In Rockland County, New York, a wooded suburb 30 miles north of Manhattan, a teenage boy lay in a room in an empty wing of a health clinic, in a fetal position, coughing.
It was October 2018. The boy had measles, which spreads through the air. His illness was the dawn of the worst outbreak in the United States for more than a quarter century, and the start of a multi-million-dollar effort by an understaffed health department to contain it.
Two miles from where the boy lay, Maria Souto was in her office in the county health department, where for 15 years she has served as the county's communicable disease coordinator. She took a call from the physician who had diagnosed him, hung up and rushed to the next-door office to alert Kevin McKay, the county epidemiologist.
Their heads were spinning, McKay said: "Everything else stopped right there."
What follows is the previously unreported story of how a suburban health department at the epicenter of a national health crisis brought the outbreak under control, in the face of campaigning by people who oppose vaccination. It is based on interviews with more than a dozen health officials, medical experts and local residents.
Measles, which causes a rash, fever and coughing, can be fatal and lands up to 20% of Americans who catch it in the hospital. It afflicted millions of Americans every year before a vaccine became available in 1963. The vaccine is 97% effective with two doses and helped the United States eliminate the disease in 2000, according to the World Health Organization (WHO), which says measles is wiped out if there is no continuous, endemic transmission for 12 months.
The Rockland County case was one of two major U.S. outbreaks last year - the other, in Brooklyn, started a day earlier. Both put the United States on the clock. If they weren't halted within 365 days, either could have cost America its WHO-certified measles-free status - damaging its reputation as a developed country with an effective public healthcare system.
In Rockland County, everything depended on whether a team of about a half-dozen health officials could rally their community to stop one of the world's most contagious diseases from spreading.
Just six days before the deadline - after more than 1,400 people across 31 states had contracted the virus and nearly 30,000 doses of vaccine been administered in Rockland County alone – county officials declared the outbreak was over. The direct cost of the county's response, according to its preliminary estimates, was between $2.4 million and $6.5 million - possibly as much as one-tenth of the county health department's annual budget.
To some health officials, it was a hollow victory – a small battle in a global fight against an enemy that respects no borders and is fed as much by confusion and mistrust of modern medicine as by microbes.
Both New York outbreaks involved international travelers. Patrick O'Connor, who leads rapid disease control at the WHO, said health officials are investigating "chains of transmission" which may link the New York outbreaks to Ukraine, a country struggling with a measles epidemic that has infected more than 58,000 people in 2019 alone. Some visitors came from communities in Israel where many people make an annual pilgrimage to the grave of a revered rabbi in the former Soviet Union state.
"A lot of people think ... it's all fine," said New York State Health Commissioner Howard Zucker last month. "But it's not done, because there are travelers that pop up, and it still comes back."
In Ukraine, only half the population believes vaccines are effective, compared with 84% in the United States, according to a report published in June by Britain's Wellcome Trust, based on a survey of attitudes among 140,000 people from 140 countries.
U.S. officials fully expect there will be fresh measles cases, potentially leading to new outbreaks of measles or other dangerous diseases, as some people harbor overwhelming suspicions about vaccines, and distrust the agencies that recommend them.
THE FIRST PATIENT
Rockland County's measles campaign started on Oct. 1 with the teenager in the clinic. Originally from Israel - officials declined to give his name and age - he was visiting for the Jewish Holy Days and fell sick during services at synagogue.
Once measles was diagnosed, the entire wing of the Refuah Health Center was evacuated and signs put up warning people not to enter. Souto and McKay drove to the clinic, saw the boy and interviewed his father. When had they arrived in the United States? Who had they come in contact with? Where had they been within the county?
They had made several visits, the father said, to the synagogue.
"The synagogue had thousands of people," Souto said in a phone interview.
McKay inspected the big, open worship hall, the sort of setting where transmittable diseases flourish. The patient's father and a rabbi pointed to the places the boy had been. Neither could be reached.
"They were pointing at this side of the building on this day, and this side of the building on this day," McKay said. "Basically you had to consider everyone exposed."
Health department phones were soon ringing again - doctors and clinics calling to report patients with rashes.
Nationwide, the rate of children in the United States who received no vaccines by age 2 has been rising - from 0.9% of those born in 2011 to 1.3% of those born in 2015, according to the U.S. Centers for Disease Control and Prevention (CDC). That represents more than 18,000 children.
In Rockland County, about a third of the population is Jewish, including a large enclave of Orthodox Jews who live in secluded communities. According to county data on vaccination rates, which only includes school-age children, some Jewish schools in the county had measles vaccination rates below 70% in 2018, compared to 99% statewide.
While the Orthodox Union and the Rabbinical Council of America strongly recommend parents vaccinate healthy children, a small minority of rabbis and Orthodox Jewish people claim ingredients in vaccines violate religious principles. Rabbi Asher Bush, who leads the Congregation Ahavat Yisrael in Rockland County, said this opposition on religious grounds is unfounded. "That's not Judaism, it's a personal choice," he said. "I think it's a silly, foolish personal choice."
