Notes from an epidemic

“Tell me, has your baby been exposed to measles lately?”…

The question hung in the air as the mother of the 4-month-old baby lying on the examining table blanched. “Why, yes, we were at my sister’s house a couple of weeks ago and one of her kids came down with it a few days later…they don’t believe in vaccination. You’re not saying he’s caught it too, doctor?”.

Unfortunately, I was. I’d never met this family before; they were patients of another doctor in another clinic. The mother had gone with her infant to his own pediatrician a couple of days earlier because he’d had very high fever for several days, a hacking cough, puffy, goopy eyes. The doctor had examined the baby, found some oral lesions, diagnosed a primary herpes simplex infection and sent him home with some mouth-soothing ointment. However, the day before I saw him, a rash had spread over his face and trunk. By the time he arrived in my office, he was semicomatose, eyes gummed tightly shut with pus, and breathing rather noisily and rapidly. The little boy was dispatched to hospital post-haste, put in an isolation unit and treated with heavy-duty antibiotics to battle possible bacterial superinfection. He made it, but he was one very sick little baby when I first saw him. I hope never to see another child like him, but given the current situation here in Israel, it’s a distinct possibility.

Since mid-August, there have been over 500 cases of measles in Israel, mostly confined to the ultra-Orthodox sector, though of course the virus doesn’t know or care how religious a person is. The large majority of the cases are babies under a year old, but there are quite a few young adults who were either not immunized, or only partially immunized as children, and the disease has taken its toll among them as well.

The Swedish medical journal Eurosurveillance has the most accurate description of how this epidemic began:

On 4 August, a 22-year-old male tourist from London presented at a hospital in Jerusalem, Israel with general malaise, a high fever and a blotchy maculopapular rash over his face trunk and limbs, including palms and soles. A junior health officer recommended hospitalisation, which the patient refused, partly as a result of there being no definitive diagnosis. Later the same day, the patient visited a private urgent care centre in Jerusalem. Although there was an absence of typical symptoms seen in the early stages of measles, such as Kopliks’ spots, dry cough and conjunctivitis, the physician in the centre suspected measles. He had seen very few cases of measles previously, but as the staff of the clinic are kept informed of infectious disease outbreaks globally by the focused use of Google Health News installed on desktops at the clinic, he was aware of recent outbreaks of measles in parts of the United Kingdom (UK), including London, which had been reported in the British media [1,2]. This, coupled with the patient’s rash and his other symptoms, led to a suspicion of measles, which the man had not been vaccinated against due to adverse reaction in a sibling…

…Upon admission, our patient was isolated in a separate room and treated for malaise, fever, cervical lymphadenopathy and dehydration. Intravenous fluids were given daily over a four-day period. He recovered and was discharged two weeks after admission. His eight-month old son was given gamma globulin, while the rest of his household was contacted by the Jerusalem branch of the Ministry of Health and vaccinated where necessary.

On 1 August, the patient had attended a wedding in Jerusalem with an estimated 2,000 guests, almost all of whom were members of the Toldot Aharon (literally ‘generations of Aaron’), also known as the Satmar, an ultra-orthodox Jewish movement with sizeable communities in the United Kingdom (UK), the United States, Belgium, Switzerland, Argentina and Israel. Globally, there are thought to be around 20,000 members of this movement. Guests at the wedding came from Israel, Europe and the United States. Considering the incubation period of measles (10-12 days), these people may have been exposed.

The last cases of measles in the Jerusalem district were in November 2004, following an outbreak that originated in a kindergarten in the ultra-orthodox community. The genotype responsible was D4. There was also an outbreak in the ultra-orthodox community in Jerusalem in 2003, with the index case being a two-year-old unvaccinated child, and 107 cases reported within three months [4]. That outbreak was caused by the D8 genotype, and is thought to have been imported from Switzerland, where there had been a large outbreak involving genotypes D8 and D5 [4,5]. Following these outbreaks, outreach programmes were launched to raise immunisation coverage and achieve herd immunity in the ultra-orthodox communities involved. Taking the success of those campaigns into account, it was not considered necessary to trace all 2,000 guests who attended the wedding on 1 August. (I think everybody now agrees this was a huge mistake, especially considering the Israeli penchant for bringing infants and young children to festive occasions~E.).

