By Sharon Otterman
Jan. 17, 2019
Through the fall, traveler after traveler arrived in the ultra-Orthodox Jewish communities of New York from areas of Israel and Europe where measles was spreading. They then spent time in homes, schools and shops in communities where too many people were unvaccinated.
Within months, New York State was facing its most severe outbreak of the disease in decades, with 177 cases confirmed by Tuesday, almost exclusively among ultra-Orthodox Jews. Health officials in New Jersey have reported 33 measles cases, mostly in Ocean County, driven by similar conditions.
In 2018, New York and New Jersey accounted for more than half the measles cases in the country.
Alarmed, health officials began a systematic effort to bring up vaccination rates and halt the disease’s spread.
But while there has been progress, the outbreak is not yet over. Health officials said part of the problem has been resistance among some people in ultra-Orthodox neighborhoods to fully cooperate with health workers, get vaccinations and promptly report infections.
“Sometimes they hang up and they don’t want to open the door,” said Dr. Patricia Schnabel Ruppert, the health commissioner of Rockland County, northwest of New York City, where the worst of the outbreak has been, with 114 confirmed cases. “It’s hard to break an outbreak if you are not getting cooperation.”
Dr. Ruppert said that health officials discovered that some religious schools, or yeshivas, in ultra-Orthodox communities in Rockland County had vaccination rates as low as 60 percent, far below the state average of 92.5 percent. Audits found that some schools were overreporting vaccination rates, she added.
Delayed vaccination also helped fuel the outbreak in the Orthodox communities of Williamsburg and Borough Park in Brooklyn, which had reported 55 cases as of last week, said Dr. Jane R. Zucker, head of the city health department’s Bureau of Immunization.
There have been no deaths in the outbreak, but there have been a few serious cases in young children that required hospitalization.
Measles is one of the most contagious infections and can live for up to two hours in the airspace where an infected person breathed, coughed or sneezed. It usually affects children, and symptoms include high fever and a rash of red spots all over the body, as well as a cough and runny nose. Some 90 percent of unvaccinated people exposed in proximity to an infected person will get it.
But the vaccine, when given in two doses — typically around age 1 and age 5 — is about 97 percent effective.
Health officials and sociologists say the reasons for low vaccination rates among the ultra-Orthodox are complex.
In part they are tied to the wider anti-vaccination movement globally, including concerns that the measles vaccine, which also protects against mumps and rubella, causes autism or other diseases. The idea has been widely debunked but persists in some circles.
Rabbi Yakov Horowitz, founder of Darchei Noam yeshiva in Monsey in Rockland County, said that some parents considering admission to his school agonized over giving their children vaccines because they had heard they were dangerous. His yeshiva insisted on them, he said, though he knew of others that did not.
“Good people, great parents were terrified,” he said. “They felt that I was asking to give their children something that would harm them.”
There have been more than 200 measles cases in New York and New Jersey in recent months, accounting for half of the cases in the country.CreditSchneyder Mendoza/Agence France-Presse — Getty Images
Alexandra Khorover, general counsel for Refuah Health Center, one of the largest health providers in the Rockland community of Spring Valley, said her health workers had encountered “a small pocket of people who are anti-vaccine who have been peddling this information, fostering confusion and fear.”
Part of the reluctance to vaccinate or allow a government health worker to enter the home, though, is cultural.
Samuel Heilman, a Queens College sociology professor who studies the ultra-Orthodox, said that there is a “fear of interference from the outside” rooted in the community’s origins in pre-World War II Europe. More recently, the ultra-Orthodox have fought back against other health department efforts, such as New York City’s efforts to limit a controversial circumcision practice, metzitzah b’peh, because of warnings from health officials that it causes herpes in infants.
“They have accepted the idea that they live by different rules than others in the outside community,” Mr. Heilman said.
While this insularity allowed the measles to spread, it has also had a protective effect on wider public health, at least so far. In part because ultra-Orthodox Jews tend to attend their own religious schools and patronize their own shops and restaurants, the disease has remained in Orthodox circles, save for several infections among non-Jewish workers linked to their communities, health officials said.
The outbreak in New York and New Jersey can be traced to the rise of measles in Israel, where some 2,700 cases and two deaths were reported in 2018, centered in Jerusalem.
