Myths and facts about vaccines, measles and religion in Israel

The ‘Magazine’ interviews professionals on measles cases in the Orthodox community and discovers that ideology is not the reason for the outbreak.

ARAB RESIDENTS of Jerusalem take their children to get the polio vaccine at a Tipat Halav clinic in the Armon Hanatziv neighborhood in 1988. (photo credit: AYALON MAGGI/GPO)
ARAB RESIDENTS of Jerusalem take their children to get the polio vaccine at a Tipat Halav clinic in the Armon Hanatziv neighborhood in 1988.
(photo credit: AYALON MAGGI/GPO)
This past year one couldn’t go online or read a newspaper without seeing something about a measles outbreak and vaccinations.
Measles became a hot topic in the US, where an outbreak took place throughout the country – in the Jewish community of New York in particular. This spurred debate on religious exemptions to vaccinations while activists who are ideologically opposed to vaccinations, known as anti-vaxxers, made headlines.
In Israel, the disease has claimed the lives of three people, the latest being 43-year-old El Al stewardess Rotem Amitai, who died earlier this month. The mother of three was hospitalized and in a coma for several months. The Jerusalem Post reported that she had received the single required measles vaccination as a child. Today, a second dose is given to children, and Israel’s Health Ministry is recommending that those born between 1957 and 1977 obtain a second vaccination. El Al released a statement mourning her loss, noting that: “once the case became known, the company acted to vaccinate [its] the company’s air crews.”
The measles virus is one of the most contagious diseases in existence. An infected person who coughs or sneezes can spread the disease, and the infection can linger in the air for up to two hours. Once someone gets the measles, they cannot get it again – but that is no comfort to those who suffer from permanent injuries or complications, including pneumonia and encephalitis.
In Israel, according to Health Ministry data, more than 4,300 cases of measles were reported from March 2018 through July 2019, including the other two deaths: a baby from Jerusalem and an elderly woman. Over 400 cases required hospitalization.
In comparison, the World Health Organization reported only 16 confirmed cases of measles in Israel in 2017 and 10 in 2016. This is further contrasted to the period before the vaccine was formerly introduced in the Jewish state in 1967, when there were thousands of measles cases.
Eventually, measles cases tapered off, indicating that the campaign for inoculations was successful. October 2018 was the height of the outbreak with over 950 cases, compared to just 14 by July 2019. Over half of all the measles cases in Israel were in the Jerusalem district.
Although measles cases occurred throughout the country, including a prestigious secular high school in Tel Aviv, statistics from the Health Ministry show that areas with a high concentration of religious Israelis had a higher rates of measles.
However, unlike the controversy raging in other countries, it appears that the measles outbreak in Israel had little to do with ideological perspectives. In Israel, ideological opposition to vaccines is estimated to be relatively uncommon. Health Ministry spokesperson Eyal Basson told The Jerusalem Post Magazine that he estimates it to be less than 1%.
Why was there an outbreak in Orthodox communities?
According to Basson, there were a number of reasons for the higher rate of measles in haredi (ultra-Orthodox) populations.
He blamed the “relative lack of nursing resources in communities to match the high fertility rates and logistical difficulties for parents with large family sizes to vaccinate all children.” For example, religious communities that have many children may find it hard to get them all to the medical center.
“Prior research experience has shown that in general, families with four or more children tend to have difficulty making vaccine appointments at the recommended ages, putting them at risk for measles and other vaccine-preventable diseases,” he explained.
Children are scheduled to receive the MMR vaccine at 12 months of age. A second shot is scheduled when the child reaches first grade.
The MMR vaccine protects against measles, mumps and rubella and is received at local Tipat Halav family health centers, which are normally open from 8 a.m. to 3 p.m. with appointments being scheduled a week in advance. Basson explained that many clinics, especially in ultra-Orthodox communities, stayed open later during the outbreak.
During the Passover holiday this past April, which usually brings a large influx of tourists, clinic hours were expanded and special “open house days” were created for children to receive vaccinations without an appointment.
When several students were hospitalized with measles at the prestigious Mir Yeshiva in Jerusalem, the post-high school religious institution converted their dining hall into a medical clinic and gave vaccines to all the students, both Israelis and foreigners.
What is herd immunity?
Dr. Hagai Levine, chairman of the Israel Public Health Physicians Association and a senior physician at Hadassah Medical Center in Jerusalem, explained to the Magazine about how herd immunity works and why close-knit communities are more susceptible to diseases.
“The reproductive number is the number of individuals that will catch the disease from one infected person,” he explained. “If 10 people are infected, the next generation of infection will be 100, and in the third 1,000. In order to prevent transmission, we need to get the actual reproductive number to one,” he said. “If it’s less than one, then the outbreak will stop. This means that if the reproductive number is 10, we need to get at least nine of 10 (90%) vaccinated. Measles is highly contagious, with a reproductive number above 10.”
This is why in years past, those unable to get vaccinated for medical reasons would not be in such danger. For example, one parent told the Magazine that his child was recovering from cancer and could not receive the vaccine due to the ongoing treatments. The parent was advised by a doctor not to take the child to certain neighborhoods where there were known measles outbreaks, even if it meant not seeing family members.
“Measles is an extremely contagious disease,” Levine said, “so you need a very high rate of immunization in order to achieve herd immunity.” The doctor hopes that this can be achieved because, unlike other diseases, measles affects only human beings.
Regarding the haredi community, Levine, like Basson, agreed that the situation was challenging, due to large households and crowded schools. He also agreed that ideological objections in both religious and secular communities in Israel were hard to find.
“Generally speaking, in Orthodox Judaism you are obligated to protect yourself and there is a strong sense of solidarity,” Dr. Levine said. “The vast majority of haredim are in favor of getting vaccinations,” he said, although anti-vaxxers do exist.
He elaborated that it was vaccine delay rather than anti-vaccine attitudes that has resulted in measles cases.
“If you look at the ordinary family with many children, it is very difficult to get them vaccinated on time,” he explained. Parents may work or study and, in some cases, older children look after their younger siblings.
“Instead of at 12 months of age, many children get it much later like 16, or 18 months of age,” Levine stated. “This means there is a huge population of toddlers who are susceptible and can easily transmit the disease in the community.”
Minuscule anti-vax movement in Israel

