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SITUATION ANALYSIS OF MEASLES IN NIGERIA
ABSTRACT Despite all the efforts expanded on routine immunization, measles still remain a disturbing cause of morbidity and mortality in Nigeria. Measles vaccination coverage of 59% in infancy in 1988 and 35% in 2003 remains low in Nigeria. The WHO and UNICEF highlighted the need to improve vaccine coverage and effectiveness at least 95% for protective herd immunity and effective measles control. In spite of active measles vaccination efforts in 2005 in Nigeria, re emergency of measles .continue to occur even after the catch up and follow up measles vaccination campaign exercise and this has invariably hamper the global measles mortality reduction initiatives and attainment of the fourth millennium development goal of reduction of under fire child mortality by 2015. Nigeria has been experiencing the incidence of measles outbreaks occurring in the year 2004, 2005, 2006.2007, 2008 and 2011. These outbreaks are a cause of concern particularly that of 2011 which occurs following a mass measles campaign earlier that year. Efforts to improve control have been ongoing and progress has been made particularly with the establishment in 2006 of a system of case based surveillance. Low immunization coverage is still the main factor involved. The inability to control measles in Nigeria is a reflection of work that needs to be done as regards to our immunization coverage and structures that are needed to be put in place.

INTRODUCTION BACKGROUND--Jamiualata (talk) 12:42, 16 April 2016 (UTC) Measles being one of the global epidemic prone diseases is a highly infectious disease of the respiratory system and a leading cause of vaccine preventable death among children. It occurs worldwide but the greatest burden lies on the developing countries. In 2014, the global measles mortality was 114,900, about 314 death every day or 13 death every hour (WHO, 2015). Up till today, measles is still an important global cause of childhood mortality. (Salako and Sholeye, 2015). In Africa, there were over 200,000 incidence 1400 mortality reported in 2010. It has been estimated that this figure could be 10 times higher due to under reporting (Salako and Sholeye, 2015). In Africa, about thirteen million incidences of measles occur with 650,000 mortality annually, with Sub-Sahara Africa having the highest mortality and morbidity. (Onoja A. B et al, 2013). Despite the effort made to control measles in Africa the disease continue to pose a threat most especially among infants and young children in Africa. In Nigeria, measles incidence have been increasingly common. In 2005 measles killed 500 children in Nigeria and 90% of the 23,575 cases of measles reported in 2005 were in the northern Nigeria. Incidence of measles continue to become increasingly high in Nigeria even with the series of efforts and strategies employed to reduce it occurrence. Nigeria recorded 14,16 cases of measles in 2010, 21000 cases in 2011, and 55,392 in 2013. Google search (March, 2016) reported that in 2015, Nigeria recorded 22,567 cases of measles with 16,000 mortality rate. In spite of the efforts made and strategies adopted to curtail or reduce measles morbidity and mortality in Nigeria, such as improved case based surveillance, effective and adequate case management, improved routine immunization and supplemental immunization activities (Catch-up and follow-up campaigns) and so on. Yet measles account for morbidity and mortality among infant and young children. Measles as one of the leading causes of death among children, it accounts for the highest number of vaccine preventable deaths. Nigeria being one of the 47 countries of the world with a very high burden of measles where cases of measles can even be under reported. Vaccine coverage of measles containing vaccine (MCV) in Nigeria is currently put at 62% with a very wide variation in a country that has once achieved 80% coverage with routine immunization. (Goodson, 2011). The information contained in this review was extracted from textbooks, journals articles, internet, and pamphlets. The aim of this paper is to analyze the situation of measles in Nigeria in term of epidemiology, prevalence, control and management. EPIDEMIOLOGY OF MEASLES Measles is a highly infectious of the respiratory system caused by virus. It has a worldwide distribution but majority of measles cases are seen in developing countries, particularly countries with low per capital income and weak health system (Salako and Sholeye, 2015). The signs and symptoms of measles includes fever, cough, rashes catarrh, conjunctivitis, anorexia, nausea, vomiting, the patient looks leathergic, koplik’s spot, etc. the incubation period is commonly 10 days from the onset of fever and 14 days to the appearance of rash. The incubation period may be within the limit of 7-14 days. Measles is identified using WHO approved standard case definition, and it says any person with fever 38oc or more (if not measured “hot to touch”) and maculopapular rash with at least one of the following- cough, coryza and conjunctivitis or any person in whom a clinician suspects measles. (WHO, 2012). The disease is transmitted or spread primarily via the respiratory system. It is passed from person to person via tiny air droplet containing virus particles such as those produced by a coughing patient. The prevention and control of measles are; health education on the importance and the need for measles vaccination, intensive routine immunization, early detection of cases through active case search, effective, prompt and adequate management of cases, intensify surveillance and reporting, immunize all suspected contact and conduct regular SIAs. WHO/FMOH, (2012) reported that case management depends on the severity of the disease suspected measles case should be kept away from young unvaccinated children. •        Uncomplicated case: give vitamin