Cases and Deaths from Notifiable Diseases by Regions, Lagos, 1965, Federal Ministry of Health. 12. Ogbeide, M. I.: The relative merits of preventive and curative services in the maintenance of health and nutrition in the rural African Child, J. N. M. A. Africa Number, July, 1967.
Measles in Nigerian children The clinical patterns o[ measles in the developing country o[ Nigeria are contrasted with those in the economically developed countries o[ Europe and North America. The areas o[ difference lie in the epidemiology, the age incidence, and particularly in the severity o[ the disease as mani[ested by the phenomenal morbidity and mortality rates in Nigeria. Malnutrition, aided and abetted by a number o[ "iatrogenic" complications, is the most important single [actor which determines the outcome o[ the disease.
M. I. Ogbeide, M.B. (Lond.) M.R.C.P.ED. LAGOS,
NIGERIA
is essentially a d i s e a s e o f early childhood, the majority of children in crowded communities (developed or underdeveloped) having had it by the age of 5 years. In developing countries, measles is still a very serious disease, 1-3 constituting a major and urgent public health problem? Although the basic clinical features of measles are the same everywhere, they are generally much more pronounced in the developing countries, resembling those seen in Europe in the early part of the present century2 This paper is devoted principally to those aspects of measles in which the character of the disease in Nigeria differs significantly from that in the economically advanced countries. In addition, a description is given of certain "iatrogenic" complications which tend to aggravate the disease. M EAS L E S
EPIDEMIOLOGY Nigerian measles is an endemic disease, no month of the year being free of it. This observation is in agreement with those of
Morleys in Ilesha in the Western Region of Nigeria. However, at certain periods of the year, commonly during March and April, just prior to the rainy season, and October and November, immediately following the rainy season, the disease often assumes epidemic proportions, occurring in severe forms and spreading rapidly. Gans and co-workers 2 and Morley 3 stressed the late dry season (period prior to the rainy season) as the epidemic period. Morley suggests that this is the time of year when the people of Ilesha leave their farms and return home for annual festivities, thus increasing the chances for spread of the disease (and also affording mothers an opportunity to take their children to the hospital). However, neither writer described the end-of-the-rains peak period of September, October, or November (depending on whether the dry season is early or late). It is clear therefore that the disease in Nigeria does not occur with the familiar biennial periodicity seen in Europe or North America. Vol. 71, No. 5, pp. 737-741
738
Ogbeide
The ]ournal of Pediatrics November 1967
AGE INCIDENCE
Some immunity to measles is transmitted from the mother to. her infant prenatally, but such immunity has generally disappeared by one year after birth. I n economically advanced countries it is relatively u n c o m m o n for measles to occur during the first year of life, and still more u n c o m m o n for it to occur before the age of 6 months. In Nigeria, however, about a third of the cases occur in the first year of life, some as early as 4 months of age. This is of great practical significance in regard to measles vaccination in developing countries: although the Council on Drug-s of the American Medical Association ~ has recommended that neither the Edmonston B nor the further attenuated Schwarz measles vaccines should be given to. children less than 12 months of age (because residual maternal antibodies may interfere with satisfactory immunological response), such interference may be expected to. be less of a problem in the developing countries.
Fig. 1. Early stage of cancrum otis in convalescent measles in an 18-month-old girl. Note the central core of necrotic tissue (slough), with cellulitis of the face and periorbital edema involving the left eye, and, to a lesser extent, the right eye as well.
MORBIDITY
It is d e a r therefore that in Nigeria measles occurs in the age group which is particuIarly liable to complications and in which such complications are often very severe. With a complication rate of up to 44.5 per cent, * m u c h morbidity arises from respiratory infections and gastrointestinal disorders, both of which are conditions that often precipitate or accentuate protein-calorie malnutrition, ophthalmitis, stomatitis, middle ear infection, and involvement of the central nervous system such as restlessness, drowsiness, muscle twitching, "febrile convulsions," and frank measles encephalitis. Consequently, a considerable number of survivors have permanent sequelae in the form of suppurative lung lesions such as empyema and bronchiectasis, blindness, hideous facial disfigurement resulting from cancrum oris (Fig. 1), deafness, mental retardation, and nerve palsies. Bronchopneumonia is by far the commonest single complication, occurring in up to 80 per cent of the admitted cases, 98 per cent of them under the age of 4 years/
Fig. 2. Measles encephalitis in a 5-month-old boy. Note, also, the severe stomatitis.
