Measlesin SouthAfrica:A Comprehensive
Interpretation of the Data
Part I -
Dr P Ferrinho
MBChB, DTM&H, MSC (MED)+
AlexanclraHealth Ccutre
ar.rdLlniversitr,Clinic and
Institute tbr Urban Priman.
Health Carc
Curriculum vitae
Paulo fcrrinho had his school education in
Mocambique and then rrent on to the
Unilersitl of Cape To\\'n to obtain the
MBChB in 1980. He did his intcrnship at thc
G r o o t e S c h L r uhr o s p i t a li n C a p c T o r r n a n d
then sorked at the GelukspanCommunitl'
Hospital from l9B2 to 1986. After that l-re
becamea registrar in Communifl'Health at thc
Universin of the Witn'atersrand.At thc
moment he is tl-reClinic Manager anclDirector
fcrr Researchof thc Alexandra Health Centre
and Universin' C.linic,/Institutefbr Urban
Priman'Health Care. Although specialisingin
Cornmunitr. Health, his professionalinterest
remains ir.rsupport to priman'health care.
P Ferrinho.E Buch
Surnrunry
Introduction
In SowthAfrico (SA) tbere is a
czncnaitrnentto and. irud.icationsthat
resoa?'ces
nre being allocated.for the
erad.icationofrneasles.Still tbere has
beenno cotnprehenstreretiew ofthe
epid.etniologyof the d.iseawin SA. Tbis
wnd.erxand.ingis itnportant to id.enttfy
factors and. trend.sto guide pwblic health
practice. Th'isset"ies
of nr'ticlestnes to
cowr this gnp.
Measlesis a doomed virus! Without
doubt mankind will succeedin the
control and eradication of this killer
of small children.'''r This could
happen sooner rather than later if
there was a clearerunderstandine of
the behaviourof the virus in huian
communities and a clearer
commitment and allocation of the
lrccessaq'resourcesto its cradication.
Patt I rwisws h'iofu the internationnl
litet"atwre on the epid.ewiologyof the
diseasennd. d.auribesthe wethod.ology
of d.ata and analys'is
followed., the sowrces
st?/ategy.The other atticles revim South
Afi,icnn repzrts 0n worbid.ity-rnortality
and relntionshilts to nge,popwlation
gt/lup, sexand.g eograpbical disn"ibwtion
(patt II); pnrt III reyiswsinfor.tnation
on weaslesrelated,worbtdity and.
wowality; pat"t IV rniews otherfnctors
inflwencirugrnenslesnaorbid.ityand.
mottality in SA (protein-enet/gywalnutrition, age at infection,
ut banisation, socio-ecoruowic
statwsand
health carc) and containsapprzpriat(
conclwsionsand. reclnunend.ations.
Measlesis a viral inf-ectionthat affects
susceptiblesofall agesand both
sexes,followed by lifelong immuniry.'
It is still a significant causeof
morbidity and mortaliw of small
children in the developing world,
including South Africa.or'
S Afr Fnw Pract 1992: 13: 61-67
I(EYWORDS:
Measles;Vaccination;
Physicians,
Research;
Family
Incidence and/or severityofthe
diseasehas been associatedwith a
number of factors.These inch.rde:
- Health oolicv factors like the
practiceof episodicopportunistic
vaccination at all health ser.,ricest
and policies on vaccination.*
- Personalcharacteristicslike
t: and sexttof the cases.
dge'rr{)'tt
- Geographicaland environmental
determinants such as latitude,'*
season.'nwhether the caseis the
index or the secondarycasein the
household,tt" nature of the human
settlement,")rype (nuclear or
extended,monogamous or
polygamous) of family 'o''''"
population mobility" and degree of
overcrowding.r
25
I'16'r8'2r
- Nutritional statusincludins the
degreeof protein energy
malnutrition'''u and vitamin A
deficicncy.tt"t
- Traditional customs.'""
- Genetic background.'"
The patterns of the infection and
6l
SA Farnilv Practice Februan' 1992
SA Huisrrtsprakn'kFcbruarie1992
Measlestn South Africa
some of the literature on the above
factors have already been reviewed in
a previous publication."
A most important recent development in the understanding of the
infection is that although vitamin A
deficienry, genetic background and
vaccination policies may have an
Most aspectsimpact on
measlesthrough the common
pathway of a stronger virus
independent impact on measles
severitv and outcome. most of the
other factors act through the
common pathway of a higher
infective dose of measlesvirus.tt'""
This model suggests that measles
mortality is relatively independent of
protein energy malnutrition. If
correct this means that measles
vaccination would in fact reduce
childhood mortality independent of
efforts to reduce protein-energy
malnutrition.
A casecontrol study from rural
Bangladesh has shown the
imoortance of measlesvaccination in
preventing not only measles
mortality, but also overall mortality.
