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Brooklyn measles outbreak of 2013: A case study of the cost of antivaccine pseudoscience

Infectious disease outbreaks are costly in human and financial terms. An analysis of the 2013 Brooklyn measles outbreak shows just how costly one outbreak can be and how much it can strain already strained public health resources. This is the cost of antivaccine madness.

A month and a half ago, I discussed a study showing where the “hotspots” of vaccine refusal leading to low vaccine uptake are in the US. As I said at the time, these are the places where antivaxers will be most likely to “make measles great again” sometime in the near future. My personal prediction is that the most likely state to suffer a big measles outbreak soon is Texas, given how antivaxers have co-opted conservative, libertarian, anti-regulation politics and portrayed the right to refuse vaccines as a matter of personal freedom and parental rights, thus politicizing what was previously an issue with strong bipartisan support, an issue that used to be as close to completely nonpartisan as there could be. Wherever the next outbreak appears, we’ve had multiple outbreaks of vaccine-preventable diseases over the last several years, most recently the outbreak among Somali immigrants in Minnesota, which was fueled by antivaccine godfather Andrew Wakefield and his white, affluent antivaccine followers spreading their message among the Somalis. What I haven’t discussed that much is the public health cost of these outbreaks, which brings me to a recent study of the public health impact of the Brooklyn measles outbreak of 2013 published earlier this week in JAMA Pediatrics. The study shows how even a relatively “small” outbreak sparked by one person can cost substantial resources.

The study, not surprisingly, sparked a number of news stories, such as these stories in the New York Post, Reuters, Healio, and MedPage Today. The outbreak began in March 2013, when a single infected child returned to New York from a trip to London. Of course, at this point, I can’t help but note that London and the UK have long suffered inadequate uptake of the measles-mumps-rubella (MMR) vaccine, thanks to the small case series Andrew Wakefield published in The Lancet in 1998, which was later shown by Brian Deer to have been fraudulent. Ultimately, then Dr. Wakefield lost his license to practice in the UK (was “struck off” the medical register, in the parlance of the UK’s General Medical Council), after which he moved to the US, took up residence in Austin, Texas, where he ran a quack clinic for autistic children; that is, until he became too toxic even for the antivaxers running the clinic. Since then, he’s been falling into even more disrepute, even going so low as to speak on a cruise for conspiracy nuts. Of late, however, he made an unfortunately successful “documentary” (successful at promoting antivaccine views, not at making a lot of money) VAXXED and was last seen canoodling with supermodel Elle Macpherson after having separated from his long-suffering and dedicated wife Carmel. (What I can’t figure out is where he got $1.4 million to buy Carmel a “dream house” before leaving her to “find himself” and get a makeover by a supermodel.) Be that as it may, he’s arguably more responsible for more suffering from measles than any single person in the world.

But back to the Brooklyn measles outbreak and the study by Jennifer Rosen et al from the New York City Department of Health and Mental Hygiene and the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Basically, Rosen et all performed an epidemiological assessment and cost analysis of the Brooklyn measles outbreak.

So how did the outbreak begin? I mentioned that an unvaccinated child returned from London on March 13, 2013. Thanks to Wakefield, London is a place where this adolescent could easily have caught the measles, and that’s what happened. Worse, the outbreak started in two Brooklyn neighborhoods, Williamsburg and Borough Park, each of which is home to large Orthodox Jewish communities. In fact, every single case was a member of a Brooklyn Orthodox Jewish community:

From March 13, 2013, through June 9, 2013, a total of 58 case patients with measles were detected in 2 neighborhoods of Brooklyn, New York, with 6 generations of transmission (Figure). The index case patient presented to a health care professional with symptoms of measles after returning from a trip to London. The case was reported to the New York City DOHMH by a commercial laboratory only once the measles IgM test results had returned positive, 8 days after the clinician initially considered a diagnosis of measles. Two additional case patients resided outside of New York City and were excluded from analyses. Orthodox Jewish persons accounted for 100% of the case patients.

