UPDATE 4.17.19 1:12 PM: The Maryland Department of Health and the Montgomery County Department of Health and Human Services, in conjunction with local health providers, will provide a free MMR clinic for adults between the ages of 30 and 62 on Monday April 22nd from 4 p.m. to 7p.m. in the social hall of Congregation Young Israel Shomrai Emunah (1132 Arcola Avenue in Silver Spring).
UPDATE 4.12.19 3:57 AM: Baltimore City Health Department will provide a free MMR clinic Friday April 12 from 10 a.m ot 5 p.m. at Congregation Shomrei Emunah (6221 Greenspring Avenue) for adults between the ages of 30 and 62 in conjunction with and sponsored by Sinai Hospital.
On April 9, the Vaad HaRabbonim of Baltimore and other Jewish community institutions issued a letter banning unvaccinated adults and children from public spaces and group settings, following confirmation of a case of measles in the Jewish community by the Maryland Department of Health (DOH) on April 5.
The Vaad announced earlier in the week that it was working with Hatzalah, local physicians, Jewish schools, the infectious disease team at Sinai Hospital, and county and state health departments to determine next steps. The Vaad’s April 9 letter reiterated its assurance that “there is not an epidemic of any kind in our community,” but that medical and government officials are recommending caution.
“The Health Department has made specific recommendations for people who might be at increased risk of measles exposure, including people planning to travel to areas with measles outbreaks or who might have contact with visitors from these areas. Please note that – especially in the light of recent patterns of outbreaks in other Orthodox communities, and because of the extensive travel and close contact between communities – we consider the entire Orthodox community at increased risk and should as such follow these recommendations.”
“Individuals who choose not to vaccinate themselves or their children must avoid public places and group settings of all kinds, as their presence poses a serious risk to the community at large,” the letter continued. This follows a November 2018 statement from the Vaad HaRabbonim urging holdouts to seek vaccination.
The letter also noted that adults born after 1957 and before 1989, who have likely only received one dose of MMR vaccine rather than the presently recommended two doses, are advised to seek a second dose from their doctor. (This is a lesson learned from combating the outbreak in Detroit.) An MMR clinic in Baltimore in partnership with Sinai Hospital is presently being planned to facilitate vaccinations.
The Big Picture
Before the vaccine against measles became available, it was a common childhood disease. Every year, however, an average of one to two in 1,000 cases were fatal – and most of the fatalities were among otherwise healthy children.
A severe reaction to the vaccine, by contrast, is estimated by the Centers for Disease Control and Prevention (CDC) to occur in about one in a million doses. An allergy to a material in the vaccine, such as gelatin or the antibiotic neomycin, is generally the culprit in such cases.
As of April 4, there were 465 reported cases of measles in 19 states in the U.S. There are currently outbreaks (meaning three or more confirmed cases) in Washington state, New York, New Jersey, Michigan, and two counties in California.
According to Dr. Ron Reisler of Silver Spring, Maryland, an infectious disease expert and the lead clinical physician at the US Army Medical Research Institute of Infectious Diseases (USAMRIID), vaccination rates among American Jews are “exceedingly high.” Of the 17 measles outbreaks in 2018, however, CDC found that the three outbreaks that contributed to most of the cases nationwide were primarily among unvaccinated people in Orthodox Jewish communities in New Jersey, New York City, and New York state.
The current outbreak in Brooklyn and Queens, for instance, has been ongoing since October 2018 and involves 285 cases as of April 8, 2019. It started when an unvaccinated child acquired measles on a visit to Israel; since then, additional people from Brooklyn and Queens who acquired it the same way contributed to the spread back home among those who had not traveled.
Reisler called for rabbinic leaders in Israel and in the U.S. to come out unequivocally against the anti-vaxxers in their communities and ensure that all schools and daycares require routine childhood vaccinations prior to matriculation.
That isn’t to say that vaccinations should be carried out without screening, he added: CDC has an important list of contraindications and precautions health care providers should look out for (https://www.cdc.gov/vaccines/vpd/mmr/hcp/recommendations.html ) . A contraindication is a condition that greatly increases the chance of a serious adverse reaction; a precaution is a condition that might increase the chance or severity of a serious adverse reaction, or compromise the ability of the vaccine to produce immunity.
A Strong Defense
As of April 10, no cases of measles have been reported by health department officials in Virginia or DC, nor have additional cases been reported in Maryland.
Still, multiple synagogues in the Greater Baltimore and Greater Washington area are opting to electronically disseminate and physically post announcements barring entry for unvaccinated children to synagogue buildings, playgrounds, and public events. Many see this as a collaborative stand – not only against a threat to communal safety, but also for the halachic obligation to protect oneself and one’s fellow from harm.