In Europe, which was the source of at least some of the Brooklyn infections, some 65,000 cases were reported in the year ending October 2018, with high concentrations in Balkan countries and Ukraine.
A flier distributed in ultra-Orthodox Jewish communities by the New York City Health Department.
A flier distributed in ultra-Orthodox Jewish communities by the New York City Health Department.CreditNew York City Department of Health & Mental Hygiene
As measles spread in New York, public health officials swung into action. Some 40,000 fliers were printed in English, Yiddish, Spanish and other languages warning of the Israeli outbreak and calling for people to be vaccinated. Health officials met with rabbis and pediatricians, who sounded the alarm to their congregations and patients.
“We are telling people the health department is looking out for your health,” said Rabbi David Niederman, a community leader and executive director of the United Jewish Organizations of Williamsburg. “They are the experts and you should take the vaccinations.”
In Rockland County, which includes the large ultra-Orthodox community of New Square, the authorities put 59 schools under “exclusion orders,” forbidding unvaccinated children to attend even if they had a valid religious or medical exemption to the vaccine. The orders are lifted when a school’s vaccination rate reaches 95 percent, which state authorities consider protective of public health. Eighteen schools have had the orders lifted, officials said.
In Brooklyn, some children have been out of school for months because of similar exclusion orders by health officials, said Rabbi David Zwiebel, the executive director of Agudath Israel, an ultra-Orthodox umbrella organization. Tensions are high, with some parents still refusing to vaccinate because of health fears, and others relenting.
“There has been some harsh language exchanged on both sides,” Rabbi Zwiebel said.
The information campaign has had an impact. In Rockland County alone, more than 13,000 vaccines have been given since October.
While the rate of infection has slowed regionwide, Rockland has recorded an uptick — 18 new cases in January, after a drop in December.
Dr. Ruppert advised caution for all residents of Rockland County, particularly for parents of young infants and others who are not immunized, because just about everyone in the county shops at the same malls and box stores.
“Rockland is a small county, and I consider everyone potentially exposed,” she said.
In New York City, health officials sounded a hopeful note: No new cases in Brooklyn have been confirmed since Jan. 8. Orange County cases have crept up in recent weeks to eight.
“I’m sort of holding my breath,” Dr. Zucker said. “I think we have promising news, but I don’t want to be optimistic too soon.”
Liz Robbins contributed reporting.
“This could become a truly major epidemic,” said one pediatrician.
By Maggie Fox
At Clarkstown Pediatrics in Nanuet, New York, babies are on an accelerated measles vaccination schedule, getting their first shots six months early and their second dose right away.
It’s part of a statewide effort to stop several outbreaks of measles from turning into an epidemic. The state has had 170 cases of the highly infectious virus since September, making it the worst year for measles since the 1990s.
Pockets of unvaccinated children have provided fertile ground for the measles virus to take hold. Although measles was eliminated in the U.S. the virus has been brought back by travelers to Israel, which has been battling an epidemic of measles for months. The victims: mostly members of close-knit Orthodox Jewish communities across the state.
“It’s a clear and present danger right here in our community,” said Dr. Douglas Puder, a pediatrician at Clarkstown Pediatrics. His practice is right in the middle of the biggest outbreak, in New York’s Rockland County. As of Jan. 10, county reported 108 cases of measles since the fall. More than 80 percent on average had not been vaccinated and just three cases had received both recommended doses of measles vaccine.
Europe's measles outbreak sparks concern over what could happen in U.S.
Local, state and federal health officials are battling to fight the outbreaks, which they believe have been fueled by a combination of anti-vaccine propaganda, lax enforcement of school requirements to vaccinate, and a growing trend among some families to turn away from standard medical care. As a result, some private schools in the county reported vaccination rates had fallen to as low as 50 percent. It takes a vaccination rate of 95 percent or higher to prevent outbreaks of disease.
Thus, the full-court press to get children vaccinated. “We have made an incredibly aggressive effort to address this,” said New York state health commissioner Dr. Howard Zucker. “This has been the worst measles outbreak in recent history in New York state.”
