Measles outbreaks among Orthodox Jewish communities in New York and Michigan: Compare and contrast

After my repairs three weeks ago, I’m trying to get back up to speed, both at work on on this blog. On the blog, I’m finding that trying to catch up on all the crazy things that occurred while I was down for repairs is as good a way as any, even if I can’t yet manage a post more than two or three times a week. So it was that I started my return with a discussion of how a Daily Beast editor managed to inadvertently make an antivaxer whom we all know and detest look more like an iconoclast than a dangerous crank. This time around, I’d like to concentrate on a more local story about the current measles outbreak going on in southeast Michigan. The story might be local, but it illustrates a couple of important things. First, it shows that, for all the reports of outbreaks among Orthodox Jewish communities, both here in the US and in Israel, not all Orthodox communties are the same in their response. Second, I can see parallels between the Orthodox Jewish communities who did fall for antivaccine misinformation (such as those in Brooklyn) and those who did not (our very own southeast Michigan community). Finally, our outbreak in the Orthodox Jewish community here demonstrates how our interconnectedness leaves us vulnerable to toutbreaks when susceptible people congregate, regardless of whether the cause of susceptibility is antivaccine beliefs or other causes.

First, let’s get into a little background. Thanks largely to the antivaccine movement, there are multiple measles outbreaks around the country. According to the CDC, as of April 11 there were 555 cases documented in 20 states, more than the total number of cases recorded in the last three years. It is, as the CDC notes, This is the second-greatest number of cases reported in the US in a given year since measles was eliminated in 2000, and we’re only a little more than one quarter of the way through 2019. At this pace, we’re unfortunately currently on track to surpass 2014 nationwide total of 667 cases—and by a huge margin.

By far the largest of these outbreaks is centered in Brooklyn and Queens, where, as of April 15, there have been 329 confirmed cases since October (273 so far in 2019), most of which involved members of the Orthodox Jewish communities in those boroughs. The New York City Department of Health notes:

The initial child with measles was unvaccinated and acquired measles on a visit to Israel, where a large outbreak of the disease is occurring. Since then, there have been additional people from Brooklyn and Queens who were unvaccinated and acquired measles while in Israel. People who did not travel were also infected in Brooklyn or Rockland County.

I’ve written about the measles outbreaks among the Orthodox Jewish communities in Israel before recently. It’s an outbreak that’s led the Israeli Ministry of Health to crack down on physicians who promote antivaccine misinformation.

The NYC Department of Health mentioned Rockland County, because further up the Hudson River, in that county in New York state, there’s another outbreak ongoing, whose 2018-2019 total is up to 186 cases, which the Rockland County Department of Health breaks down this way:

Vaccination rates for confirmed measles cases in Rockland County as of April 15, 2019:

  • 81.2% have had 0 MMRs
  • 4.3% have had 1 MMR
  • 3.2% have had 2 MMRs
  • 11.3% unknown status

Unsurprisingly, it’s mainly the unvaccinated falling victim to (and spreading) measles in Rockland County.

You might remember that when our old antivaccine “buddy” Del Bigtree donned a Yellow Star of David with the words “no vax” on it, he claimed that he was doing it in solidarity with the Orthodox Jewish communities of Brooklyn, Queens, and Rockland County and their “persecution” by the state in the form of an order by Rockland County that the unvaccinated cannot go to public places (since stayed in legal proceedings) and the then-impending mandatory vaccination order by NYC Mayor Bill DeBlasio.

Elsewhere another large outbreak is in progress centered in Clark County, WA just across the Columbia River from Portland, OR. There, they’re up to 74 cases as of April 10. Not surprisingly, a prominent antivaxer, Dr. Paul Thomas, whom I’ve called a “rising star” of the antivaccine movement, practices in Portland and is making claims that he has almost no autism among his unvaccinated patients.

Here We have a measles outbreak that’s currently up to 42 cases. However, here things are a bit different. In contrast to the New York and Rockland County outbreaks the Orthodox Jewish community here has reacted much more responsibly, and, although the cause of the outbreak is similar (a traveler who was in the three week period before symptoms when still infectious), the reason for spreading is different, as I learned from our local paper, The Detroit Free Press, in an article entitled “How Oakland Co.’s Orthodox Jewish enclave became the epicenter for Michigan measles outbreak“. It’s a story that’s now gone national, with additional reporting from The Washington Post and other outlets. As you’ll see, I was in error when I first reported on this outbreak three weeks ago (maybe my malfunctioning component was to blame); it’s far less due to Michigan antivaxers than it is to adults with little immunity to measles infected by a traveler from Brooklyn.

Here’s how The Washington Post reported it:

Last month, a traveler raising money for charity in Brooklyn’s ultra-Orthodox Jewish community drove through the night to Detroit — his next fundraising stop. He felt sick en route and saw a doctor when he got there. But the doctor, who had never seen measles, misdiagnosed the man’s fever and cough as bronchitis.

