measles 3

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9 m lin N uir 1986 ;44 : 9 24-30 . P rin ted in USA . © 1986 Am erican Soc iety fo r C lin ica l N utrition

Re la tion sh ip be tw een m eas les m alnu tr itio n

and b lin dn ess : a p ro sp ec tiv e s tu dy

in In d ian ch ild ren13

V in od in i R ed dy M D D C H P h ask ara m M D N R ag hu ra mu lu P hD

R oy C M ilton P hD V itha l R ao M S D O J M ad hu su da n D CH

a nd K V R ad ha K rishn a D C H

A B S T R A C T A pro sp ec tive

study w as conducted in s lum ch ild ren to de term in e th e in c id ence o f

po st-m easles cornea l d isease

an d to

clarify it s

re la t ionship w i th n u tr it io n al

status.

A to ta l o f3 1 8 cases

of

m eas le s w ere id en tified ov er a p eriod o f 1 5 m o; m ax im um inc id en ce w as

observed

f or c hi ld r en

b e tw een 1 -2 yr . M o st o f th e ch ild ren sh ow ed w e igh t lo s s an d serum p ro te in s decrease dur ing th e

acu te

s tage ofm eas les . C orn ea l le sio ns w ere obs e r v ed

in 3 o fth e c hild re n a nd th e le sio ns re sp on de d

w ell to

trea tm en t . Serum vitam in A and RBP leve ls w ere s ign ifican tly dep ressed d ur ing the acu te

s tag e ofm easles b u t w ere res to red

to n orm a l 8 w k

af te r

r ec ov ery . T he re we r e n o s ig n if ic an t d if fe re n ce s

in the se rum lev e ls fo r th ose w ith a nd w itho u t e ye le s io ns w h ich s ug ge s ts tha t th es e les io ns m a y n o t

be m ed ia te d s im ply th ro ug h th e e ffec t o fin fec tio n o n serum concen tra t io n o fv itam in A .

m

lin u ir

1986 ;44 :924-30 .

K EY W OR D S M ea sle s, m a ln u trition , b lin dn ess

Introduction

M eas le s is o ne o f the m o st com m on in fec -

tiou s d isease s th at o ccur du ring ch ildhood .

H igh d ea th rate s d ue to s econda ry infection

hav e

been repo rted

from deve lop ing coun tr ie s

, 2 ). M eas le s is con s ide red to be an im portan t

c ause o fch ild ho od b lind ne ss.

In Z am b ia it h as

b een es tim a ted th a t 80 o f b lind ne ss in ch il-

d ren w as due to co rnea l le sion s , and ha lf o f

t he s e

w ere cau sed by m ea sle s 3 . C ornea l u l-

cera tion resem b ling kera tom a lac ia is a fre-

quen t com plica tio n o f m eas le s in N ig erian

ch ild ren 4 , 5 ). S im ila r o bse rva tio ns

have

been

rep or ted from A sian cou n tr ies 6 ,

7 . Som e

obs e rve rs

have a ttribu ted th is to specific m ea -

s le s k era titis w h ile o th ers be lieve tha t un de r-

ly ing v itam in A de fic ien cy is the p rim a ry cau se

o f eye le s ion s . P rote in -energy m aln u trition is

a lso con sid ered to b e a sign ifican t backg round

fac tor in the pa thogenesis o f th ese les ion s .

M ost o f th e ear lie r stu d ie s w ere condu cted

in ch ild ren at ten d in g h osp ita l c lin ic s fo r tre a t-

m en t o f com plica tio ns asso cia ted w ith m ea-

s le s , an d li ttle in fo rm a tion is ava ilab le o n th e

sequ en ce o feven ts re la ted to th e d ise a se in th e

com m un ity . F u r therm ore, th e re la tive im por -

tan ce o f va riou s risk fac to rs m ay va ry in d if-

fe ren t p op u la tio ns . A pro sp ec tiv e stud y w as

co nduc ted , the refo re , to a sse ss th e s ig n ific ance

of m ea sle s as a cau se of

co rnea l

b lind ness in

In d ian ch ild ren and to c la rify its rela tion sh ip

with nu tritiona l sta tu s .

Me t h od s

A s lu m a re a s itu ate d

n e a r

th e a irp ort o fH yd erab ad c ity

w as se le c ted fo r th e s tu dy . T h e s lum popu la tio n w as o f

low soc io econom ic s ta tu s and th e res iden ts w ere m ostly

lab orers sub sis ting on

da i ly w a g e s Regula r

h ea lth care w as

n o t a va ilab le an d there w as no v itam in A p roph y lac tic

p rog ram . In

D ecem ber 1982

th e

to ta l popu la tion res id ing

1 From

t he N a ti on a l

In s titu te o f N u tr ition V R e , P B ,

N R , V R a , JM , K V R K , H yderab ad , In d ia an d th e N a -

t iona l E ye In stitu te R C M ,

B e t h e s d a

MD .

