The increase in the number of cases of measles in Israel began in March, but until three months ago it seemed that the figures were just a bit higher than usual. Now the local health establishment believes the country is experiencing a serious outbreak of one of the world’s most infectious diseases – one that led to the death of an 18-month-old child last week.
The local situation is related to a concurrent, sharp rise in the incidence of measles in Europe, but here the disease can take hold in “pockets” of unvaccinated people in certain towns and neighborhoods.
What is measles?
Measles is caused by a virus from the morbillivirus family, and it affects only humans and not animals, unlike many other infectious diseases. Although an effective vaccine against it has existed since the 1960s, measles is still common and it is one of the most contagious diseases of all, with a 90-percent risk of infection among unvaccinated people. The virus is highly infectious because it can survive a long time in the open air: When someone with the disease coughs, sneezes or talks, infected droplets are sprayed into the air, which are then inhaled by other people. After infection, the virus attacks the immune system; it usually incubates for a period of between eight to 12 days before symptoms occur.
What are the symptoms?
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Signs and symptoms include high fever, runny nose, coughing, red eyes and sensitivity to light. Four or five days after the appearance of these symptoms (which are common to many conditions), a dark red rash appears on the skin. It generally starts on the neck and spreads to the face, the body and the extremities.
The rash begins as individual spots, but these often converge into a rash that covers large areas of the body. On the third day after it appears, the rash starts to fade and begins to look like the small, dense flowers of the squill plant – hatzav in Hebrew, which is why the disease’s Hebrew name is hatzevet. At this point the patient will generally begin to feel better, although the progress of the disease varies in certain cases.
What are the complications and risks?
Aside from being extremely contagious, measles is dangerous because there is no remedy for it. The illness can damage the respiratory and nervous systems. One-third of sufferers will develop middle-ear infections, diarrhea or cornea inflammation. A rare complication, which can emerge up to 10 years after infection, is a degenerative brain condition that causes severe and irreversible damage to the central nervous system, including mental deterioration and seizures. One in 1,000 cases of measles is fatal.
Why is there an outbreak now?
Measles is passed on only among human beings and since there is an effective vaccine to prevent it, the outbreak is solely man-made. If the immunization rate in a population drops, however, the collective immunity provided to unvaccinated individuals by all the vaccinated people – known as "herd immunity" – is undermined. Larger parts of the population are then exposed to the disease and the risk of a flare-up increases.
The source of the current outbreak in Israel is attributed to outbreaks last year in various European countries that have also seen a drop in inoculation rates – countries that Israelis often visit, like Italy, England, Ukraine and Romania. Since then the number of European cases has skyrocketed to 40,000, and more than 40 people have died.
But the situation didn’t arise here because some unvaccinated person was infected abroad and brought the disease back home. The overall measles-inoculation rate in Israel surpasses 95 percent – but there are a few densely populated communities and neighborhoods with much lower vaccination rates. According to the Health Ministry, in some Jerusalem neighborhoods, for instance, the vaccination rate is only 55 percent. As a result, there has been an uptick in the number of cases of measles 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 is facing such a surge in cases of measles?
In the 1950s, before there was a vaccine, there were thousands of cases reported annually. Since 1967, when the inoculation became part of the Health Ministry’s protocol, there has been a consistent drop in the number of cases to a few dozen a year. Still, there have been other outbreaks. In 2003, for example, 60 Israeli youngsters contracted measles within two weeks, and one of them died. The last large flare-up was in 2008, when within a few months there were 1,452 cases reported among unvaccinated people, most of them in the Jerusalem area.
How effective is the measles vaccine?
Like other vaccines, the measles shot has two purposes – to protect the person from being infected, and to prevent the spread of the disease and protect populations at risk who cannot be vaccinated for medical reasons. The two doses of the vaccine that are part of the protocol offer 97 percent protection from the disease. The shot is administered at the age of one year and again at age 6, as part of a quadruple vaccine that covers rubella (German measles), mumps and chicken pox.
What does the Health Ministry do when a measles case is discovered?
In recent months the health establishment has monitored every case of infection, whether the patient was discovered on a flight, in a hospital, at school or elsewhere. Once the symptoms appear and a case of the disease is suspected, a sample of the patient’s blood is sent to a laboratory to determine if measles is indeed present; at the same time, medical teams try to locate all those who have come in contact with the person and determine if he was vaccinated and what the condition is of his immune system. In many cases, Health Ministry or hospital doctors will summon those exposed for preventive treatment, i.e., to be inoculated.
The race to identify each case has become more intense as the disease spreads. Doctors in Jerusalem, where so many instances of measles have been recorded, are finding it difficult to keep pace with the identification and treatment of patients. The Health Ministry is focusing its efforts on raising the immunization rate in ultra-Orthodox neighborhoods by extending the reception hours at Tipat Halav well-baby clinics. A vehicle belonging to the Natali healthcare service has been also been making the rounds to allow easier access to vaccinations.
What other steps are being taken?
The Health Ministry has banned unvaccinated people from hospital departments that are considered particularly sensitive, such as neonatal units, intensive care, oncology, hemato-oncology, etc. In addition, the ministry is considering banning unvaccinated children from schools, and is checking whether the inoculation now given to children at one year can be routinely administered at 9 months.
If someone unvaccinated is exposed to measles, can anything be done to lessen its intensity?
Yes, but one must act immediately. Preventive care of first resort involves administering of the live-virus vaccine within 72 hours of exposure, but someone who cannot get the active vaccine can get a passive one that will produce antibodies against the disease within six days.
When should one be vaccinated or update his vaccinations?
The Health Ministry is calling on adults who have never had the measles and never got two shots of the vaccine to get vaccinated. The vaccine must be given in two doses of at least four weeks apart. This recommendation does not apply to those born before 1956.
The ministry is also advising parents who received their first shot not to wait for the second dose until they reach school age, but to have the child inoculated immediately, as long as four weeks have passed since the first dose. The ministry is also advising that people traveling abroad who have doubts about their immunity get inoculated before they leave Israel, even though it takes two weeks for the vaccine to take full effect. If they are traveling with a baby between 6 and 11 months of age, the child should receive the first shot before leaving.
People born in Israel between 1957 and 1977 are considered to be unvaccinated or only partially vaccinated, since during those years only one vaccination was administered and not everyone received it. Such people are advised to get inoculated now.
Who should not be vaccinated?
The Health Ministry says the following people should not be vaccinated: Pregnant women; a person with a high fever; a person who has had an allergic reaction to a previous vaccine; someone who has a sensitivity to one of the components of the vaccine; and people whose immune systems are seriously compromised.