During the next two weeks, the traveler would become Michigan’s Patient Zero, spreading the highly contagious respiratory virus to 39 people as he stayed in private homes, attended synagogue daily and shopped in kosher markets. His case offers a cautionary tale about how easily one of the most infectious pathogens on the planet spreads within close-knit communities — especially those whose members live, work and socialize outside the mainstream.

“Every one of our cases has had a link to the initial case,” said Leigh-Anne Stafford, health officer for Oakland County, a Detroit suburb where all but one case was reported.

As the Free Press reported over the weekend:

Once he got to Michigan, the man spent his time at Jewish synagogues and institutions to pray and study every day from March 6-13, unaware that he was spreading the virus along the way.

As one of the victims explained:

Eliav Shoshana, a father of six from Southfield, didn’t know that the traveler had exposed him to the measles at Congregation Yagdil Torah in Southfield on March 9, said his wife, Henny Shoshana.

“My husband was sitting in a synagogue and studying Torah and praying” that day, Henny Shoshana said. “He realized in retrospect there had been a person there who seemed sick and was coughing a lot. He was covering his mouth. … I am sure he was horrified when he realized what had occurred. He probably had no idea that he had measles and that it is so highly contagious, even covering your mouth can allow some droplets to escape.”

Recall that measles is incredibly contagious, with at least 90% of susceptible people exposed to it coming down with the disease. It’s every easily spread through droplets from sneezes and coughs. That’s what happened. It didn’t help that the exposures occurred right before a major Jewish holiday:

“There was this perfect storm that led to the outbreak in the Michigan Orthodox community,” Henny Shoshana said. “In the run-up to this holiday, which as you can imagine takes a lot of preparation … people were contagious but not aware yet they were sick — either entirely asymptomatic or maybe feeling a little under the weather.

“Because it happened over Purim, the breadth of the exposure was enormous, obviously. That’s really the story of what happened over here.”

She recalls celebrating Purim at parties on the evening of March 20 and continuing until March 21.

“We went to this big party that had at least 150 people there, including infants and pregnant women,” she said. “And again, we went not knowing he was sick at all, and certainly not with the measles. Then, that night, he came home, and it was very clear he had a fever. So he stayed in bed.”

Also, before the characteristic rash appears, the early symptoms of measles can easily be confused with other febrile illnesses. Now here’s where it gets interesting. As reported in The Washington Post, the man who had traveled from Brooklyn was initially not correctly diagnosed. He saw a doctor upon his arrival to Michigan because he had a fever and a cough. The doctor prescribed an antibiotic. The man developed a rash the next day. Initially the doctor thought it was an allergic reaction, but then he started to worry that it might be measles:

But after the doctor thought more about it, he worried about the possibility of measles and decided to leave a voice message for the health department with the man’s cellphone number. Health officials jumped on the case — but couldn’t reach the man because of a problem with his cellphone.

They turned to Steve McGraw, head of Oakland emergency medical services and longtime member of the Detroit-area Hatzalah, the ultra-Orthodox community’s emergency medical response group, an all-volunteer effort with deep ties to many families. McGraw alerted rabbinical leaders, then jumped in his car and drove to the area the traveler was supposed to be staying to look for the man’s rental car, a blue sedan, knowing it would stand out among the minivans used by virtually every family.

Hatzalah members and rabbinical leaders also mobilized to search for the traveler, who was staying in a neighborhood guesthouse. When they found him a few hours later, the traveler was stunned. He told McGraw and the rabbi who found him they had to be wrong since he believed he had had the measles.

“There is only one disease, and you have it,” McGraw recalled saying, as one rabbi translated into Hebrew. “He put his head down and was very emotional. I could tell from the look on his face that he was devastated. He was doing the math in his head,” counting all the people he had been in contact with, McGraw said.

On March 13, serological tests confirmed that the traveler had measles and that his strain matched the strain causing the New York City outbreak.

Now here’s where our outbreak is different than the other outbreaks going on in the US and, in particular, from the one currently raging among NYC’s Orthodox Jewish communities. There, the measles outbreak occurred mainly among unvaccinated and undervaccinated children. Here, the outbreak occurred primarily in susceptible adults. It turns out that a lot of adults are not adequately covered for measles. Either they don’t have documentation of having been vaccinated with MMR or their immunity has waned. What facilitated the spread of measles within the Oakland County Orthodox Jewish community was that there was a larger number of susceptible people than thought. There were many adults who thought they were immune who turned out not to be. I’ll admit that this outbreak is leading me to contact my doctor to see if I should have my titers checked or just get an MMR booster, as I’m right in the age range where my immunity might not be what it should be.

The reaction in Michigan has also been also much different than the reaction in NYC has been thus far. Whereas in NYC, cooperation with health officials has been problematic, here in Michigan the Orthodox Jewish community went all in cooperating with the Michigan Department of Health and Human Services.