2

S tudy conducted as pa rt o f IN DO -US

co l labora t ive

pro jec t o n N utritio na l B lin dn es s.

3 Add res s

repr int

reques ts

to :

D r V in od in i R eddy , N a-

t io na l I ns tit ut e o f Nu t r it io n J ama i - O sma n ia P0 , Hyd e r -

a ba d 5 00 0 07

India .

R ece ived F eb ruary 3 , 1986 .

A ccepted fo r p ub lica tio n M ay 27 1986 .

7/25/2019 measles 3


R esults

Initia l nutr itio na l s ta tus

A t th e in itial b aselin e su rvey, 4 ofth e ch il-

dren show ed clinical signs of kw ashiorkor or

m arasm u s. T hirty-five percent

ofthe children

w ere in grade I , 48 in grade I I , and 1 1 in

grade III m aln utrition w h ile 6 o fth e ch ild ren

w ere of norm al nutri ti onal grade. Ocular

m anifestations of vitam in A deficiency seen

in 5 of the chi ldren w ere mostly conj uncti v al

lesions (eg, B i tot Spots and conjuncti v al xe-

rosis) (T able 1). T he prevalence of corneal

scars w as 0.1 .

M E A SL E S

A N D CH I L D H O O D B L I N D N ESS

925

T A B L E 1

B a s e l i n e s urv e y s ho win g p re va le n c e o f n u tritio na l d e fic ie nc ie s in children

Ag e

T o t a l

n u m b e r

K w a s h i o r k o r

Marasmus

V ita m in A

d e f i d e n c y

C o n j u n c t i v a l

x e r o s i s

B i to t

s p o t

N i g h t

b l i n d n e s s

C o m e a l

s c a r

<1

3 3 0 1

7 0 0 0 0

0

1+ 345

4 23 4 1 3 0 0

2 3 5 2 1 1 8

2 4 1 4 8 2

1

3

3 1 5

3

3 2 7 1 8 1 6 3 1

4 2 2 2 6 1 3 1 7

2

0-4+ 1544 19

41 81 46 44 7

2

( 1 0 0 ) ( 1 . 2 )

( 2 . 6 )

(5.2 ) (3 ) (2.8 )

0 .4 ) 0 .1 )

intheslumareawas95l0.

A l l c h i l d r e n a g e d

<

5 y r( l5 4 4 )

w ere

registered

for the study.

Dur ing th e stu dy th e registry o f ch ild ren w a s ad ju sted

for b ir th s , im m igran ts, em m igran ts, d eath s, an d age lim it.

W eights w ere

recorded

and

c li ni cal ex am i nat io ns

w ere

conducted

fo r a s s e s s m e n t o fn u tr it io n a l s t a tu s . N u t r it io n a l

s ta tu s w a s d e te rm in e d u si ng w ei ght fo r

a ge a s p erc en ta ge

o f N a t i o n a l

Center

fo r H ea lt h

Stati sti cs (N CH S) standard

(8 ) .

Children > 90 of standar d w ere

c la s sifie d a s n o r m a l ,

w hi l e chi l dren betw een 75-90 , 60-75 ,

and <

60

w ere

considered t o b e s u ffe rin g from grad es I, II, an d III m al-

n u tr it io n , r es p e c tiv e ly .

A f ter the basel ine surv ey , the chi ldr en

were

placed

under

c lo s e s u r v e illa nc e a n d m o r b id it y d at a w e re

collected

b y

field w orkers by m aking

weekly

house

v isi ts. T hree

h un dred eigh teen cases of m easles w ere detected over the

15-m o period from January 1983 to M arch 1984. T hese

children

w ere exam in ed clin ically d aily d urin g th e acu te

s t a g e , a n d t h e a s s o c ia t e d c o m plic a t io n s in c lu d in g e y e

changes w ere record ed . A fter a p ortab le slit lam p w a s p ro-

c u r e d , a m o re detailed eye exam ination w as conducted in

th e 125 chi ldren w ith m easles seen d urin g th e secon d h alf

o f the s t u d y . Patients w ere given sym p tom atic treatm en t

a n d t h o s e w ith s e v e re c om p lic a t io n s w er e referred t o t h e

h o s p i t a l . O n ly th ose w h o had corneal lesion s w ere treated

w i th v ita m in A M in je c tio n o f

1 0 0 0 0 0 H i

w a t e r - m i s c i b l e

preparati on) and local an tibiotic drops w hi l e others did

n ot receive a ny sp ecific th erap y. T w o h un dred eigh ty-on e

c a s e s o fm e a s le s c o u ld b e fo llo w e d for 6 m o a ft e r r e c o ve ry .