Since August 2007, there have been approximately 50 cases of measles in Israel, the majority of which have been serologically confirmed. Most cases have been concentrated around the Jerusalem area, with almost all patients from the ultra-orthodox community. In the third week of August, a member of the nursing staff at a private urgent care centre in Modiin, 35 kilometres outside Jerusalem, developed measles. Due to comprehensive computerised records of visits to these centres, all contacts were traced within hours of the request by the Ministry of Health, and all those at risk were recalled for measles, mumps and rubella (MMR) immunisation. A three-year-old girl who was hospitalised in Jerusalem in mid-August with measles encephalitis was also ultra-orthodox and non-immunised, but she was neither a tourist nor from the Satmar community. Her contact was traced back to an ultra-orthodox un-immunised child who had travelled from London (with her parents) to a different wedding in Jerusalem that took place earlier in the summer. The three-year-old was treated in an Intensive Care Unit for a few days and appears to have made a full recovery. Two more children were reported to have been hospitalised on 16 September [6], meaning that the infection is now in its third generation, as every two weeks those in contact with an infected person can themselves become infected.

This dispatch is from mid-September 2007; as mentioned earlier, the number of cases has since grown tenfold. Despite what some in the Israeli press are saying, I have not encountered opposition to vaccination; on the contrary, the local public response to the vaccination campaign has been overwhelmingly positive. Now that the Health Ministry has finally gotten around to instructing the government-funded well-baby clinics (Tipot Chalav), who are responsible for giving children their routine vaccinations, to administer MMR to babies exposed to measles even as young as 6 months old, and to give immunoglobulins to babies younger than 6 months within 3-6 days of exposure, maybe we’ll finally be able to lick this epidemic.

Contrary to what you may have read on various anti-vaccination websites, measles is not a benign disease. The measles virus is highly contagious via droplets of saliva – over 90% infectious in susceptible cases – and is capable of suppressing T-cell mediated immunity; a patient with acute measles is as prone to opportunistic infections as a full-blown AIDS patient, though thankfully, this vulnerability only lasts a few days (the MMR virus, which contains a live, but weakened form of the vaccine, also induces a degree of immunosuppression, but not nearly as much as the real thing: we often see ear infections within a week or two of vaccination). According to the CDC, up to 20% of measles patients will suffer one or more complications of the disease: ear infections, pneumonia (which accounts for 60% of the deaths from measles), and encephalitis. Death occurs in 1-2 per 1,000 patients in the developed world; in the developing world (usually in the context of malnutrition, most specifically Vitamin A deficiency), it remains a major cause of death in infancy and childhood. Just to illustrate, there is also an epidemic going on in Kano, Nigeria right now; over 200 children have died in the past month.

While the parents of the young man from London who started our local epidemic may have had a semi-reasonable (emotionally, not necessarily medically resonable, that is) reason not to vaccinate their son with the MMR vaccine – to remind you, his sibling had an adverse reaction to the vaccine – many parents in the UK were scared out of vaccinating against measles due to the unfounded rumors spread by a British gastroenterologist, Andrew Wakefield, that the MMR vaccine causes autism. Not surprisingly, British uptake of the MMR vaccine was low, and measles cases in Britain are at an all-time high…enabling our index case to acquire the disease, either off the street or in his doctor’s waiting room, and ‘import’ it here. We’ll be discussing Wakefield’s shenanigans and the evidence (or rather, lack thereof) of any connection between the MMR vaccine and autism in a future post.

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One Response

  1. Good post. I printed it out. I am going to discuss it with my nursing students today. We were discussing Hepatitis and gamma globulin last week.

    I am starting to think of a day when we all walk around in Hazmat suits. Scary but true. Maybe I should start up a company selling Hazmat suits to the public? Sounds silly but who knows?

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