Surprise! Surprise! All but one of the people who developed the measles were unvaccinated:

The median age of the case patients was 3 years (range, 0-32 years). None of the case patients had documentation of receipt of measles-containing vaccine prior to their presumed exposure to measles virus. Of the 58 case patients, 45 (78%) were at least 12 months old and were unvaccinated owing to parental refusal or intentional delay. Twelve case patients (21%) were less than 12 months old and therefore were too young for routine immunization with measles-containing vaccine. One case patient (1%) was an adult who verbally reported a history of receiving measles-containing vaccine as a child; although no vaccination documentation was available, a high IgG avidity test result obtained at the CDC was consistent with a prior history of vaccination.

This is about as clear-cut as it gets; there isn’t even wiggle room for antivaxers to invoke their misleading trope that there were “more vaccinated than unvaccinated children affected” while ignoring attack rates (i.e., the actual risk of being affected as a percentage of the vaccinated or unvaccinated population, which always shows the unvaccinated to be a a much higher risk of developing the measles during an outbreak).

As you might expect, there were complications, including one case of pneumonia and one miscarriage. I’d say that Brooklyn was lucky, because usually the complication of pneumonia usually occurs at a higher than one in 58. It’s usually more like one in twenty.

Now here’s where the real work and expense comes in from an outbreak like this:

A total of 3,351 exposed contacts were identified, excluding the 58 case patients who developed measles. Among those contacts, 2,214 (66%) had evidence of immunity to measles based on receipt of 2 documented doses of measles-containing vaccine, having a positive measles IgG titer, or birth before 1957; 376 contacts (11%) had received 1 dose of measles-containing vaccine; 335 contacts (10%) were susceptible; and immunity status was unknown for 426 contacts (13%). The MMR vaccine was administered within 3 days of initial exposure to 114 contacts who were 6 months or older, and immunoglobulin was administered within 6 days of initial exposure to 77 infants younger than 6 months or to infants aged 6 to 11 months who had not received MMR prophylaxis. Immunoglobulin was not administered to immunocompromised or pregnant persons.

That was a lot of work to track down all those contacts, figure out who was at risk, administer MMR prophylaxis, including vaccine and immunoglobulin, as appropriate. The total cost came to:

Total direct costs were $394 448 ($62,102 for inputs and $332,346 on compensated personnel time) (Table 3). The incremental cost was $73,135, or 19% of the total direct costs. Salaries and fringe benefits combined accounted for $321,313 (97% of personnel costs). Overtime pay totaled $11,033 (3% of personnel costs). The majority (99%) of the cost of inputs was attributed to advertising ($29,425), MMR vaccine ($17,590), laboratory supplies and testing ($9,316), and courier service ($4,886).

To be honest, I was surprised that it wasn’t more. Similar cost analyses performed after the Somali measles outbreak in Minnesotal finally burned itself out last year estimated a cost of $1.3 million to contain the outbreak, with $900,000 coming from the Minnesota Department of Health and the rest coming from Hennepin County, which dispatched 89 staff members to interview affected families at a cost of about $400,000. During the height of the outbreak, health officials were asking for $5 million for an emergency fund to deal with the outbreak, as well as other infectious diseases, such as Zika and syphilis. Of course, the Minnesota measles outbreak was larger, sickening more people (79), sending 22 to the hospital. (Also, the Brooklyn measles outbreak only sent three people to the hospital, and in 31% of cases no medical care was sought.) but it wasn’t that much larger. I’m just speculating, but likely the reason for the more than three-fold difference in cost between Minnesota and New York included the much tighter geographic area in Brooklyn where the cases occurred and needed to be investigated compared to Hennepin County and the added expenses of investigating measles cases among a population of immigrants.

The authors did note that dealing with outbreaks is expensive. The Brooklyn outbreak was one of the largest in the last few decades and was resource-intensive to deal with. It was, however, within the cost estimates in the literature: $2,685 to $22,375 for small outbreaks, from $47,732 to $208,829 for medium outbreaks, and from $280,829 to $1,640,789 for large outbreaks.