More than 13,000 people, mostly young children, have been vaccinated over the past three months at state and county clinics. More than 40,000 educational flyers have been distributed to homes in the hardest-hit communities, and more than two dozen schools and daycare centers closed because of low vaccination rates. Unvaccinated children have been required to stay home for their own protection until they get the shots.
“To date there are more than 30 schools, daycares, and nursery schools in Rockland county that have been required to enact exclusion policies to help stop the spread of measles as permitted by New York State Public Health Law,” the county says on its website.
And individual clinics are making their own efforts.
“We have brought in every child six months and older to give them an MMR (measles, mumps and rubella vaccine),” Puder told NBC News.
A child usually receives the first MMR vaccine at the age of one year, and a second dose by age four. But to protect local kids in the face of a spreading, highly contagious virus, the schedule has been accelerated. “We have been bringing the one-year-olds back at 13 months to get a second dose,” Puder said. “It’s up to us to keep this from spreading. This could become a truly major epidemic.”
It took years for the pile of dry tinder to build. Three things have to happen to before a measles outbreak can take hold in the U.S., where homegrown measles has been eliminated: A population must have substantial numbers of unvaccinated or under-vaccinated people; some of those unvaccinated people must travel to an area where measles is spreading and then must themselves get infected and bring it back.
Health officials have struggled to get a handle on how this happened. Statewide, New York has good vaccination rates. More than 92 percent of children in New York have received at least one dose of the MMR vaccine, according to the Centers for Disease Control and Prevention.
But New York is one of 47 states that still allow parents to refuse to vaccinate their children for religious reasons, and confusion over that may have led some parents to opt out, Zucker said. That’s even though no organized religious group forbids its member to vaccinate children, and Jewish law specifically instructs followers to protect their own health as well as the health of their children and community.
“I have been out to the community many times now and met with the rabbis there,” Zucker said. He said religious leaders have been puzzled by some of the vaccine skepticism and are advising their congregations to vaccinate.
One issue: Private schools don’t necessarily follow state guidelines for vaccinating students as a prerequisite for enrollment, and Rockland County has a large number of private schools, said John Lyon, a spokesman for the county.
“People usually wait until the school or the doctor makes them get vaccinated,” Lyon said. “In many cases, it seems like they didn’t have to do it so they chose not to do it.” Enforcing school vaccination requirements appears to have helped encourage more vaccinations, Lyon said.
“There is also a strong movement by the anti-vaccination community to get into this community,” Zucker said. Some groups have complained that they were targeted for years by an anti-vaccine group called PEACH, or Parents Teaching and Advocating for Children’s Health — including with pamphlets and robo-calls.
Measles is extremely infectious. An unvaccinated person has a 90 percent chance of becoming ill if exposed to the virus and the virus itself is unusually transmissible. It can hang in the air and infect people even hours after an infectious person has left a room.
Puder said parents are often vague about their fears. “Parents will say things ‘like so many vaccines’ or ‘my child is too small to get so many vaccines’,” he said. “When the fear is not put into words ... it’s hard to respond.”
Many of the cases are among people who have skipped regular medical visits, Puder said. “I know in our group, it’s the kids you don’t see that don’t get vaccinated,” he said. "It's the group that is interested in alternative medicine."
And some pediatricians have enabled the vaccine-shy. “There are a few pediatricians who are more tolerant of vaccine-refusing parents,” he said. “I know who they are and I am not going to say their names.”
Although some people consider measles a benign childhood illness, it can kill. Measles causes encephalitis and pneumonia and before mass vaccination began in the 1980s, measles killed nearly 2.6 million people a year, according to the World Health Organization. It still kills more than 100,000 people a year, mostly children under five.
So every time a case is identified, public health workers must track down everyone else that patient was in contact with over the preceding days and weeks and check to make sure they do not become infected. “Whenever you get a confirmed case of measles, you have to interview the person and find out everywhere they have been and every person they met during the communicable period,” Lyon said.
But efforts are slowly working.
“It’s a clear and present danger right here in our community."
“I think we are on top of the outbreaks. The issue is to get all these kids vaccinated and to get a very strong campaign to raise public awareness,” Zucker said.
