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The measles virus. (Cynthia Goldsmith, the Centers for Disease Control and Prevention via AP)
Centers for Disease Control and Prevention via AP, showing the measles virus
'All it takes to spread measles is a few unvaccinated kids'

Ill-prepared Israeli health system struggles to keep measles at bay

Israel is the 6th-most measles-stricken country and the only developed nation in World Health Organization’s ‘blacklist’. A booming birthrate and stratified society provide clues

Main image by Centers for Disease Control and Prevention via AP, showing the measles virus

Common hypothetical doomsday scenarios often include terrorism or a nuclear war, but in the 21st century, especially in Western countries, they don’t usually involve a lethal worldwide pandemic.

That all changed in late 2016, when the World Health Organization (WHO) first reported a 30 percent spike in measles cases worldwide, warning that multiple countries experienced “severe and protracted outbreaks” of the disease believed to have been all but stamped out back in 2000.

Measles is considered the most contagious of all infectious diseases. The virus causes severe flu-like symptoms and a characteristic bumpy rash, but in certain cases, complications that affect the respiratory and nervous systems could be life-threatening.

The most recent update from WHO says: “The latest year for which WHO global measles case and death estimates are available is 2017; in that year there were 6.7 million estimated measles cases and 110,000 estimated measles-related deaths, based on 173,330 reported cases.” These figures make this the worst measles outbreak in 25 years.

Worse, the WHO warned that the actual number of people afflicted with measles is most likely higher, saying its database comprises only cases confirmed through lab testing or clinical visits.

This means that there are probably thousands of people who contracted measles and never sought medical attention.

A map of the global measles outbreak (World Health Organization via Zman Yisrael)

According to WHO data, as of mid-2019, “Sizeable measles outbreaks” have been noted in the Democratic Republic of the Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand, and Ukraine, while “spikes in case numbers” have been recorded in the United States, Israel, Thailand, and Tunisia.

These kinds of reports create the impression that measles is running rampant in poor countries, while in Israel it is still under control. But that is a misleading conclusion, as the measles outbreak in Israel is severe even compared to the countries worst-stricken.

The WHO’s latest update on the global outbreak lists 16 countries that “have had a high rate of measles cases in the past year.” Fifteen of them are considered Second and Third World countries. The only developed, OECD member-state on this apparent “blacklist” is Israel.

The only developed, OECD member-state on this apparent ‘blacklist’ is Israel

Israel is not included in this list erroneously or due to political pressure by its adversaries. WHO data says 3,755 Israelis have been diagnosed with measles between April 2018 and March 2019. By July, the Israeli Health Ministry pegged the number of local measles cases at 4,292.

These figures put Israel at the sixth worst-plagued country in the world, in absolute terms.

The latest outbreak has so far claimed three lives in Israel: In November 2018, an 18-month-old toddler who was not vaccinated succumbed to it, becoming the first recorded measles-related death in Israel in 15 years. In December, the disease claimed an 82-year-old woman, and in August 2019, Israeli flight attendant Rotem Amitai, 43, who had contracted measles on a flight from New York in late March, became the third fatality of the outbreak.

A newborn baby suffering from measles. (Illustrative. iStock by Getty Images/andriano_cz)

According to WHO data, there are 59 measles patients for every 100,000 people in Israel. This places the Jewish state before Albania (64 patients per 100,000 people) but behind India, (28 patients per 100,000 people), and far behind Brazil, with five cases per 100,000 people.

One could argue, of course, that Israeli authorities simply know about a higher number of patients than their counterparts in developing countries such as India and Brazil, where many patients are undiagnosed and untreated. But even when comparing the situation in Israel with that of other developed countries, the number of measles cases here is still much higher.

France — another measles hotspot — has an average of 42 measles cases per 100,000 people. In Italy, which is considered the epicenter of the severe measles outbreak overrunning the European Union, there are 36 cases per 100,000 people. In Britain that number stands at 19; in Germany it is pegged at 10, and in the US there is less than one measles patient per 100,000 people.

‘Herd immunity is a must’

“If a person who is not vaccinated against measles enters a room where a measles patient spent time hours before, he may contract the disease — that’s what we mean when we say it’s highly contagious,” Edva Lotan, CEO of Mida’at, a nonprofit organization committed to advancing public health, told The Times of Israel’s Hebrew sister site, Zman Yisrael.

Every population has groups that cannot be immunized against measles: babies under one year, people with medical sensitivities, and those for whom the vaccine simply does not work. Measles can spread very quickly wherever more than five percent of the population has not been vaccinated, much like other infectious diseases.

