Epidemiological, Clinical Aspects and Outcome of Measles in a Low-Income Country in 2023 ()
1. Introduction
Measles is a highly contagious disease caused by the measles virus which belongs to the Paramyxoviridae family [1] . Measles can affect everyone but it is most common in children [2] . It is characterized by fever, cough and skin rashes and it can lead to severe complications such as otitis, pneumonia, encephalitis, which can lead to death [3] [4] . Having humans as the only reservoir and with the existence of a vaccine, strategies have been put in place to eradicate the illness since 1963 [2] [5] . For 16 years, there has been no endemic measles in the United States. However WHO-Afro zones and some European countries continued to be affected by outbreaks of this illness [3] [6] [7] . In sub Saharan Africa, measles continues to be an important public health problem due to the frequent occurrence of complications in children [8] . In 2021, an estimate of 128,000 people died of measles according to WHO reports. Most of these were children [1] [2] . In 2012 a global vaccine action plan approved by the WHO assembly set a goal for measles and rubella elimination by 2020 in at least 5 of the 6 WHO zones [3] . However there have been reports of outbreaks in China from 2015 to 2016, in the Philippines and Greece from 2018 to 2019 and recently in the WHO-Afro zones such as Democratic Republic of the Congo in 2019, Nigeria in 2020 and Cameroon in 2020 [3] [4] [9] [10] [11] [12] . Therefore, the goal of the 2012 global plan for eradication of measles and rubella is far from being achieved. WHO and UNICEF noted an increase in February 2022 in the number of measles cases and the risk of larger outbreaks [13] . Sub-optimal vaccinal coverage and pandemic disruption are the main reasons for these outbreaks [11] [13] . Symptoms of measles include fever, maculopapular skin rash, cough, coryza, conjuntivitis and we can have the Koplik’s spot which appears 1 or 2 days before the rash [7] .
Complications of measles include pneumonia, tracheitis, diarrhea, superimposed bacterial infections, subacute sclerosing panencephalitis and death. These complications are most common in young infants who are immunocompromised or undernourished particularly children with vitamin A deficiency [7] .
In Cameroon, measles outbreak is still raging with the Centre region being the most affected [11] . The viral PCR test to confirm the measles was done for the first cases at the beginning of the outbreaks. It is under this context that we conducted a study during the most recent outbreak (2022 to 2023), which aimed at describing the epidemiological, clinical aspects and outcome of children affected by measles and hospitalised at the Gynaeco-Obstetric and Pediatric Hospital of Yaounde.
2. Methodology
We conducted a hospital based cross-sectional descriptive and prospective study at the Gynaeco-Obstetric and Pediatric Hospital of Yaounde (YGOPH). It is a first category health facility on the health pyramid of Cameroon, specialized in mother and child healthcare. It is located in the city of Yaounde in the center region, making it a reference facility for the management of measles. Our study lasted for one year from October 1 2022 to September 30 2023 during the most recent Measles outbreak. We used a consecutive sampling. Every child hospitalized for measles at the YGOPH during the study period were included in our study.
After obtaining an ethical clearance and authorizations from the parents, we collected data using a questionnaire administered to parents and the children, we observed and collected data on the clinical manifestations, complications and outcome.
Variables of interest included sociodemographic characteristics of children included caregiver: age, monthly revenue, level of education; concerning children: age, sex, nutritional status, clinical manifestations of measles, complications and outcome.
Data was entered and analyzed using EPIINFO 7.2.5.0.
3. Results
During our study period, 60 children were admitted and followed up for measles for a median duration of 4 days with the maximum hospitalization duration being 10 days. The main caregiver was the mother (60%), most of them were less than 40 years old (73.33%) with a mean age of 34.71 years. The majority worked in the informal sector (85%) with a monthly salary of less than 50,000 FCFA for most of them (60%). The highest level of education reported was secondary level (53.33%). Most parents were cohabitating (44.19%) and the majority of them resided in Yaoundé (86.67%). Table 1.
The median age of children was 16 months (09 - 30 months) with a majority of them being less than 2 years old (71.67%). There were 5 children less than 6 months (8.33%), 11 (18.33%) children aged from 6 to nine months. Girls were predominant (55%) and only one child was orphan (01.67%). Most children were not up to date with their routine EPI vaccination (80%) and most did not receive the measles and Rubella vaccine (76.67%). However, the majority of children received Vitamin A supplementation (65%). Table 2.
