LETTERS TO THE EDITOR
oliguric renal failure and were managed conservatively. Renal dysfunction leading to uraemia together with anaemia, and hyperbilirubinaemia secondary to hepatocellular damage were responsible for increased morbidity and delayed recovery needing intensive supportive care for complete recovery. V. P. CHOUDHRY, A. BAGGA, and N. DESAI
Department of Hematology & Pediatrics All India Institute of Medical Sciences New Delhi-110029 India References
Sir, Measles, Mortality and Malnutrition Morley's publications 8 about severe measles in Nigeria (1964, 79) suggest that malnutrition is an important cause for the high mortality in measles in developing countries. This view seems to be proven by many other authors. Among them Peereboom (1987)1 reports from the Foumban hospital, Cameroun a measles mortality of 20-30 per cent in undernourished children (W/A < P3), but till a mortality of 10 per cent in well-nourished children. It is well-known that well-nourished European children died from measles in developing countries. Here other causes must predominate; in our opinion, presumably a superinfection. Now we report the reverse scenario of measles in malnourished children without mortality. During the measles epidemic of October 1989 in the Hmong refugee camp Ban Vinai, Thailand, 7 only the 221 cases with complications were admitted in the camp hospital. The most common complication was 140
(1) even mild Vitamin A deficiency seems to be more serious than an anthropometric measurable malnutrition; (2) malnourished children predominate among those with complications of measles; (3) adequate antibiotic treatment is essential in all cases of measles with complications. HENK W. A. VOORHOEVE, MD, P H D , MPH, DTM&H
2285 HE Rijswijk (ZH) Prof. Meyerslaan 133 Netherlands References 1. Peerenboom PBG. Les soins de sante au Cameroun. Academic Thesis, Amsterdam, 1987. 2. Paul MA, Voorhoeve HWA. Ondervoeding, mazelen & mazelen sterfte. Voeding, 1986; 47: 8. Memisa Nieuws, Med Edn, 1985; 51: 134-7. 3. Sommer A, et al. Increased mortality in children with mild Vitamin A deficiency. Lancet 1983; ii: 585-8. 4. Bloem MW. Vitamin A deficiency, anemia and infectious diseases in Northeast Thailand. Academic Thesis, Amsterdam, 1989. 5. West KP, et al. Efficacy of Vitamin A in reducing preschool child mortality in Nepal. Lancet 1991; ii: 66-71. 6. Editorial. Vitamin A and malnutrition/infection complex in developing countries. Lancet, 1990; ii: 1349-50. Journal of Tropical Pediatrics
Vol. 38
June 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of Michigan on August 30, 2015
1. Balgir RS. Ethnic and regional variations in the red cell glucose-6-phosphate dehydrogenase deficiency in India. J Hematol 1989; 7: 101-9. 2. Madan N, Talwar N, Maheshwar A, Sood SK. Incidence of glucose-6-phosphate dehydrogenase deficiency in a hopsital population of Delhi. Ind J Med Res 1981; 73: 425-9. 3. Tandon BK, Gandhi, RM, Joshi VK. Etiological spectrum of viral hepatitis and prevalence of markers of A and B virus infection in north India. Bull Wld Hlth Org 1984; 62: 87-92. 4. Chan, TK, Todd D. Hemolysis complicating viral hepatitis with glucose-6-phosphate dehydrogenase deficiency. Br Med J 1975; 1: 131-3. 6. Upadhyaya PR, Nanda RB, Oberoi MS, Ahuja IM. A comparative study of acute hemolytic anemia in patients of viral hepatitis in relation of erythrocyte G6PD deficiency. J Ass Phys Ind 1987; 35: 561^t. 6. Snyder AL, Satterlee N, Robinson SH, Schmid R. Conjugated plasma bilirubin in jaundice caused by pigment overload. Nature (Lond) 1967; 213: 93. 7. Morrow RH, Smetana MF, Sai FT, Edycomb JH. Unusual features of viral hepatitis in Accra. Ghana Ann Int Med 1968; 68: 1250-64.
