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 It was October 2018. The boy had measles, which spreads through the
air. His illness was the dawn of the worst outbreak in the United
States for more than a quarter century, and the start of a
multi-million-dollar effort by an understaffed health department to
contain it.
Two miles from where the boy lay, Maria Souto was in her office in
the county health department, where for 15 years she has served as
the county's communicable disease coordinator. She took a call from
the physician who had diagnosed him, hung up and rushed to the
next-door office to alert Kevin McKay, the county epidemiologist.
Their heads were spinning, McKay said: "Everything else stopped
right there."
What follows is the previously unreported story of how a suburban
health department at the epicenter of a national health crisis
brought the outbreak under control, in the face of campaigning by
people who oppose vaccination. It is based on interviews with more
than a dozen health officials, medical experts and local residents.
Measles, which causes a rash, fever and coughing, can be fatal and
lands up to 20% of Americans who catch it in the hospital. It
afflicted millions of Americans every year before a vaccine became
available in 1963. The vaccine is 97% effective with two doses and
helped the United States eliminate the disease in 2000, according to
the World Health Organization (WHO), which says measles is wiped out
if there is no continuous, endemic transmission for 12 months.
The Rockland County case was one of two major U.S. outbreaks last
year - the other, in Brooklyn, started a day earlier. Both put the
United States on the clock. If they weren't halted within 365 days,
either could have cost America its WHO-certified measles-free status
- damaging its reputation as a developed country with an effective
public healthcare system.
In Rockland County, everything depended on whether a team of about a
half-dozen health officials could rally their community to stop one
of the world's most contagious diseases from spreading.
Just six days before the deadline - after more than 1,400 people
across 31 states had contracted the virus and nearly 30,000 doses of
vaccine been administered in Rockland County alone – county
officials declared the outbreak was over. The direct cost of the
county's response, according to its preliminary estimates, was
between $2.4 million and $6.5 million - possibly as much as
one-tenth of the county health department's annual budget.
To some health officials, it was a hollow victory – a small battle
in a global fight against an enemy that respects no borders and is
fed as much by confusion and mistrust of modern medicine as by
microbes.
Both New York outbreaks involved international travelers. Patrick
O'Connor, who leads rapid disease control at the WHO, said health
officials are investigating "chains of transmission" which may link
the New York outbreaks to Ukraine, a country struggling with a
measles epidemic that has infected more than 58,000 people in 2019
alone. Some visitors came from communities in Israel where many
people make an annual pilgrimage to the grave of a revered rabbi in
the former Soviet Union state.
"A lot of people think ... it's all fine," said New York State
Health Commissioner Howard Zucker last month. "But it's not done,
because there are travelers that pop up, and it still comes back."
In Ukraine, only half the population believes vaccines are
effective, compared with 84% in the United States, according to a
report published in June by Britain's Wellcome Trust, based on a
survey of attitudes among 140,000 people from 140 countries.
U.S. officials fully expect there will be fresh measles cases,
potentially leading to new outbreaks of measles or other dangerous
diseases, as some people harbor overwhelming suspicions about
vaccines, and distrust the agencies that recommend them.
THE FIRST PATIENT
Rockland County's measles campaign started on Oct. 1 with the
teenager in the clinic. Originally from Israel - officials declined
to give his name and age - he was visiting for the Jewish Holy Days
and fell sick during services at synagogue.
Once measles was diagnosed, the entire wing of the Refuah Health
Center was evacuated and signs put up warning people not to enter.
Souto and McKay drove to the clinic, saw the boy and interviewed his
father. When had they arrived in the United States? Who had they
come in contact with? Where had they been within the county?
They had made several visits, the father said, to the synagogue.
"The synagogue had thousands of people," Souto said in a phone
interview.
McKay inspected the big, open worship hall, the sort of setting
where transmittable diseases flourish. The patient's father and a
rabbi pointed to the places the boy had been. Neither could be
reached.
"They were pointing at this side of the building on this day, and
this side of the building on this day," McKay said. "Basically you
had to consider everyone exposed."
Health department phones were soon ringing again - doctors and
clinics calling to report patients with rashes.
Nationwide, the rate of children in the United States who received
no vaccines by age 2 has been rising - from 0.9% of those born in
2011 to 1.3% of those born in 2015, according to the U.S. Centers
for Disease Control and Prevention (CDC). That represents more than
18,000 children.
In Rockland County, about a third of the population is Jewish,
including a large enclave of Orthodox Jews who live in secluded
communities. According to county data on vaccination rates, which
only includes school-age children, some Jewish schools in the county
had measles vaccination rates below 70% in 2018, compared to 99%
statewide.
While the Orthodox Union and the Rabbinical Council of America
strongly recommend parents vaccinate healthy children, a small
minority of rabbis and Orthodox Jewish people claim ingredients in
vaccines violate religious principles. Rabbi Asher Bush, who leads
the Congregation Ahavat Yisrael in Rockland County, said this
opposition on religious grounds is unfounded. "That's not Judaism,
it's a personal choice," he said. "I think it's a silly, foolish
personal choice."