According to the CDC, 2018 was not worst recent year on record for measles in the U.S. As of Dec. 1, 292 cases were reported nationwide. In 2014, 667 cases were reported, fueled in large part by an outbreak traced to travelers returning from the Philippines and linked to Disneyland, as well as unvaccinated Amish communities in Ohio.
And anti-vaccine propagandists helped set the stage for an outbreak of measles among Somali immigrants in Minnesota in 2017.
CityMD, the fast-growing urgent care chain, has reached a contract to remain in the network of UnitedHealthcare, the country's largest health insurer, just before the companies' agreement was set to expire at the end of the year, CityMD said.
If a deal had not been reached, members of United and its subsidiary Oxford Health Plans, would have faced higher charges when seeking care at one of CityMD's locations. A letter dated Nov. 26 warned members that they might need to seek out other providers.
"Utilizing an out-of-network provider may result in higher costs for you," United wrote.
CityMD has more than 120 locations in New York, New Jersey and Washington. In Manhattan, the urgent-care chain dots the map like subway stops, with 22 clinics. Private-equity firm Warburg Pincus acquired a majority stake in CityMD for an undisclosed price in 2017.
Crain's New York
By News Desk on December 29, 2018
A New York resident sickened with Brucellosis by raw milk from Pennsylvania has state agricultural officials warning residents in a three-state region about the threat. Importing unpasteurized, raw milk from state to state is a violation of federal law.
The New Yorker has an RB51 infection, from a strain of the Brucella abortus bacteria, that has been traced to Miller’s Biodiversity Farm in Quarryville, PA. The farm is now under quarantine.
New York, New Jersey, and Pennsylvania consumers were warned not drink raw milk or consume other dairy products from the Miller’s dairy.
Anyone with raw milk or other dairy products from Miller’s is urged to discard them and contact their healthcare provider to discuss preventive treatment, according to the New York Department of Health.
“The New Jersey Department of Agriculture is working with surrounding states to determine the extent to which raw milk from the farm in question has been received by New Jersey residents and consumers at the New Jersey locations listed on the farm’s website,” said New Jersey Secretary of Agriculture Douglas Fisher.
Miller’s Biodiversity Farm lists several “group pickup locations” for its raw milk products. Those locations can be found here. The website shows raw milk priced at more than $15 per gallon.
The Pennsylvania dairy farm claims to be a “private buying club,” or membership organization, providing food from local farms to members who must pay a fee to become eligible to make purchases.
The New York resident with the bacterial infection is being treated and, according to the New York Department of Agriculture, is recovering. Brucellosis can cause fever, sweats, chills, weight loss, headache, fatigue and muscle and joint pain and symptoms may appear up to six months after exposure.
More severe cases include infections of the bones, central nervous system and reproductive organs and fetal loss in pregnant women.
The New York resident infected by drinking raw milk is the third Brucellosis case confirmed in the U.S. in the past two years, with the other incidents occurring in 2017 in New Jersey and Texas. Those patients had also consumed raw milk before becoming ill.
Epidemiologists from the federal Centers for Disease Control and Prevention and state health officials across the country, including those in Pennsylvania, say the only way to avoid Brucella exposure via milk is to drink pasteurized milk. In 2017 the CDC reported people in at least seven states were sick with brucellosis symptoms after drinking raw milk. At least one person in Texas and another in New Jersey were confirmed with infections linked to raw milk.
(To sign up for a free subscription to Food Safety News, click here.)
With flu season starting to peak, doctors on Long Island and across New York State are encouraging anyone still unvaccinated to roll up their sleeves for a shot.
Since the season started in October, 3,283 laboratory-confirmed cases of the flu have been reported statewide to the State Department of Health. One child died of the illness, and 923 people of all ages have been hospitalized, according to numbers compiled by the state from physicians and hospitals. The peak flu period runs from this month into February.
The majority of the cases, reported from New York City, have been caused by the dominant A-strain of influenza, called A/Singapore H3N2, which is one strain the flu shot protects against, according to the Centers for Disease Control and Prevention.
"It's not too late to get vaccinated," Dr. Susan Donelan, medical director of health care epidemiology and assistant professor of infectious diseases at Stony Brook University's Renaissance School of Medicine, wrote in an email.