Measles vaccination was shown to
reduce the overall death rate by 360/o
and the rate ofdeaths directly
attributable to measles,diarrhoea,
respiratory illness or malnutrition by
57o/o.u
Control of measleswill therefore
have a significant impact not only on
morbidity and mortality caused
directly or indirectly by measlesbut
also will reduce the incidence and
prevalence of many long term
comolications associatedwith the
diseise. Measles vaccination will
The importance of this new
understandingis that strategiesto
correct the impact of measlesin a
community should not address
confounders ofthe true pathway, but
should rather take measuresto
overcome exposure to a heary dose of Vaccination reduces mortality
infection, especially by improved
independently of better
vaccination coverage and by
nutntl0n
reduction of overcrowding, through
better housing policies and effective
fertility control." This theory is
consistent with the changes in the
epidemiology of measlesin developed prevent not on-lymeaslesmortality
but also overall mortaliw. The imoact
countries before the advent of
It also counters
of vaccinationwill be better felt if
vaccination.t6'r8'20
carried out in the context of
arguments that measlesspecific
comprehensive policies that also
policies would not be effective in
address the problem of overcrowding
reducing childhood mortality in
underdeveloped communities32'33'34.36and ofother factors that affect the
occurrence and/or seve'rityof
becauseits prevention would only
measles.
result in deaths from other childhood
illnessesassociatedwith malnutrition
In South Africa (SA) there is a
or other diseases.
62 SA FamilyPracriceFebruary1992
commitment to and indications that
resources are being allocated for this
task." Still there has becn n<,r
comprehensive review of the
epidemiology of the diseasein SA.
This understanding is important to
identify the feasibility of explaining
the local epidemiology according to
Measles vaccination reduces
measlesand overall mortality
the above model and to identify
factors and trends to guide public
health practice. This seriesofarticles
tries to cover this gap.
Sourcesof Data
Published
literatureon measles
epidemiology and control was
selectedfor review from the Index
Medicus for the period 1960-1989
and experts in the field were
contacted. We focused on literature
from Africa and from SA, in
particular on reports on levels of
morbidity and mortality due to
measles.
Srhere appropriate the data will be
grouped under the following
headings: notifi cation, certified
deaths, active surveillance, hospital
reports and miscellaneous.
Quality of the Data
Notifi,cotions
Measles has been a notifiable disease
in SA sinceAugust I979.'e Measles
and measlesdeaths are notifiable as
seDarateoccurrences.Notifi cations
.ti"n"t. from many sources and
follow a processofcollection and
Februarie1992
SA Huisartspralrryk
... Measlesin SouthAfrica
collationnothat has inherent
systematic and random bias. Still,
notification data is the only data with
sufficient regularity to allow the
study oftrends ofthe diseaseover
time and to allow for regional
comparisons.
The major bias in notification data is
undernotification of cases.ntThis is
consistently so for whites and nonwhites., for urban and rural, for
public facilities and for doctors in
private practice.e's2Ketdes reports
that 607o of 59 general practitioners
surveved bv him did not know that
measieswas notifiable.r It seems
therefore that the process of
notification is hampered by ignorance
on the part of notifying offrcers, ie
doctors and nurses.
-
Freqwentlywereferto nsians,bla.cks,
nlouredsnnd whites.Tbewseof these
is afupted.
expressi,ons
for thispapersiwe
vital statisticsand,thesocial,econornic
and.political institwtionsin SA are
strwctared.
alang thesel.egnllydzf.ned.
t
ra.ci.alcategories.o
As notification is done by health
personnelit is alsolikely to be further
biasedin favour of communitieswith
readyaccessto healthcare.This is
exemplifiedby the observationthat,
in the Cape,50oloof notifications
the same reasons as notifications of
disease.Wittenberg reported that
only 83 (23o/o)of 356 deathsdue to
measlesin two academic hospitals in
Natal-Kwazulu were notified.s'z
Denth certifi,cates
Still no review of the
epidemiology of measlesin SA
originate from the single hospital for
infectious diseasesnt'"and, in
Johannesburg 59o/oof notifi cations
originate from hospitals, only I37o
from general practitioners and 3o/o
from local authorities.u' In NatalKwazulu the Clairwood Infectious
DiseasesHosoital accounts for 40o/o
of all notificaiions." This bias is likely
to lead to underestimates of disease
in rural communities and the urban
poor. Disease rates for groups with
poor accessto local health care are
either not acknowledged, or are
reflected in the health service
statistics of better served contiguous
areas.Our impression is that nurses
are usually, but not always,* less
likely than doctors to noti4/ the
disease,possibly becausethey are not
aware that they are allowed to. This
comoounds the underestimation of
diseise in rural areaswhere nearly all
health centres are staffed onlv bv
nurses,These health centresire'also
not likely to have notification books."
of literatwre
There'isa significant bod.y
on thelachof rcientificjustiftration to
Still in SA
theuseof ra.cialexpressi.ons.
racinl classirtcation
hasbeenoneofthe
dpterwinantsofpoti,calpmaer,social
cla,ss,
enrnmicexperi+nces,
accessibikty
to
environmtntnlexplsures,
'4s
healthcnrennd illnessexperience.
swchit isjustif.able to lnobat experiences
of measles
in tbed.ifferentrecesa.shgaily Lastly, notification is more likely to
occur in the more seriously ill, ie
fufi.ned.
in SA.na*Morerenntly the
those in need of hospital care. As
%aoialgroaps"hnsbeen
expression
replncedby'popula.tinngmups". Theuse these are usually young infants,
underestimates will be qreater in
of expressi.ons
reflectingthelegal
older children.
stl,ttctureof ra.cialgrowpsin theSowth
African society
dna not imply that we
Notification of deaths are suspect for
a.cce[,t
their lcgitirnaty.