pneumonia: in 94 per cent of the 221 cases. In 15 per cent there was gastro-enteritis (GE) and 9 per cent together with pneumonia. The nutritional status of the approximately 6000 under-fives in the camp is routinely measured by the Mid-Upper Arm Circumference (MUAC). Through the years 2-4 per cent of the 1-5year-old children are undernourished (MUAC < 12.5 cm). However, from the 221 children admitted with measles complications 47 per cent were undernourished. The nutritional status was borderline in 20 per cent (MUAC =12.5-13.5 cm) and in 34 per cent adequate (MUAC> 13.5 cm). So it seems that it is mainly the malnourished children in the (camp) community who developed complications during the measles epidemic. Remarkably there was no mortality among the 221, mostly malnourished children admitted with measles complications. Presumably this is the result of an adequate treatment with antibiotics. In 1986 we reported about a measles epidemic in an also malnourished children's population (25 per cent MUAC< 12.5 cm) from Nigeria with a low mortality of only 2 per cent. The explanation for this good result is seen in the high amount of Vitamin A in the Nigerian diet due to red palmoil.2 An increased child mortality in children with even mild Vitamin A deficiency is described by Sommer et al.3 from Indonesia, and by Bloem from Thailand. 4 West et al. described the effect of Vitamin A in reducing preschool child mortality in Nepal. 5 The conclusions from our experiences from Thailand, Nigeria and the literature about measles in the tropics are:
LETTERS TO THE EDITOR
Kyin Win, Voorhoeve HWA. Measles, malnutrition and mortality in Ban Vinai, Thailand, 1989. Memisa Nieuws, MedEdn 1991; 57: 4. Morely D. Severe Measles. In: Paediatric priorities in the developing world. London, Butterworth 1979; 207-30.
(1) The incidence rates for major disease groups showed an initial increase with age, declining after 36 moqths (Table 1); (2) no significant seasonal fluctuations or gender differences were detected; (3) all disease groups except upper respiratory infections showed a relation to the quality of environment, with the most favourable environment having least risk; (4) in general, the morbidity load among the children in the study area was less compared to that in
Journal of Tropical Pediatrics
Vol. 38
June 1992
Age group [months]
Illness group Fever URI LRI
Diarrhoea Dysentery
0-6
7-12
13-24 25-36 37-48 49-72
5.6 1.3 0.7 0.0 0.0
8.4 6.8 0.7 1.6 0.0
11.5
11.2
5.1 3.5 2.9 0.4
5.7 3.1 1.2 0.4
7.6 4.9 0.7 1.6 1.1
7.7 4.3 1.8 1.1 0.3
urban Kerala: the prevalence of respiratory infections comes to 6, 12, and 8 per cent of total observation days in the three areas, and that of diarrhoeal diseases was 2, 3, and 0.8 per cent. These figures were lower than those reported from the two urban areas. The fact that with a lesser morbidity load, rural pre-school children have comparable mortality, is probably indicative of their poorer accessibility to health care facilities. V. RAMAN KUTTY
Sree Chitra Thirunal Institute for Medical Sciences and Technology Thiruvananthapuram 695 011 India K. VIJAYAKUMAR and C. R. SOMAN
Medical College Thiruvananthapuram 695 011 India References Soman CR, Damodaran M, Rajasree S, Raman Kutty V, Vijayakumar K. High morbidity and low mortality—the experience of urban preschool children in Kerala. J Trop Pediat 1991; 37: 17-23.