Also, Minnesota undertook a massive immunization program, while in the surrounding communities in Brooklyn, MMR uptake was very high, with New York’s five boroughs having an overall MMR uptake rate of 97%. If you want to see an example of how effective herd immunity can be, just take a look at this outbreak. It raged on among several families in the Orthodox Jewish communities in Brooklyn with low MMR uptake but outside of those communities:

The report also displays the effectiveness of a strong vaccination program, said Jason Schwartz, an assistant professor with the Yale School of Public Health.
New York City has a measles/mumps/rubella (MMR) vaccination rate near 97 percent, Schwartz explained. This kept the outbreak confined to a group of people who apparently eschewed the vaccine for religious reasons.

“Even in the largest city in the world, in densely populated neighborhoods in Brooklyn, those individuals who were vaccinated around these clusters were unscathed,” Schwartz said.

The rapid public health response also limited the spread:

But 335 exposures occurred in people completely unprotected against measles, officials found.

About 114 unvaccinated children and adults who’d been exposed to measles were given an MMR vaccine shot to ward off infection, the report said. There were 77 infants too young for immunization who received a dose of measles antibodies, Zucker added.

These post-exposure vaccinations kept the measles case count from being even higher, Zucker said.

This case study of the public health response to a measles outbreak illustrates three main points. First, it shows how easily measles can tear through an unvaccinated population. As mentioned before, these particular families of Orthodox Jews apparently eschewed vaccines for religious reasons, even though Jewish rabbis and leaders emphasize that there is nothing in the Jewish faith that requires foregoing vaccines and thus urge their fellow Jews to have their children vaccinated. Second, it emphasizes how important high levels of vaccination are. If the surrounding New York City environs hadn’t had such a high MMR uptake rate, well over the level needed for herd immunity, it is very likely that this outbreak would have sickened many more children. If this were Romania or countries in Europe with low MMR uptake, the results could have been disastrous. We already see this in the massive measles outbreaks that are ongoing in countries with low MMR uptake. Finally, this study portrays yet another example of why a robust public health infrastructure is so important for a rapid and effective response to outbreaks like the ones in Brooklyn, Minnesota, and Disneyland. Unfortunately, unless we can find a more effective means of dealing with antivaccine misinformation and vaccine hesitancy and refusal, our public health officials and frontline doctors, nurses, and other professionals will continue to have too much work too do.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

56 replies on “Brooklyn measles outbreak of 2013: A case study of the cost of antivaccine pseudoscience”

Before visiting London a few years ago, I made sure I was up to date on my MMR (unfortunately, my childhood vaccination records got lost somewhere while I moved out from my parents and then they moved out of their place). Which has an additional benefit, since I work at school with 600+ students and 80+ staff.

I just got back from a trip to Boliva. Since my mother lost my vaccination card when I was a kid I had to get titers for nursing school years ago. I keep a copy, and had to bring copies of all my vaccination/titer records with me in case Immigration wanted to inspect them.

There was some question as to whether I needed yellow fever since I wasn’t going into the jungle (we stayed in La Paz and went to the Uyuni salt flats), but since I didn’t want to be denied entry I got it anyway. It was a no brainer, and supposedly it’s good for life now.

I once listened to an academic talk about immune memory where the researcher calculated the “half-life” of immune memory to various vaccines. They put up a chart of immune memory duration in years, except the yellow fever, which calculated out to past the heat death of the universe. (Obviously this isn’t true, it’s the lifetime of the individual, but the math got a good laugh from the audience.)

JustaTech: it got a laugh out of me. I needed that first thing in the morning–thanks 🙂

Mark: No kidding! 😉 Yeah, I’ve read on the history of yellow fever. Just shoot me now. Like I said: it was really a no brainer. I got vaccinated for typhoid fever as well. I did have the strongest set of side effects to the yellow fever vaccine that I’ve ever had to any vaccine–24 hours of severe body aches and low grade fever.

Worth it.

I think the entire cost of the outbreaks should be charged directly back to those who have applied for personal belief exceptions as a fine. If they don’t pay the fine, they go to jail. Hopefully whoever takes responsibility for the children after that will choose to vaccinate them right away since they will have custody.