Mary Ellen Laurain, a spokeswoman for the Nassau County Department of Health, urged residents 6 months of age and older to get their flu shot.
Donelan also advised anyone who isn’t feeling well to be mindful about possibly exposing others.
"Stay home if you are sick, regardless of whether you ‘think’ you may or may not have the flu," Donelan added in the email. "There are a number of viruses out there circulating and any one of these may make someone else sick enough to be hospitalized, even if you are only mildly ill."
Dr. Bruce Farber, chief of infectious diseases for the Northwell Health system, also stressed the importance of getting the vaccine, which if it doesn't completely prevent the illness, will modify its severity. The vaccine protects against four strains of influenza.
"I think the mistake many people make is that they think that if they get the flu after getting a flu shot that it was a failure," Farber said. "But many times, although it didn't prevent it, it made the flu less severe and can prevent hospitalization or complications."
Health officials underscore that state figures are lower than the actual number of flu cases because most people do not seek medical attention.
Other seasonal respiratory viruses in circulation include respiratory syncytial virus — RSV — coronavirus, rhinovirus, enterovirus, human meta-pneumovirus and parainfluenza virus, which despite its name, does not cause the flu.
The flu remains an ongoing health concern not only because of its contagiousness, but also because of its capacity to morph into pneumonia, which can be deadly.
Unvaccinated health care workers must wear "surgical" or "procedure" masks in the presence of patients, according to a state law in effect since the 2013-14 flu season.
“Health care personnel are routinely exposed to sick patients and are also in close contact with vulnerable patients,” State Health Commissioner Dr. Howard Zucker said in a statement. “The requirement that unvaccinated health care personnel wear a mask when patients are nearby protects both our critical health care workforce and at-risk New Yorkers."
An estimated 80,000 people died nationwide during the 2017-18 flu season, a total that included 200 children, according to the CDC. It was the highest flu-death toll in 40 years.
The high number of deaths arrived in the 100th anniversary year of the 1918 flu, the worst flu season in human history. An estimated 675,000 people died in the United States and 50 million worldwide. Within months, the pandemic killed more people than any other infectious illness in recorded history.
Simple measures can help limit influenza's spread.
"Cover your coughs and sneezes," Donelan said, "and perform hand-hygiene with either soap and water or alcohol-based hand rubs after blowing your nose. Avoid touching mucous membranes such as your eyes, nose and mouth."
Importance of vaccinations
SOURCE: State Health Department/Centers for Disease Control and Prevention
How to limit spread of influenza
SOURCE: Dr. Susan Donelan, Stony Brook University Renaissance School of Medicine
ALBANY — Influenza is officially prevalent in New York, with 1,230 cases confirmed statewide as of Saturday.
State Health Commissioner Howard Zucker announced the news Thursday, triggering a regulation to go into effect that requires all unvaccinated health care workers to wear surgical masks in areas where patients are typically present. Influenza and its complications have led to 923 hospitalizations across the state so far, and one child's death.
"The importance of getting vaccinated against influenza to protect yourself, as well as your family and friends, cannot be overstated," Zucker said. "Healthcare personnel are routinely exposed to sick patients and are also in close contact with vulnerable patients. The requirement...protects both our critical healthcare workforce and at-risk New Yorkers. I encourage all New Yorkers older than six months to get their influenza vaccine as soon as possible."
Flu season occurs primarily from October through May, often peaking in February.
The number of cases confirmed at labs in New York so far this season outpaces cases from the same time last year, when there were 891 cases confirmed as of Dec. 15. Last year's season, which was unusually vicious, peaked at 18,258 cases statewide as of Feb. 17. For comparison, previous seasons in New York peaked at 6,076 cases as of Feb. 11, 2017 and 6,422 cases as of March 12, 2016.
It was one of the deadliest in four decades. More than 80,000 Americans died of flu in the 2017-18 season, the Centers for Disease Control and Prevention said.
Saratoga County appears the hardest hit of all upstate counties this season with 28 cases confirmed. The Capital Region as a whole has had 77 cases confirmed.
New Yorkers can see just how prevalent the flu is near them using a new flu tracking platform published on the NYS Health Connector website. It includes a breakdown of confirmed cases by county, week and year dating back to 2015-16, making year-over-year comparisons possible.