“Over Pesach, we receive hundreds of visitors and guests who are traveling during Chol HaMoed [the intermediate days of Passover], many of whom are coming from communities already experiencing outbreaks or vaccination issues,” said Aaron Tessler, a member of Kesher Israel Congregation in Washington, D.C. “We believed it was necessary to take this step ahead of that visitor boom.”
The synagogue’s policy statement was written in close coordination with shul lay leadership, its rabbi, and medical experts in infectious disease. “It was shul members who did everything, from drafting signage in three languages to researching halachic statements to determining how best to get out the word in the most effective and persuasive manner,” said Kesher Israel President Andrew Cooper.
Advice for Travelers
The physicians, epidemiologist, and infectious disease specialist consulted for this article recommended that pregnant women and anyone with a compromised immune system reach out to their doctors for advice if they plan to be in an area experiencing a measles outbreak. People who are otherwise healthy and certain they received two doses of the MMR vaccine do not need to check their titers (the concentration of antibodies against a particular pathogen).
“I always recommend early MMR for infants over six months traveling abroad, including to Israel and Europe,” said pediatrician Dr. Rebecca Elias-Bachrach of Silver Spring. “New York, New Jersey, and Detroit are all involved in active outbreaks right now, and I think early vaccination or a booster dose would be appropriate for any young child traveling to one of those places.”
“It’s too soon to say for certain if Baltimore will fall into that high-risk category, and my practice is currently following updates and not yet recommending early vaccines. If a parent is concerned, they can always talk to their child’s pediatrician,” she said.
The typical vaccine schedule is for healthy children to receive a first dose at 12 to 15 months and a booster dose at 4 years old (vaccination is not recommended for children under 6 months). Children who get an early dose still need two doses after they turn 1, as vaccines prior to that age do not have the same level of effectiveness. Children under 4 traveling to high-risk areas can get their booster dose early, as long as it is has been more than four weeks since their first dose, said Elias-Bachrach. “They probably don’t need a third dose at 4 years old, but schools might insist on it for records purposes,” she said. “There are no significant risks to getting three measles vaccines under either of those circumstances.”
When it comes to Pesach resorts, Elias-Bachrach said she is worried about the risk of transmission.
“I don’t know what the right answer is for Pesach resorts,” she said. “Sharing information about measles symptoms would be a good place to start, so guests know what to look out for. Another idea might be a generous cancellation policy, so that a guest with fever and rash isn’t tempted to come anyway.”
Pesach program administrators are aware there is concern. For instance, the Jewish Heritage Center Pesach Program in Stamford, Connecticut, preemptively emailed its guests.
“As a preventative measure for the health of all children spending Yom Tov with us we can only allow children that are properly vaccinated to attend this hotel program,” the email said. Guests were asked to “click to confirm” they understood and would comply with this policy.
Summer camps require vaccination records, said Reisler, but for this year it may be too late for the Pesach resort programs to implement a vaccination requirement prior to attending.
Resort programs hosting families from an area of ongoing outbreak may be putting their guests at risk, he said.
“In order to mitigate this risk, the resort should have a medical professional on staff that is ready to spring into action if a guest develops measles during Pesach. Guests exposed to measles can be offered post-exposure prophylaxis (PEP), such as an MMR vaccine and/or IV gamma globulin, unless contraindicated or if the risk outweighs the benefit.”
“In fact, if a guest were to actually develop measles, there is an investigational intravenous antiviral treatment for severe cases of measles – remdesivir, developed by Gilead – that can be administered in a hospital setting,” he added. The treating physician would have to request the drug directly from Gilead, however.
In general, anyone notified that they may have been exposed to measles should determine if they are susceptible and seek treatment if necessary. (See inset.) “Three out of every 100 people who get the two doses of measles vaccine may still contract measles if exposed, but it is likely to be less severe and less infectious to others. That’s true regardless of titers, though it’s not completely clear why,” said Elias-Bachrach.
Measles: Exposure and Symptoms
The measles virus spreads by air when an infected person sneezes or coughs and someone nearby inhales the infected droplets. It can also be transmitted by direct contact with fluids from the nose or mouth of an infected person and can survive on a hard surface for up to two days.
Symptoms usually appear 10 to 12 days after exposure to the virus. In some cases, symptoms may start as early as seven days or as late as 21 days. It usually takes 14 days (range 7-18 days) after exposure to develop a rash.
Early symptoms include fever, cough, runny nose, and/or red, watery eyes.
Three to five days after initial symptoms, a rash of red spots appears on the face and then spreads over the entire body. The rash fades in the order in which it appears.
Complications include middle ear infection, seizures, pneumonia, encephalitis (swelling of the brain), and premature birth or low birth-weight in pregnancy. Complications from measles can be fatal.
If you suspect you or your child may have been exposed to measles or are experiencing measles symptoms, notify your doctor’s office before your visit.
(Sources: CDC and Maryland Department of Health)
By Rachel Kohn
Rachel Kohn is editor in chief of Kol HaBirah.