A using the table below: Age	Immediately on diagnosis	Next day 0-5 months	50,000 1u	50,000 1u 6-11 months	100,000 1u	100,00 1u ≥ 12 months	200,000 1u	200,000 1u For ocular manifestations, give the third dose 2-4 wks after the second dose. Provide supportive measures such as control of fever, using tepid sponging and giving analgesic, provide good nutritional support. For complicated cases, give two doses of vitamin A as in uncomplicated cases, treat pneumonia or otitis media with the appropriate antibiotics, treat malnutrition and diarrhea with ORS and high quality diet. During measles outbreak all children 6-59M should receive measles vaccination regardless of previous immunization status and this does not replace any routine schedule. SITUATION ANALYSIS OF MEASLES CONTROL & ELIMINATION IN NIGERIA. Measles remain a public health problem in all parts of Nigeria. In spite of the different strategies employed by the government at all levels to curtail it. The impact of the disease is being felt even more among the vulnerable population especially the infants and young children. These populations are especially worse hit because their immunity is not fully developed. Nigeria, in its attempt to control and eliminate the circulating indigenous measles virus, implement the recommended strategies to achieve sustainable measles mortality reduction. Measles SIAs were first implemented in Nigeria in 2005 with catch up campaign which was conducted in two phases. Phase one was conducted in three northern zones (Northwest, Northeast, North Central) from 6th-10th December. While the second phase involving the three southern zones (Southwest, Southeast and South South) started from 3rd-9th, October 2006. The national population of 133 million (projected from 1991 census) was used and 56 million of them were children between the target age group of 9 months to below 15. At the end of the northern (phase1) and southern campaign (phase 2) a total of 28, 538,974 (95.52%) out of the targeted 29,877,057 and (21,873,648 (83%) out of targeted population of 26,353,793 were vaccinated respectively. Shortly after the AMC in 2005/2006 Nigeria commence case based measles surveillance in all the 36 states and the federal capital territory and has quickly achieved a high level of performance, including the establishment of four measles laboratories located in FCT, Gombe, Kaduna and Lagos states. The first follow up campaign (Integrated Measles Campaign IMC) was conducted in 2008. At the end of the northern and southern campaigns a total of 28, 363,479 children 9-59 months were vaccinated with measles vaccine irrespective of their previous immunization status. The monitoring data conducted after the 2008 IMC (inside and outside household) showed that 93% of the children were vaccinated during this first follow up campaign. Sequel to the above mentioned strategies put in place and the various efforts made by Nigerian government, there was a marked decline of measles incidence between the year 2005 and 2009. Morbidity was reduced from slightly over 61,000 in 2005 to 1,372 cases in 2009. (FMOH/NPHCDA, 2013). Meanwhile the incidence of measles in Nigeria began to increase up to 14,616 n 2010 (WHO/FMOH, 2012) & 21,000 in 2011 (Salako and Sholeye, 2015). Looking at this, effort was again made to curtail this resurgence of measles. Therefore Nigeria implement another measles follow up campaign for 2013. In line with the current measles and polio epidemiology the country and the managerial financial and logistical benefits achieved during previous campaigns, a decision as taken by the country to integrate polio into measles campaign in 2011, having an overall objective of sustaining the reduction of measles burden and preventing resurgence of measles incidence and to vaccinate at least 95% of children aged 9 to 59 months regardless of their previous immunization status as the specific objective. CURRENT STATUS OF MEASLES IN NIGERIA Measles is endemic in Nigeria and is one of the top ten causes of childhood morbidity and mortality in Nigeria. Large numbers of susceptible children accumulate every year due to birth cohort and low immunization coverage. Morbidity and mortality figures on measles are still uncomfortably high in Nigeria. For instance in 2013 Nigeria recorded 55,392 cases of measles and 16,357 in 2014, while in 2015 22,567 cases were recorded with mortality rate of 16,000. (WHO, 2015). While the citizens of this country continue to cry over the children who lost their lives to measles, checks revealed that 25million Nigerian children are yet to receive vaccination against measles; this means that the country should expect an increase in the number. Master web,(March, 2016) reported that according to Dr. Damaris Onwuka, the Director Disease Control and Immunization National Primary Health Care Development Agency, over 63% of children among those suspected or confirmed cases of measles are zero doses, which means they have never had any immunization. Among the efforts made by some states in Nigeria, WHO in partnership with Taraba State Ministry of Health in November, 2015 vaccinated not less than 760, 128 children against measles in the state. Bauchi state records 80% measles immunization in December, 2015, Ekiti state plan to minimize 515,531 children against measles in 2016. The national surveillance officer, World Health Organization (WHO) Dr. Irena Isibor frowned at the 19th Biennial Conference and Annual General Meeting of the medical Women’s Association of Nigeria, held at Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, saying that “due to people’s wrong attitude” most children in Nigeria still die from vaccine-preventable disease such as measles. The rise in morbidity and mortality of measles in Nigeria currently appear to be related to under utilization of measles vaccine due to inaccessible and sub-optimal vaccine programmes, poor immunization coverage and effectiveness and inadequate monitoring and evaluation of immunization programmes. All these are problems that are still lying in our environment and are yet to be addressed. Until this is done or else measles will continue to remain a significant threat to child health in Nigeria. ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION The percentage performance in advocacy, communication and social mobilization was very low looking at this review in terms of current status of measles as well as the analysis of control and elimination of measles in Nigeria. The established social mobilization committee (S.M.C.) right from the federal down to the state and local government were facilitating behavior change and communication. Information Educational and communication (IEC) materials were developed by developing partners like UNICEF and inadequately distributed to the local communities in the local government areas of this country. After a round of measles campaign, there is no continuous sensitization on the disease again until when another round of measles campaign is by the door step. As a result of these some rural dwellers in some parts of this country(particularly in the northern part of this country) looked at it as a right that health workers should bring to their door step inject able vaccines just as in the case of oral polio vaccine. There are no regular visits to nursery schools, market squares and other public places to conduct health talk on measles control activities .Social media as an effective channel of information dissemination is not effectively use for mobilization on measles control. CONCLUSION

Measles still remains a foremost source of morbidity and mortality in Nigeria regardless of being vaccine – avertable, the disease affect both sexes and all ages but the most vulnerable are infants and young children which is the main reason why children are supposed to habitually get measles vaccination mostly at nine months. A lots of efforts were made and series of strategies were employed aimed to reduce and sustain the resurgence of measles in Nigeria, but to no avail. Everyday children under the age of 5 years continue to die from measles. The high morbidity and mortality following measles infection in Nigeria appears to be attributed to gross under utilization of vaccine, the measles surveillance system, even though much improved is still sub optimal. Much of it is carried out at the local government level by DSNO who filled out form with different information. Also the inability of Nigeria government to establish itself as a credible authority to implement immunization programs because it fails to acknowledge the risk involved in vaccination. Finally, measles have become a cause for concern in Nigeria as many children are becoming victims every day. It then means that if nothing urgent is done then measles will continue to wipe away lots of children apart from the number it has already recorded. RECOMMENDATION

Measles morbidity and mortality is found to occur all year through in Nigeria irrespective of whether rainy or dry season, as such it has become an endemic disease in Nigeria. Sequel to the above, the following recommendation were made 1.     Advocacy strategy should include identifying key messages concurring measles eradication and consistency in message about each aspect of measles eradication is essential to the success of the advocacy strategy. 2.     Immunization strategy should be designed specifically to improve measles control and reduce death from measles in densely populated areas (urban and rural) and should be developed and supported by federal government, WHO and UNICEF. 3.     Maintenance of cold chain for vaccine should be a priority as diumal temperature varies and so does the time taken to get to vaccination locations which reduces vaccine quality as a result of thawing and ultra low freezers should be made available in all the 36 states of the federation with steady power supply in them. 4.     A strategic annual three year national mass vaccination plan should be put in place to reduce the wide interval of  between follow up campaign in order to increase herd immunity which is needed to stamp out measles virus completely. 5.     The government should establish itself as a credible authority to implement immunization programmes. 6.     More budgetary provision should be made to measles vaccination efforts in Nigeria so that infrastructure will be in place that will serve as a frame work for other vaccine preventable disease interventions as the health institutions are weak at the primary and secondary levels especially in remote and rural areas.

REFERENCES 1.     Salako, A. A & Sholeye, O.O (2015). “control of measles in Nigeria a critical review of literature”, british journal of medicine and medical research, 5(2) : 160 – 168 2.     Onoja A. B., & atel,  (2013). “Measles complication in a Nigerian hospital setting”, clinical reviews and opinions, 5(2): 18 – 23. 3.     Goodson, J. L atel (2011). “changing epidemiology of measles in Africa”, Journal of infectious disease, JD 2011: 204 (supply) S205 – S214. 4.     World health organization / federal ministry of health (2012). Report on “guidelines for measles surveillance and outbreak response” 5.     Masterweb reports, breaking news (2016) public mobility (roads) and environmental challenges. 6.     Nnebe, A. U. (2005) “ measles control in Nigeria the case for a two close vaccine policy” Nigeria journal of paediatrics, 32 (3): 41-45 7.      World Health Organization (2015). Report on “global measles mortality” and “measles cases and incidence rates” by WHO member states 2013, 2014 and 2015. 8.     World health organization / federal ministry of health, (2013). Report on “health care providers guide for managing measles cases.” 9.     National primary health care developed agency / federal ministry of health (2013). Report on “measles follow up campaign field guide”, 2013.