It also shows which type of flu is prevalent (A, B or unspecified). So far this year, 1,140 of the 1,230 confirmed cases around New York are Type A.
State health officials are reminding New Yorkers that it's not too late to get vaccinated, noting that there's plenty of vaccine still available. While the vaccine is not always effective at preventing flu, studies have shown it can lessen the symptoms and duration of the illness.
By Bethany Bump
The state Department of Financial Services approved CVS Health's $69 billion acquisition of insurer Aetna on Monday morning, lifting the final barrier to the deal's closure.
Aetna said in a Securities and Exchange Commission filing the companies expect the deal to close on Wednesday.
The U.S. Department of Justice approved the purchase in October and the companies have already received all other necessary approvals from other states. Bloomberg News reported that 28 states, including New York, weighed in on the combination of the nation's largest drugstore chain and one of the nation's largest health insurers.
DFS said it received commitments that the costs of CVS' acquisition will not be passed on to Aetna customers in New York in the form of higher premiums. CVS also agreed to provide $40 million to the state to support health insurance education and enrollment, including payments to the state's Health Care Transformation Fund. That fund has been used previously by the Cuomo administration to support struggling hospitals.
"DFS listened to the concerns of the public and has obtained significant commitments from CVS and Aetna to address those concerns, ensuring that the companies hold to their promises of reduced costs and improved health care for New Yorkers," DFS Superintendent Maria Vullo said in a statement.
The department held a public hearing on Oct. 18 with local trade groups representing pharmacists and physicians who opposed the transaction. CVS Caremark is one of the three biggest pharmacy benefit managers, which negotiate drug prices on behalf of insurers, employers and union benefit funds. Opponents said the deal would limit competition.
CVS and Aetna have said their combination will lead to lower costs for consumers and greater access to care through a network of health clinics at CVS stores. The chain and its subsidiaries own 573 pharmacies in the state. Aetna received about $3.5 billion in premiums from New York customers last year, according to DFS.
To win approval from New York, CVS also agreed not to offer any preferential pricing to Aetna-affiliated insurers in the state and to continue to include non-chain pharmacies in its local networks for at least three years.
The health plan will maintain its current set of insurance products for three years, add an additional product in the small- or large-group market and document the "synergies" it said it would create by combining with CVS.
The Cuomo administration has previously supported legislation that would require that pharmacy benefit managers, including CVS Caremark, are licensed and regulated by the Department of Financial Services. A previous bill was not ultimately approved by the state Legislature but DFS said Monday that CVS Health has agreed to "take no action to oppose such future legislation."
Dr. Thomas Madejski, president of the Medical Society of the State of New York, said he supported the Cuomo administration’s push for legislation to more closely monitor pharmacy benefit managers. He said the "enormous power" of the combined company would marginalize physicians.
"Physicians fully expect that the merger will further reduce competition in New York’s health insurance market," he said in a statement. "This is one more reason why physicians deserve the right to collectively."
JONATHAN LAMANTIA CRAIN'S NEW YORK BUSINESS
PM Pediatrics, an urgent-care chain for kids, has opened its 35th location in Wayne, Pa., near Philadelphia, marking the seventh state for the fast-growing company. The Lake Success, Long Island–based chain treats children and adolescents exclusively and hires physicians who specialize in pediatric emergency care to handle cases including fevers, fractures and wounds.
Dr. Jeffrey Schor, the company's founder and co-CEO, said PM Pediatrics seeks to complement primary care practices by operating from noon to midnight Monday through Saturday and 10 a.m. to midnight Sundays and holidays. It also does not perform immunizations or physicals and encourages patients to follow up with a primary care doctor. We capture the peak hours when children would otherwise have to go to the emergency room," Schor said.
Schor said Pennsylvania fit well with the rest of the company's portfolio, which includes locations in southern New Jersey and Maryland. It has 18 New York locations, including eight on Long Island.
The area where the new clinic is located had a median household income of $122,000 in 2016—about double the national average. Schor noted that PM Pediatrics takes most major Medicaid plans and will do so in this new location.
He said he expects the company to reach 60 locations by the end of next year. Its expansion has been aided by $48 million from private investors, including Scopia Capital. —J.L.