T h o u g h it used to be taught, and it is probably still the case in the advanced countries, that encephalitis is a more c o m m o n complication in older children, measles encephalitis is not at all u n c o m m o n even in the infant under one year of age in Nigeria
(Fig. 2). "IATROGENIC"
COMPLICATIONS
T h e group of complications which may be termed "iatrogenic" are not confined to measles and may be present in any child who is ill with fever and febrile convulsions. T h e offending "physician" here, however, is not
Volume 71 Number 5
the ordinary qualified registered medical practitioner, but usually the local medicineman or the child's parent, relative, or wellmeaning neighbor. Certain measures based on tradition, ignorance, and misconceptions are carried out in the treatment of measles and convulsions and have the effect of aggravating these conditions. Conjunctivitis. Varying degrees of involvement of the conjunctivas are common in measles, and often constitute a useful adjunct to the diagnosis of the disease during the prodromal phase. However, worsening of the usual conjunctivitis is caused by the application of such agents as red pepper (Capsicum minimum) to the child's eyes. It is believed that the child who is unconscious and convulsing is in deep sleep, and that a sufficiently painful stimulus such as the smarting effect of red pepper in the eyes will rouse him. Sometimes, drops of local "palm-wine" are applied. Hyperpyrexia. Heat is believed to have a similar rousing effect, and it is usual to place a convulsing child in a room with all doors and windows shut and to start a big fire. The effect is to eliminate the natural processes of body cooling by evaporation of perspiration and movements of convection currents. The child's temperature is thereby kept at high levels for long hours, with perpetuation of the convulsions and consequent cerebral damage. Dehydration. It is a common practice to administer a purgative to the child with measles because it is believed that, unless this is done, the measles rash will tend to be "locked up" in the child's body and fail to erupt, which would be a bad thing. The disastrous effect of such a measure on the already dehydrated child is obvious. Ulcerations of the skin. Ordinarily, desquamation of the skin is a more prominent feature of convalescent measles in Nigerian children than in children of the advanced countries, and this may be a further indication of some deficiency, possibly related to vitamin A. However, this is often made worse by the topical application of some traditional concoctions, employing local "illicit gin" as
Measles in Nigeria 7 3 9
the medium, which give rise to severe blisters of large areas of the skin. When such skin lesions are associated with the concomitant conjunctivitis, stomatitis, and sometimes also vulvitis or urethritis, a picture practically indistinguishable from erythema multiforme exudativum (Stevens-Johnson syndrome) may be produced. The consequent loss of body liquids in a child already gravely ill with toxemia and dehydration renders this complication particularly lethal. Burns. Another common procedure employed in trying to rouse the unconscious child in convulsions is to submerge the feet and buttocks in boiling water, resulting often in severe burns. Poisoning by cow's urine. A product of fermentation in cow's urine is used traditionally both in the treatment of a n established convulsion and for prophylaxis against it in the febrile and restIess child. The composition of this product appears to. vary somewhat from one medicine-man to another, but it is now felt that its clinical effects cannot be ascribed to cow's urine per se, the urine probably being a vehicle for other ingredients. The high level of nicotine content confirms the suspicion that tobacco leaves, in addition to some others, are used in its preparation. Sometimes comphor is added by the more sophisticated medicine-men. However, whatever may be the exact composition of this product, its characteristic penetrating, nauseating odor is an unmistakable sign. Large quantities of this potent cerebral depressant are administered, and the more the child takes, the more he is given. Consequently, many such children are left in coma or semi-coma for days after the cessation of the convulsions, and eventually die. Because of the frequency of its use, the assessment of the exact incidence of true encephalitis as a complication of measles is difficult. The preparation is also rubbed on the child's body and may pIay some part in the pathogenesis of ulcerations of the skin. Furthermore, an attempt to "force-feed" this preparation to the unconscious child frequently leads to inhalation pneumonia with its attendant disastrous consequences.
74 0
Ogbeide
The Journal of Pediatrics November 1967
MORTALITY
Hendrickse and Sherman 1 in the University Teaching Hospital at Ibadan noted an over-all mortality of 2.2 per cent; the rate was about 31 per cent, however, in cases which were severe enough to require intensive care in the emergency room or the wards. No reliable figures can be obtained for the over-all case mortality of measles in most of the less well-organized hospitals in Nigeria, but 20 to 30 per cent 8, 4, 7 of the patients admitted to the hospital die, and the disease accounts for 6.7 per cent of total hospital deaths? The results of a recent review of the 163 deaths from measles in an 80 bed children's hospital in Lagos between January, t963, and December, 1964, are recorded in Table I. A total of 161 (98.8 per cent) of the 163 deaths occurred in those under 4 years of age, with the greatest number of deaths for any single year occurring in the first year of life. DISCUSSION In most of the advanced countries, measles is a relatively minor childhood ailment. It has a low rate of complications, and encephalitis, which is the most dreaded, occurs only in about 1 per 1,000. The death rate is less than 2 per 10,000. 8' 9 Hendrickse's figure of 2.2 per cent (220 per 10,000) was based on cases in a university hospital, and, though they were unselected rather than referred because of their severity, they cannot be taken as representative of the general