Children

o f t h e

same

a g e a n d

sex

w ho d id n o t s u ffe r from

measles

d urin g th e s tu d y

period

s e rv e d a s c o ntro ls W e ig h t

c h a ng e s , m o r b id it y , a nd n u t r it io n a l d efic ie n c y s ig n s w er e

recorded

in b oth

groups

d u r in g t h e fo llo w-u p p er io d .

Blood

sam p les w e re collected from

children

w ith m ea-

s l e s , w henever parental c o n s e n t co uld b e o btain ed , d urin g

the acute s t a g e a nd a ga in

8 w k af ter recovery . Sam ples

a ls o w e re c o lle c te d

f rom chi ldr en

w ith n o h istory of

measles

a n d s e rv ed a s c o n t r o ls . S o m e o ft h e s e children

subsequently

d e ve lo p ed m e a s le s w ith in a w ee k, a n d a tt em p ts w e r e m a d e

t o c o lle c t blood samples a g a i n d u r in g t h e acute s t a g e a n d

after recovery. S e r u m vitam in A concentration w as esti-

m at e d b y h ig h p r e s s u r e

l i qu i d c hr om at og rap hy

(H P L C )

9), r e t in o l b in d in g p r o t e in R B P ) b y im mu n o d ifu -

s io n te c h n iq u e (1 0 ), a n d s e ru m a lb u m in by t h e d y e

m eth o d 1 1 ).

T he si gni f ican ce o f di f fer en ces

betw een groups

w as as-

s e s s e d

b y

:

t e s t a n d c h i s q u ar e t e s t .

T he p ro to co l w as ap proved b y th e E th ical C om m ittee

of

our institution.

Inc ide nc e o f m e asle s

O fth e 318 cases ofm easles, ‘ 55

w ere in

children

< 2 y r of age (T able 2). T he disease

sh ow ed a season al

pattern

w ith peak incidence

duri ng the sum mer m onths of M arch-A pri l

F ig 1).

E ye c om plic atio ns

N ine patients show ed corneal haziness dur-

i ng the acute stage of measles, and one addi -

t ional patient dev eloped corneal ulcerat ion,

TABLE

2

I n c i d e n c e of com p lication s d urin g m easles

Ag e

groups

N o of

m e a s l e s

c a s e s

W ith

b r o n c h o -

p n e u m o n i a

Wi t h

d iar r he a

w i t h

c o r n e a l

l e s i o n s

yr

<1

1 +

2+

3

4 +

0 4

6 9

105

62

4 7

3 5

3 1 8

( 1 0 0 )

2 4

4 0

2 1

1 6

8

1 9

( 3 4 . 3 )

2 9

4 5

2 2

1 1

1 1

1 1 8

( 3 7 . 1 )

3

4

0

3

1

( 3 . 1 )

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Jan Feb M ar A pr M ay Jun Jul A ug S e p O ct N ov D ec Jan Feb M ar

926

RED D Y ET A L

6 0

50

4 0

30

2 0

10

0

FI G 1 . M on t h ly in c id en ce of m ea sles .

w hich resul ted in a sm al l opaci ty af ter heal i ng.

N one of them show ed conjuncti val signs of

v it a m in A d e fic ien cy w h ile a ll h a d b r on ch o -

p n eu m on ia o r d ia r r h ea . O n e ch ild h a d seve r e

protein-energy

m a ln u t r it io n gr a d e I I I m a l-

n u t r it io n ) w h ile t h e r es t sh ow ed m ild e r g r a d e s

o f m a ln u t r i t ion T a b le 3 ).

Sl it l amp obser vati ons

O f t h e 12 5 ch ild r en exam in ed b y s li t la m p

d u r in g t h e a cu t e s t a g e o f m ea s le s , 50 h a d

coarse punctate k erati ti s w hich disappeared in

2-3 w ks. T he lesions f i rst appeared on t h e

co n j u n ct iva a n d t h en sp r ea d t o t h e cen te r o f

T A B L E 3

Details

of ch ild r en w it h co r nea l lesio n s d u r in g m ea s les

Nutr i t ional

A g e g ra d e S e rum v itam in A S e rum albumin A s so c ia te d c o m plic a tio n s

‘

zgJdL g/dL

6 I 19 5 3 1 B ronchopneum onia

8 II 6. 0

2 .7 B ro nc ho p n e um o n ia

1 2 I 5 .5 3 .5

B ron chopn eumon ia

13 I 9 8 3 4 B ronchopneum onia Dia rrhea

14 II 15.0

3 .2 B ro nc ho p n e um o n ia

+ D i ar rh ea

1 7 I 18.6

3.2 D iarrhea

22 II 6 0

3 3 B ronchopneum onia

54 I

1 2 3 5

Diarrhea

57 I I

1 3 .8 3 .3 D ia rrhe a

58 III 8.2

3.4 B ronchopneum onia

M ean±SE

11.5±1.63 3 . 3±0 . 0 7

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M E A S LE S A ND C H ILD H OO D BL INDNESS