“The only way to protect everyone and prevent measles from spreading is to create ‘herd immunity,’ which means reaching a situation where over 95% of people are immune to the disease,” Lotan said, referring to a form of indirect protection that occurs when a large percentage of a population has become immune to an infection, thereby lowering risk for individuals who are not immune.

“The problem is that it’s not just 95% of the people in the country, but 95% of the people who are in any public place at any given time. To get there, we need anyone who can get vaccinated to just do it,” she said.

Edva Lotan, CEO of Mida’at public health NGO. (Felix Lotan via Zman Yisrael)

According to the WHO, in most countries there is a proven link between the number of vaccinated children and the ratio of overall measles cases.

In 10 of the 12 countries examined it was found that the more children were vaccinated against measles, the fewer cases there were of the disease. In the US and Germany, more than 90% of children and youth under 21 have received the full measles vaccine.

The United States Centers for Disease Control and Prevention recommends all children receive two doses of the combined measles-mumps-rubella vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. This two-dose practice is common in most Western countries, including in Israel.

Anti-vaccination propaganda taking its toll

Contrary to popular belief, measles is not spreading worldwide. On the contrary — the number of measles patients has dropped dramatically over the last 40 years, from about 4 million in the 1980s to about 400,000 today. We owe this decline to the fact that nowadays, hundreds of millions of children in developing countries, especially in Asia and Africa, are vaccinated against the measles.

But it is precisely in developed countries, where a large part of the population has been routinely vaccinated for decades, that the opposite trend has been manifesting and an increasing number of children go unvaccinated.

As a result, in all the countries where the number of unvaccinated children has risen, without exception, measles has once again reared its head.

A one-dose bottle of measles, mumps and rubella virus (MMR) vaccine at the Health Department of Salt Lake County, Utah, on April 26, 2019. (Illustrative. George Frey/Getty Images)

In some countries, budgetary issues or the privatization of the health care system have resulted in a shortage of vaccines. In most developed countries, though, the problem lies not with insufficient access to vaccines, but rather with a growing number of parents who refuse to vaccinate their children.

Much of that has to do with false anti-vaccine propaganda, which is spreading like an epidemic on social media.

This combination of a vaccine shortage and massive anti-vaccine propaganda has caused a sharp decline in the number of vaccinated children in Eastern European countries, resulting in the highest increase in the number of measles cases.

The most serious outbreak in Europe has been in Ukraine. While at the turn of the century about 99% of Ukrainian children had received all the necessary vaccines, by 2013 only 57% of Ukrainian children and infants were vaccinated against measles, as well as against other equally or more dangerous diseases.

Thus, Ukraine went from having almost no measles patients in the previous decade to a recorded 54,000 cases in 2018, including 25 deaths.

Ukraine went from having almost no measles patients in the previous decade to a recorded 54,000 cases in 2018, including 25 deaths

The vaccine shortage, bureaucratic corruption, mistrust of the health care system, and online lies were taking a heavy toll on public health.

In Ukraine, it seems the disdain and mistrust of scientific knowledge have spread not only among the general public but within the health care system itself, as doctors increasingly recommend that parents opt not to vaccinate children, and about 30% of medical publications penned by physicians do the same.

The Israeli anomaly

WHO data found only two countries where most children are vaccinated for measles and yet many others still have high rates of infection: The first is Albania, whose government reports a 99% vaccination rate among children and is nevertheless experiencing a measles outbreak. The second is Israel.

The data shows that Israel has seen a slight drop in vaccination rates in recent years, which is believed to be what caused the local epidemic: In 2000, 97% of Israeli children in the relevant age groups were immunized; in 2013, 96% of children were vaccinated, and a similar number of children were vaccinated in 2017.

This means there are more vaccinated children in Israel than, for example, in the US, France, the UK, Germany, and Italy — yet it seems that measles has hit the Jewish state harder.

Dr. Hagai Levine, an epidemiologist with the Hadassah School of Public Health and secretary of the Israeli Association of Public Health Physicians, says the measles outbreak in Israel is an anomaly.

Dr. Hagai Levine of the Israeli Association of Public Health Physicians (The Hebrew University of Jerusalem via Zman Israel)

“Scientific research has proven beyond doubt that exposure to attenuated measles virus, the kind given in the vaccine, results in a near-complete elimination of measles morbidity on both the individual and population levels. The more people are vaccinated, the lower their risk of contracting measles, and the lower the risk of society as a whole to experience an outbreak,” said Levine.

“As measles is a highly contagious disease, all it takes is a few unvaccinated children in certain sectors of society, schools or neighborhoods, for measles to spread, even if the majority of other people have been vaccinated. That’s exactly the situation in Israel,” he explained.

