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  Measles Mortality and Treatment
  

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By: Bob Witsenburg

Extended version of a paper previously published in Der Merkurstab 1975, p. 116 ff. German title: "Masem-Sterblichkeit and Therapie", Der Merkurstab 1992; 45:177-80. English by Anna R. Meuss, FIL, MITI.

Considered relatively harmless in the temperate zones, measles are a serious problem in tropical countries, where a high percentage of children requiring clinical treatment die of complications, generally secondary infections such as gastroenteritis (in the rainy season) or bronchopneumonia (in the dry season). Inevitably, children in a reduced state of health are particularly at risk, the main causes being malnutrition, anemia and malaria. Children between the ages of 6 to 12 months have been found to be particularly susceptible.

During a severe epidemic in 1967-1968, marked differences in mortality at a hospital in Ghana* were found to be due to different methods of treatment. The standard treatment at our hospital included the following:

1 Sedatives, apart from anything else for fear of convulsions, which are more common and severe in the tropics.

2 Antipyretic drugs (salicylates, pyrazolone derivatives) as a general measure to reduce pyrexia; this, too, reduces the risk of convulsions and rapidly improves the general condition.

3 Antitussives, antihistamines or codeine, alone or combined with expectorants.

4 Treatment of manifest or subclinical malaria.

5 Antibiotics as required (for pneumonia, enteritis, etc.)

6 Blood transfusion in case of severe anemia.

7 General measures such as bed rest, fluids, diet.

Strangely enough, children whose measles were most severe, with high temperatures (40-41°C persisting for 3-4 days, severe exanthema, subjectively feeling very ill), were found to have the best prognosis.

This led us to realize that the symptoms and signs, and especially the pyrexia, signaled activation of defense reactions that would give a successful outcome. Both the exanthema and the expectoration would appear to be effective eliminatory measures on the part of the organism.

It could be concluded from this that antipyretics are contraindicated. Antitussives inhibit expectoration and may therefore make bronchopneumonia more likely, particularly if purulent secretions cannot be coughed up. Febrile convulsions occur mainly while the temperature is rising and are not dangerous in themselves. Malarial convulsions are much more serious; they can be avoided by treating the malaria as soon as the child is admitted, which is the generally accepted method.

To put our thoughts into practice, the treatment scheme was changed as follows:

1.-3.: Sedatives, antipyretics, antiphlogistics and antitussives were omitted altogether. Expectorants were given on a routine basis.

4.-7.: were given as indicated.

The method of treatment was changed when the measles epidemic was exactly half-way towards reaching its peak (mid-November 1967 – early March 1968). The first-mentioned regimen was used until the beginning of January 1967, and the revised regimen after this. In either case the number of patients was 56. The result- 20 of the 56 children in the first group (given sedatives, antipyretics and antitussives), i.e. 35%, died. Four of the 56 children in the second group (not given those drugs but malaria therapy, antibiotics, blood transfusions and general measures as indicated), i.e. 7%, died, one of encephalitis, one of rupture of the trachea. The difference was significant at P < 0.001.

Bronchopneumonia was the most common cause of death in the first group. Many of the children in the second group also developed bronchopneumonia but all recovered from it The groups showed no major climatological or other differences (age distribution, nutritional state, hygiene, etc) and the period of hospitalization was approximately the same.

Measles vaccination is widely recommended today, primarily because the disease is said to be increasingly more dangerous. The clinical observations described above show that there is an evident connection between severity of the condition and complications on the one hand and unsuitable therapeutic measures on the other. The latter include administration of antipyretics, sedatives and antitussives, which are part of the routine treatment used with all febrile childhood diseases today.

It seems reasonable to assume that these conclusions also apply to other infectious diseases, particularly in childhood. It is not difficult to see the reason why, especially as the significance of pyrexia with virus infections is now widely recognized. (For a detailed discussion of basic experimental studies and conclusions drawn from them see the new edition of Husemann/Wolff, The Anthroposophical Approach to Medicine vol. l.) Eliminations via the skin, and secondarily via the lungs, also play a crucial role in measles (loc. cit. p. 47).

Abstract

Different methods of treatment were used with two groups of 56 children each who were admitted to hospital during a measles epidemic in Ghana. Mortality was 35% in the group treated with sedatives, antipyretics and antitussives, compared with 7% in the group not given this type of medication, the contraindications of which are discussed.

Additional comments

Those were the bare figures. Amazement at the high mortality with this childhood disease, reflections on this and the battle that had to be fought with colleagues before the trial could be made are another story, which is told below.

On arrival in Africa I had the good fortune of being able to work with an experienced Dutch colleague for a time. He taught me a great deal about local conditions, surgical facilities, the cost and effective use of drugs, etc. We shared the work in the outpatient department and on the wards, and initially I only saw the children's wards when I had to take someone else's place. Children with measles would often die of pneumonia, heart failure and other complications. My colleague thought the reasons were that they must have a particularly virulent strain of the virus in Africa, that the children were less robust (which was true) and perhaps the constitution of Africans predisposed them more to encephalitis or heart failure.

Every effort was made to improve the children's condition, who felt better when the fever had been brought down and they had been given antiphlogistics; they would eat and drink more and were not so much exhausted by coughing and convulsions.

I began to think that African children probably were not all that different from European children and that it was possible that they were suffering from the consequences of the treatment they were given. I therefore suggested that we discontinue all symptomatic treatment, but my colleague was convinced that the method, which had been evolved in many years of experience with tropical medicine, had proved effective and should be adhered to in every detail. He argued that the children would feel extremely miserable with high temperatures and the continuous coughing unless they were given antiphlogistics and that surely it was the physician's task to relieve suffering. I suggested that it was more important to survive the illness than to suffer more for a limited period. Gradually our discussions grew more acrimonious. I wrote to a well-known pediatrician in Holland who also gave the opinion that high temperatures should be treated with aspirin.

A change of wards had already been agreed upon when the measles epidemic came to its peak I was supposed to take over the children's ward on January 1. My colleague implored me not to change the method of treatment. When I said I would nevertheless try to do so we had a row. 'The children will die," he shouted in the end. "First let me see those dead children...," was my reply, my heart in my mouth.

The result of the change surprised me as well. Yet my colleague was not convinced. I'd just been lucky, he said, and the trial would have to be repeated. There was no dispute about the method of treatment, however. Still, I was glad I was able to take over another hospital soon after this.

A report was published in Medicus Tropicus, the journal of the Dutch Association for Tropical Medicine, in September 1975, together with a request to do further trials so that polypharmacy would become a thing of the past in tropical medicine.

Unfortunately I heard no more. The episode has, however, left a deep impression. Never since have I known such a striking example of an idea being proved right in practice.

It seems that destiny clearly took a hand in arranging that the change to the children's ward coincided exactly with the natural peak and mid-point of the epidemic (56 cases in six weeks both before and after).

 

Author's address:

B.C. Witsenburg, general practitioner, Raamsingel 28, 2012 DT Haarlem, Netherlands.

 

 

* Catholic Hospital St John of God. Duayaw Nkwanta Brong Ahafo, Ghana, W. Africa.

 





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