An increase in the number of measles cases in Israel began in March, but up to three months ago it seemed the number was slightly higher than usual. Now, local health agencies believe that the country is experiencing a serious outbreak of one of the most contagious diseases in the world – which caused the death of an 18-month-old child last week.
The local situation is related to the increased incidence of measles in Europe simultaneously and sharply, but here the disease can enter into the "pocket" of unvaccinated people in certain cities and environments.
What is measles?
Measles is caused by a virus from morbillivirus family, and it only affects humans and not animals, unlike many other infectious diseases. Although the effective vaccine against it has been around since the 1960s, measles is still common and is one of the most contagious diseases of all, with an infection risk of 90 percent among unvaccinated people. This virus is very contagious because it can last long in the open air: When someone with coughing, sneezing or talking, infected droplets are sprayed into the air, which is then inhaled by other people. After being infected, the virus attacks the immune system; usually incubated for a period of between 8 and 12 days before symptoms appear.
What are the symptoms?
Signs and symptoms include high fever, runny nose, cough, red eyes and sensitivity to light. Four or five days after the appearance of these symptoms (which are common in many conditions), a dark red rash appears on the skin. It usually starts in the neck and spreads to the face, body and extremities.
The rash starts as individual spots, but this often gathers into a rash that covers a large area of the body. On the third day after it appears, the rash starts to fade and starts to look like small, dense flowers from the squill plant – hatzav in Hebrew, which is why the Hebrew name is the disease hatzevet. At this point patients will generally begin to feel better, even though the development of the disease varies in certain cases.
What are the complications and risks?
Apart from being very contagious, measles is also dangerous because there is no cure for it. The disease can damage the respiratory system and nerves. One third of patients will experience middle ear infections, diarrhea or inflammation of the cornea. A rare complication, which can appear up to 10 years after infection, is a degenerative brain condition that causes severe and irreversible damage to the central nervous system, including mental damage and seizures. One in 1,000 cases of measles is fatal.
Why is there an outbreak now?
Measles is only transmitted among humans and because there is an effective vaccine to prevent it, the outbreak is only man-made. If the immunization rate in the population decreases, the collective immunity given to unvaccinated individuals by all vaccinated people – known as "group immunity" – is destroyed. The larger part of the population is then affected by the disease and the risk of increasing flare-ups.
The current source of the outbreak in Israel has been linked to last year's outbreaks in various European countries which have also seen a decline in the level of inoculation – countries frequented by Israel, such as Italy, Britain, Ukraine and Romania. Since then the number of European cases has jumped to 40,000, and more than 40 people have died.
But the situation did not arise here because some unvaccinated people were infected overseas and brought the disease back home. The overall measles inoculation rate in Israel exceeds 95 percent – but there are some communities that are densely populated and the environment with a much lower vaccination rate. According to the Ministry of Health, in some Jerusalem neighborhoods, for example, the vaccination rate was only 55 percent. As a result, there has been an increase in the number of measles cases in the country as a whole: from 40 cases in all of 2017 to 1,334 cases so far this year.
Is this the first time Israel has faced a surge in measles cases?
In the 1950s, before there was a vaccine, there were thousands of cases reported every year. Since 1967, when inoculation became part of the Ministry of Health protocol, there has been a consistent decline in the number of cases of up to several dozen years. However, there are other outbreaks. In 2003, for example, 60 Israeli youths developed measles within two weeks, and one of them died. The last major explosion occurred in 2008, when within a few months there were 1,452 reported cases among unvaccinated people, mostly in the Jerusalem area.
How effective is the measles vaccine?
Like other vaccines, measles injections have two purposes – to protect people from being infected, and to prevent the spread of disease and protect at-risk populations who cannot be vaccinated for medical reasons. Two doses of vaccine which are part of the protocol offer 97 percent protection from the disease. Shots are given at the age of one year and again at the age of 6 years, as part of a quadruple vaccine that includes rubella (German measles), mumps and chicken pox.
What did the Health Department do when measles was found?
In the past few months, health institutions monitored every case of infection, whether patients were found on flights, in hospitals, at school or elsewhere. After symptoms appear and suspected cases of the disease, the patient's blood sample is sent to the laboratory to determine whether measles does exist; at the same time, the medical team tried to find everyone who had contact with the person and determine whether he had been vaccinated and what was the condition of his immune system. In many cases, the Ministry of Health or hospital doctors will call those who are exposed to preventive care, that is, to be inoculated.
The race to identify each case becomes more intense when the disease spreads. Doctors in Jerusalem, where so many samples of measles have been recorded, find it difficult to balance the identification and care of patients. The Ministry of Health is focusing its efforts on increasing immunization rates in the ultra-Orthodox environment by extending the hours of admission to the Tipat Halav baby clinics. A vehicle owned by Natali health services has also made a round to allow easier access to vaccination.
What other steps have been taken?
The Ministry of Health has banned unvaccinated people from hospital departments that are considered very sensitive, such as neonatal units, intensive care, oncology, hematology, etc. In addition, the ministry is considering banning unvaccinated children from school, and checking whether the inoculation currently given to children in one year can be routinely given at 9 months.
If someone is not vaccinated against measles, is there anything that can be done to reduce the intensity?
Yes, but someone must act immediately. The first resort preventive care involves administering a direct viral vaccine within 72 hours of exposure, but someone who cannot get an active vaccine can get a passive vaccine that will produce antibodies to the disease within six days.
When should someone be vaccinated or renew vaccinations?
The Ministry of Health calls on adults who have never been exposed to measles and have never received two injections of vaccines to be vaccinated. The vaccine must be given in two doses at least four weeks. This recommendation does not apply to those born before 1956.
The ministry also advised parents who received their first injection not to wait for the second dose until they reached school age, but so that the child was immediately inoculated, for four weeks had passed since the first dose. The ministry also advised that people traveling abroad who had doubts about their immunity were inoculated before they left Israel, even though it took two weeks for the vaccine to be fully functional. If they travel with babies between the ages of 6 and 11 months, the child must receive the first injection before leaving.
People born in Israel between 1957 and 1977 were considered not vaccinated or only partially vaccinated, because during those years only one vaccination was given and not everyone received it. Such people are recommended to be inoculated now.
Who should not be vaccinated?
The Ministry of Health said the following people should not be vaccinated: Pregnant women; someone with a high fever; someone who has experienced an allergic reaction to a previous vaccine; someone who has sensitivity to one component of the vaccine; and people whose immune systems are seriously compromised.