For example, The Council of Orthodox Rabbis of Greater Detroit issued a statement:

Statement of Orthodox Jewish Rabbis of Greater Detroit

The response was immediate and striking. Members of the Orthodox Jewish Community turned out in droves to be vaccinated. In just three days, the health division administered 970 MMR vaccinations, and in one week the health department gave over 2,000 doses of MMR, not counting the hundreds of vaccine doses administered in private doctors’ offices to babies, children, and adults for whom documentation of measles vaccination could not be found. There’s a reason why the number of new measles cases in Michigan has slowed to a trickle over the last couple of weeks. Clearly, if it hadn’t been for the quick action of the state and county health officials and the Orthodox Jewish community’s enthusiastic cooperation and effective communication network that warned people and urged them to be vaccinated, our outbreak would likely have been far worse.

So why is the Michigan outbreak among its Orthodox Jewish community so different from the NYC and Rockland County outbreaks. The reason, I think, is that our Orthodox communities haven’t been targeted by antivaxers. As reported by NBC News, in Brooklyn, an anonymous group of antivaxers called Parents Educating and Advocating for Children’s Health, or PEACH, published an antivaccine magazine for Orthodox Jewish parents. Copies of the magazine were passed from person to person:

Inside its 40 pages, between cartoons mocking the medical establishment, PEACH’s magazine inaccurately suggests vaccines are made up of “toxins.” Without evidence, it claims that vaccines are the nation’s greatest threat to public health, linked to autism, ADHD, Sudden Infant Death Syndrome, miscarriage and other maladies.

A note from the handbook’s editor in chief explains why Parents Educating and Advocating for Children’s Health is an anonymous organization: “Please forgive us for our anonymity. It is not because we don’t believe in our cause. We do! It is because many of us have suffered abuse from fellow community members for questioning the medical authorities and advocating for children’s health.”

Yet according to New York State’s Department of State and internet domain registration records, PEACH appears to be linked both to a decade-old misinformation hotline targeting the Orthodox community and to Enriched Parenting, a website that peddles new-age cures from a Jewish perspective alongside vaccine hoaxes.

The magazine is available online, and I perused a copy. It’s chock full of pretty much every antivaccine trope, distortion, and lie you can think of, including claims linking vaccines to autism, sudden infant death syndrome, and brain damage; the “toxins” gambit that claims vaccines are chock full of nasty “toxins”; the (mis)informed consent gambit; the intellectually dishonestvaccines didn’t save us” gambit; and more. Basically, if I’ve written about it here, it’s probably in PEACH’s misinformation-filled booklet. The twist here is that it appears from my perspective that PEACH is an anonymized marketing arm of Enriched Parenting designed to sell quackery among the Orthodox Jewish community.

Does the spreading of antivaccine propaganda among the Orthodox Jewish community in NYC sound familiar? It should. It’s very much similar to how antivaccine advocates targeted another vulnerable community, the Somali immigrants in Minnesota, leading to huge measles outbreaks. Basically, white privileged antivaxers saw a community receptive to their message, and they pounced, even doubling down in the midst of massive measles outbreaks.

The narrative is not as simple as saying that antivaxers are solely responsible for measles outbreaks. They are, without a doubt, a major factor, but other factors contribute as well. In the case of Orthodox Jewish communities, there are important differences, and in Michigan Orthodox Jews are concerned that a false narrative is developing that Orthodox Jews are antivaccine:

That’s a misconception that also worries David Kurzmann, executive director of Jewish Community Relations Council of Metro Detroit/AJC.

“It’s troubling to hear that perception, and … we unfortunately could see this story brewing,” he said.

“Let’s set the record straight. The reality is that the Council of Orthodox Rabbis of Greater Detroit, which is sort of the umbrella for all of the orthodox synagogues and rabbis, they put out a very clear, unequivocal statement that families are obligated to vaccinate their children and that community members who are not vaccinated are obligated by Jewish law … to go and get vaccinated and if you are showing any symptoms of the measles, you are forbidden in their viewpoint from engaging in the community.

“In Judaism, protecting life and the preservation of life supersedes every other precept and commandment. You can break the rules of the Sabbath to save a life. There is just nothing more important than that. And so the perception that the Jewish community would be the ones perpetrating this intentionally is factually incorrect and you know, for many members of our community, it’s causing great anxiety because frankly it’s offensive.”

Finally, antivaxers are an easy scapegoat, the more so because they most definitely do contribute to outbreaks of vaccine-preventable diseases. Indeed, in the US, arguably they are the biggest contributors to outbreaks. However, antivaxers could not be so effective if there were not other factors that leave people unvaccinated or susceptible to disease for other reasons. Combatting antivaccine misinformation is still critical to containing outbreaks and preventing new ones, but, as the measles outbreak in the Orthodox Jewish community here shows, we are all interconnected. “Patient zero” was exposed to measles in Brooklyn, likely because antivaccine views resulted in low vaccine uptake there, but his causing an outbreak in Michigan arguably had nothing to do with high levels of antivaccine views here. We should not forget to pay attention to other factors that leave people susceptible to measles, even as the media reports antivaxers’ contributions to the current outbreaks.