Possible resurgence of childhood measles; last thing we need

Dr B.J.C. Perera
MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL)
Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

The disease measles, also known as rubeola and morbilli, is an extremely contagious infective viral illness in children, characterised by fever and a skin rash, with the potential to cause diarrhoea, respiratory complications, like pneumonia, ear infections and inflammation of the brain. It has a very characteristic clinical picture, and the diagnosis is clinically quite obvious to those doctors who have seen it before. Currently, there are sophisticated antibody and viral isolation tests that could be used to confirm a definitive diagnosis of a measles infection.

Measles, though often recognised as a usual childhood illness and, perhaps, as just a part of growing up, was, however, well known to be a killer of some affected children, right up to about the middle of the 1980s. The younger the affected child, the more the likelihood of the occurrence of complications; infants under one year are the most vulnerable. Many children succumbed to the development of intractable respiratory infections and acute brain inflammation. This author, who saw loads of measles cases in his medical student days, early career and consultant stages, can vouch for what is documented here.

Of course, in many affected children, it was a rather mild disease. Yet for all that, in some, it caused very many problems. The crux of the matter was that it was not at all possible to predict which of those affected by the virus was likely to develop major complications. The acute involvement of the brain in the form of inflammatory encephalitis could kill or leave the child with permanent brain damage. There is no treatment or anti-viral drugs to treat this condition.

Even more importantly, measles was recognised in the late 1960s to be the cause of delayed onset brain damage known by the technical term Sub-acute Sclerosing Panencephalitis (SSPE). In that condition, known as a ‘slow-virus’ infection, the virus remains in the brain and slowly eats into the tissues of the brain over months and years. It is a slow but relentlessly progressive terrible complication of measles and is characterised by disturbances of motor functions with uncontrollable jerky movements of the head, trunk or limbs, overt convulsions or fits, progressive cognitive and higher brain function deterioration, changes in behaviour and even blindness.

In the advanced stages of the disease, individuals may lose the ability to walk as their muscles stiffen or spasm. There is progressive deterioration to a comatose state, and then to a persistent vegetative brain-dead state. Death is inevitable as there is no effective curative treatment. It kills and the diagnosis is a very definitive death certificate. Even if one child gets SSPE, it is one too many as there is no known treatment. It is a terrible complication of measles and doctors are entirely helpless in treating it.

This scenario completely changed, totally for the better, when Sri Lanka started an island-wide immunisation programme against measles in 1984. Later, we used the Measles-Rubella (MR) vaccine from 2001 and then we started using the Measles-Mumps-Rubella (MMR) vaccine from 2011. This author was the Consultant Paediatrician in Badulla when the measles vaccination was started and then he was transferred to the General Hospital, Ratnapura, in January 1985. In both these institutions, we saw a dramatic reduction in measles cases and later on in cases of SSPE.

From then onwards, over the years, there were a few catch-up campaigns of vaccination to vaccinate those who had missed. There was practically 100 percent coverage of all children through our Expanded Programme of Immunisation with fantastic results. The World Health Organisation (WHO) certified Sri Lanka as a measles-free country in 2016.

Having been put through the mill over the years, and through many a natural as well as man-made catastrophe in the not-too-distant past, we need a resurgence of measles, just like a hole in the head. We have got more than our fair share of problems to worry about without having to deal with the resurrection of an awfully contagious viral disease, like measles.

However, there are very loud alarm bells being sounded this year. Around the middle or so of May 2023, there was a diagnosed case of measles in a 23-year-old admitted to the National Hospital in Colombo. Then there were confirmed cases being reported from the Lady Ridgeway Hospital for Children and also from other areas of the country. Up to the time of writing this article, close to 50 cases have been reported, mostly from Colombo and the suburbs of Colombo, and some sporadic cases from several other areas of the country.

One thing was a common denominator for all these cases. THEY HAVE ALL NOT BEEN PROPERLY AND COMPLETELY VACCINATED AGAINST MEASLES. Eighty-seven percent were not given even one dose of the vaccine, and 17% had only one dose. None of those with measles had both doses of the vaccine. It was all due to vaccine hesitancy and vaccine refusal on the part of the parents. The vast majority of the patients were from one ethnic group.

Many things worry all of us in situations like this. From experience, this could just be the start of an epidemic as we know to our cost that this is how such things start. This is particularly so because we have an extremely vulnerable cohort of 6- to 9-month-old babies who have not been vaccinated and who do not have natural immunity transferred from the mother. Originally, it was decided to give the first dose of the vaccine at nine months of age because the immunity in the mothers as a result of acquiring the natural disease during their childhood, had sufficient antibodies to be transferred to the babies which lasted up to around nine months of age.

However, once the disease was wiped out, the current set of mothers have immunity against measles only through two doses of the vaccine that they have had during their childhood rather than through natural measles infection. Research work done internationally and in Sri Lanka has very clearly shown that the babies of those mothers have very little, if any, antibodies against measles from six months of age. They belong to the lot of an extremely susceptible and defenceless group in whom the disease could spread like wildfire. By their age, they are also a group of children in whom the propensity to develop all complications of the disease is sky high.

The Epidemiology Unit and the Family Health Bureau of the Ministry of Health have responded ever so promptly to the current situation by instituting certain measures. To their eternal credit, no stone has remained unmoved in a dedicated quest towards thwarting the development of an epidemic of measles.

However, there is a limit to what they could do. The success of it all depends on public cooperation and reinvigorating a sense of public-spiritedness and intense responsibility on the part of all Sri Lankan parents. All these vaccine-avoider parents may have their reasons for taking such a course of action and on closer scrutiny, all of them are based on myths. None of those reasons stand up to scientific scrutiny and as I said before, any death from measles, EITHER IN THE ACUTE PHASE OR YEARS LATER DUE TO SSPE, IS A DEATH THAT IS ONE DEATH TOO MANY.

All parents in our country, irrespective of age, caste, creed, religion, or ethnicity, simply owe it to our nation to put their collective shoulder to the wheel to prevent a dismal and disastrous calamity of a measles epidemic in our country. This writer has fought many valiant battles in the past to protect our children from infectious diseases. He has even crossed swords with the Health authorities for the sake of the children of our Motherland. All he is asking now is unstinted cooperation from the parents. If you have the slightest regard for what I say, PLEASE, PLEASE, VACCINATE ALL CHILDREN. Let none of them be left behind.

I have said this before, even very recently at that, and I will say it again, even ad nauseam…, even to ad infinitum…., VACCINATION SAVES LIVES!