Health officials believe opponents of vaccination have become increasingly influential in the Orthodox community in the last 5 to 10 years. They trace this skepticism to a pamphlet that came out at least five years ago from an anonymous group calling itself "P.E.A.C.H." (Parents educating and advocating for children's health) which circulates in print and online. The pamphlet contains bogus or unsupported assertions about vaccines, scientists say. To reduce the risk of contracting measles, for instance, the pamphlet recommends Vitamin A supplements instead of vaccination.
"From our research (and for some of us, from personal experience) many more than 'one in a million' lives have been ruined by vaccines," its authors write.
P.E.A.C.H. and other anti-vaccination advocates did not respond to emails requesting comment.
Within the first half of October 2018, Rockland County had recorded a dozen measles cases. By month's end, there were 51. More than 300 people would eventually be diagnosed with measles, or about 1 in every 1,000 residents.
Rockland County's health department staff of 180 had between six and eight employees dedicated to the outbreak. Others helped occasionally while running some 50 county health programs and services. Between 2008 and 2013 overall staff numbers were cut by 30%, said Patricia Ruppert, the County Health Commissioner. Some positions have since been filled.
Employees were joined by state health officials, local doctors, school administrators, rabbis and, as the crisis worsened, federal health officials. The county executive declared a state of emergency in March. Staff frequently worked 14-hour days. "I'm talking day and night, weekends, holidays, it didn't matter," said Ruppert.
Over the year, around 1,200 of the people known to have been exposed to the virus were deemed to be susceptible to infection. Health officials called or visited their homes every day for the measles incubation period of at least 21 days, to ensure the disease did not appear and that those who might be carrying it stayed home. Some days they checked on more than a hundred people.
Staff would also drive two hours each way to bring nasal swab samples from patients with rashes to the state lab in Albany to be tested. At first, they mailed the samples overnight, but then learned some were left in a shipping warehouse over the weekend. Wanting to confirm new cases as soon as possible, staff hand-delivered them in coolers.
Meanwhile, anti-vaccination advocates were conducting a live campaign to prevent people in the Orthodox community from having vaccinations.
As measles cases topped 250 in May, a group called the United Jewish Community Council hosted a symposium five miles from the health department. Speakers included Andrew Wakefield, whose medical license was revoked in the UK for repeatedly breaching "fundamental principles" of research medicine, and Lawrence Palevsky, a pediatrician in New York. Neither speaker responded to requests for comment, and the Council could not be reached. Health workers said attendees, many of whom were Rockland County Orthodox Jews, were given pamphlets saying - falsely - that vaccines cause autism.
Debra Blog, a state health department epidemiologist, attended, but left after she heard a doctor say vaccines were unsafe. "It was not a forum where I could counter anybody or say anything," she said.
Common side effects of the measles, mumps and rubella (MMR) vaccine include a sore arm, fever and a mild rash. Serious reactions are rare: According to the CDC, about 4 out of every 10,000 children who receive the MMR vaccine between ages 1 and 2 have febrile seizures and 1 out of 40,000 will develop a non-life threatening bleeding disorder.
Many Orthodox Jews in the Rockland community did not want to talk to the health officials. "I think there are people who resent having others tell them what to do," Rabbi Bush said. But as the staff knocked on doors and made phone calls to persuade people to immunise their children, they made progress with one key constituency: mothers.
The mothers they reached were often not strongly opposed to vaccines, but had simply delayed scheduling their children's shots.
In December, the New York State Department of Health contacted Shoshana Bernstein, herself an Orthodox mother of five children living nearby in Monsey, NY. She wrote a pro-vaccination pamphlet geared towards Orthodox Jews a few years ago.
The department ordered 50,000 copies and sent them to around 15,000 Orthodox Jewish homes in Rockland County.
Bernstein said she offered an alternative to the rumor-mill of false claims about vaccines: "If someone tells you if you give your baby daughter a shot she's going to have cancer in 10 years, what's a mom supposed to do with that information?" she said in a phone interview. "I sort of became known as the person to call when you had a question."
There were holdouts, and County Health Commissioner Ruppert's team combed through hundreds of thousands of school immunization forms to check who had been vaccinated. They excluded more than 5,500 students from school until the students had received shots. In the end, more than 29,000 doses of the vaccine were administered, Ruppert said.
Six days before the United States would have fallen short of WHO standards, the Rockland County health staff gathered for a regular call with health officials from the state and neighboring counties.
The question: had 42 days had passed since the last measles rash had been recorded? If it had, this outbreak would have been contained.
The call was short. "My update that day was 'Rockland County's outbreak is over,'" Souto said.
Cheers erupted on the line.