The Zero Patient Case: A Study of How Rapid Measles Can Spread

Last month, an American traveler who raised funds for a charity within the ultra-orthodox Jewish community in Brooklyn went all night to Detroit – his next step in fundraising.

He felt bad on the way and saw a doctor when he arrived. But the doctor, who had never seen measles, misdiagnosed human fever and coughed as bronchitis.

Over the next two weeks, the traveler would become Michigan's Patient Zero, transmitting the highly infectious airway virus to 39 people while he stayed in private homes, went to the synagogue daily and made purchases. in kosher markets.

His case offers an edifying account of how easily one of the most infectious pathogens on the planet spreads in very close communities – especially those whose members live, work and socialize outside the general public. .

"Each of our cases had a connection with the original case," said Leigh-Anne Stafford, Oakland County Health Officer, a suburb of Detroit where all but one case has been reported.

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In the past five years, 75% of measles cases reported to the Centers for Disease Control and Prevention have occurred in various island communities, including the Amish of Ohio, the Somali community of Minnesota, East European groups from the Pacific Northwest and the ultra-Orthodox Jewish community in New York.

In the current outbreak, the New York contagion has spread through Patient Zero and other travelers into predominantly ultra-Orthodox communities of Westchester and Rockland counties in New York City; Oakland County in Michigan and Baltimore County in Maryland.

On Saturday, Connecticut officials announced that an adult was contracting measles during a visit to Brooklyn in late March.

New Jersey officials are studying possible links between 11 cases in Ocean County and those in New York.

"What's similar in all these communities is that they live close to each other and spend a lot of time interacting," said Daniel Salmon, professor of international health at Johns Hopkins Bloomberg. School of Public Health and Director of the Institute for School Vaccine Safety.

"It's what counts." Measles is not interested in your cultural heritage.

Many of these communities are wary of government, avoid television and the Internet, and often rely on their own clinicians for medical care.

In such a vacuum, anti-vaccine misinformation has sometimes taken hold, dissuading parents from fully vaccinating their children.

The traveler had arrived from Israel in Brooklyn last November, the epicenter of a measles outbreak, and he stayed about two months before traveling to the Detroit area in early March, said Russell Faust, Oakland County physician.

The man, whom Michigan health officials did not identify, told them he was traveling to ultra-Orthodox communities in the United States to raise money for a charity.

Feeling feverish and coughing after his arrival, he consulted a doctor who prescribed antibiotics.

When the man recalled the next day to complain of a rash, the doctor thought that he had an allergic reaction. But after the doctor thought it over, he worried about the possibility of a measles and decided to leave a voice mail to the health department with the cell phone number of the doctor. man.

Health officials jumped on the case – but could not reach the man because of a problem with his cell phone.

They turned to Steve McGraw, Oakland Emergency Medical Services Manager and longtime member of the Hatzalah of Detroit Region, the Emergency Medical Response Group. the ultra-Orthodox community, a fully volunteer initiative with deep ties to many families.

McGraw warned the rabbinical chiefs, then jumped into his car and went to the area where the traveler was supposed to stay to pick up the car rental car, a blue sedan, knowing that she would figure among the mini -Vans used by virtually all families.

Hatzalah members and rabbinical leaders also mobilized to search for the traveler who was staying in a neighborhood guest house.

When they found him a few hours later, the traveler was stunned. He told McGraw and the rabbi who found him that they had to go wrong because he thought he had measles.

"There is only one disease, and you have it," recalls McGraw, as translated from a rabbi into Hebrew.

"He lowered his head and was very emotional, I could tell his face that he was devastated, he was doing the math in his head", counting all the people he had been in contact with, said McGraw .

It turned out that the traveler had had hundreds of contacts with members of the community that health officials had to find. He had stayed mostly in private homes in the Oak Park and Southfield areas.

He went to synagogues three times a day to pray and study and frequented kosher markets and pizzerias, among 30 different places in a week.

"This guy was contagious throughout the community," McGraw said. "We knew our show was really meaningful."

The measles virus is so contagious that if an unvaccinated person walks into a room up to two hours after the person with measles leaves, there is a 90% chance that the unvaccinated person will fall sick.

People can transmit measles four days before and four days after the revealing rash. Since measles is so contagious, at least 96% of people in the community need to be vaccinated to prevent the risk of an epidemic.

On March 13, blood tests confirmed traveler's measles. The strain corresponded to the genetic fingerprint of the New York outbreak, McGraw said. On the same day, health officials alerted the public.

To convey information to the ultra-Orthodox community, health officials used its internal messaging system called the call station.

The recorded voice messages ring on about 1200 mobile phones. McGraw recorded a message that Rabbinic leaders approved for delivery, the first of several that provided information on the disease and vaccination clinics.

In the coming weeks, Janet Snider, a pediatrician of many ultra-Orthodox families, and Gedalya Cooper, an emergency doctor, members of the Hatzalah, visited people at home to diagnose and test them.

The Council of Orthodox Rabbis of the Great Stripe issued an unequivocal statement, saying that Jewish law required all community members to be "properly and fully vaccinated," according to the CDC.

The agency recommends that children receive two doses of measles, mumps and rubella (MMR) vaccine, starting with the first dose of 12 to 15 months and the second dose of 4 to 6 years.

"In order to protect and protect every individual in the wider community, every individual, family and institution must take the necessary precautions against anyone who chooses not to be vaccinated," the statement said.

Hatzala and rabbinical leaders helped the health department set up three dispensaries in a synagogue, immunizing nearly 1,000 people in a week.

In early April, health officials had administered more than 2,100 vaccines. The refusal of vaccination does not appear to be a major factor in the Oakland County cluster, officials said.

In Michigan, at least, the close collaboration between health officials and the religious community seems to have controlled the spread of the disease, which can lead to serious complications, including deafness, pneumonia, brain damage and the death.

At present, with 555 cases of measles in 20 states – the highest in five years – other localities are studying this model.

Hatzalah groups in other parts of the country are seeking advice from county authorities to strengthen immunization within the ultra-Orthodox community, Faust said.

Oakland County had something else to do: outbreaks of measles usually start with children. But patient zero had spent most of his time with adults and most of the 39 cases were adults.

Many adults who had been sick thought they were immune because some had learned that they had the disease when they were children or that they had been vaccinated.

"There are lots of non-immune or under-immunized adults," said Faust, the licensed physician. Some of the infected adults were also born before 1957, the year when most people contracted measles and they are thought to have natural immunity.

Officials said the risk remains high for unvaccinated or under – vaccinated people traveling to communities at home or abroad where measles cases are raging.

Gaps in immunization coverage have led to a 20-year high among measles cases in Europe. Major epidemics are also occurring in parts of the Middle East, Southeast Asia and Japan.

More than 1,200 people died in Madagascar. While spring break and summer vacation are approaching, travelers to countries in Europe affected by the outbreak, such as France and Italy, have a much higher chance to convey the infection to "islands or pockets of vulnerability," said Saad Omer, an infectious disease specialist at Emory University. .

"Measles is a very ruthless disease," he said. "Even though most people are vaccinated, that number may not be enough."