Course Management of Prevalent Infections in Children Following a Disaster

Unfortunately, isolation of patients is not an effective preventive measure since individuals are most contagious in the prodromal period, before a diagnosis can be made. The only effective approach is to vaccinate the population as soon as possible. Give measles vaccination the highest priority early in disaster situations. Do not delay until cases of measles have been reported (Box 2) (CDC, 1992).

Consider vaccinating children presenting with acute illness, such as fever, diarrhea, and ARI, as well as malnourished children and those with tuberculosis or HIV infection.

Vitamin A and measles

Vitamin A deficiency increases measles associated morbidity and mortality.

Moreover, measles infection increases the severity of the complications resulting from vitamin A deficiency. Vitamin A is important in maintaining epithelization of the respiratory tract and in the recovering process after infection. It also plays a key role in the body’s immune defenses.

Children deficient in vitamin A who become infected with measles have higher cornealulceration and fatality rates. Develop a plan to administer prophylactic vitamin A in conjunction with a measles immunization program. However, when measles vaccine is not yet available and a delay is anticipated, administer vitamin A. This vitamin by itself reduces morbidity and mortality during measles outbreaks. The prophylactic dose of vitamin A according to World Health Organization current recommendations is 100,000 IU for infants and 200,000 IU for children older than 12 months. Pregnant women should receive only 30,000 IU of vitamin A.

Measles diagnosis

Following an incubation period of 10 to 12 days from exposure, measles prodrome is characterized by 2 to 4 days of fever, cough, coryza, and conjunctivitis. During this period, Koplik spots can be seen as tiny blue-white spots on an intensely reddened oral mucosa. These lesions disappear within 3 days. The maculopapular erythema or morbilliform rash of measles first appears on the hairline and forehead, then moves downward to involve the face, neck, and the rest of the body. Initially the lesions are discrete and then become confluent. If no complications occur, fever disappears within 2 to 3 days after the onset of rash.

The rash persists for 4 to 6 days. It becomes brownish in color for a few days before desquamating. Many children have anorexia, conjunctivitis, diarrhea, and some have mild stomatitis. Generalized lymphadenopathy can occur, but it is uncommon.

Measles complications

Measles is a highly catabolic disease, associated with reduced food intake, increased gastrointestinal losses, and rapid weight loss. Complications occur in approximately 30% of cases; complication rates are even higher in developing countries. The most frequent acute complications are pneumonia, croup, otitis media, and diarrhea. Measles virus is immunosuppressive and predisposes to secondary viral and bacterial infections, as well as to the reactivation of tuberculosis.

Malnourished children often have atypical presentations hemor that may vary rhagic lesions associated mucosal bleeding and from with disseminated intra vascular coagulation (called black measles), to a less intense rash because of compromised cell mediated immunity. These children may also have a deeper desquamation resulting in extensive areas of depigmentation. Providing nutritional support continued feeding, even if diarrhea is present, is crucial. If the child refuses feeding, consider using a nasogastric tube. Give additional fluids to prevent or treat dehydration. When acute infection has resolved, enroll malnourished children in a feeding program, if available.

Most measles-related deaths are associated with pneumonia, croup, and diarrhea. Rare acute encephalitis, complications gingival necrosis, include ulcerative stomatitis (NOMA disease) and endocarditis. Major longterm sequelae in developing countries include measles-r elated blindness, malnutrition, and chronic lung disease. The immunosuppressive effect of measles may delay recovery for many months and cause recurrent infections and later death.

Classification

Measles is classified according to the severity of the illness. Refer severe or very severe cases to a hospital (Hussey and Berman, 2003)

Mild: Fever resolves within 4 days and rash within 8 days with no sign of complications.

Moderate: There are signs of secondary bacterial upper respiratory infection: acute otitis media, sinusitis, or cervical adenitis.

Severe: Signs of respiratory distress emerge with tachypnea, indrawing, reduced oxygen saturation, or stridor.

Other possible signs are heart murmurs or electrocardiographic changes, ophthalmologic signs of vitamin A deficiency or corneal ulcerations, deep or extensive mouth ulcers, bloody diarrhea, jaundice, abdominal pain, moderate to severe dehydration, or purpura (hemorrhagic measles). Patients with severe malnutrition, immunodeficiency disorders, cardiopulmonary disorders, or pre-existing tuberculosis are most at risk.

Very severe: Patient exhibits any of the following symptoms: altered mental status with coma, seizures, or focal neurologic signs; shock with poor peripheral perfusion; upper airway obstruction or signs of respiratory failure; signs of congestive heart failure; or acute abdominal pain with peritoneal signs.

Management

Children with measles must also be evaluated fully for associated infections using the IMCI strategy described earlier in this module. Following IMCI guidelines any child with measles having a general danger sign, clouding of the cornea, or deep or extensive mouth ulcers should be classified as severe complicated measles and be referred urgently to the hospital. Prior to leaving for the hospital the child should be given vitamin A, the first dose of an appropriate antibiotic, and if there is eye discharge or corneal clouding an dose of tetracycline eye ointment. The presence of eye drainage and or mouth ulcers without other signs of serious illness is classified as yellow. Treatment includes Vitamin A, tetracycline eye ointment for eye discharge, and oral hygiene with salt water. These children need a follow up visit in 3 days. A child without complications is green and needs only vitamin A and zinc for 10 days.