927

T A B L E 4

P erc en t d is tr ib u t io n o f m e as le s cases according to

n u t r it io n a l s ta tu s a t d if f e re n t t im e s

N u t h t i o n a l

s t a t u s

Initialt

3 0 7

D a t i n g

m easles

3 0 7

3m o

L a t e r

3 0 0

6m o

l a t e r

2 2 0 )

N orm al 1 3 . 7

5 .2 3 .3 1 .8

G rade I 3 7 .5 3 0 .9 3 6 .7 3 2 . 3

G rade II 4 3 . 6 50.8 4 9 .3 5 4 .5

G rade III 5.2 1 3 .0 1 0 .7 1 1 .4

S Initial v s o th er t im e s, p < 0 .0 01 . F ig u re s in p a r e n t h e s e s

indicate num ber of ch ild ren .

3-6 m o b e f o re m e a s le s .

the cornea. N one of these cases progressed to

m acr oe r o s ion s or u lce r a t io n .

Fin e p u nct a t e k e r a t op a t h y w as seen in 1 5

of t h e p a t ien t s . T he les io n s ap p ear ed first in

t h e low er and nasal part of t h e co r n ea and in

tw o p a t ien t s p r og r e ssed t o co r n ea l xe r os is d e-

t e c t ed b y clin ica l exam in a t io n .

Wei ght changes

A m ong 142 ch ild r en w h o w er e r eg is t er ed a s

controls and subsequently developed m easles

w ithin a w eek, w eigh t s w er e av a ilab le b efo r e

an d d u r ing m ea s les . T he m ean w e igh t o f t h is

group w as 8.7

0 . 1 7 k g d u r in g m ea s les , w h ich

w as s ign ifican t ly low er com p ar ed w it h 9 .1

0 . 19 k g b e for e m eas le s . C h ild r en w it h m ea -

sles show ed low er w eight gain in t h e first 3

m onths of the follow -up period than did age-

m a tch ed con t r o l ch ild r en 0.3 ± 0 .06 k g v s 0 .5

0.02 kg).

T hese d iffe r en ce s w er e st a t is t ica lly

significant

p <

0.001).

W hen

t h e

children

w er e c la ss ified b y v a r io u s

nutr i t iona l grades on t h e basis of w e igh t fo r

a ge , it w as

observed

t h a t t h e p r ev a len ce o f

grades II and H I m aln u t r it ion w a s significantly

h igher d u r ing m eas le s th an d u r in g t h e in it ia l

survey.

T h is d iffe r en ce p er s is t ed u p t o 6 m o

a ft er m eas le s T ab le 4

Nutritional deficiency signs

O u t o f 28 1 cases of m ea sles fo llow ed , 1 2

children (4.3 ) developed clinical signs of se-

v er e PEM -lik e ed em a and w ast in g o f m u scle s .

In t he a ge -m at ch ed

controls,

t h e in c id en ce w a s

on ly 1 .3 . C on j unc t iv a l s ign s o f v it am in A

d efic ien cy eg , xe r os is and B it o t sp o t s) w er e

n o t ed in 1 . 1 o f ch ild r en fo llow in g m eas le s

com pared w ith 0 .5 in con t r o l ch ild ren . T her e

w a s no ca se o f corneal xer op h t ha lm ia d u r ing

the follow -up period.

M orbidity during measles

N early 60 ofthe children developed bron-

chopneum onia or diarrhea or both during the

acute stage ofm easles (T able 2). T he incidence

of t h e se in fec t ion s w a s s ig n ifican t ly h igh e r

during t h e 6 m o p os t -m ea sles fo llow -up p er io d

com pared w ith m atched-control children for

this period (Table 5

In sp it e o f t h e ou t p a t ien t t r ea tm en t g iv en ,

som e ofthe children w ith bronchopneum onia

and gastroenteritis becam e m ore ill and w ere

hospitalized. The incidence of such severe

cases w as significantly higher in the m easles

t h an in t h e con t r o l g r oup . H ow ev e r , t h e r e w er e

no deaths perhaps because of the im m ediate

m edical care.

Biochemical changes

Serum

levels ofalbum in and vitam in A w ere

low in m ost ofthe slum children, but the m ean

levels w ere found to be significantly low er in

children w ith m easles than in the control chil-

d r en T ab le 6 and T ab le 7 ). In ch ild r en w hose

serum level tests w ere repeated 8 w k later, all

the biochem ical param eters w ere restored to

norm al after recovery even w ithout vitam in

A su p p le m en ta tio n.

