Friday, June 21, 2013

Just a Plane Ride Away

He boarded the plane, heading from India back to his home in North Carolina. Around his late twenties or early thirties, he settled in for the long, trans-oceanic flight toward the end of March. He wasn't traveling alone; he had company with him, though he didn't know it at the time. In fact, he was carrying stowaways he'd picked up during his visit, and now they were replicating inside him. It was a long flight. He relaxed and waited while his fellow passengers worked feverishly.

The plane touched down. He collected his bags and started off to his home in Stokes County. Perhaps he was tired from the flight. A few days passed, and his head grew warm to the touch. Runny nose, a bit of a cough. If it weren't for the fever, it could have just been allergies. Probably just a cold picked up on the plane or during his trip. Nothing to worry about.

Also around the end of March, another individual, a Hasidic Jew from New York is flying home from London. He or she lives in a highly religious, insular community in Borough Park, Brooklyn. Just as with the visitor to India, a hitchhiker accompanied them on the flight home. And just as with the fellow further south, several days after returning home, the signs of a cold begin.

In both North Carolina and New York, others in the travelers' households start to show signs of a cold, as well. And then the rashes appeared. Starting around the head and neck, they began to spread down the bodies. In North Carolina, the answer came on April 16; in Brooklyn, the first five cases are confirmed by April 12.


One of the most infectious diseases known, Rubeola morbillivirus infects over 90% of those who come in contact with the virus and are not yet immune. If you are infected and cough, you leave viral particles in the air that can infect others even several hours after you have left the room. Roughly 5%-10% of those infected will have some manner of complication, from ear infections or conjunctivitis (pink eye) to pneumonia. There is a 1 in 1,000 chance of suffering encephalitis, and 1-2 people per thousand who get it will die. Then there is subacute sclerosing panencephalitis, or SSPE. After recovering from measles without any apparent problems, SSPE can rear its head anywhere from days to years after recovery. With SSPE, the measles virus is never fully cleared from the body, but begins to destroy the cells of the central nervous system. It is slow. It is painful. And it is fatal. While most people recover without lasting damage, it is not a benign or harmless disease.

The North Carolina outbreak spread across three counties, infecting 23 individuals. The young man who brought the disease back from India was hospitalized, along with one other adult. Both suffered respiratory complications. The twenty-three people who were infected ranged in age from 1 year old to 59 years old. Eighteen of the 23, including the index case, were unvaccinated, having refused the MMR for various personal or religious reasons. Four had received at least 1 dose and 3 had received two doses. One had unknown vaccination status. When the full two-dose series is completed, over 99% of the time, the patient gains full immunity to the disease, but other factors can reduce the efficacy, from individual biological responses to poor storage to expired vaccine. We may never know why it failed in the few who received the vaccine. The last case was diagnosed on May 7.

According to the North Carolina Department of Health and Human Services, many of the cases occurred among those who were home schooled and, thus, were not required to be immunized like students attending public schools would be.

The outbreak in the Burrough Park neighborhood of Brooklyn also grew. More cases appeared in that neighborhood and spread to another Orthodox Jewish community in Williamsburg. To date, 48 people have contracted the disease. Two have been hospitalized. Several have had pneumonia. One young mother who got measles was pregnant. She lost her baby because the disease caused her to miscarry. Every single one of the 48 was unvaccinated because they had either refused the vaccine, had delayed getting it, or were too young. At the start of the outbreak, ages ranged from 10 months to 23 years old. As more cases appeared, the median age has shifted down to 2 years old.

As I read the news reports of the New York outbreak, I wondered if religion played any role in vaccine refusal. Was there an anti-vaccine element like there was in North Carolina?

I spoke to Joshie Berger, a former Hasidic Jew and outspoken advocate of secularism who grew up in these neighborhoods. Last year, I had looked into what some of the more mainstream religions said about vaccination, finding that almost universally they either supported it as an obligation for the faithful or at the very least encouraged the practice. That included the more liberal sects of Judaism. And Joshie confirmed that there was nothing in orthodox teaching that endorsed anti-vaccine policies. He told me:
Orthodox rabbis have ruled over the years that vaccines, while acceptable, aren't imperative, and a parent who doesn't vaccinate isn't liable for harm that may happen to the child. So it's not that they are against vaccinations as much as they don't really take it all that seriously.
He added that the nature of Hasidic education places lots of kids in small classrooms, making it easy for the virus to spread. Coupled with large families, the problem is compounded.

These families also have little, if any, secular education. Many have not learned much about diseases unless there is some specific connection to the Jewish community, such as with Tay-Sachs disease, which most commonly affects people of Ashkenazi Jewish descent. Access to the internet and other secular sources of information is limited, so it is difficult for the Hasidic community to get news and information about topics like vaccination. As Joshie said:
They don't see the ads on TV, they aren't hit by the current drive to vaccinate everyone that most people that read, go to movies, etc. are privy too. If the Rabbis aren't making their congregants cognizant of something, it's tough for them to become of aware of it.
So while religion is playing a role in the New York outbreak, it is not a driving motivation to decline immunization, but rather may be acting as a barrier to understanding within the community.

We have two major recent outbreaks in the U.S., one of which is still ongoing. In addition, there have been cases in New Jersey, Texas and elsewhere. They could be isolated cases or may be the beginnings of similar large outbreaks. There have been over a thousand cases of measles in the United Kingdom this year, and thousands in Pakistan have suffered from the disease (with over a hundred dead). In nearly every case, the victims are unvaccinated, whether due to lack of education and understanding of the importance of vaccination or because they have refused or delayed the vaccine based on misinformation and fear.

The truly sad part of all this is that measles is so easily prevented. Those who want to take a free ride on the wave of herd immunity should note: infection is just a plane ride away.

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