63 SA FamilyPracticeFebruary1992
Death certification in SA, as distinct
from death notification, also has
many problems, especially for the
black population group.5q56'5'
Problems again occur from selective
reporting due to differential rates of
accessibility to and inadequate skills
ofthe certifying officers (health
workers and police officers) leading
to misclassification of causesof
death. There have been no changes in
the classification of measlesin the
International Disease Classification
so this will not have affected
mortality statistics.
Notified measlesdeaths in SA
representbetween 37o (1980) and
4,4o/o(1983) of deaths registered
with the central statistical servicesin
Pretoria.s
Actipe swrveillanoednta
There is only one report of what
approaches active surveillance of
measlesin SA. The study is based on
follow up of notified casesof measles
and their contacts in Johannesburg
and Benoni.s3
Hospital data
Data on hospital inpatients and
outpatients with measles or dying
from it has never been rigorously
assessedand reported. The data is
limited and the qualiry is
unassessable.The most collmon
reDorts are found in the
co-rrespondencecolumn of the South
African Medical Journal.
SA HuisartsorakokFebruarie1992
... Measlesin SouthAfrica
The most important bias of these
data sets are younger age profile,
more severedisease,higher moftality
and greater accessibility to health
care.
Miscellaneows
One report based on a mix of
methodologies is also reviewed.
Loenig and Coovadia report on
surveysof communities and health
centres in the Natal-Kwazulu area to
postulate a relationship between
urbanisation and measles." Although
the limitations of their methods have
been debated in the literaturese'uo
the
casefor this relationship remains
strong.
Statistbal analysis
The raw data used to calculate rates
and trends is reported elsewhere.ut
Some of the notification data
reviewed is converted by us from
absolute numbers to rates. Some of
the rates reported in the literature are
600/oof GPs in a survey did not
know that measleswas
notifiable!
further submitted to statistical
analysis to improve the
interpretability of the data.
The denominators used to calculate
rates have some limitations. One is
undercounting, particulary of the
Black population group. Still this has
been corrected to some extent in the
population fi gures utilised here.u'
Secondly, with the granting of
"independence" to the TBVC
countries (Transkei,
Bophuthatswana, Venda, Ciskei) a
significant proportion ofcases and of
individuals at high risk for measles
have been removed from the
nrunerator and the denominator
leading to reduced national rates.
Thirdly, some areasof SA are
occupied by refugees of local or
foreign civil wars. These refugees are
not counted in the denominators
used to calculate rates and they are a
high risk group very likely to be
represented in the numerator.
Notified incidence has been
extensively reported upon by the
National Directorate of
Epidemiology. Their data is
essentially of a descriptive nature with
little analltical and inferential
statistics.u'When appropriate, linear
regression is applied to the data as
reported by them to identify
statistically significant changes in
trends over time. If trends over time
are statistically significant for data
sets of more tian one population
group, these are then compared
statistically with each other by
multiple linear regression
methods.
each one of the two time periods are
compared using multiple linear
regressron.
All analyseswere stratified by
population groups. The rates for
population groups are compared with
one another, using the regression
methodologies mentioned above.
For each population group the data
for death certificates is grouped into
5 age groups: O-to-(l year; 1-to-qS
Nurses are not aware that they
are allowed (and should!)
notifi/ measles
years; 5-to-410 years; l0-to-(20
years and 20 years and over. Each
group is studied as a proportion of
the total. Trends over time of these
proportions are plotted and analyzed,
again using linear and multiple linear
regressron.
Despite the limitations of the data
described above, it does provide
trends and patterns that are usefirl for
the planning of health services.
Death certification data was similarly
analyzed. This data was further
analysedfor the time periods up to
1979 andthereafter and up to 1978
and therafter. The reasonsfor these
cut off points include the perception,
from looking at the data, that major
gains in reducing mortality took
place before 1978 but not thereafter;
the fact that mortality for blacks is
not available before 1979: Iastlv to
assessthe gains for the 1980 dicade
as opposed to preceding years.Again,
if the slopes of the regression lines
for each one of the time periods is
found statistically signifi cant, then
the slope of the regression line for
epidemiology of measles will have to
be based on incomplete data sets
(notified data and certified mortality)
or data sets of dubious quality
(hospital reports). Still the qualitative
and quantitative nature of some of
the bias are known and will be taken
into account when analysing,
speculating, concluding or making
recommenqailons.
64 SA Family Practice Februrry 1992
SA HuisansprakwkFebruarie1992
Conclusions
It is apparent
thatthestudyofthe
... Measlesin South Africa
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SA Fan-rih'PracticeFebruan' 1992
SA Huisar-tspraknkFebruarie I992