TA B LE 5

Post-m easles m orb id ity d u rin g th e 6 m o fo llo w-u p

period

Noofchi ldr en

M e a s l e s

28 1

C o n t r o l

81 9

L ow er r es pir at or y

infection

Percent o f c hil dr en

a f f e c t e d

34.2t

6.2

N o o f episodes/

child

0.5 ± 0.04t 0.08 ± 0 . 0 1

D uration/episode

d a y s )

6 .8±0 .24 5 .5 ±0 .12

P e r c e n t inc id en ce of

h o s p i t a l i z a t i o n

2.9t 0.4

D iarrhea

Percent o f c hil dr en

affected

76.9t 4 8 . 7

No of episodes/

child

2.3 ± 0. 1 3t

1.4 ± 0.07

D uration/episode

days

4.3±0.20 3.7 ±0.10

Percent incidence of

d e h y d r a t i o n

0. 5

a

V alues

are

M ean

± SE.

p < 0 .0 0 1.

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928

R ED D Y ET A L

TA B LE 6

Biochem ical param eters (Cross-sectional data)*

S e ru m le ve ls

G ro up A lb um in R e tino l

RBP

a

g/dL g /dL m g / d L

C o n t r o l C ) I 1 7 3 .6 ± 0 .0 3

M easles

D u r in g in fe c t io n M 1 ) 1 5 3 3 .4 ± 0 . 0 3

A f t e r

r ecover y (M 2) 108 3.5 ± 0.05

1 7 .9 ± 0 .8 1

1 1 . 5 ± 0 . 4 4

19 .8 ± 0.69

2 .5 ± 0 .0 6

2 . 1 ± 0 . 0 7

2.5 ± 0 .06

S V alues are M ean ± SE . Statistical significance: C vs M l, p

<

0.001

f or R B P; M l vs M 2, N S f or alb u m in ,

p < 0 . 0 0 1 fo r r e tin o l, p < 0 . 0 0 1 fo

f or a lb u m in , p

<

0.001

r R BP .

f or r et in ol ,

p < 0.0 01

D u r in g m easl es, m ean ser um vi t am in A

levels w er e n ot sign i f i can t l y d i f f er en t in ch i l -

d r en w i t h or w i t hou t secon dar y in f ect ion s.

M al nou r ish ed ch i ld r en w i t h m easl es had si g-

n i f i can t l y low er m ean level s of

al bum in and

serum

v i t am in A t h an d i d t h ose w i t h b et t er

nutrition

(T ab le 8). H ow ever , t he b ioch em ical

param eters sh ow ed no cor r elat ion with corneal

changes (T able 9).

Di s c u s s i o n

V i t am in A d ef i ci en cy i s a m aj or p u b l i c

health

p r ob lem i n m any cou n t r ies of

Southeast

A sia. I n I nd ia, 5-10 of ch i ld r en in

poor

com m u n i t ies ex h ib i t ocu lar si gns of v i t am i n

A def iciency (12). Sever e l esions of t he cor n ea

r esu l t ing in per m an en t b l in dness ar e

seen

m ost ly in ch i ld r en < 5

yr. Inadequate dietary

intake of vitam in A is the m ost im portant

c au se o fx er o p ht h al m i a.

A part

f r om t h is, ot her

f act or s t hat i n f l u ence v i t am in A m et ab ol i sm ,

su ch as p r ot ein -en er gy m al nu t r i t i on an d i n -

fection,

also con t r ibu t e t o t he d i sease p r ocess.

R esu l t s of t h e p r esen t su r vey show ed t hat

T L E

7

B iochem ical p a r a m e t e r s Lo n g it u d in a l d a t a o n 3 2

ch i ld ren )

G r o u p

Serum Le v e l s

A lbumin

R e t i n o l

R BP

gJdL ,g/dL mg/dL

Prem easles(PM )

M easles(M l)

Postm easles(M 2)

3.6±0.07

3.4±0.08

3.7±0.07

16.5± 1.75

11.1±1.10

19.2± 1.68

2.4±0.14

2.2±0.17

2 .3 ± 0.1 5

* V alu es ar e M ean ± S E . S tatistical sig nificance: P M vs

M l, p < 0 .0 5 fo r a lb u m in , p < 0 .0 2 fo r re tin o l N S fo r

R B P; M l

vs M 2, p

<

0.01 f or

a lb u m in , p < 0 . 0 0 1 fo r r e t -

i n ol , N S f or R B P.

5 of t he p r eschool ch i l d r en h ad ocular

signs of v i t am in A d ef iciency con f i r m ing t hat

x er oph t halm ia is a si gn i f i can t h eal t h p r ob lem

i n t he slu m p opu lat ion . A cu t e cor n eal lesi ons

w er e not obser v ed t hough healed scar s w er e

seen

i n 0.1 of t h e popu l at ion . I n m easles t he

incidence w as high; -‘ ‘3.0 of the patients

show ed changes resem bling corneal xeroph-

thalm ia. K rishnam u rthy and A nantharam an

7 ) r epor t ed t hat k er at om alaci a is a f r equ en t

com p l icat ion of m easles in I nd ian ch i ld r en .

