This month’s “Boots on the Ground” column is a bit different from the first two columns. First, because its primary author, Dr. Jana Shaw, is a pediatric infectious disease physician; second, because it addresses a current public health crisis, the measles outbreaks in New York; and finally, because of the complexity of the issue, it is longer. Jana, an extraordinarily public health minded practicing physician and a dear colleague of mine, contacted me a couple of weeks ago to discuss her thoughts about what was happening in Rockland County and New York City. She was concerned about some of the media coverage about the measles outbreak and that public health officials were not getting the support that they needed in these difficult situations. The post below reflects our thoughts on the current situation in New York.

As of April 19th, 2019, 626 cases of measles were reported in 22 states in the United States this year. With the number new cases reported by states since that date, this outbreak will be the largest outbreak since measles elimination in the US in 2000. The majority of the cases can be attributed to outbreaks in New York. The current outbreak in NY has been linked to an international traveler who arrived in Rockland County in September 2018. Since then, in spite of a concerted effort of the public health experts to contain the virus, the outbreak continues to spread, particularly among intentionally unvaccinated Hasidic and Orthodox Jewish communities in Rockland County, Brooklyn, and Queens. Additional cases have been reported in Orange, Westchester, and Sullivan Counties. Thankfully, no death has been reported so far although severe complications of measles requiring hospitalization, including admission into intensive care units, have been reported.

Measles infection is uniquely challenging to contain as it has a long incubation period (7 to 21 days), the virus is very contagious and spreads easily via cough or sneezes, it has a high attack rate as it sickens 90% of people without immunity, and it persists in the environment for 2 hours after the infected individual leaves the room. Furthermore, the transmission can occur before the onset of symptoms, making it very difficult to identify infected people during the early incubation period. MMR vaccination is the most cost-effective and safest intervention to control measles outbreak. During measles outbreaks, MMR vaccine should be offered to exposed people who lack evidence of immunity and to unvaccinated individuals to ensure community vaccination coverage of 96% and greater to prevent spread of the virus. Since the beginning of the outbreak in October 2018, elected officials and public health directors have pursued several measures to try to interrupt transmission of measles, including encouraging MMR vaccination of unvaccinated people and, in accordance with the NYS Public Health Law, enforcement of the school exclusion policy for children who were not immune to measles and were exposed or attended a school in close proximity to confirmed cases.

Outreach strategies to affected communities have included conference calls with families of affected children and meetings with school principals, as well as informational strategies such as door hangers, posters, public service announcements, and postings in local journals, provider offices, and schools. Health education materials about measles have also been provided to health care providers, school administrators, and the general public including health advisories, facts sheets, letters to school administrators, and a school exclusion algorithm. Healthcare provider education has included the importance of identifying, reporting, and testing of suspect measles cases. In addition, in order to protect medical staff who care for ill patients, there has been an emphasis on the importance of measles immunity through vaccination and post-exposure MMR vaccination prophylaxis of a non-immune staff. Despite the employment of a broad and thoughtful range of strategies to control the outbreak, new cases have continued to emerge.

In addition to outreach and education efforts, there have been several policy decisions made in response to the outbreak. In Rockland County, the Health Commissioner, Dr. Patricia Schnabel Ruppert enacted an order on December 3, 2018, to bar unvaccinated students from schools that have less than a 95% vaccination rate. Because of ongoing measles transmission among unvaccinated individuals, County Executive Ed Day declared State of Emergency on March 26^th, banning unvaccinated individuals younger than 18 years of age from public places (eg, schools, churches, malls) for 30 days. In response, Michael Sussman, representing families of unvaccinated children attending a private secular school at the Green Meadow Waldorf School in Chestnut Ridge, filed a lawsuit against the Rockland County Department of Health over the school exclusion. The lawsuit cited abuse of power and argued that unvaccinated children from Waldorf School lived in a close-knit community without any confirmed cases of measles and therefore should not be forced to stay home. On April 5^th, Acting State Supreme Court Justice Rolf Thorsen ruled against the County, arguing that a State of Emergency was not justified as there was no epidemic. He lifted the ban, allowing all unvaccinated children back to school on April 9^th. As of April 22^nd, an additional 31 cases of measles have been reported, bringing the case count to 199 (over 80% of whom were unvaccinated) since the first case was reported in October. Rockland County Executive Ed Day’s office issued a statement: “It is unacceptable to sit back and do nothing as more of our residents fall ill to this deadly disease and court decisions aside, we will never do that,” said County Executive Day. Subsequently the Rockland County Health Commissioner issued a new order on April 16, 2019, requiring:

• Infected individuals to stay home until no longer infectious,
• Individuals exposed to measles to stay away from indoor and outdoor public places,
• Individuals to cooperate with public health investigations regarding their illness and contacts,
• All unvaccinated students without evidence of MMR vaccination to be excluded from school, unless they have medical or religious exemption.

On April 19, the state appellate panel refused to reinstate Day’s public emergency order.

In New York City, the response to the outbreak has included control measures similar to those used in Rockland County but cases have kept on popping up, especially in Williamsburg and Borough Park, neighborhoods in Brooklyn. NYC Mayor Bill De Blasio declared a public health emergency on April 9^th and required that adults and children who live or work in four ZIP codes of Brooklyn be vaccinated against measles because the outbreak was being “driven by a small group of anti-vaxxers” in the targeted neighborhoods. Refusal to get vaccinated could lead to a $1,000 fine. A group of five parents represented by Manhattan attorney Robert Krakow filed a lawsuit in the Brooklyn Supreme Court against the New York City Health Department on April 15^th, claiming the measures are extraordinary and unwarranted. By April 18^th, the case count was 359, the same day Brooklyn judge Lawrence Knipel ruled against the parents and dismissed their religious, moral, and scientific objections against vaccination.

We think it is important to reflect on policy issues that are in play here. The New York State school immunization mandate is very effective to maintain high vaccination coverage, but it allows for loop holes for parents who object to vaccinations on religious grounds. Those loop holes have been increasingly used by parents whose objections to vaccinations are personal. The anti-vaccination movement has been growing over the past decade and the number of New York State children exempted from school immunization requirements for non-medical reasons increased from 0.45% in 2010 to 1.1% in 2017-18. While the state level mean exemption percentage is small, it doesn’t adequately capture the burden of exemptions at local, community, and school levels where transmission of measles occurs and is facilitated by lack of herd immunity. In New York State, private school immunization coverage for required vaccines including measles can be as high as 99% and as low as 0%, illustrating the need for a focused and unapologetic enforcement. As an example, at Green Meadow Waldorf School in Rockland County, only 49% of the school’s population was vaccinated in 2013-14 school year.

Immunization laws have been challenged by anti-vaxxers for centuries, and the Supreme Court has consistently ruled that current vaccine laws are constitutional. In a landmark case of Jacobson vs Massachusetts in 1905, Jacobson refused to get vaccinated against smallpox in the midst of a smallpox epidemic. The Supreme Court upheld the state order and Jacobsen could either get vaccinated or pay a fine of $5. The court then argued that “the freedom of the individual must sometimes be subordinated to the common welfare and is subject to the police power of the state.” A more recent, and perhaps more controversial, example of a vaccine order was issued during a measles epidemic in Philadelphia in 1991. Unlike mandatory vaccination orders in NYC for which the penalty for refusal is a fine, in Philadelphia, children were actually vaccinated against their parents’ will. Although the policy was in the best interest of the children, it was very traumatic for the parents. Philadelphia’s compulsory vaccination order was not challenged in court. This illustrates how public health authorities at times have to resort to measures that appear to violate individual rights in order to ensure the safety and protection of rights of the general public.  