While in the US, vaccines are mandatory to attend public schools, they could be bypassed with a religious exemption. In June, New York joined several other states in banning religious and philosophical exemptions for vaccinations due to the outbreak.  In Israel, vaccines are not mandatory and thus religious exemptions are not an issue. Yet vaccine rates are at 97% in Israel throughout all demographic groups, and the percentage of Israelis opposed to vaccines is minuscule.
The scant anti-vax information in Hebrew online is mostly translated from information originally written in English and distributed in the US.
We spoke to several vaccine skeptics living in Israel. Concerns range from fear of big government and big pharmaceutical companies, to stories of babies being irreparably injured from being vaccinated. One person had a negative experience with being prescribed medication. None were against them on religious grounds.
Few issues are as sensitive as the concern for the well-being of one’s child. Stories of vaccine injuries have proliferated on the Internet in the US and in Ukraine, spurring vaccine fears.
We inquired about the specific incident of a child who was injured in the late 1970s by a defective DPT vaccine, which protects against diphtheria, pertussis (whooping cough), and tetanus. Dr. Neta Soffer-Tsur, a spokeswoman for the Israeli nonprofit public health organization Midaat, told us that unlike 40 years ago, “vaccines today are much better regulated, so the chance of something like that happening here today is very small.” Basson concurred.
“Serious adverse reactions reported after vaccines are very rare and may not be caused by the vaccine," Basson explained. "The Health Ministry monitors all reported adverse effects of vaccination in Israel, as well as notifications of adverse effects after vaccinations in other countries that may impact vaccine policy in Israel.” Regarding the rare injury, he added, “Israel has a law, originally enacted in 1989, regulating compensation for vaccine-related injury.”
“Some serious side effects can still occur, though, including very rare allergic reactions or other phenomena that result from immunologic over-sensitivities,” Soffer-Tsur explained.
THE HEALTH Ministry office in Jerusalem is one location where adults can receive the MMR vaccine. (Credit: BEN BRESKY)THE HEALTH Ministry office in Jerusalem is one location where adults can receive the MMR vaccine. (Credit: BEN BRESKY)
“We need to keep in mind that the dangers from the diseases that we wish to prevent are much more substantial," she continued. "Complications from measles, for example, are estimated as 10% to 30% of all cases. Many of these complications lead to hospitalization and sometimes cause permanent disabilities or even death. Therefore, there is no doubting the necessity of vaccines in order to prevent that.”
Soffer-Tsur's attitude seems to be the consensus view in Israel, as the Health Ministry reports that among the country's children, 97% receive their first dose of the MMR vaccine and 96% receive the second dose recommended in first grade.
Not only is there no serious anti-vax movement in Israel, Levine noted that Jewish law calls for the protection of one’s health and that of the broader community, even when at odds with tradition.
Ya’acov Litzman, a Ger Hassid who has headed the Health Ministry since 2015, has been a strong advocate for vaccination.
Rabbi Nachman, Uman and vaccines

Every year on Rosh Hashanah, thousands travel to Uman in Ukraine to visit the grave of Rabbi Nachman of Breslov, the famous 18th-century hassidic leader known for his songs, folk tales and inspirational spiritual teachings. In recent years it has morphed from a religious pilgrimage into a phenomenon that attracts religious and non-religious people from around the world.
It is from here that many of the measles cases were brought into Israel, although according to Basson of the Health Ministry, “the first case of measles in 2018 was imported from Thailand and spread to several districts within Israel.”
As far as how the outbreak first started, Levine said, “It’s from many different countries. Nowadays we live in a global world, which is a good thing, but we have to adapt by thinking globally and acting locally.”
Ukraine recorded 54,000 cases of measles in 2018 with 16 deaths, according to the World Health Organization. The numbers are correspondingly just as high for the first part of 2019. Hesitancy to vaccinate and a shortage of vaccines have been blamed for the problem.
Rabbi Nasan Maimon of the Breslov World Center in Jerusalem told the Magazine that Rabbi Nachman was himself an early advocate of vaccines, while they were just being developed. Maimon added that Judaism advocates taking all precautions necessary to protect human life.