I n d ev el op i ng cou n t r ies w her e m easles vac-

cine is not given routinely, virtually all chil-

d r en su f f er f r om t he d isease bef or e t h ey r each

5 yr of age. H ow ever, severity of the disease

varies i n d i f f er en t r egi ons of t he w or ld . I n A f -

rican countries m easles is considered to be a

ser ious d isease con t r ibu t ing t o h igh m or bid i t y

and m or t al i t y in ch i l d r en (1) w h i le in A sian

coun t r ies

t h e

disease appears

t o be

less

severe.

C o m m u n i t y based

studies

carried

ou t in B en -

gal (1 3) and M aharastra (14) show ed that

m easles is a m ild disease

w it h a low m or tal i t y .

I n t h is st u dy, t h ough secondary i n f ect ions l i k e

gast r oen t er i t i s an d r esp i r at or y i n f ect ion w er e

com m on dur ing m easles, t her e w er e n o deat h s

TA B LE 8

B iochem ical param eters in m e a s le s a cc o r d in g t o

n u tr it io n a l s t a tu s *

Nutrition

g r a d e

N o o f

c hild re n A lb um in

R e tino l R BP

gm/dL eJdL

mgJdL

No rm a l

G rade I 5 8 3 .4 ± 0.05 12 .5 ±

0.80 2.0 ± 0.80

G rade II 74

3 .4

±

0.05 1 1.3 ± 0.60 2.2 ± 0.09

G rade

I II

21 3.2±0.07t 8.3± 0.75t

2.2

±0 .15

a va lurs

a re M e an ± S E .

t

p

< 0.05

com pared

with No rm a l G ra d e I.

p<0.02

c om p a r e d

w ith N orm a l

Gra d e I.

7/25/2019 measles 3


M EA SLES A N D C H ILD H O O D B LIN D N ESS 929

TABL E 9

Serum v i t a m in A le v e ls in re la t i o n to m ea s le s an d

corneal l e s ions

Co rn e al c ha ng e s

in m e a sle s No

A lb u m in R e t in o l

g /dL g /dL

No c h a n g e

C o a rs e k e ra titis

F in e k e ra tit is

C o r n e a l

x e r o s i s

47

19

6

1

3.3±0.09

3 2 ± 0 . 0 9

3 .2 ±

14

3 3 ±

0 . 0 7

3 7 ± 3 7

1 8 ± 1 . 0 9

1 1 6 ± 1 39

1 1 .5

± 1 63

p er h ap s b ecau se o f im m ed ia t e

m edical care.

J oh n e t a l 15 ) ob ser v ed t h a t t h e case f a t a lit y

rate

w as low er in

villages

w it h h ea lt h -car e su -

p er v is ion t h an in a r eas w h er e su ch f ac ilit ie s

w er e n ot av ailab le.

A cu t e u lcer a t iv e le sion s o f t h e ey e an d

m ou t h h av e

been described in A frican children

w ith

m easles

6 ). T h e les io n s t en d t o b e m or e

sev er e in m aln ou r ish ed ch ild r en an d p r ogr ess

rapidly

in sp it e o f t r ea tm en t .

This

h as

been

a t t r ib u t ed t o im m u n osu p p r ess ion a n d sec -

ondary

in fec t ion

w ith herpes

sim p lex . S u ch

u lcer a t iv e le s ion s ar e ex t r em ely r a r e in I n d ian

children.

I n t h is s tu dy , sl it -lam p ex am in a t ion

revealed coarse-punctate

le s ion s in 50 of t h e

c h i l d r e n .

These

le s io n s a r e s im ilar t o t h e

c h a n g e s

described

b y

D ekkers

in m ea sles k er -

a t i t is 17); h ow ev er , t h ey d isap p ea r ed sp on -

t a n eou sly a f t e r

2-3 w k. O n clinical exam ina-

t ion

corneal

le sion s w er e ob ser v ed in 10 ch il-

d r en , b u t t h ey w er e

m ild

an d r esp on d ed w ell

t o t r ea tm en t . H a z in ess o f t h e cor n ea

disap-

peared

com p let e ly in a ll, a n d on ly t h e ch ild

w it h a cor n ea l u lce r sh ow ed r esid u a l op a cit y

after healing.

T h e con seq u en ces m ay b e m or e

ser io u s in u n t r ea t ed cases an d m easle s m ay ,

t h er ef o r e , b e a p o t en t ia l cau se o f b lin d n ess in

I n dian ch ild ren .

Infection can adversely affect

t h e n u t rit io n al

s t a tu s b y r ed uc in g

food intake

an d b y cau sin g

m a la b s o r p t i o n

and

m et ab o lic losses . T h e im -

p ac t o fm easle s m ay b e m or e

sev ere co m p ared

w ith o t h er in f ect io n s b ecau se o f

secondary

c omp l i ca t i o n s

and

p r o l ong e d illness. T he ef f ec t

m ay b e

seen during

t h e a cu t e s t a ge o f t h e

dis-

ease or during the subsequent period. This

lon g it u d in a l s t u d y ga v e u s a u n iq u e op p or -

tunity

t o a s s e s s

these effects.

