This week, the US CDC announced that the 555 cases of measles that have been reported in the US since January, representing the second highest number of cases since measles was declared eliminated in the US in 2000. The highest number of cases occurred in 2014, when 23 measles outbreaks accounted for a total of 667 cases. Measles has been well covered here on Outbreak Thursday. So far this year, we have written several posts on this topic: one centered on a high-profile outbreak in Clark County, WA; another looked at the rise in measles cases around the globe due to low vaccination coverage; and one discussed measles as a rising health threat coinciding with a humanitarian emergency in Venezuela. It hardly seems plausible for there to be another post on measles without us repeating the same messages. And yet, here we are: measles again. But this time we are looking at the challenge of interrupting transmission in hard-to-reach populations, specifically, insular religious communities.

The majority of measles cases reported in the US this year have occurred in or are linked to cases from New York State. In Rockland County, NY, health officials have been trying to control a measles outbreak that began with an international traveler at the end of September 2018. To date, Rockland County has confirmed 190 cases of measles. Similarly, health officials in New York City are also working to contain a large measles outbreak with 329 cases to date, which began in September 2018 when an infected child returned from international travel. Other parts of the US have also reported cases of measles tied to both of these outbreaks. Detroit, Michigan, is among the latest, where a traveler from Brooklyn, NY, infected 39 people.

What both of these outbreaks in New York have in common is that they are largely occurring among an Ultra-Orthodox Jewish community. Members of these communities may reject many aspects of and maintain strict separation from secular society. For example, children in these communities typically attend religious schools known as yeshivas, and some members of the community speak only Yiddish. As pointed out by Alexander Rappaport, who has been described as the public face of an Ultra-Orthodox community in Brooklyn, these tendencies can create public health communication challenges: “We see governments invest in public health awareness a lot...but it never trickles down to Yiddish speakers or people who don’t own TV sets.”

In both Rockland County and New York City, health officials have reported difficulty enlisting the full support of the affected communities to control the outbreak through vaccination. While prominent rabbinical authorities have generally spoken of the importance of vaccination, anti-vaccination sentiments have been found within the Ultra-Orthodox community, as with many other US communities.

A lack of full cooperation with public health recommendations has led both health departments to take punitive measures. Rockland County initially issued an emergency order that would have banned from public places unvaccinated children, but a court issued an injunction that put the measure on hold. This week Rockland County announced two new orders mandating that unvaccinated remain at home from school and banning individuals infected with measles from public places. New York City announced emergency measures that mandate measles vaccines for anyone residing in a list of affected zip codes. NYC is also reviewing vaccination records at yeshivas in those area codes and closing those that do not comply with public health orders.

Though these measures may be required in the short term to stem the growing measles outbreaks, there have been some questions about what the long-term effects of punitive measures will be. Some have argued that punitive measures fail to address the root causes of anti-vaccine sentiments and vaccine hesitancy. Individuals who do not vaccinate are often lumped together as “anti-vaxxers,” but there are a range of positions and motivations among those who do not vaccinate. Similar to what has been observed in other communities, there have been reports about vaccine misinformation circulating among the Ultra-Orthodox community.

The minority status of Ultra-Orthodox communities and their desire to separate themselves from secular influences may play a role in whether punitive measures are effective at improving vaccination. Though health officials in New York City have linked vaccine hesitancy observed in the community to misinformation about vaccines, characterizing anti-vaccine sentiments as not being “mainstream” may not be an effective communication approach for some individuals. As noted by Alexander Rappaport, characterizing information as being “fringe” may not be a deterrent: ”Being a religious Jew, you...get used to having a minority viewpoint. So if something is not mainstream, it doesn’t take you away from believing it.”

Another concern is whether the punitive measures being implemented will lead parents to have more strident views about vaccines. While the initial source of parents’ hesitation may be not religious in nature, public health measures to enforce vaccine requirements at yeshivas may be perceived as secular interference in the communities’ religious practices. In this way, punitive measures linked to yeshiva attendance may create beliefs that vaccinations equate to loss of religious liberty. Individuals who are worried about infringements on their religious freedoms may not be deterred by the legal consequences of not complying with vaccine mandates. Punitive legislative actions also have potential to cause harm by pushing vaccine-hesitant individuals further away from the public health system.

As has been pointed out in a recent op-ed by public health legal scholars James Hodge and Lawrence Gostin, punitive measures that appear to target and punish the Ultra-Orthodox Jewish community may be ethically and constitutionally problematic. The fact that the punitive measures have been limited to specific zip codes may be problematic. The areas targeted by health officials represent those areas where the greatest number of measles cases are occurring, but the fact that “it is impossible to localize a fast spreading infectious disease likes measles in dense urban areas” raises the possibility that the targeted communities could allege unfair discrimination. On Monday, a group of parents in New York City filed suit against the city’s mandatory vaccination measures.

The challenge of controlling the spread of measles within insular religious communities is not new or limited to the New York area. In 2014, when the largest number of measles cases occurred in the US since elimination, more than half of all cases were attributable to a single outbreak that occurred among Amish communities in Ohio. During that outbreak, it was noted that there was no specific religious opposition to vaccination; however, parental concerns about vaccines were similar to those observed in non-religious communities.

This suggests that even with the use of mandatory vaccination measures, there may still be a need to educate and engage with parents to address the root causes of their hesitation about vaccines. Though the vaccination concerns of parents in Ultra-Orthodox Jewish, Amish, or other insular religious communities may be similar to those seen in other communities, sensitivity regarding religion and culture must factor into how public health authorities engage with these groups. Effective engagement will require resources and continued partnership with trusted religious leaders and healthcare providers as well as direct two-way engagement with parents.

Elena Martin is a Master of Public Health (MPH) student at the Johns Hopkins Bloomberg School of Public Health. Her hometown is located in Rockland County, New York.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly in near-real time to allow others to learn from these experiences in order to improve global outbreak response capabilities.

 Photo courtesy of CDC/Allison M. Maiuri