Kuntres Hanhagot Yesharot
(A Compilation of Upright Behaviors), is a collection of Rabbi Nachman’s writings compiled by his students after he died of tuberculosis in 1811. It is written there that: 
“We must be exceedingly careful about the health of children, especially while they are still small. One should in no way be lax in this matter... our Rabbi, of blessed memory, said that one must vaccinate every baby against smallpox before the age of three months, for if he does not do so, he is like one who sheds blood. Even if one lives far from the city, one must travel there, even if the season is very cold.”
Another influential rabbi who stressed the value of life was Rabbi Israel Salanter, founder of the Mussar movement. During the deadly cholera epidemic in the fall of 1848, he went as far as to eat a small roll on the solemn fast day of Yom Kippur, to set an example to his congregants to guard their health.
The famous Rabbi Moses Isserles (1530-1572) advocated fleeing the city from a plague rather than waiting just in case it doesn’t spread. The Lubavitcher Rebbe, Rabbi Menachem Mendel Schneerson (1902-1994), the last leader of the Chabad hassidic movement, advised his followers to get vaccinated for polio when it was first introduced in Israel in the 1950s, quoting the Jewish axiom, “Do not set yourself apart from the community.”
Religious authorities in all streams of Judaism in Israel and the US have backed vaccines, quoting religious teachings as their source.
Close-knit communities are susceptible

In addition to the aforementioned issues of parents getting their kids to medical appointments on time, there is also the structure of religious society in Israel.
In the religious community, having larger families means attending more public celebrations in the same social circles. When the same people shop at the same stores and attend the same schools, it increases the likelihood of contracting measles, despite the high rate of vaccinations.
Dr. Daniel Berman and Prof. Awi Federgruen, in a May article from the New York Daily News, explained the phenomenon of measles in the Orthodox community of New York and New Jersey.
“In a densely populated and highly interactive community,” they wrote, “the average infected individual transmits measles to 24 others, so 99% of the community must be vaccinated in order to ensure herd immunity. If the average transmission is 36, then even a virtual 100% vaccination rate fails to ensure herd immunity.”
Not just Jews

Orthodox Jews are not the only close-knit minority group to suffer an outbreak.
In 2017, an outbreak of measles occurred in the mostly Muslim Somali-American community of Minnesota. The Minneapolis-based Star Tribune reported that 75 people were infected.
Minnesota health care officials patiently listened to residents’ concerns and held special seminars for the Somali community with translators for the older generation and new immigrants, quelling the outbreak.
In 2014, a measles outbreak occurred in Ohio among the Amish, a religious Christian community that advocates avoiding modern conveniences. In both cases, religious belief was not a major factor in lower vaccination rates.
Steps for the future

Levine, while calling for greater steps to be taken, praised certain aspects of the local healthcare system.
“Israel was really a role model for other countries for its maternal and child health clinics and vaccination programs,” he said. “However, this outstanding system starved with time. There is little mechanism to increase the number of personnel and resources according to the needs and the constituents,” he said.
“In the past, a nurse could immediately call and if needed, do a house visit,” Levine related. “Now there are fewer resources for outreach programs.”
He called it a wake-up call for the Israeli health system. However, he also allayed fears that Israel would run out of vaccines for kids.
“There is no shortage of measles vaccines for the target population of children,” he said. “There is a professional discussion about the availability of vaccines for adults,” he said regarding those who never received a second booster shot as a child.
Levine lauded the emergency campaign of extra nurses and longer opening hours at Tipat Halav clinics and called for more.
“Mobile units must come to the neighborhoods and it’s not very expensive to do so,” he stated.
“We’re starting from a very good place, where the vast majority of Israelis trust in the healthcare system and in science," Levine added. "However, trends in other places in the world are also reaching Israel, and we should monitor and work systematically to secure the public trust.
“We physicians and scientists must go to the public and listen to them – not only about vaccines, but also about nutrition, drug use and all current issues,” he noted.
“We don’t see the severe cases of measles, rubella, polio and other diseases that were prevented by vaccines and saved millions of people’s lives,” Levine stated. He called it a “prevention paradox,” in that only the tragic losses are reported, not the countless lives saved. “Now, during the outbreak, it demonstrates how lucky we all were during years we were protected. Prevention is the best investment in healthcare.”
Although tragically too late for the three who succumbed to the disease, the fact that measles rates have dramatically declined is a positive sign.

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