Better yet, make it a high fee before the outbreak occurs, and stash it in a response fund for the public health department to fix the problems caused by these ideas.

The high expense will cause the fence sitters to vaccinate.

Serious proposal:

Externality tax: charge people the 1/N cost that their behaviors impose on society.

Example: take the total cost of treating smoking-related illnesses in a year, divide by the total quantity of packs of cigarettes consumed in a year, charge that amount as a tax on the price of cigarettes per pack (instead of “sin” taxes that cause backlashes).

For anti-vaxers: Take the total cost of treating & tracing measles outbreaks over a rolling ten-year period, divide by the total number of kids whose parents willfully refused to vaccinate over a rolling ten-year period, charge that amount as a tax per willfully-unvaxed kid.

In both cases, the people doing the behaviors in question have exactly no basis to complain: they are being asked (required by law, thank you) to pay for the costs of their chosen behaviors, whereby to neutralize those costs to society-at-large.

The general principle is that nobody has a right to impose a cost upon another person against the latter’s will. This even works under hardcore libertarianism, as externalities violate libertarians’ consenting adult transactions principle.

Yes we should write up some model legislation and then go proposing it & lobbying for it in every state.

Williamsburg and Borough Park, each of which is home to large Orthodox Jewish communities

“Ultra” Orthodox. I know orthodox Jews, and the Hasidic trip is not requisite. Poverty, breeding, and lack of education. They’re the Amish with brit milah thrown in for good measure.

Poverty might be an important factor:

I always saw women from Kiryas Joel at the designer outlet mall and assumed that they were middle class.- they had nice clothes although conservative.
HOWEVER a little research has shown that the average income in that enclave is quite low: most women don’t work and they have more children than is average.
There are several communities in suburban/ upstate NY amongst them New Square, Monsey and the aforesaid village as well as in Lakewood, NJ. Kids attend private schools within the towns although there may be state assistance for special education.

brainmatterz: One imagines Denice means “don’t work” for pay. Obviously they’re working.

One imagines Denice means “don’t work” for pay. Obviously they’re working.

Well, if you consider studying Gemara all day (and/or figuring out how to bilk social services for megabucks) “working,” I suppose. I’ve studied Gemara; I htink it’s approximately antithetical to “work.” I don’t like working.

Ultra-Orthodox men don’t work, if they can manage not to. They’re of the opinion that their time is better spent studying Torah (and Gemara and so on) than working a job. The women have the kids and take care of them and are responsible for the financial upkeep of the family, which often includes working.

The 14-person 2008 measles outbreak in Tucson cost $799K ( https://academic.oup.com/jid/article/203/11/1517/862546 ). Expensive in part because the initial measles patient went to the ER twice before being diagnosed, so lots of detective work to track down potential exposures. Of note, the two hospitals involved in this outbreak were caught not knowing full vaccine histories on a lot of their employees not all of whom were vaccinated. Here’s to hoping hospitals are doing better with that now.

Two points. While in some states right leaning politicians are more sympathetic to antivaccine views, people of both parties are still strongly provaccine, and vaccines have strong political support on the right and left in most states and the federal level.

Here is a recent Texas poll. data:text/html;base64,PG1ldGEgZGF0YS1mYnByZWZldGNodGFyZ2V0IC8+

I don’t want to understate the concern about the appeal to the right of the antivaccine movement – I share your concerns – but this still isn’t a partisan issue, nor should it be. Everyone can get behind preventing diseases.

Second, these costs are why we floated, several years ago, the idea of billing unvaccinated people for costs of outbreaks after the fact or imposing a fine or fee in advance, and I still think it’s fair to do.