Mida’at’s Lotan added that Israel has a unique set of circumstances: It is a very densely-populated country with the highest ratio of children among all developed countries. And when it comes to measles, children are the fastest-infected and most contagious population.

“There are large communities in Israel that are not vaccinated and live in very close proximity to each other. Some are poor and have no access to vaccines, some oppose immunization, and in some, it’s a combination of the two,” she said.

Current data, however, makes it difficult to determine where “hotspots” of the infectious disease are truly located.

“We don’t have enough information to determine whether anthroposophical or democratic schools and the communities they serve are places from which the disease is spreading,” Lotan said, referring to education streams where parents have been particularly vocal about their objections to immunization.

When it comes to measles, children are the fastest-infected and most contagious population

“There have been clusters of cases in certain schools but does that mean anything for the communities as a whole? I don’t know,” she said.

The data, however, is much more conclusive with respect to ultra-Orthodox communities.

“With regard to the Haredi population, the information is clear because we know that there is a high ratio of anti-vaxxers among them,” she noted. “The majority of Haredim get vaccinated, and there are rabbinical decrees supporting it. On the other hand, some rabbis oppose vaccination and because of the authority they wield, people refuse [to immunize their children].”

A sign warns people of measles in the ultra-Orthodox Jewish community in Williamsburg on April 19, 2019, in New York City. (Spencer Platt/Getty Images/AFP)

“In Haredi society, there are also all-boys schools and the principal can decide he doesn’t want the students to get the vaccines in order to prevent them from coming into contact with female nurses. There are solutions for that, but [the schools] just prefer to skip the vaccine,” Lotan said.

“Some in the Haredi sector have no access to vaccinations,” she continued. “It’s not easy for a family with 10 children to get to Tipat Halav [maternal-child health clinic]. Many Haredi families vaccinate their children when they are two or three years old, instead of when they turn one. Statistically, these children are considered as having been vaccinated, but in reality, they don’t have the protection immunization offers at precisely the age when they are most vulnerable to measles.”

The question remains why similar religious and spiritual communities in the United States, for example, have not become measles hotspots but their Israeli counterparts have.

The answer, Lotan said, has to do with the basic size of the population. “Communities of this nature in the US have also experienced measles outbreaks, but they are a relatively small part of the huge American society,” which as of 2018 numbered 327.2 million people. “In Israel, the ultra-Orthodox and other segregated communities make up a substantial part of society.”

 The legal leverage

The solution for the measles outbreak is seemingly simple — mandating vaccination. Many countries have countered the anti-vaccination trend by passing laws compelling parents to immunize their children.

In 2015, France passed a law requiring all parents to vaccinate their children against 11 diseases as a precondition for their admission to kindergartens and schools. The result was immediate: the number of vaccinated children rose from 75% in 2013 to 84% in 2017.

Germany has no actual law on the matter, but new parents are required to attend a series of sessions with a pediatrician who explains why they should vaccinate their child. In 2018, Germany passed a law requiring schools to provide authorities with a list of unvaccinated children and their parents are required to attend mandatory counseling with pediatricians. Parents who fail or refuse to attend these meetings are fined to the tune of €2,500 ($2,800).

In 2016, Italy passed emergency legislation seeking to curb its measles outbreak. The law made it a requirement for parents to immunize their children with 12 compulsory vaccines; it increased state funding for vaccines; ordered a mandatory counseling session for all parents on the importance of immunizing their children; banned unvaccinated children from kindergartens, and imposed a €500 ($560) fine on parents who send unvaccinated children to school.

In an attempt to battle the measles outbreak, some countries in Europe have enacted laws making vaccinating children mandatory. (Illustrative. Miriam Alster/FLASH90)

In the UK, parents are not legally obligated to vaccinate their children. But unlike most countries, British schools are allowed to vaccinate children without their parents’ consent, if the children themselves have received the appropriate explanation about the procedure and agreed to it.

Federal law in the United States prohibits children who are not vaccinated from entering educational institutions. However, the law has only been adopted in some states and is enforced only in public schools and not in private schools.

As a result, some states tolerate the fact that certain sectors opt not to vaccinate children over “religious or conscientious objections.” These communities are exactly the ones that have been experiencing an uptick in measles cases over the past few months.

Eastern European countries are also trying to make it harder for parents not to vaccinate their children.

Georgia, for example, has enacted a law banning children who are not vaccinated from schools. It has also instated a national parental education program and has recently taken the aggressive step of criminalizing the refusal to immunize children. All these have resulted in a steady rise in the number of vaccinated children.