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Health officials believe opponents of vaccination have become
increasingly influential in the Orthodox community in the last 5 to
10 years. They trace this skepticism to a pamphlet that came out at
least five years ago from an anonymous group calling itself "P.E.A.C.H."
(Parents educating and advocating for children's health) which
circulates in print and online. The pamphlet contains bogus or
unsupported assertions about vaccines, scientists say. To reduce the
risk of contracting measles, for instance, the pamphlet recommends
Vitamin A supplements instead of vaccination.
"From our research (and for some of us, from personal experience)
many more than 'one in a million' lives have been ruined by
vaccines," its authors write.
P.E.A.C.H. and other anti-vaccination advocates did not respond to
emails requesting comment.
Within the first half of October 2018, Rockland County had recorded
a dozen measles cases. By month's end, there were 51. More than 300
people would eventually be diagnosed with measles, or about 1 in
every 1,000 residents.
HOME VISITS
Rockland County's health department staff of 180 had between six and
eight employees dedicated to the outbreak. Others helped
occasionally while running some 50 county health programs and
services. Between 2008 and 2013 overall staff numbers were cut by
30%, said Patricia Ruppert, the County Health Commissioner. Some
positions have since been filled.
Employees were joined by state health officials, local doctors,
school administrators, rabbis and, as the crisis worsened, federal
health officials. The county executive declared a state of emergency
in March. Staff frequently worked 14-hour days. "I'm talking day and
night, weekends, holidays, it didn't matter," said Ruppert.
Over the year, around 1,200 of the people known to have been exposed
to the virus were deemed to be susceptible to infection. Health
officials called or visited their homes every day for the measles
incubation period of at least 21 days, to ensure the disease did not
appear and that those who might be carrying it stayed home. Some
days they checked on more than a hundred people.
Staff would also drive two hours each way to bring nasal swab
samples from patients with rashes to the state lab in Albany to be
tested. At first, they mailed the samples overnight, but then
learned some were left in a shipping warehouse over the weekend.
Wanting to confirm new cases as soon as possible, staff
hand-delivered them in coolers.
Meanwhile, anti-vaccination advocates were conducting a live
campaign to prevent people in the Orthodox community from having
vaccinations.
As measles cases topped 250 in May, a group called the United Jewish
Community Council hosted a symposium five miles from the health
department. Speakers included Andrew Wakefield, whose medical
license was revoked in the UK for repeatedly breaching "fundamental
principles" of research medicine, and Lawrence Palevsky, a
pediatrician in New York. Neither speaker responded to requests for
comment, and the Council could not be reached. Health workers said
attendees, many of whom were Rockland County Orthodox Jews, were
given pamphlets saying - falsely - that vaccines cause autism.
Debra Blog, a state health department epidemiologist, attended, but
left after she heard a doctor say vaccines were unsafe. "It was not
a forum where I could counter anybody or say anything," she said.
Common side effects of the measles, mumps and rubella (MMR) vaccine
include a sore arm, fever and a mild rash. Serious reactions are
rare: According to the CDC, about 4 out of every 10,000 children who
receive the MMR vaccine between ages 1 and 2 have febrile seizures
and 1 out of 40,000 will develop a non-life threatening bleeding
disorder.
THE DECISION-MAKERS
Many Orthodox Jews in the Rockland community did not want to talk to
the health officials. "I think there are people who resent having
others tell them what to do," Rabbi Bush said. But as the staff
knocked on doors and made phone calls to persuade people to immunize
their children, they made progress with one key constituency:
mothers.
The mothers they reached were often not strongly opposed to
vaccines, but had simply delayed scheduling their children's shots.
In December, the New York State Department of Health contacted
Shoshana Bernstein, herself an Orthodox mother of five children
living nearby in Monsey, NY. She wrote a pro-vaccination pamphlet
geared towards Orthodox Jews a few years ago.
The department ordered 50,000 copies and sent them to around 15,000
Orthodox Jewish homes in Rockland County.
Bernstein said she offered an alternative to the rumor-mill of false
claims about vaccines: "If someone tells you if you give your baby
daughter a shot she's going to have cancer in 10 years, what's a mom
supposed to do with that information?" she said in a phone
interview. "I sort of became known as the person to call when you
had a question."
There were holdouts, and County Health Commissioner Ruppert's team
combed through hundreds of thousands of school immunization forms to
check who had been vaccinated. They excluded more than 5,500
students from school until the students had received shots. In the
end, more than 29,000 doses of the vaccine were administered,
Ruppert said.
Six days before the United States would have fallen short of WHO
standards, the Rockland County health staff gathered for a regular
call with health officials from the state and neighboring counties.
The question: had 42 days had passed since the last measles rash had
been recorded? If it had, this outbreak would have been contained.
The call was short. "My update that day was 'Rockland County's
outbreak is over,'" Souto said.
Cheers erupted on the line.
(Reporting by Gabriella Borter; Edited by Paul Thomasch and Sara
Ledwith)
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