I n ch ild r en w h o

w er e ex am in ed b e f o r e an d af t e r m easle s , t h er e

w a s n o t on ly w eigh t loss d u r in g in f ec t io n b u t

grow th

r a t e a f t e r w a r d s w as a lso low er t h an t h a t

o f con t r o l ch ild r en . F r eq u en t occu r r en ce o f

infections observed

d u r in g t h is p er iod can ac -

count

f or t h e slow er gr ow t h . T h e f r eq u en cy o f

children w ith severe PEM also show ed an in-

crease confirm ing the role of m easles in ag-

gravating m alnutrition.

T h e ad v er se ef f ect o f m easle s on v it am in A

status also has

b een w ell d ocu m en ted .

Serum

v it am in A lev e ls w er e sign if ican t ly r ed u ced in

a ll t h e m easle s cases st u d ied h er e con f ir m in g

our earlier observations (18). T he reduction

w as m or e m ar k ed in t h o se w h o h ad a ssoc ia t ed

m alnutrition. In children subsisting on m ar-

ginal diets, serum vitam in A levels are

low al-

ready. A n episode ofinfection can cause a fur-

t h er d r op in v it am in A lev e ls in cr easin g t h e

risk of corneal xerophthalm ia; how ever, this

m echanism alone cannot explain the corneal

lesions associated

w it h m easle s . T h er e w er e n o

sig n if ican t d if f er en ces in t h e v it am in lev e ls o f

ch ild r en w it h an d w it h ou t co r n ea l d isease.

S om e of t h e ch ild r en st u d ied h er e sh ow ed f in e

p un ct a t e k er at o p at h y

described

in v it am in A

d ef icien cy 19 ), b u t ev en

these changes

s howed

n o co r r e la t ion w it h v it am in A lev e ls . F u r t h er -

m or e, b o t h t h e f in e an d gr oss les io n s o f cor n ea

w ere seen only during the acute stage of m ea-

s l e s an d n o t d u r in g t h e f o llow -u p p er iod w h en

t h e st r ess o f m aln u t r it ion w as st ill p r e sen t .

S t u d ies in N iger ian ch ild r en h av e sh ow n t h a t

though

p lasm a v itam in A lev e ls w er e d e -

pressed

in m ea sles t h er e w er e n o d if f er en ces

betw een

t h ose w it h an d w it h ou t ey e le s ion s

(20). Sim ilar findings

h a v e

been reported

f r om

K en y a 17). T h ese ob ser v a t ion s su gg est t h a t

apart

f r om h y p ov it am in o sis A , t h er e m ay

b e o t h er f a ct o r s th a t con t r ib u t e t o

corneal

dam age.

B ot h m ea sles an d m aln u t r it ion a r e k n ow n

t o cau se im m u n osu p p r ess ion p r ed isp o sin g t o

secon d ar y in f ec t ion .

This

can ex acer b a t e t h e

epithelial dam age caused by viral

k er a t it is a n d

vitam in A deficiency. C orneal ulceration is

ob v iou sly cau sed b y a v a r ie t y o f in t e r ac t in g

factors,

b u t m easle s p lay s t h e m ost sign if ican t

r o le in t r igg er in g t h e d est r u ct iv e ch an ges .

A p-

p r ec ia t ion o f t h is f ac t h as im por t an t b ea r in g

on p u b lic h ea lt h p o licie s an d p r og r am s f or t h e

con t r o l o f ch ild h ood b lin d n ess . I n I n d ia an d

ot h er A sian cou n t r ie s w h er e x er op h t h a lm ia is

com m on , e f f or t s ar e b ein g m ad e t o im p r ov e

v it am in A st a t u s o f t h e com m u n ity t h r ou gh

n u t r it ion ed u ca t io n an d v it am in A su p p le-

7/25/2019 measles 3


93 0

m en t a t ion . T he p r e sen t s t u d y d em on st r a t e s

t h e im p o r tan ce o fm ea s le s a s an ad d it iona l r isk

fac t o r in cau s in g b lin d n ess and em p hasiz e s t h e

need

fo r e ffec t iv e v acc ina t ion p r og r am s fo r

con t r o l o f m ea sles .

W e

wish

t o t h ank t he D ir ec t or , BS

N arasi nga R ao,

fo r

h is v al uab le su gg est io ns.

T he sk il led t echni cal

assistance

prov ided by M r Chennia and M s H em alatha i s gratef ul l y

ack now ledged. T hanks are al so due to the f iel d assi stants

w ho helped us w ith data collection

Re f e r e n c e s

1 M orley

D . S ev er e m eas les in the t r op ics . B r M ed J

1 96 9 ; 1 :2 97 -3 00 .

