Organism Measles is a member of the Para-myxoviridae family of viruses.

Clinical features Measles normally commences with a prodromal fever, cough, conjunctivitis and small spots (Koplik's spots) most easily seen inside the mouth. The characteristic blotchy rash begins on the third to seventh day of the illness, generally on the face, but soon spreads to the whole body.

In developing countries, it is a serious disease and accounts for a considerable amount of mortality and morbidity in the childhood population. It particularly has a severe effect on the nutritional status of the child, resulting in the healthy child losing weight and the malnourished child becoming critically ill. The peak of infection is between 1 and 2 years of age, at the very time when breast milk alone is an inadequate source of food supply and weaning foods may not yet have been introduced. The association of nutritional change and measles can be, and often is, a lethal combination.

There are a number of reasons for the nutritional depletion produced by measles. Any disease process puts extra demands on the body, increasing catabolism. Fever and the desquamation of all epithelial surfaces demands protein replacement, which is handicapped by a sore mouth, often secondarily infected by Candida, thus preventing the child from sucking properly so that even breast milk is not taken. Then from the other end, diarrhoea, which is such a common feature of measles in developing countries, discharges the body reserves further. Perhaps the greatest weight loss is due to im-munosuppression, much of which takes place after the child has recovered from the acute attack.

The disease process attacks all epithelial surfaces, producing most of its complications in the respiratory tract. Pneumonia is the commonest complication, while lar-yngo-tracheo-bronchitis is serious, with a high mortality. Acute respiratory infections (see Section 13.1) are one of the leading causes of childhood ill health and the sequelae of measles are responsible for a large component of this problem. If the acute pneumonia does not kill, the damage done makes the child more susceptible to further attacks of respiratory infection when the measles has long gone.

The effects on the eye can cause blindness. Corneal lesions result from epithelial damage, which can lead to ulceration, secondary infection and scarring. In severe cases, perforation or total disorganization of the eye can occur. These severe effects only result if there is concomitant vitamin A deficiency, so giving vitamin A to all measles cases is effective. Measles by its nutritional and direct effects has been regarded as the most important cause of blindness in a number of tropical countries.

Measles is an important cause of otitis media. It can also result in encephalitis, either in the acute form or a late slow-onset sclerosing panencephalitis, which is always fatal.

Diagnosis is on clinical criteria, but measles IgM can be found in the saliva with im-munological tests.

Transmission Although the main feature of measles is the skin rash, it is transmitted by the airborne route from nasal and pharyn-geal secretions. This can be by articles contaminated with secretions such as cloth or clothing used to wipe a running nose as well as by respiratory droplets produced in a coughing bout.

Measles is the most contagious of all infectious diseases and no age is spared. In the Fijian outbreak in the 1870s, adults as well as children succumbed, affecting families as a whole at the same time, causing deprivation and starvation that resulted in a high death rate. Now adults have experienced measles as children, with the age of infection getting younger. This is explained by greater contact of communities due to improvement of communication, while the intense social contact at a very young age (babies carried on their mother's back) gives maximum opportunity for early transmissions.

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