Ultra-Orthodox Jews vaccinate, too: Stop blaming one community for the measles
outbreak
In this year’s U.S. measles
outbreak, parts of Brooklyn and Rockland County have experienced two-thirds of
the reported 704 infections. The media generally blame an alleged low vaccination rate in these areas, each with a large
percentage of ultra-Orthodox Jews.
Public health experts corroborate
this message. Dr. Nancy Messonnier of the Centers for Disease Control testified to
Congress: “I do believe that…most cases that we’re seeing are in unvaccinated
communities.” Dr. Anthony Fauci, who heads the National Institute of
Allergy and Infectious Diseases, declared:
“Coverage in a given community,
when it falls below a certain critical level, you get the kinds of outbreaks
that we’re seeing, particularly in places like New York City and the
Williamsburg section of Brooklyn…. his is a relatively closed community, a
Hasidic Jewish community in that area — that are not vaccinating their children
at a rate that would provide that broad umbrella of protection that we call
herd immunity…When you drop down to the 80s or
even the 70s [emphasis added] or even lower, where it is now in that
community, that’s exactly the explanation of why we’re seeing the outbreaks
that we’re seeing.”
However, the New York State Health
Department reports the
average vaccination rate for measles among the
nearly 200 Jewish K-12 schools in Brooklyn — mainly in Borough Park and
Williamsburg — is 96%, six percentage points higher than the statewide average
among private schools. In contrast, six other New York counties have a vaccinationrate below 50%.
Moreover, the measles vaccination rate among Jewish school-age children is above
the assumed 95% threshold required for “herd immunity,” i.e.,
protection of the community from sustained outbreaks.
What, then, explains the outbreak?
Regardless of the vaccination rate, some communities have characteristics
that enhance and sustain epidemics. Population density and a community’s social
mixing patterns are two critical determinants of whether an outbreak dies out
or remains sustained. Orthodox Jewish communities are densely populated.
Families have many children and interact frequently.
The vaccination rate
of 95%, assumed to provide herd immunity, is derived from a basic model
assuming the vaccine is effective 97% of the time, and that, in the absence of
immunity an average infected individual transmits the infection to 12 others,
the “basic reproduction number” (what we in medicine refer to as “R0”).
If, however, in a densely populated
and highly interactive community, the average infected individual transmits
measles to 24 others, then 99% of the community must be vaccinated in order to
ensure herd immunity. If the average is 36, then even a 100% vaccination rate fails to ensure herd immunity. R0 estimates in
the literature vary from 1 to 203.
Implicit in the current media
coverage is the assumption that measles outbreaks should not occur anymore. But
despite the fact that measles were declared eliminated from the United States
in 2000, complete elimination may no longer be realistic.
Anyone born before 1957 is
generally assumed to have complete natural immunity to measles, gained through
childhood exposure to the virus. Today most rely on vaccination for
their immunity, which is only 97% effective. Indeed, 13% of the typed 2019 cases were
vaccinated.
Another obstacle to elimination is
the persistence of “anti-vaxers” (though no evidence suggests that their
presence among Orthodox Jews is above average). As long as there is a cohort of
people refusing vaccination, together with a group
which the vaccine fails to immunize, it will be extremely difficult to
eliminate measles.
What remedies are available, then?
First, it is time to stop vilifying
the Orthodox Jewish community when the data show their vaccination rates
are as high as any. Continuing to blame this segment of the Jewish community —
especially in the news media — is not only wrong. It actually jeopardizes the
cooperation that is necessary to stem the outbreak.
Current recommendations are likely
being revisited. In 1968, a single vaccine was believed to achieve lifelong
immunity. However, from 1987 to 1992, a large outbreak infected many vaccinated
young adults. The recommendation was then changed to administer two vaccine
doses — the first at age one, and a second dose between the ages of 4 and 6.
Upon review, the guidelines could perhaps change to recommend giving the second
vaccine earlier, or even to administer a third dose.
Reducing measles here in the U.S.
also calls for better international cooperation. From 2001 to 2016, 553 measles
cases in the U.S. originated abroad. As of April 24 of this year, 170 countries
have reported 112,163 measles cases to the World Health Organization — four
times last year’s numbers. The trend calls for WHO to initiate a global vaccinationcampaign, similar to its successful campaign to
eradicate the polio virus globally. This will, however, require large donations
by first world governments and organizations like GAVI and the Gates
Foundation.
Additionally, with the community’s
cooperation and trust, the "identify, isolate and track” strategy,
effective in containing the Ebola virus, could be implemented successfully.
Last but not least, anti-vaxers
must be engaged respectfully instead of with derision or condescension. Some
anti-vaxers’ concerns are, prima facie, reasonable. Their claim that vaccines
are associated with autism is not. The only study ever claiming a relationship
was fraudulent. And a new Annals of Internal
Medicine study, once again, dispels any links.
Medical practitioners, especially,
have a duty to provide clear explanations and to engage patients in joint
decisionmaking. On the other hand, anti-vaxers must understand that their
personal decision impacts others very significantly. We urge them to get
vaccinated for the general good, as only very high vaccination rates
prevent enduring outbreaks.
In summary, there is a worldwide
and national surge in measles, disproportionately affecting the Orthodox Jewish
community, even though its vaccination rate is
similar to those elsewhere. Outbreaks are more likely in dense populations with
frequent social mixing patterns. Blaming the Jewish community is therefore wrong,
offensive and counterproductive by enhancing resistance and suspicion.
Vaccination rates should be maximized,
nationally and globally, and the current vaccination schedule
reevaluated. Finally, antivaxers should reevaluate the relative risks,
understand that autism is a baseless concern, and consider the benefit vaccination provides to society.
Berman is an infectious disease attending physician at the Montefiore Medical Center.
Federgruen is the Charles E. Exley Professor of Management, Graduate School of
Business, Columbia University and member of the Routine Immunization to Secure
Eradication (RISE) Roundtable.
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