Yep.
It seems every religion has their loons.
Jewish ‘fundamentalists’ also caused the 2016-2017 measles outbreak in Los Angeles, California:
http://www.latimes.com/local/california/la-me-ln-measles-20170120-story.html#
Measles outbreak grows in L.A.’s Orthodox Jewish community despite California’s strict new vaccination law
.
Leading rabbis issued pro-vaccine statements just as had the imams in Minnesota in response to the outbreak in the Somali community.
In the Christian community most sects have some sort of statement in support of vaccination/public health/medical science.
Whether these statements make a large enough impact is to be seen, but I doubt it.
It seems to me that people who are suffering arrogant ignorance to the extent they will reject expert medical advice will also have no problem rejecting advice from their religious authorities if it contradicts their Dunning-Kruger derived opinions.
.
… But, every bit of rationalism helps so religious leaders should be encouraged to teach that public health/vaccination is a moral good. They may, at least, influence those in their flocks who aren’t anti-vax fanatics.

Although I know that Brooklyn is now hipster central BUT if you’ve never been there:
it is really densely populated. Apartment buildings, brownstones and row houses. My uncle’s house ( now worth a fortune) is 17 feet wide. Tiny apartments. Stores and new style malls. Crowded subways and buses. Some kids commute to school.
Imagine the possibilities for disease transmission.

Here’s a modest proposal…

If you are a parent who refuses to get their children vaccinated, then you have to do three things:

You take an 8-hour course in infectious disease prevention and vaccine science over at the local community college and pass an exam at the end with at least 60% correct answers. (Come on, I’m not even asking you to get a C in the course.)*
You take out an insurance policy that covers you for liability if you are found to have contributed to an outbreak.**
You report to the quarantine office at any port of entry upon returning from any international trip and submit yourself to a mandatory quarantine of at least one incubation period of measles (about 21 days).***

Deal?

I mean, since some states mandate that women wishing to terminate a pregnancy need to be “educated” about the fetus through sonograms and such, it seems fair antivaxxers need to be “educated” as well.

** You already have to maintain liability insurance for driving, or if you’re in a line of work where you could seriously hurt someone else.

*** I’m sure there’s some tent cities up at the border that could house these folks.

@ brainmatterz:

OBVIOUSLY.

If you read about these particular communities women are less likely to work outside the home after having a second child. Average incomes quoted in Wikipedia or city data only take outside work into consideration.
If the average family has ( I don’t have the exact figures) say, 4 kids rather than 1.5 that can affect their lifestyle as well.

@ Narad:

I think that KJ may be splitting off entirely next year.

I’ve been familar with these communities over the years because I visit the area, took classes near Monsey ( a few students/ instructors were Orthodox) and SRSLY – Brooklyn! My late cousin lived in another area that was predominately Hasidic ( he wasn’t); my Irish friend lives in another area nearby.

The most common way most people have liability insurance for tort suits is through their renter or house owner insurance. The problem you run into is that many policies have an infectious disease exception, added in after companies were liable for HIV transmission in the 1980s. So it won’t cover this, and yes, non-vaccinating parents will need to either get a separate policy or negotiate to remove the exception. Maybe that’s a goal for their organizations to lobby for.

I agree with the course. I have much more serious hesitation about quarantining, because we would be quarantining the kids who didn’t make the decision, not the parents that did, and it seems harsh on a kid, without reason for exposure. It’s bad enough that these kids are unprotected.

I’m pretty sure the rash that little girl has in the linked article is vericella and not measles. Guess there are no stock photos of little white kids with measles.

CApt

Ah. Yeah. They picked a poor choice of a stock photo for that article. That’s not measles. Probably varicella, as you suspect.

Orac I would really really really appreciate it if you could add at least a ‘DM’ to links so I don’t click onto the Daily Mail site. I hate to give that prejudiced, malicious slug slime rag clicks, they have been and are responsible for formenting hate of the EU and of immigrants in the UK, as well as gleefully spreading lies about anyone much farther left than Jacob Rees Mogg.

The image Orac uses at the beginning of this post shows the M-M-R II from Merck & Co. The live virus vaccine is produced from a growth medium containing fetal bovine serum. The serum is produced from blood collected at commercial slaughterhouses. It is harvested from the blood of the bovine fetus after the baby is removed from the slaughtered mommy cow.

It’s a fascinating manufacturing process that’s a good read.