NEW CITY, N.Y. – The number of measles cases in the United States so far this year has surpassed 2017 with the potential for about a quarter of the highly contagious respiratory infections to be occurring in one New York county north of New York City.
Nationwide as of Oct. 6, the most recent nationwide data available, 142 measles cases had been reported, according to the federal Centers for Disease Control and Prevention. The number of people sickened, mostly unvaccinated, exceeded the 2017 total of 120 in mid-August.
As of Friday, Rockland County had 46 confirmed cases and nine suspected cases, according to the county's health commissioner, Dr. Patricia Ruppert. A month ago, Rockland County Health Department officials were worried about an outbreak and offering emergency measles vaccination clinics because a traveler from Israel had visited an ultra-Orthodox Hasidic synagogue and a sukkah, a temporary structure built for the weeklong Jewish festival of Sukkot, near a Jewish boys school in New Square, New York.
"There's a component ... that are not in favor of vaccines," said Dr. Howard Zucker, New York state's health commissioner. "We need to dispel any worries that they have."
None of those infected in Rockland County were fully vaccinated, Ruppert said. The state has banned unvaccinated students from attending classes in three communities if their school has a vaccination rate of 70 percent or lower.
Two doses of the measles, mumps and rubella vaccine, generally given at age 12 to 15 months with a booster at 4 to 6 years old, are 97 percent effective in preventing measles. One dose is 93 percent effective, according to the CDC.
“I've seen these diseases, all of them, diptheria to measles. I've seen the measles encephalitis. ... I don't think any parent would want to experience that with a child.”
The measles virus is transmitted via the misty droplets that come when an infected person coughs, sneezes and even breathes. The virus can live up to two hours in the air and on surfaces in a room where an infected person has been.
Someone infected can transmit the disease from four days before to four days after a flat, itchy, red rash shows up. Measles symptoms may not appear for a week to three weeks after exposure.
While Rockland County's overall vaccination compliance rate is 94 percent, Orthodox Jewish schools in the area vary widely in vaccination rates from 40 to 100 percent.
The World Health Organization considers herd immunity to be achieved when a community has 95 percent of its members vaccinated. This helps protect those who cannot receive vaccinations because they are too young, have immune system problems or are too ill to get the shots.
Nationwide in the 2017-18 school year, 94.3 percent of kindergarteners in 49 of 50 states had received both doses of the MMR vaccine, the CDC said.
The outbreak in Rockland County, about 25 miles north of New York City, is one of 11 outbreaks in 25 states reported so far this year. States affected are Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia and Washington.
South Carolina is not on the CDC's most recent list; however, three cases have been confirmed in the past week in Spartanburg County, according to the South Carolina Department of Health and Environmental Control. Three or more linked cases constitute an outbreak.
Rockland County's measles outbreak and cases in New York City – and Bergen County and Lakewood, New Jersey – have been linked to Israel.
An 18-month-old unvaccinated girl died from complications of measles Thursday in Jerusalem, the country's first measles death in 15 years, according to The Jerusalem Post. Nearly 1,300 cases in the country of 8.5 million residents have been reported so far this year; in contrast, the United States has about 329 million people.
Needles used in a free measles vaccination clinic Nov. 2, 2018, in Monsey, N.J., are put into medical waste containers. (Photo: Rochel Leah Goldblatt, The (Westchester/Rockland county, N.Y.) Journal News)
Meanwhile, an outbreak in Europe has left more than three dozen dead.
General skepticism about vaccinations, including the MMR shots, continues among some, no matter where they live.
This questioning of vaccines plays out in different ways, though. Some swear off all vaccines, believing they carry more risks than the diseases they are designed to fight.
Other parents remained concerned about what they see as an overwhelming and aggressive vaccination schedule.
They may want to slow the amount of shots given or skip certain inoculations. In a vacuum, they may opt out of vaccinations because they don't think their ideas will be welcome.
Ruppert said she's been talking with families who are "in between," who focus on delaying a vaccination schedule. She has found them amenable to education and explanation if their concerns are respectfully addressed.
Part of today's problem has been the success of childhood immunizations in previous generations, said Zucker, who is a pediatrician with a subspecialty in critical care. People aren't familiar with many of the diseases that killed or maimed children as few as 25 years ago; the chicken pox vaccine was introduced in the United States in 1995.