Such laws, however, are not always successful.

Ukraine passed a law mandating immunizations, but this birthed an industry of doctors selling inexpensive fake vaccination certificates

The Ukrainian government passed a law that makes immunizing children mandatory, but according to WHO studies, this birthed an industry of doctors selling parents fake vaccination certificates for a price lower than that of the vaccine.

‘The Health Ministry isn’t doing anything’

One would think that, given the increase in measles cases in Israel the government would be proactive, but that has not been the case. There is no law compelling vaccination, no law barring unvaccinated children from attending schools, no disciplinary action against anti-vaxxers, and no educational effort targeting the parents.

Israeli law, which allows the government to shutter schools in case they experience a measles outbreak, has so far only been applied to two schools, in Jerusalem and Harish, near Haifa. But stopping an epidemic requires more than simply isolating the patients — it requires mass vaccination. So far, the government has done nothing to promote that.

“Measles is spreading because there is no policy to prevent that from happening,” Lotan said. “There is no enforcement, there is little to no education on the importance of vaccines, and there is also no move to vaccinate adults ages 40-60 who were not vaccinated in childhood. Other than a PR campaign and putting out fires, the Health Ministry isn’t doing anything.”

Last year, former MKs Yoel Hasson (Zionist Camp), Shuli Moalem-Refaeli (Jewish Home) and Meirav Ben Ari (Kulanu) presented a bill meant to both encourage vaccinations and give authorities the power to ban unvaccinated children from all educational frameworks, as well as obligate the Health Ministry to promote immunization and penalize parents who adamantly refuse to immunize their children for anything other than medical reasons.

The proposal passed its preliminary and first Knesset readings almost unanimously and was referred, as the legislative process demands, to the relevant parliamentary committee — in this case, the Knesset Health Committee. But then came April’s general elections with their political deadlock, which led to September’s elections.

It is unclear at this time whether a government will be formed in the wake of the elections and regardless, none of the three lawmakers who drafted the vaccination bill were reelected, so for the proposal to move forward, another MK will have to assume the mantle.

A baby receives a vaccine at a Tipat Halav maternal-child health clinic. (Illustrative. Noam Moskowitz/FLASH90)

But even if this bill becomes a law, it is unlikely to materially change the scope of vaccination for the simple reason that it does not impose a sweeping legal obligation to immunize children, nor does it allow schools to remove unvaccinated children.

Lotan, whose organization co-drafted the bill, said many of her colleagues “criticized if for being too ‘weak.’ But the point wasn’t to target anti-vaxxers — the point was to pass a law that can be implemented in Israeli reality. If you remove unvaccinated children from school, they don’t get vaccinated — they just stay at home.”

If you remove unvaccinated children from school, they don’t get vaccinated — they just stay at home

Israel’s Tipat Halav maternal-child health clinic, whose nurses administer vaccines for babies and children through kindergarten age, suffers from a continuously diminishing budget and loss of personnel.

“It is quite clear that a much wider measles outbreak has been avoided thanks to Tipat Halav,” Levine noted. “But this system is suffering from severe erosion. It’s starved for budgets, manpower, and additional locations, all while the population is rapidly growing.”

According to Levine, affording this public health care provider the budgets it needs will go a long way towards boosting vaccination rates, thus improving morbidity and mortality rates in Israel.

The Health Ministry, for its part, said it is sparing no effort to fight the measles outbreak.

“In recent years, measles outbreaks have been reported in Europe, the US, and elsewhere,” it said in a statement. “The high number of recorded cases in Israel can be traced back to ‘imported’ measles cases combined with ‘pockets’ of unvaccinated people among the general population.”

The ministry ascribed the high figures quoted by the WHO to an acute increase of cases during the last four months of 2018 (at which time up to 900 new patients were reported per month). In recent months, it claimed, there has been a significant decline in reports of the disease.

Eliminating the disease “requires complete immunization coverage of the entire population, especially children,” said the ministry, noting that laws do not currently make vaccination mandatory, though the option of penalizing parents who do not immunize their children is still being considered.

“It should be noted that most of the countries that enacted a mandatory vaccination law had lower vaccination rates than Israel before and after said legislation was passed. In addition, countries with mandatory immunization laws have still experienced measles outbreaks,” the ministry said.

“During the outbreak, the Health Ministry bolstered personnel at Tipat Halav clinics and vaccination stations nationwide,” said the ministry, “as well as operated a mobile vaccine station so as to increase immunization among the general population, especially in the ultra-Orthodox sector.”

A version of this article first appeared in Hebrew on The Times of Israel’s sister site, Zman Yisrael.

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