It gets better, or rather, worse. I read last year of vets in Brooklyn, the hipster communities, reporting that people were refusing to get their dogs vaccinated for rabies (!), because it might cause autism. Yes. Autism. In their dogs.

That would not end well. But, since you can be arrested for not vaccinating for rabies, perhaps it will end sooner than the measles problem.

Even most anti vax vets will vaccinate for rabies . . . they have no choice. And yes, there are anti vax vets.

nods my vet dropped a couple of talking points that were definitely anti-vax dogwhistles, WHILE HE WAS VACCINATING MY CATS. It was a very awkward moment.

@ JustaTech:

Right.
Sometimes I take shortcuts when I comment because I assume that people will know what I mean – in this case it has been a major point of feminism . So have low paying jobs..
Women in more traditional communities have been entrusted with child care, elder care, house work, etc. Many also work outside the home.

It would be great if we had a safe measles vaccine, instead of the MMR.

Measles vaccine should be administered by itself, not in combination with two other pathogens.

But separate M, M and R vaccines are not available. Why is that?

It would be great if we had a safe measles vaccine, instead of the MMR.

Citation needed that the MMR is unsafe. And use better cite than those you have hitherto used.

Measles vaccine should be administered by itself, not in combination with two other pathogens.

Why?

But separate [Measles], [Mumps] and [Rubella] vaccines are not available. Why is that?

1) It is cheaper to combine the 3 into one shot.
2) One shot means fewer visits, which saves time and money for both patient and Medical Practitioner.

And if people think it’s the evil “toxins” in vaccines, you’d think they’d want combo shots. 3 separate shots = three times the “toxins”

MMR safety ? Measles causes more deaths that vaccine causes mild side effects. And this leaves out congenital rubella syndrome. And what about “mild form of disease” ? A child cannot know that that the disease is mild, as an adult could.
Separate M, M, and R would mean two more vaccine shots, and, though this is does not cause problem, perhaps three times adjuvant. Interesting that you would like that.

Why are you so concerned about the MMR anyway?

You had previously stated that the antigens aren’t the problem with the vaccines. It’s the aluminum adjuvants that cause the problems. And the MMR, like all live-attenuated virus vaccines, does not use an adjuvant, aluminum or otherwise.

Why are you so concerned about the MMR anyway?

Because Dan is a welded on anti-vaxxer who considers all vaccines harmful.

The aluminium adjuvant nonsense is just some smoke and mirrors to try and give some legitimacy to his anti-vaccine views.

I’m beginning to think he craves the adoration of the more rabid anti-vaxx set so wants to cover all the bases. He seems to be getting worse with time, just like Ginger Taylor.

Perhaps because it is demonstrable that uptake is better when fewer visits to doctor/practice nurse/school nurse are required?

“It would be great if we had a safe measles vaccine, instead of the MMR.” and “Measles vaccine should be administered by itself, not in combination with two other pathogens.”

Why? Especially that measles, mumps and rubella vaccines never contained adjuvants nor thimerosal. The MMR comes as a dried powder that is rehydrated with sterile water, and must be used in a set amount of time.

The MMR vaccine has been used in the USA since it was first approved in 1971, and was the preferred vaccine for the 1978 Measles Elimination Program. If there is evidence it causes more harm than measles, mumps or rubella it would have been documented years before Wakefield even knew of its existence. So produce some verifiable documentation dated before 1990 that there was an issue noted for the any American MMR vaccine.

And do not plop a link to your webpage here! Make it an actual PubMed citation from reputable sources not on the Dwoskin payroll.

Don’t forget that in addition to the actual costs there is the additional factor that the medical professionals treating preventable diseases are therefore unavailable to treat any other sick or injured patients. The hospital beds that taken up by people with preventable diseases are unavailable as well …. the list goes on.

It would be great if there was a single vaccine in use today that dyed-in-the-wool antivaxers were willing to endorse.

Alas, they only support the idea of a mythical vaccine with zero side effects, while blissfully ignoring the many harms of vaccine-preventable diseases.

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