Regarding the clinical manifestations, everyone presented fever, conjunctivitis, and cough. Most presented skin rash and catarrh (98.33% and 86.67% respectively), which are the case definition signs of measles. Other clinical manifestations were reported and their frequencies can be observed in Table 3. We recorded 29 children (48.33%) who had pneumonia, Fifteen percent of our patients convulsed.
![]()
Table 1. Socio demographic characteristics of caregiver.
Concerning the nutritional status of our children, 10 children (16.67%) presented an acute malnutrition with one presenting a kwashiorkor. Fifteen percent were underweight for their age. Table 3.
Concerning the outcome, it was favourable in 93.3% (56). Four deaths due to measles complications (06.67%) were noted. The children who died were aged from 6 to 24 months. One had a neurological disorder: coma, three had pneumonia with severe respiratory distress. Table 4.
![]()
Table 2. Characteristics of children.
![]()
Table 4. Outcome of Measles in the study population.
4. Discussion
Cameroon is facing an outbreak of measles. According to the report of the center of emergencies of Cameroon on the 26 November 2023, 6054 cases of measles were confirmed with 31 deaths due to measles since the beginning of the year 2023 and the Center region is the most affected. Knowing that measles can lead to complication that can end up being fatal, we studied the epidemiological and clinical characteristics of children who were hospitalized for measles at gynaeco-obstetric and pediatric hospital of Yaounde in the center region, which is a reference center.
We collected 60 cases of measles who were hospitalized. Knowing that all non-complicated cases were treated at home.
Our data confirm that measles continues to be an important public health problem and especially during epidemics causes significant morbidity and complications.
Concerning our patients hospitalized, most of their parents lived in a significant level of precariousness (60%) and this could explain the exposure of their children to measles. Because measles is a highly contagious disease.
Most children (71.67%) affected were aged below two years, 16 children (26.6%) affected were less than 9 months. we noticed five (8.33%) less than 6 months and these findings were similar to those reported by Domai et al. in Philippines [9] and Gianniki in Greece [12] or Sindhu in India [14] . Those cases of children aged less than 6 months were relevant.
This could be explained by the vaccination policies in Cameroon, which target 9 months to start vaccination against measles. It is expected that maternal measles IgG antibodies cover children below these ages. It would be relevant to start vaccination earlier as illustrated by Martins et al. in Guinea-Bissau [15] . Maybe the beginning of vaccination at 6 months or less can help to reduce the cases for the population of 6 - 9 months. Advocacies towards partners should be done to reduce the age of administration of measles and rubella vaccines.
There was a predominance of girls in our study and this could be explaining by the predominance female population in our context. These findings did not concord with those reported by Gianniki et al. in Greece, who found no sex related difference, Boushab et al. in Mauritania and Wang et al. in China where boys where predominant. For the latter this difference could be explained by the context too, where boys population are predominant [4] [8] .
It should be noted that most affected children (80%) were not up to date with their EPI immunization status as well as with their Measles and Rubella vaccination status (76.67%). This could be explained by the fact that we have a low immunization coverage of routine EPI vaccines. Or vaccination is free of charge in our country. Intensive community sensitization has to be done to understand why parents are not bringing children to vaccination and to encourage parents to take their children for vaccination following EPI calendar.
Regarding their clinical manifestations, most of them presented with the case definition signs of measles (body rash, conjunctivitis, cough and catarrh) and the enanthema was found in 41.67% of our study population. Respiratory disorders represented the main accompanying manifestations with pneumonia being the leading manifestation. these results concord the findings reported by Sindhu et al. in India [16] , Hassan et al. in Somalia [17] Boushab et al. in Mauritania [8] Domai et al. in the Philippines [9] . This is explained by the early targets of the virus which are the alveolar macrophages and the dendritic cells located in the lungs [1] .
Concerning the Outcome, it was unfavorable for 4 cases (6.67%). Their complications were marked by Coma, for one case, severe respiratory distress for three. The reported fatality rate was similar to the findings of Boushab et al. in Mauritania who reported a fatality rate of 8% [8] . However, it was higher than that reported by Hassan et al. in Somalia who found a fatality rate of 1.8% [17] . This shows that measles cases need to be detected early and managed adequately especially in our context.
5. Weakness
Our study was done in only one hospital therefore the generalization of our results should be taken with caution.
6. Conclusion
Measles remains a reality, and continues to claim children’s lives in our context. The 2022 to 2023 outbreak clearly shows that the goal of elimination of measles in 2020 was not achieved. Therefore, there is an urgent need to review strategies put in place. Studies should be done to determine the duration of maternal protection of children against measles and advocacies should be formulated to reduce the age of vaccination against measles.