141
Downloaded from http://tropej.oxfordjournals.org/ at University of Michigan on August 30, 2015
Sir, Pattern of Morbidity in Pre-school Children in Rural Kerala Earlier observations indicate that morbidity in young children in Kerala state, India, remains at high levels despite the low mortality attained. We had reported significant relationships between morbidity in urban children with environmental conditions. 1 In the light of minimal urban-rural difference in pre-school mortality in children in Kerala, we were interested in studying the morbidity in rural children. Randomly selected children under 6 years of age (n = 316) from three villages in the Kuttanad area in Kerala were followed up for 1 year. The villages were selected on the basis of the quality of the environment, especially availability of drinking water and sanitation. They represented good, average, and poor quality of environment. Common symptoms of illnesses in the subjects were recorded weekly by trained field workers. The results were:
TABLE 1
Incidence rates of common illnesses among rural preschool children in Kerala
oliguric renal failure and were managed conservatively. Renal dysfunction leading to uraemia together with anaemia, and hyperbilirubinaemia secondary to hepatocellular damage were responsible for increased morbidity and delayed recovery needing intensive supportive care for complete recovery. V. P. CHOUDHRY, A. BAGGA, and N. DESAI
Department of Hematology & Pediatrics All India Institute of Medical Sciences New Delhi-110029 India References
Sir, Measles, Mortality and Malnutrition Morley's publications 8 about severe measles in Nigeria (1964, 79) suggest that malnutrition is an important cause for the high mortality in measles in developing countries. This view seems to be proven by many other authors. Among them Peereboom (1987)1 reports from the Foumban hospital, Cameroun a measles mortality of 20-30 per cent in undernourished children (W/A < P3), but till a mortality of 10 per cent in well-nourished children. It is well-known that well-nourished European children died from measles in developing countries. Here other causes must predominate; in our opinion, presumably a superinfection. Now we report the reverse scenario of measles in malnourished children without mortality. During the measles epidemic of October 1989 in the Hmong refugee camp Ban Vinai, Thailand, 7 only the 221 cases with complications were admitted in the camp hospital. The most common complication was 140
(1) even mild Vitamin A deficiency seems to be more serious than an anthropometric measurable malnutrition; (2) malnourished children predominate among those with complications of measles; (3) adequate antibiotic treatment is essential in all cases of measles with complications. HENK W. A. VOORHOEVE, MD, P H D , MPH, DTM&H
2285 HE Rijswijk (ZH) Prof. Meyerslaan 133 Netherlands References 1. Peerenboom PBG. Les soins de sante au Cameroun. Academic Thesis, Amsterdam, 1987. 2. Paul MA, Voorhoeve HWA. Ondervoeding, mazelen & mazelen sterfte. Voeding, 1986; 47: 8. Memisa Nieuws, Med Edn, 1985; 51: 134-7. 3. Sommer A, et al. Increased mortality in children with mild Vitamin A deficiency. Lancet 1983; ii: 585-8. 4. Bloem MW. Vitamin A deficiency, anemia and infectious diseases in Northeast Thailand. Academic Thesis, Amsterdam, 1989. 5. West KP, et al. Efficacy of Vitamin A in reducing preschool child mortality in Nepal. Lancet 1991; ii: 66-71. 6. Editorial. Vitamin A and malnutrition/infection complex in developing countries. Lancet, 1990; ii: 1349-50. Journal of Tropical Pediatrics
Vol. 38
June 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of Michigan on August 30, 2015
1. Balgir RS. Ethnic and regional variations in the red cell glucose-6-phosphate dehydrogenase deficiency in India. J Hematol 1989; 7: 101-9. 2. Madan N, Talwar N, Maheshwar A, Sood SK. Incidence of glucose-6-phosphate dehydrogenase deficiency in a hopsital population of Delhi. Ind J Med Res 1981; 73: 425-9. 3. Tandon BK, Gandhi, RM, Joshi VK. Etiological spectrum of viral hepatitis and prevalence of markers of A and B virus infection in north India. Bull Wld Hlth Org 1984; 62: 87-92. 4. Chan, TK, Todd D. Hemolysis complicating viral hepatitis with glucose-6-phosphate dehydrogenase deficiency. Br Med J 1975; 1: 131-3. 6. Upadhyaya PR, Nanda RB, Oberoi MS, Ahuja IM. A comparative study of acute hemolytic anemia in patients of viral hepatitis in relation of erythrocyte G6PD deficiency. J Ass Phys Ind 1987; 35: 561^t. 6. Snyder AL, Satterlee N, Robinson SH, Schmid R. Conjugated plasma bilirubin in jaundice caused by pigment overload. Nature (Lond) 1967; 213: 93. 7. Morrow RH, Smetana MF, Sai FT, Edycomb JH. Unusual features of viral hepatitis in Accra. Ghana Ann Int Med 1968; 68: 1250-64.