2. G hosh 5, D hatt PS. Com pl i cati ons of m easles.

I nd J

C h i l d

Health

l 9 6 l ; l O: l 1 1 9

3 Aw drey PN , C ob b B , A d am s PC G . B lin d n ess in th e

L uapula V al l ey . C entral A frJ

M ed l 967;l 3: 197- 201.

4.

Jam es HO ,

W est

CE, D uggan M B, N gw a M . A con-

tro lled

study on the ef fect of

i nf ected w ater m isci bl e

r et in y l p a lm it a t e on p lasm a con cen t r a t io ns of

retinol

and r e t in o l b in d in g p r o t ein in

children w i th measles

in N or th er n N iger ia .

A cta Peadiatr Scand

l984;73:

22-8.

5 . S and for d -Sm ith JH ,

Whit t le

H C.

C or neal u lcer at io n

follow ing

measles

in N iger ian ch ild ren . B r J O phth a l-

mo l l 9 7 9; 6 3 : 7 2 0 4

6. Som mer A . N utr i t i onal bl indness

xerophthalmia an d

keratom alaci a. N ew

Y o r k :

O xf ord U ni versi ty Press

1982

7 Krishna m urthy KA Ana nthara m a n V M ea sles a

dangerous di sease: a s tu dy o f 1 00 0 c ases

i n M a d hu ra i.

Ind ian

Pediatr

1 97 4; l 1 :2 67 -7 1.

8.

H am i l l PV V , D ri zd

T A , J ohn son C L ,

Reed RB , Roche

A F. N CH S grow th curves

for ch ild ren . H ya tt sv ille ,

M D N ati onal Center

fo r

H e al t h S tat i st i cs,

1977 .

(V i ta l

an d heal th st ati st ics. Ser ies 1 1: D at a

from

t he N at io na l

REDDY ET AL

H eal th Survey , no 165 [ D H EW publ icati on no(PH S)

78-1650].)

9 . B ier i JG , T o lliv er T J ,

Catiguani

G L

Simultaneous

determination oftocopherol an d r et in ol in plasm a or

r ed c el l s

b y h igh p r essu r e liq u id ch r om atogr ap hy . A m

J

C l i n N utr

197 9;32:2l43 9

10 M ancin i G ,

Carbonara

A O ,

H erem ans JF. Immu -

n ol og ic al q uan ti f ic at io n

of

antigens

by

si ngl e r adi al

im m unodi f f usi on. I m m unochem 19652:235-54.

1 1.

Gustafsson JE C. I m pr ov ed specif ic ity

of ser um al-

bum in determ inati on and estim ati on of ” acute

phase

reactants”

b y u se of

brom cresol green reacti on. Cl i n

C h em l 97 6; 22 :6 16 -2 2.

12.

In d ia n C o u n c il

of M edi cal R esearch. Studies on pre-

school

ch i ldren .

(T echni cal report seri es, no 26.) N ew

D elhi : I CM R,

1974:17 .

13

Sinha D P. M eas les

and m alnutri ti on i n a W est B engal

v i l l a g e T r o p Ge o g r Med l 9 7 7 ; 2 9 : 1 2 5

14 Shah U , B anei j ee K L, N anavati A ND , M ehta A N . A

test survey of m easles i n a rural com m uni ty i n I ndia.

B ull WHO

1972;46:l30.

15.

John T J , Josep h A ,

George T I . Epidem iology and

pr ev en ti on of measl es in rura l S outh India md

j M ed

Re s 198 0;72:l53 8

16. W hi tt l e

H C ,

Sandf ord-Sm ith JH , K ogbbe

0 1, D os se te r

J, D uggan M .

Severe

ulce rative

herpes of m outh and

eyes follow ing

m easl es. T rans

R oy Soc M ed H y g

1 9 7 9; 7 3 : 6 6 9

17

D ekk ers N W HM .

T h e c or nea

i n m easl es. M o no gr ap hs

in o p h th a lm olog y . 3 . T he H agu e-B os t on -L ond on:

Junk P u b l i s h e r s

1 9 8 1 : 7 1

18 . Bhask ar am P , R ed d y V , Shy am R ,

Bhatnagar

R C .

E f f ec t o f m easl es on the nutr i ti onal status of preschool

children. J T rop M ed H yg 1984 ;87:21 5

19 . S om m er A , Em r am M ,

T am ba T . V itam in A respon-

sive p un ct at e k er at op at hy

in xer op h th a lm ia . A m J

O pht hal mol l 979; 87 :3 30- 3.

20

I nua M , D uggan M , W est CE,

e t a l. P os t -m ea sles cor -

n eal u l cer at i on in children

i n N or t he rn

Nige r ia the

m leof vi tam in A , m al nutri ti on and m easl es A n n T r op

P e d i a t r 1 9 8 3; 3 : 1 8 l 9 1

measles 3

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