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      Ongoing Measles Outbreak in Orthodox Jewish Community, London, UK


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          To the Editor: Measles outbreaks have been reported in Orthodox and ultra-Orthodox Jewish communities across Europe and Israel ( 1 – 5 ). We describe an ongoing outbreak within the largest European Orthodox Jewish community (including a Charedi population of 17,587), based in London, focused in Hackney ( 6 ). Vaccination coverage within this community is lower than in the general population of London, causing low herd immunity and outbreaks of vaccine-preventable diseases. Vaccination coverage data within the communities cannot be extrapolated, because membership is not classified as an ethnicity and not collected within health electronic recording systems. However, general practice surgeries in Hackney known to have high proportions of Orthodox Jewish patients have considerably lower vaccination coverage (55%–75% of patients 24 months of age had received measles, mumps, rubella [MMR] vaccine in the 3rd quarter of 2012) compared with the London average (87.3%) ( 7 ). Health beliefs, family size (the average Charedi household size is 6.3 persons), and underutilization of immunization services contribute to low coverage ( 8 , 9 ). The outbreak clinical case definition was taken from Public Health England’s guidance ( 10 ). It also included membership in the Orthodox Jewish community; residency in the London borough of Barnet, Hackney, or Haringey; and notification during December 20, 2012–March 19, 2013. After serologic confirmation of measles in the index case-patient, an unvaccinated Orthodox Jewish 4-year-old from Hackney, the case was reported to the Health Protection Team (HPT) on December 20, 2012. The family could not recall having contact with someone with measles. The child attended nursery while infectious; subsequently, cases in 3 secondary patients in the nursery were reported to the HPT. Transmission was observed within households, extended family groups, nurseries, schools, and a camp for Orthodox Jewish teenagers attended by 80 girls (mainly from Hackney) with staff from Italy. Five secondary cases from this camp were reported (in 3 residents of London, 1 resident of Sheffield, and 1 resident of Hertfordshire). During December 20, 2012–March 19, 2013, a total of 62 notifications of measles cases meeting the case definition were received in residents of Barnet (8 cases), Hackney (47), and Haringey (7). Patients’ ages ranged from 7 months to 27 years (median 7 years). Thirty-four (55%) were female. Fifty-four (87%) had never received an MMR vaccine, and 8 (13%) had received only 1. Three were admitted to the hospital, and 5 were clinically assessed in accident and emergency departments (patients’ ages ranged from 7 months to 4 years). All case-patients were assessed for risk by the local HPT for vulnerable contacts and source of infection. The HPT provided infection control guidance and an oral fluid testing kit. Sixteen (26%) case-patients could not recall any contact with a person with measles; the remainder stated various epidemiologic links to a case-patient (Figure). Figure Reported measles cases by week of rash onset and likely source of infection, United Kingdom, 2012–2013. Forty-two cases have been confirmed (measles IgM detected) by serologic testing (4 cases) or oral fluid (38). One notified case-patient did not have measles IgM on oral fluid testing but had an epidemiologic link to a case-patient and clinical symptoms. They are included in this analysis. Seventeen IgM-positive oral fluid samples were genotyped, and all were D8, currently the most common genotype in the United Kingdom. One confirmed case was detected in an unvaccinated child from Haringey who was not Orthodox Jewish but was known to have had contact with a case-patient from the community. The child’s illness did not meet the case definition and is not included in this analysis. In response to the outbreak, active case finding and awareness-raising have been undertaken by the HPT, National Health Service (NHS) public health departments, and community NHS services focused on health and education services and Orthodox Jewish communities. Information letters were sent to the 38 Orthodox Jewish schools and nurseries in Hackney and to attendees of the youth camp. Community NHS vaccination clinics have been maintained to complement standard immunization services offered in general practice surgeries. This includes a Sunday vaccination clinic. Furthermore, community NHS staff provided a vaccination clinic in a secondary school that had an attack rate of 7% (9 cases) at which 9 pupils received 1 MMR vaccine after parental consent. This was the only on-site school vaccination clinic offered; thus, no comparative uptake data are available to supplement our evaluation of the intervention. Information relating to the outbreak was placed in 2 Orthodox Jewish newspapers and targeted information for families (in English, Yiddish, and Hebrew) has been disseminated. Finally, all 25 HPTs were alerted to this outbreak and the national Public Health England database (HPZone) has been enhanced to capture notifications from Orthodox Jewish communities. This ongoing outbreak highlights continued health risks in communities with low vaccination coverage. The outbreak has been largely contained within London’s Orthodox Jewish communities, with limited spread outside of the city and to just 1 local non–Orthodox Jewish child. Given the mobility of members, the risk for transmission outside of London is relatively high. The outbreak underscores the need for ongoing evidence-based and culturally appropriate health interventions that seek to improve vaccination coverage.