"I've seen these diseases, all of them, diptheria to measles," he said. "I've seen the measles encephalitis, I've seen whooping cough. I don't think any parent would want to experience that with a child.
"I recognize the worries of this," Zucker said of parents' concerns. "But I recognize the need for vaccinations."
Because the vaccinations prevent diseases, they don't see what could happen, he said.
Complications of measles include pneumonia, brain damage, deafness and death. The disease can be dangerous, especially for babies, young children and pregnant women who haven't had the virus.
A clinic Friday in Monsey, New York, drew 99 people. One child was turned away because he showed symptoms of measles, Ruppert said.
"If they're looking sick, they don't come in the building," she said, explaining that every person is given a quick analysis at the door so anyone infected doesn't end up spreading the virus at the clinic. She was gratified that the parents of the sick child decided to have the siblings receive the vaccine anyway.
Contributing: Liv Osby, The Greenville (S.C.) News; USA TODAY. Follow Nancy Cutler on Twitter: @nancyrockland
Walmart and the parent company of Mucinex are partnering with Doctor On Demand, a virtual care provider headquartered in California that has spread nationwide and is steadily expanding.
On Wednesday, RB, the English-based health and hygiene company, announced that consumers who purchase their products Mucinex, Airborne or Digestive Advantage at Walmart stores or through walmart.com would receive a limited-time offer for a medical video visit with a Doctor on Demand physician at no cost.
Doctor on Demand already has a number of direct contracts with large employers including Walmart, Wells Fargo, Comcast, American and United Airlines. Employees at these companies are able to use Doctor on Demand services.
WHY THIS MATTERS
Virtual care is a big part of the future of healthcare. It is not replacing face-to-face physician visits, but represents a less expensive, more convenient consumer care experience, exactly the direction the healthcare industry has been told to head.
In-office visits are more expensive and time-consuming, Doctor on Demand said. Plus, 30 percent of adults don't have a primary care physician.
The Centers for Medicare and Medicaid Services and private health plans are increasingly reimbursing providers for telehealth.
Doctor on Demand works with national health plans such as UnitedHealthcare and Humana and others, which pay less for the virtual services than in-patient care.
Medicare will begin allowing monitoring from homes starting in 2020 and other changes are coming that will further open up the business.
Doctor on Demand got onboard the virtual visit trend before it crested and has been riding it to success.
The company has grown with smartphone adoption, according to Dr. Ian Tong, chief medical officer at the San Francisco headquarters.
When Doctor on Demand launched in 2012, it was a direct to consumer medical company. It then began adding large companies. It also expanded into rural areas such as in upstate New York, where Doctor on Demand is an in-network provider.
Patients accessed a video-based virtual visit through a mobile device.
Consumers wearing a Fitbit or who have a smartphone can download an app that gives the heart rate, oxygen saturation or an EKG reading.
Doctors use a mobile device camera to see down the back of throats, a method that works as well, or even better, than a tongue depressor, Tong said.
The company developed its own EMR and embedded the video component in its platform, so patients and physicians are seeing the same health information.
The majority of patients are between the ages of 25 and 50. About 10 percent of its patient population is between the ages of 50-55, and that drops to 8 percent for those aged 55-65.
Physicians are attracted to the business model because they can work from home.
The company isn't paying the overhead for real estate and to staff buildings. Doctor on Demand has three offices to handle administrative work.
The core message is that virtual care works as well as an office visit. But it's not meant to displace primary care physicians.
An audit run by Humana showed virtual visits have similar results to in-person visits as far as how many patients revisited their provider.
Humana assessed the severity score and diagnosis comparison and followed with claims data 14 days later.
The rate for those patients going to the emergency room who had used Doctor on Demand was 1.3 percent, compared to 1.1 percent for those who originally went into an office.
The antibiotic fill rates were 36.1 percent for telemedicine and 40 percent for in-office visits.
Doctor on Demand did have a higher 14-day revisit rate to urgent care than those who had seen a physician in-person. The revisit rate for Doctor on Demand was 0.9 percent, compared to 0.1 percent for in-office.
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