NYT: Current NY Measles Outbreak Traced to Uman Ukraine

NYT - The measles outbreak that led to a state of emergency in New York’s Rockland County began far away: in an annual Hasidic pilgrimage from Israel to Ukraine. Scientists believe New York’s measles outbreak has its roots in Uman, Ukraine, the site of a Rosh Hoshana pilgrimage that attracts tens of thousands of Orthodox men each year.

 The Ukraine connection

Ukraine is suffering through a measles outbreak that began in 2017. The country has had almost 70,000 cases — more than any other country in recent years. The infections have not been confined to a particular ethnic group. The country is at war with pro-Russian separatists on its eastern border, distrust in government is high, and rumors about vaccines are rife — one of which began when a 17-year-old died of unrelated causes after getting a shot. The Ukrainian government also rejected cheaper Indian and Korean vaccines in favor of European ones, but they cost more than the government could afford, Dr. Larson said. But the real problem appears to have begun at Rosh Hashana. Each year on the holiday, tens of thousands of Orthodox men travel to Uman, a Ukrainian city where the grave of Rabbi Nachman of Breslov, founder of one branch of Hasidism, has become a popular pilgrimage site. (The festivities have been called the “Hasidic Burning Man.”) Last year, Rosh Hashana fell in early September. Later that month, measles cases exploded in Israel, rising to a peak of 949 in October. The cause? Numerous pilgrims came back from Ukraine with the virus, experts believe.
 New York’s outbreak began in October; the first patient was a child in the Bensonhurst section of Brooklyn who had visited Israel. At the same time, a measles outbreak began among Orthodox Jews in London. The Israeli government responded rapidly, recruiting Orthodox Jews onto vaccine advisory groups and sending mobile clinics into their neighborhoods. “Coverage improved immensely, and the numbers are getting smaller,” Dr. O’Connor said.

 Orthodox Jews in Britain and the United States also have big families and may struggle to keep everyone vaccinated. But vaccine skepticism is more common in the United States than in Israel and much more common in Britain. The false rumor that measles vaccines cause autism was started in 1998 by Andrew Wakefield, a British doctor whose medical license was later revoked. It is emblematic of a series of fierce, sometimes connected measles outbreaks — in places as diverse as Indonesia, the Philippines, Madagascar and Venezuela — that have shaken global health officials, revealing persistent shortcomings in the world’s vaccination efforts and threatening to tarnish what had been a signature public health achievement. In 2001, the United Nations declared war on measles. With help from the federal government, the American Red Cross and big donors like Ted Turner and Bill and Melinda Gates, the U.N. began the Measles and Rubella Initiative and created Gavi, the Vaccine Alliance. Together, they poured billions of dollars into buying vaccines and helping countries deliver it safely, which meant building refrigerated storage facilities, supplying clean needles, training vaccinators and countering other logistical obstacles common in poor countries. Public health officials worldwide tracked the results, monitoring cases and tracking outbreaks. The news was good: Measles declined worldwide by nearly 80 percent between 2000 and 2016, with fatalities — mostly among children younger than age 5 — plummeting to about 90,000 per year from about 550,000. But two years ago, measles cases unexpectedly popped upward again, rising 30 percent in a single year. The virus re-invaded countries where it had been vanquished. The biggest factor in that increase, World Health Organization officials said, was poverty: Medical systems in many countries remain too weak to vaccinate enough children year after year to wall out the virus. To stop imported cases from spreading, about 95 percent of a country’s citizens must be immune, either through vaccination or because they had measles as children. As babies are born, new pools of potential victims are created — unless vaccination is constant. Anti-vaccine activists, false rumors and serious missteps by some vaccine companies have all contributed to the global rebound. Jet travel has fueled the spread, as it has with viruses like MERS and Zika. So have “diaspora networks Many outbreaks, many triggers Several other measles outbreaks are crisscrossing the globe. They follow similar patterns but have unique triggers and pose individual public health challenges. Many countries are having outbreaks bigger than Israel’s. Madagascar has seen 66,000 cases of measles, with more than 900 dead. India has had 63,000 cases; Pakistan, 31,000; Yemen, 12,000; Brazil, 10,000; and Venezuela, 5,700. Most of these countries have chronically low vaccination rates. But some are worsened by unique constellations of challenges. Yemen is in the middle of a civil war. Venezuela’s medical system has broken down; part of Brazil’s outbreak is in refugees from Venezuela. Madagascar is one of the world’s poorest countries. It is an island with a high birthrate, and there had been no measles outbreak since 2003, so it had a huge pool of susceptible children and teenagers. And many of those children are dangerously malnourished. In wealthy countries, measles kills about one in every 1,000 victims. But when children are malnourished, and when they cannot get hospital care for complications like pneumonia or encephalitis, measles can kill one in 10 children, sometimes even more in refugee camps, said Dr. Katrina Kretsinger, a W.H.O. medical officer.