pneumonia: in 94 per cent of the 221 cases. In 15 per cent there was gastro-enteritis (GE) and 9 per cent together with pneumonia. The nutritional status of the approximately 6000 under-fives in the camp is routinely measured by the Mid-Upper Arm Circumference (MUAC). Through the years 2-4 per cent of the 1-5year-old children are undernourished (MUAC < 12.5 cm). However, from the 221 children admitted with measles complications 47 per cent were undernourished. The nutritional status was borderline in 20 per cent (MUAC =12.5-13.5 cm) and in 34 per cent adequate (MUAC> 13.5 cm). So it seems that it is mainly the malnourished children in the (camp) community who developed complications during the measles epidemic. Remarkably there was no mortality among the 221, mostly malnourished children admitted with measles complications. Presumably this is the result of an adequate treatment with antibiotics. In 1986 we reported about a measles epidemic in an also malnourished children's population (25 per cent MUAC< 12.5 cm) from Nigeria with a low mortality of only 2 per cent. The explanation for this good result is seen in the high amount of Vitamin A in the Nigerian diet due to red palmoil.2 An increased child mortality in children with even mild Vitamin A deficiency is described by Sommer et al.3 from Indonesia, and by Bloem from Thailand. 4 West et al. described the effect of Vitamin A in reducing preschool child mortality in Nepal. 5 The conclusions from our experiences from Thailand, Nigeria and the literature about measles in the tropics are:
LETTERS TO THE EDITOR
Kyin Win, Voorhoeve HWA. Measles, malnutrition and mortality in Ban Vinai, Thailand, 1989. Memisa Nieuws, MedEdn 1991; 57: 4. Morely D. Severe Measles. In: Paediatric priorities in the developing world. London, Butterworth 1979; 207-30.
(1) The incidence rates for major disease groups showed an initial increase with age, declining after 36 moqths (Table 1); (2) no significant seasonal fluctuations or gender differences were detected; (3) all disease groups except upper respiratory infections showed a relation to the quality of environment, with the most favourable environment having least risk; (4) in general, the morbidity load among the children in the study area was less compared to that in
Journal of Tropical Pediatrics
Vol. 38
June 1992
Age group [months]
Illness group Fever URI LRI
Diarrhoea Dysentery
0-6
7-12
13-24 25-36 37-48 49-72
5.6 1.3 0.7 0.0 0.0
8.4 6.8 0.7 1.6 0.0
11.5
11.2
5.1 3.5 2.9 0.4
5.7 3.1 1.2 0.4
7.6 4.9 0.7 1.6 1.1
7.7 4.3 1.8 1.1 0.3
urban Kerala: the prevalence of respiratory infections comes to 6, 12, and 8 per cent of total observation days in the three areas, and that of diarrhoeal diseases was 2, 3, and 0.8 per cent. These figures were lower than those reported from the two urban areas. The fact that with a lesser morbidity load, rural pre-school children have comparable mortality, is probably indicative of their poorer accessibility to health care facilities. V. RAMAN KUTTY
Sree Chitra Thirunal Institute for Medical Sciences and Technology Thiruvananthapuram 695 011 India K. VIJAYAKUMAR and C. R. SOMAN
Medical College Thiruvananthapuram 695 011 India References Soman CR, Damodaran M, Rajasree S, Raman Kutty V, Vijayakumar K. High morbidity and low mortality—the experience of urban preschool children in Kerala. J Trop Pediat 1991; 37: 17-23.
141
Downloaded from http://tropej.oxfordjournals.org/ at University of Michigan on August 30, 2015
Sir, Pattern of Morbidity in Pre-school Children in Rural Kerala Earlier observations indicate that morbidity in young children in Kerala state, India, remains at high levels despite the low mortality attained. We had reported significant relationships between morbidity in urban children with environmental conditions. 1 In the light of minimal urban-rural difference in pre-school mortality in children in Kerala, we were interested in studying the morbidity in rural children. Randomly selected children under 6 years of age (n = 316) from three villages in the Kuttanad area in Kerala were followed up for 1 year. The villages were selected on the basis of the quality of the environment, especially availability of drinking water and sanitation. They represented good, average, and poor quality of environment. Common symptoms of illnesses in the subjects were recorded weekly by trained field workers. The results were:
TABLE 1
Incidence rates of common illnesses among rural preschool children in Kerala
