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US county bars unvaccinated children from public spaces amid measles emergency

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1481 (Published 28 March 2019) Cite this as: BMJ 2019;364:l1481

Linked opinion

Measles in America—what’s playing out in New York State is nightmarish

Re: US county bars unvaccinated children from public spaces amid measles emergency

New York state is one of 47 states that allow parents to claim a religious exemption from their children's vaccines. One to two percent of parents take advantage of this legal avenue to avoid vaccinating their children.

The US has about 10-20 outbreaks of measles yearly (there were 17 in 2018)[1], usually initiated by visitors who were incubating measles when they entered the country. Health departments perform case-finding, track exposures, apply quarantines, and these outbreaks generally resolve quickly. The Disneyland outbreak of 2014-2015 lasted under 2 months.[2]

In Rockland county, New York, things have gone differently. The current measles epidemic (156 total cases) has been ongoing for more than 5 months, longer than any outbreak since endemic measles was declared eradicated. While it is attributed to 7 infected overseas visitors, they all arrived in October. Why are there still cases? We don't know whether the response by the health department was thorough, and if it followed standard procedures.

Orthodox Hasidic Jews and others with unvaccinated children in Rockland county, had their children removed from schools as a consequence of the epidemic, beginning in December--even when there had been no measles cases in the school and no identified exposure to a case. A tense situation developed. Some parents sued the health department; their request for a restraining order was denied, although the lawsuit continues.

While some parents chose to vaccinate, others held back. Meanwhile, the outbreak slowed down, with currently "under ten" active cases.[3] I was told there are 4 current measles cases.

On March 26, Ed Day, the Rockland county executive officer and former police detective, issued an inflammatory order. All unvaccinated (but still uninfected) children would be prohibited from all indoor public spaces for 30 days, or until they got an MMR. While the order was framed as a means of protecting the public, it was timed to coincide with (and disrupt) Easter and Passover holiday gatherings.[4]

"Day said the order was not about enforcement but rather is to garner attention so people get vaccinated and educate residents about the seriousness of the highly contagious virus."[5]

Public officials in authority cannot be unaware of state law granting religious exemptions. Yet, "officials say there are no religious exemptions, and that they have been working with area rabbis who have been encouraging their members to get vaccinated."[6]

It is well known that vaccine efficacy is reduced when given to children under 12 months old, and those children vaccinated early will require an additional (3d) MMR dose before school entry. Furthermore, safety of the mumps and rubella components in children under 12 months has not been established. From the MMR label[7]:

"Infants Between 6 to 12 Months of Age. Local health authorities may recommend measles vaccination of infants between 6 to 12 months of age in outbreak situations. This population may fail to respond to the components of the vaccine. Safety and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have not been established. The younger the infant, the lower the likelihood of seroconversion. Such infants should receive a second dose of M-M-R II between 12 to 15 months of age followed by revaccination at elementary school entry."

Despite this warning, children as young as six months old are being vaccinated with the MMR at clinics throughout Rockland county.

During the Disneyland outbreak year of 2015, CDC genotyped reported measles cases, and found that 73 of the tested strains (38%) were vaccine strain measles.[8] But CDC has been silent about these cases. Instead, CDC's website states, "Analysis by CDC scientists showed that the measles virus type in this outbreak (B3) was identical to the virus type that caused the large measles outbreak in the Philippines in 2014".[9]

Are any Rockland cases are due to recent vaccinations?

In the midst of a 156 case measles outbreak which has caused no deaths, a county administration has ignored religious freedom laws and is taking multiple, unprecedented measures that are designed to thwart parental authority around vaccinations. Is this a trial balloon, or a taste of things to come?

The real question is whether epidemics of vaccine-preventable diseases are going to be managed by knowledgeable, capable physicians who provide the public with the facts, or will they continue to be stage-managed for maximal media attention, using extraordinary means to force greater vaccine uptake?

[1] https://www.cdc.gov/measles/cases-outbreaks.html

[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a5.htm

[3] https://www.lohud.com/story/news/local/rockland/new-hempstead/2019/03/27...

[4] https://www.usnews.com/news/health-news/articles/2019-03-26/county-bans-...

[5] https://abc7ny.com/health/measles-outbreak-rockland-bars-unvaccinated-fr...

[6] https://abc7ny.com/health/measles-outbreak-rockland-bars-unvaccinated-fr...

[7] https://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedPr...

[8]https://jcm.asm.org/content/55/3/735 "Of the 194 measles virus sequences obtained in the United States in 2015, 73 were identified as vaccine sequences (RJ McNall, unpublished data)." RJ McNall is a CDC virologist and coauthor of this paper.

[9] https://www.cdc.gov/measles/cases-outbreaks.html

Competing interests: No competing interests

30 March 2019
Meryl J Nass
Internist
Private Practice
Ellsworth, Maine, USA