Measles in Jerusalem, 2018–2019: How 2,202 Cases Spread and How They Were Stopped

Between March 2018 and May 2019, Israel had 4,115 measles cases, sparked by imported infections, mainly from Ukraine. More than half — 2,202 — were in Jerusalem District, mostly among unvaccinated children in orthodox Jewish communities. The outbreak showed how fast measles moves where vaccination has long lagged — and what it takes to stop it.

A coverage gap

Jerusalem District has 1.25 million people, about 14 percent of Israel's population; 70 percent are Jewish, and about a third of those are orthodox. In the orthodox communities, first-dose measles vaccine coverage among children was 78.4 percent, against 90.1 percent in all other communities.

How it spread

The first two Jerusalem cases, in August 2018, were an unvaccinated 20-year-old religious boarding school student and an unvaccinated 2-year-old, both arriving from affected communities in the Northern District. Their contacts included 300 of the student's schoolmates and 40 of the child's relatives and neighbors. Measles then spread quickly through densely populated, low-income orthodox neighborhoods, where families average seven children and households may hold 12–15 people. It surged during the September–October high holidays: 1,029 cases by October 31, 2018.

The toll

Israel's schedule gives measles vaccine at 12 months and 6 years.

The response

• Tracing and isolation. The Jerusalem District Health Office found and confirmed cases, traced contacts and briefed providers. Patients were told to isolate, but many did not: infectious people attended crowded events and child care and rode public transport, and the sheer number of contacts made tracing hard.
• Prophylaxis. Exposed people were offered vaccine or immune globulin depending on age and risk.
• Mass vaccination of children and adolescents aged 1–14, from September to December 2018 — clinics open 12-hour shifts every day for vaccinations only, school health services and a mobile unit.
• Culturally adapted outreach through phone calls, community visits, wall posters and word of mouth.
• Rabbinic support. As parents grew anxious, rabbinic leaders issued written statements backing vaccination, and acceptance was high at the epidemic's peak.

The result

First-dose coverage at maternal-child health clinics in orthodox neighborhoods rose from 76.3 percent in June 2018 to 96.1 percent in November. Cases fell sharply from December: Jerusalem District's share of Israel's cases dropped from 66 percent (1,652 of 2,486) in October–December 2018 to 25 percent (248 of 969) in January–April 2019. Keeping coverage high will need continued targeted effort — two doses for everyone eligible is what protects infants too young to be vaccinated.

Sources

Based on "Notes from the Field: Large Measles Outbreak in Orthodox Jewish Communities — Jerusalem District, Israel, 2018–2019," by Chen Stein-Zamir, Nitza Abramson and Hanna Shoob of the Jerusalem District Health Office, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.