Last month, a traveler who raised money for charity in the ultra-Orthodox Jewish community of Brooklyn drove through the night to Detroit – his next fundraising stop. He felt ill on the way and saw a doctor when he got there. But the doctor, who had never seen measles, diagnosed the man's fever and coughing as bronchitis.
In the next two weeks, the traveler would become Michigan's Patient Zero, which spreads the highly contagious Airway virus for 39 people while living in private homes, visiting the synagogue daily and shopping in kosher markets. His case offers a cautionary tale of how easily one of the Earth's most infectious pathogens spreads in close communities – especially those whose members live, work and socialize outside the mainstream.
"Every one of our cases had a connection with the original case," said Leigh-Anne Stafford, health officer for Oakland County, a suburb of Detroit, where, with one exception, only one case was reported.
In the past five years, 75 percent of measles cases reported at the Centers for Disease Control and Prevention have occurred in various island communities, including the Amish in Ohio, the Somali community in Minnesota, the Eastern European groups in the Pacific Northwest, and the ultra-Orthodox Jewish community in New York.
During the current outbreak, New York's contagion over Patient Zero and other travelers has spread to predominantly ultra-Orthodox communities in Westchester and Rockland County, New York. Oakland County in Michigan and Baltimore County in Maryland. On Friday, Connecticut representatives said that an adult had to suffer measles at the end of March in Brooklyn. Representatives of New Jersey are investigating possible links between eleven cases in the area of Ocean County and those in New York.
"What's similar about all these communities is that they live close to each other and spend a lot of time together," said Daniel Salmon, professor of international health at the Johns Hopkins Bloomberg School of Public Health and director of the school's Institute for Vaccine Safety. "That's what counts, measles does not care what your heritage is."
Many of these communities are suspicious of the government, abstain from television and the Internet, and often rely on their own medical doctors. In such void, vaccine disinfection has sometimes gained a foothold, preventing parents from completely vaccinating their children.
The traveler came to Brooklyn last November from Israel, the epicenter of a measles outbreak, and stayed about two months before moving to the Detroit area in early March, said Oakland County Fist Officer Russell Faust. The man, whom health authorities in Michigan do not identify, told them he was visiting ultra-Orthodox communities in the United States to raise money for charity.
Feverish and coughing after his arrival, he saw a doctor prescribing antibiotics.
When the man called the next day to complain of a rash, the doctor thought he had an allergic reaction. However, after thinking more about it, the doctor worried about the possibility of measles and decided to leave the health department with a voice message with the man's mobile phone number. Health officials jumped on the case – but could not reach the man because of a problem with his mobile phone.
They turned to Steve McGraw, head of the Oakland Rescue Service and longtime member of the Detroit Hatzalah area, the Emergency Relief Group of the ultra-Orthodox community, a volunteer volunteer that works closely with many families. McGraw alerted the rabbinical leaders, jumped into his car, and drove to the area where the traveler wanted to stop to look for the man's rental car, a blue sedan. He knew he would stand out among the minivans that virtually every family used.
Hatzalah members and rabbinical leaders also went in search of the traveler who was staying in a guest house in the neighborhood. When they found him a few hours later, the traveler was stunned. He told McGraw and the rabbi, who had found him, that they were wrong, believing he had the measles.
"There's only one disease and you have it," McGraw remembers when a rabbi translated into Hebrew. He laid his head down and was very emotional. I could see from his expression that he was devastated. He did the math in his head, "McGraw said, counting all the people he was in contact with.
The traveler, as it turned out, had hundreds of contacts with community members who needed to be prosecuted by the health authorities. He had lived mainly in private homes in Oak Park and Southfield. He visited synagogues three times a day to pray and study, and visited kosher markets and pizzerias in a week between 30 places.
"This guy was running around the community and contagious," McGraw said. "We knew we had a really great relationship."
The measles virus is so contagious that if an unvaccinated person passes through a room for up to two hours after a person has gone through measles, there is a chance that the unvaccinated person may become 90 percent ill. People can spread measles four days before and four days after the telltale rash. Because measles are so contagious, at least 96 percent of the population must be vaccinated to prevent the risk of outbreaks.
On March 13, blood tests confirmed the measles of the traveler. The strain matched the genetic fingerprint of the New York City outbreak, McGraw said. On the same day, health officials alerted the public.
To bring information to the ultra-Orthodox community, health officials used their internal messaging system known as the Call Station. Voice messages ring on about 1,200 mobile phones. McGraw recorded a message approved by rabbinical leaders for the delivery, the first of several to provide information about the disease and vaccination clinics.
In the next few weeks, Janet Snider, a pediatrician for many ultra-Orthodox families, and Gedalya Cooper, an ambulance, both members of the Hatzalah, visited people in their homes to diagnose and measles them.
The Council of Orthodox Rabbis of Greater Detroit made a clear statement that Jewish law obliges each parishioner to be properly and fully vaccinated according to the CDC. The Agency recommends that children receive two doses of measles, mumps and rubella (MMR), starting with the first dose at the age of 12 to 15 months and the second dose at the age of 4 to 6 years.
"To protect and protect each and every one of the wider community, each individual, family and institution must take the necessary precautions against anyone who does not want to be vaccinated," the statement says.
The leaders of the Hatzalah and the rabbis helped the health department set up three clinics in a synagogue, and in a week nearly 1,000 people were immunized. Since the beginning of April, health officials have performed more than 2,100 vaccinations. Vaccine vaccination does not seem to be a major factor in the Oakland County cluster.
At least in Michigan, close collaboration between health officials and the religious community seems to control the spread of the disease, which can lead to serious complications such as deafness, pneumonia, brain damage and death.
Well, with 555 measles cases in 20 states – the highest in five years – other localities are considering this model. Hatzalah groups in other parts of the country are asking the government officials for advice to increase vaccination within the ultra-Orthodox community, said Faust.
Oakland County had something else to offer: measles outbreaks usually start with children. Patient Zero, however, had spent most of his time with adults, and most of the 39 cases involve adults. Many adults who became ill believed that they were immune. Some had said they had the disease as children or had been vaccinated.
"There are quite a few unimmunized or under-immunized adults," said medical officer Faust. Some of the infected adults were also born before 1957, when most people got measles and were believed to have natural immunity.
Officials said the risk remains high for those who are unvaccinated or under-vaccinated and travel in communities or overseas where measles cases are raging.
Gaps in vaccine coverage have led to a 20-year high in measles cases in Europe. Great outbreaks are also taking place in parts of the Middle East, Southeast Asia and Japan. More than 1,200 people have died in Madagascar. With the upcoming spring break and summer break, travelers visiting European countries with outbreaks such as France and Italy have a much greater chance of returning infections to "islands or vulnerable areas," said Saad Omer, an infectious disease expert at Emory University.
"Measles are a very unforgiving disease," he said. "Even if most people are vaccinated, this number may not be high enough."
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