Table I. Age distribution of 163 deaths in measles
]
A~e i 2 3 4 5
Total
No. 60 54 19 28 2 163
Death,; I Per cent 36.8 33.1 11.7 17.2 1.2 100.0
population, because they were privileged to have excellent hospital care, perhaps the best available in West Africa. In spite of this, the case mortality, rate was over 100 times than that for the United States or Great Britain. The corresponding figure for tile Federal Territory of Lagos in 1964 ~~ was about 6 per cent. (600 per 10,000) but this fell to 2.5 per cent. (250 per 10,000) in 1965,11 probably because of the influence of the Health Centers established in Lagos during that period. T h e absolute accuracy of these figures might be questionable, but the trend which they indicate would appear to be in no doubt. During a severe epidemic in a Nigerian village some 5 miles from the nearest dispensary, and 30 miles from the nearest cottage hospital, up to a quarter of the affected children may- die. 12 Why are morbidity and mortality rates for measles among Nigerian children so much higher than among children in the United States or Great Britain? By and large, the outcome of any disease is determined by the interaction between the virulence of the causative organism and the' resistance of the host. Virological studies indicate that there is only a single strain of measles virus. In this significant respect it is different from the viruses of smallpox and influenza, both of which have a number of different strains. It is therefore unlikely that virulence plays any part in the observed differences in the morbidity and mortality rates. When measles occurs in American or British children residing in Nigeria, the course of the disease is the same as that in the country of origin of such children; when it occurs in Nigerian children fi'om well-to-do families, again the result is almost uniformly favorable, with full recovery within a week of the appearance of the rash. When, however, the same disease occurs in children of the poorer classes in Nigm~a, a large number of them either succumb to the complicating conditions of bro.nchopneumonia and gastrointestinal disorders, or else die of protein-calorie malnutrition a few weeks later. Evidently-, therefor% the reason for this dif-
Volume 71 Number 5
ference is not genetic, racial, or climatic, but is due to a number of socioeconomic factors of which malnutrition is doubtless the most important. Factors other than nutrition, such as unsanitary conditions~ poor housing, and over-crowding, must play an important role in the development of bronchopneumonia which, although not confined to the poorer children, is unquestionably more c o m m o n a m o n g them. But while children of well-to-do families nearly always recover, and recover completely from the disease in a m u c h shorter time in hospital, children of the poorer class very often succumb to it. If they recover they do so only after a prolonged period of illness, and with a m u c h higher incidence of p e r m a n e n t sequelae in spite of the use of antibiotics and other forms of m o d e r n therapy? 2 CONCLUSIONS I n economically developed countries like the United States or Great Britain, where an adequate diet is within the means of the majority and a good nutritional state provides the first line of defense against disease in children, measles is a relatively minor childhood ailment. I n a developing country like Nigeria, on the other hand, where measles occurs among children whose general body resistance has already been depleted by malnutrition and other debilitating diseases, aided by peculiar "iatrogenic" complications, measles is a pernicious disease and an urgent public health problem. SUMMARY
Epidemiology, increased incidence at an early age, and the astounding severity of
Measles in Nigeria
74 1
measles account for its very high morbidity and mortality rate in Nigeria. T h o u g h a number of socioeconomic factors contribute to the complications, it is considered that malnutrition, aided by certain "iatrogenic" complications, is the most important factor in deciding the outcome of the disease. I am grateful to Dr. M. P. Otolorin, the Chief Medical Adviser to the Federal Military Government of Nigeria, for permission to publish this paper. REFERENCES
1. Hendrickse, R. G., and Sherman, P, M.: Morbidity and mortality from measles in children seen at University College Hospital, Ibadan, Arch. Gesamte Virusforsch. 16: 27, 1965. 2. Gans, B., Macnamara, F. N., Morley, D. C., Thompson, S. W., and Watt, A.: Some observations on the epidemiology of measles in West Africa, W. African M. J. 10: 253, 1961. 3. Morley, D. C.: Measles in Nigeria, Am. J. Dis. Child. 103: 230, 1962. 4. Ogbeide, M. I.: Curative paediatric needs for Lagos, W. African M. J. 15: 84, 1966. 5. Morley D. C.: The severe measles of West Africa, Proc. Roy. Sue. Med. 57: 846, 1964. 6. Report by the Council on Drugs of the American Medical Association, J. A. M. A. 194: 1237, 1965. 7. Gans, B.: Paediatric problems in Lagos, W. African M. J. 10: 33, 1961. 8. U. S. Weekly Morbidity and Mortality Report, January 15, 1966. 9. Miller, D. L.: Frequency of complications of measles, 1963, Brit. M. J. 2: 75, 1964. 10. Federation of Nigeria Reported Cases and Deaths from Notifiable Diseases by Regions, Lagos, 1964, Federal Ministry of Health. 11. Federation of Nigeria Reported Cases and Deaths from Notifiable Diseases by Regions, Lagos, 1965, Federal Ministry of Health. 12. Ogbeide, M. I.: The relative merits of preventive and curative services in the maintenance of health and nutrition in the rural African Child, J. N. M. A. Africa Number, July, 1967.