N.Y. Officials Struggle to Contain Measles Outbreaks
Health commissioners take emergency measures after hundreds of cases reported
by Elizabeth Hlavinka, Staff Writer, MedPage Today
MedPage Today traveled to New York’s Rockland County, where officials responding to a measles outbreak had announced a ban on unvaccinated individuals entering public spaces. We spoke with the county health commissioner, pediatricians, and leaders of the Jewish community about how the outbreak originated and what other measures have been taken to contain it.
ROCKLAND COUNTY, N.Y. — The outbreak of measles here, one of the largest in the U.S. since the virus was declared eradicated in 2000, sparked an emergency order that rippled through the state and brought renewed attention to the global resurgence of the highly communicable disease.
To stem the growing number of cases here, officials initially pulled unvaccinated children from schools where measles had been reported, then expanded this approach to include any school with a vaccination rate below 70%, then finally to any school with a vaccination rate below 95%.
As of this writing, 180 cases have been confirmed in Rockland, with most arising in Jewish Orthodox communities where only about two-thirds of children have historically been vaccinated, said Commissioner of Health Patricia Ruppert, DO, MPH.
“I can say safely that there are many, many, many more that go unreported,” she told MedPage Today. “The problem with that is that we don’t find out about them in a timely manner — if we ever find out about them — and therefore it’s more difficult to contain this.”
One case in the county caused a preterm birth and congenital measles, while others have led to pneumonia and intensive care unit admissions, Ruppert said. No cases of encephalitis, one of the more severe complications that can cause blinding, deafness, or seizures, have been reported, although certain forms like subacute sclerosing panencephalitis can take months or years to surface, she added.
The total cases of measles in 2019 have already surpassed those of 2018 and will likely soon eclipse totals for 2017 and 2018 combined (120 and 372, respectively), according to data from the CDC.
Rockland County Executive Ed Day declared a state of emergency on March 26, which barred unvaccinated individuals under 18 years of age from attending indoor places where 10 or more people are intended to congregate — minors unvaccinated for medical reasons and infants under 6 months were excluded.
But the declaration was short-lived, overturned by a temporary judicial restraining order issued on April 5, with the presiding judge stating that 0.05% of the population in the county affected by measles didn’t meet the criteria for an “epidemic.”
In the 10 days the ban was in effect, over 500 measles, mumps, and rubella (MMR) vaccinations were administered. In all, over 18,000 MMR vaccines have been administered in Rockland County since the outbreak started last October.
Day said the declaration was tailored to the community here and that he wouldn’t necessarily recommend going to this length in other counties, states, or countries, but this Tuesday the health commissioner in neighboring New York City declared a state of emergency to help contain the measles outbreak there, where 285 cases have been reported since the fall.
The New York City declaration orders anyone residing, working, or attending school in four ZIP codes in Williamsburg — where a large portion of the population is also Jewish Orthodox — to get the MMR vaccine. “Disease detectives” determine who is sick and who might have been exposed, and violating the order could result in a $1,000 fine.
In Rockland, no violations were reported while the public ban was in effect, and Day emphasized that it was not intended to be enforced. “There have been no directed patrols, arrests, or efforts to go out and find people that have vaccines or not,” he said.
Instead, he explained, the intention was to motivate county residents to get vaccinated with the backing of law in order to prevent the spread of the disease, and to support Ruppert’s prior order that all schools maintain a “herd immunity,” or at least a 95% vaccination rate, an order that was unaffected by the judge’s decision.
“We have seen people who were on the fence who now, with a lot more cases happening every week, and according to the [Department of Health’s] advice and according to the Rockland County legislator’s advice, are much more interested in getting that vaccine,” said Stanley Jacob, MD, a pediatrician at Helping Kids Pediatrics in New City, New York.
Ruppert emphasized that most people who have been vaccinated within the last 6 months had been hesitant to do so after hearing misinformation or were waiting until their children were older. As a result, she has focused efforts on educating the county’s residents and debunking rumors like the belief that after receiving the MMR, the live-attenuated virus will “shed” itself and spread to others, perpetuating the outbreak.
“It is so rare or uncommon for that to be the case,” Ruppert said. “That truly should not hold someone back from getting a vaccination.”
Fears of Anti-Semitism
Since the travelers who initially contracted measles in Rockland mostly lived in Jewish Orthodox areas of the county, many in the community feared this association would create a platform for anti-Semitism, said CEO of the Jewish Federation & Foundation of Rockland Gary Siepser.
He clarified that there is no objection in Jewish tradition or law to getting vaccinated, and that several prominent rabbis have recommended doing so. Last year, the Orthodox Union and the Rabbinical Council of America strongly urged parents to vaccinate their children as their family physicians recommended.
“I think the county executive went to great lengths to say, ‘This is about health and it’s about everybody’s health,’ and made sure that no one would mistake this as a reason to target any particular people or community,” Siepser told MedPage Today.
Siepser said for the most part, the community has not used this as a platform for anti-Semitism, although he has heard of a few isolated incidents.
Rabbi Aaron Fink, dean and founder of Ateres Bais Yaakov Academy of Rockland in New Hempstead, New York, does not admit students to the K-12 school unless they meet vaccination requirements. However, some schools in the area allow religious exemptions, which has recently been criticized as a way for “anti-vaxxers” to circumvent immunization requirements. In New York, a recently proposed piece of legislation would ban such exemptions.
“My school’s decision has been if you want to be an anti-vaxxer, go to another school,” Fink told MedPage Today.
“We took a risk about that and I’m sure it affected our enrollment and therefore our income, but we felt it was worth the public risk,” he said. “We just don’t want any of our young teachers [who are] women in their childbearing years being exposed to a disease that could really affect their unborn child.”
What’s Next for Rockland?
While Day’s declaration was generally met with a positive response, it was by no means universally accepted. A group of about 30 parents sued Day for enacting the public spaces ban, and one group of anti-vaxxers protested outside the Palisades Center Mall in West Nyack a couple of days after the declaration, wearing T-shirts that read “Research before you vaccinate” and “My religion, my family, my choice.” Others took to social
“We are not going to sit idly by and wait for a judicial decision to take action,” Day said at a recent press conference. “This outbreak is an imminent threat to public health — you have to not be paying attention to understand that — and we will take every action within our power to combat it.”