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          Most cited references5

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          Perceptions of childhood immunization in a minority community: qualitative study.

          To assess reasons for low uptake of immunization amongst orthodox Jewish families. Qualitative interviews with 25 orthodox Jewish mothers and 10 local health care workers. The orthodox Jewish community in North East London. Identification of views on immunization in the orthodox Jewish community. In a community assumed to be relatively insulated from direct media influence, word of mouth is nevertheless a potent source of rumours about vaccination dangers. The origins of these may lie in media scares that contribute to anxieties about MMR. At the same time, close community cohesion leads to a sense of relative safety in relation to tuberculosis, with consequent low rates of BCG uptake. Thus low uptake of different immunizations arises from enhanced feelings of both safety and danger. Low uptake was not found to be due to the practical difficulties associated with large families, or to perceived insensitive cultural practices of health care providers. The views and practices of members of this community are not homogeneous and may change over time. It is important that assumptions concerning the role of religious beliefs do not act as an obstacle for providing clear messages concerning immunization, and community norms may be challenged by explicitly using its social networks to communicate more positive messages about immunization. The study provides a useful example of how social networks may reinforce or challenge misinformation about health and risk and the complex nature of decision making about children's health.
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            An outbreak of measles in orthodox Jewish communities in Antwerp, Belgium, 2007-2008: different reasons for accumulation of susceptibles.

            From August 2007 to May 2008, an outbreak of at least 137 cases of measles occurred in some orthodox Jewish communities in Antwerp, Belgium. The outbreak was linked to outbreaks in the same communities in the United Kingdom and in Israel. The reasons for this outbreak were diverse: cultural factors, misinformation on vaccination by some medical doctors and the lack of a catch-up vaccination programme in private Jewish schools. The identification of smaller susceptible groups for measles transmission and vaccination of these groups represent a major challenge for the measles elimination programme.
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              An outbreak of measles in an ultra-orthodox Jewish community in Jerusalem, Israel, 2007--an in-depth report.

              Measles elimination in Europe is hindered by recurrent outbreaks, typically in non-immunised specific sub-populations. In 2003 and 2004, two measles outbreaks occurred in Jewish ultra-orthodox communities in Jerusalem, Israel. In 2007, another measles outbreak emerged in Jerusalem. Epidemiological investigation and control activities were initiated. Three measles cases (15 years old, 22 years old and an infant; all unvaccinated) were diagnosed in Jerusalem in August 2007. All three belonged to Jewish ultra-orthodox communities in London, United Kingdom, and had had contact with patients in London. The epidemiological investigation did not reveal any connection between these cases other than their place of origin. The disease spread rapidly in extremely ultra-orthodox sub-groups in Jerusalem. Until 8 January 2008, 491 cases were reported. Most patients (70%) were young children (0-14 years old), 96% unimmunized. Frequently, all the children in a large family were infected; two thirds of the cases belonged to family clusters of more than two patients per family (in part due to non-compliance with post-exposure prophylaxis recommendations). The high age-specific incidence among infants 0-1-year- (408.5/100,000) and 1-4-year-olds (264.1/100,000) is a cause for concern. The hospitalisation rate was 15% (71/491), mainly due to fever, patients (26.7%) presented with pneumonitis or pneumonia and two patients presented with encephalitis. There have not been any deaths to date. The outbreak was apparently caused by measles importation into unprotected groups. Despite a high national immunisation coverage (94-95%), programmes to increase and maintain immunisation coverage are essential, with special focus on specific sub-populations.

                Author and article information

                Emerg Infect Dis
                Emerging Infect. Dis
                Emerging Infectious Diseases
                Centers for Disease Control and Prevention
                October 2013
                : 19
                : 10
                : 1707-1709
                [1]Public Health England, London, UK (V. Baugh, J. Bosanquet, S. Addiman, D. Turbitt, J. Figueroa);
                [2]Homerton University Hospital Foundation Trust, London (P. Kemsley)
                Author notes
                Address for correspondence: Vanessa Baugh, North East and North Central Health Protection Team, 2nd Floor, 151 Buckingham Palace Rd, London SW1W 9SZ, UK; email: vanessa.baugh@ 123456phe.gov.uk
                Letters to the Editor

                Infectious disease & Microbiology
                vaccination,measles,infectious disease outbreaks,judaism,mumps-measles-rubella vaccine,viruses,united kingdom


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