But in NY today, the court ruled against Rockland County’s Executive Order while a judge in Brooklyn ruled against the parents opposing mandatory vaccination. These policies have different approaches, different challenges, and potentially different long-term consequences. Regardless of the ultimate outcome of the court challenges, the measles outbreak in NY and the responses it has evoked from the local politicians and public health directors serve as great reminders of the extent to which public health workers are on the front line. Behind the headlines, there are nurses providing vaccinations, communicable disease investigators calling families and medical offices to obtain valuable information, epidemiologists poring over the data, and public health educators developing and disseminating messages to both assure and motivate the public. And there are so many other public health workers doing their best to protect their community. We must continue to support those on the front lines, who may also find themselves on the front pages. How do we support the women and men making incredibly difficult decisions about the best way to protect their communities while recognizing that some of the decisions are controversial or could even backfire? 

We must return to the core functions of public health: A science-based assessment of the problem, evidence-based policy development, and assurance that we have an appropriately trained workforce to effectively and equitably implement the policy (and related programs and services) needed to address the problem. With respect to the measles outbreak in New York, the problem has been definitively assessed and the involved health departments appear to have the workforce needed to address the problem. The issue thus is that of policy development. We must assess policy in its entirety, including its potential unintended consequences. Could New York City’s policy, in its attempt to provide a tailored approach to certain zip codes based on valid evidence of risk, unintentionally discriminate, as suggested by Gostin and Hodge, even if the court ruled against the parents? Could Rockland’s policy and the subsequent judicial ruling against it unintentionally undermine current efforts to tighten school immunization entry requirements in New York? Could the newspaper headlines generated in large part by elected officials be perceived of as the politicization of public health, thereby potentially undermining the public’s trust in public health? These questions remain unanswered at this time, but they are important questions for all of us in public health to consider.

There is much that we do not yet know about the measles outbreaks in New York, but what we do know is that dedicated local public health officials and all of the public health workers with whom they work are doing their very best to protect and promote the health and rights of all members of their communities by trying to prevent the next case of measles.

Related Reading in the Journal of Public Health Management and Practice:

• Health Departments’ Experience With Mumps Outbreak Response and Use of a Third Dose of Measles, Mumps, and Rubella Vaccine
• CDC Guidance for Use of a Third Dose of MMR Vaccine During Mumps Outbreaks
• Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County
• Effects of California Assembly Bill 2109 in Low Vaccination Rate Counties: Are We Looking at the Right Variables?

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Cynthia Morrow, MD, MPH, a former local health director for Onondaga County, NY, is currently teaching at Virginia Tech Carilion School of Medicine. Previously, she was the Lerner Chair for Health Promotion at Syracuse University. Her prior academic positions include Professor of Practice in the Department of Public Administration and International Affairs at Syracuse University and an assistant professor with the Center for Bioethics and Humanities as well as with the Department of Public Health and Preventive Medicine at Upstate Medical University. Dr. Morrow served as Commissioner of Health for Onondaga County during which time she earned numerous awards from community-based organizations. She is a consulting editor for the Journal of Public Health Management and Practice and is also an editor of two books, including Public Health Administration: Principles for Population-Based Management and JPHMP’s 21 Public Health Case Studies on Policy & Administration. She is a graduate of Swarthmore College (BA) and Tufts University School of Medicine (MD, MPH). [Full bio]

Jana Shaw, MD, MPH, is an Associate Professor at the Department of Pediatrics at the SUNY Upstate Medical University with specialty training in pediatric infectious diseases, public health, and immunology. She is also a chief medical officer at the Federally Qualified Health Center-North Country Family Health Center in Watertown, NY. In the past, she has worked on variety of projects focusing on vaccine hesitancy and refusal. Her area of expertise has extended beyond the national borders. She has been collaborating with colleagues in New Zealand in an effort to identify opportunities to enhance coverage in a country without school immunization laws and has collaborated with the University of Hradec Kralove in the Czech Republic and the Czech Ministry of Health to assist with improving vaccination coverage in the Czech Republic and Europe. She previously collaborated with the CDC on trends of vaccination refusal at the state level and has been collaborating with the University of Albany, the Bloomberg School of Public Health at Johns Hopkins, the New York State Department of Health, and the CDC on variety of vaccination coverage improvement topics. In her capacity as the Golisano Children’s hospital epidemiologist, she has partnered with the local and state health departments on the management of outbreaks of mumps and enterovirus D68.