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An unprepared Israeli health system is battling measles

Common last-day hypothetical scenarios often involve terrorism or nuclear war, but in the 21st century, especially in Western countries, they do not usually involve a deadly world pandemic.

That all changed at the end of 2016, when the World Health Organization (WHO) first reported a jump of 30 percent in measles cases worldwide, warning that more countries had experienced a "severe and protracted epidemic" of the disease, which is believed to be all only died in 2000.

Measles are considered the most contagious of all infectious diseases. The virus causes severe flu-like symptoms and a characteristic purulent rash, but in some cases complications affecting the respiratory and nervous systems can be life-threatening.

The most recent WHO update says: “The last year for which WHO global case and death estimates are available is 2017; that year there were 6.7 million estimated measles cases and 110,000 estimated measles deaths, based on 173,330 reported cases. "These figures make this the worst measles outbreak in 25 years.

Worse, the WHO warned that the actual number of measles patients is likely to be higher, saying its database contains only cases confirmed by laboratory testing or clinical visits.

This means that there are probably thousands of people who have contracted measles and have never sought medical attention.

Map of Global measles epidemic (World Health Organization via Zman Yisraeli)

According to WHO, "significant measles outbreaks" have been observed in Mid-2019 in the Democratic Republic of Congo, Ethiopia, Georgia, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand and Ukraine, while "spikes in numbers" have been reported in the United States, Israel, Thailand and Tunisia.

These kinds of reports give the impression that measles is spreading in poor countries, while it is still under control in Israel. But this is a wrong conclusion, because the measles epidemic in Israel is serious even in comparison to the countries that are worst affected.

The latest World Health Organization update on the global epidemic lists 16 countries that "had a high rate of measles last year." Fifteen of them are considered second and third world countries. The only developed OECD member state on this obvious "black list" is Israel.

The only developed OECD member country on this obvious & # 39; black list & # 39; is Israel

Israel is not included in this list by mistake or because of political pressure from its opponents. WHO figures say 3,755 Israelis were diagnosed with measles between April 2018 and March 2019. By July, the Israeli Ministry of Health had increased the number of local measles cases to 4,292.

These figures rank Israel in the sixth worst country in the world.

The last epidemic has claimed three lives in Israel so far: In November 2018, an 18-month-old unvaccinated toddler succumbed to it, becoming the first recorded measles death in Israel in 15 years. In December, an 82-year-old woman claimed the disease, and in August 2019, Israeli flight attendant Rotem Amitai, 43, who became ill with measles in late March, became the third fatal epidemic in the summer.

Newborn baby suffering from measles. (Illustrative. IStock by Getty Images / andriano_cz)

According to WHO, there are 59 measles cases in every 100,000 people in Israel. This place places the Jewish state before Albania (64 patients per 100,000 people) but behind India, (28 patients per 100,000 people) and far behind Brazil, with five cases per 100,000 people.

It could be argued, of course, that Israeli authorities simply know more patients than their counterparts in developing countries such as India and Brazil, where many patients are undiagnosed and untreated. But even if we compare the situation in Israel with the situation in other developed countries, the number of measles cases here is still much higher.

France – another measles hotspot – has an average of 42 cases of measles per 100,000 people. In Italy, considered the epicenter of a severe measles epidemic that has plagued the European Union, there are 36 cases per 100,000 people. In Britain, that number is 19; in Germany it is limited to 10 and in the USA there are less than one measles per 100,000 people.

"Herd immunity is mandatory"

"If a non-measles person enters a room where the measles patient spent hours before hours, they can contract the disease – we mean it when it is highly contagious," Edva Lotan, CEO of MIDA, a nonprofit organization dedicated to promoting public health, Hebrew Sister of the Times of Israel told Zims Yisrael.

Each population has groups that cannot be immunized against measles: babies under the age of one year, people with medical sensitivities, and those for whom the vaccine simply does not work. Measles can spread rapidly where more than five percent of the population is unvaccinated, similar to other infectious diseases.

"The only way to protect and prevent the spread of measles is to create 'herd immunity', which means reaching a situation where over 95% of people are immune to the disease," Lotan said, referring to the form of indirect protection that occurs when large a percentage of the population became immune to infection, thereby reducing the risk for individuals who are not immune.

"The problem is that it's not just 95% of the people in the state, but 95% of the people who are in any public place at any time. To get there, we need everyone who can be vaccinated just to do it," she said.

Edva Lotan, Director of Mida's Public Health NGO. (Felix Lotan via Zman Yisrael)

According to the WHO, in most countries there is a proven link between the number of children vaccinated and the ratio of total measles cases.

In 10 of the 12 countries examined, it was found that the more children vaccinated against measles, the fewer cases of the disease. In the US and Germany, more than 90% of children and young people under 21 have received the measles vaccine.

The US Centers for Disease Control and Prevention recommends that all children receive two doses of the combined measles-mumps-rubella vaccine, starting with the first dose at 12 to 15 months of age and the second dose at 4 to 6 years. This two-dose practice is common in most Western countries, including Israel.

The vaccination props are taking a toll

Contrary to popular belief, measles does not spread worldwide. On the contrary – the number of measles patients has fallen dramatically in the last 40 years, from about 4 million in the 1980s to about 400,000 today. We owe this decline to the fact that hundreds of millions of children in developing countries, especially in Asia and Africa, are vaccinated against measles today.

But it is precisely in developed countries, where much of the population has been routinely vaccinated for decades, that the opposite trend is observed and an increasing number of children are not vaccinated.

As a result, in all countries where the number of unvaccinated children has increased, without exception, measles has reared its head.

One-dose vial of measles, mumps and rubella (MMR) vaccine at Salt Lake County Health Department, Utah, April 26, 2019 (Illustration. George Frey / Getty Images)

In some countries, budgetary issues or the privatization of the healthcare system have resulted in a lack of vaccines. However, in most developed countries the problem lies not in the lack of access to vaccines, but in the increasing number of parents who refuse to vaccinate their children.

Much of this has to do with false propaganda propaganda that is spreading like social epidemics on social media.

This combination of vaccine deficiency and mass anti-vaccine propaganda caused a sharp drop in the number of vaccinated children in Eastern Europe, resulting in the largest increase in the incidence of measles.

The most serious epidemic in Europe was in Ukraine. While at the turn of the century, about 99% of Ukrainian children received all the necessary vaccines, by 2013, only 57% of Ukrainian children and newborns had been vaccinated against measles, as well as other equally or more dangerous diseases.

Thus, Ukraine has moved from virtually no measles cases in the previous decade, to a record 54,000 cases in 2018, including 25 deaths.

Ukraine has moved from almost no measles in the previous decade to a record 54,000 cases in 2018, including 25 deaths

Vaccine deficiencies, bureaucratic corruption, distrust of the health care system and internet lies have all led to great public health implications.

In Ukraine, it seems that contempt and distrust of scientific knowledge have spread not only to the general public, but also within the healthcare system itself, as doctors increasingly recommend that parents decide not to vaccinate children, and about 30% of medical publications that doctors write do also.

Israeli anomaly

WHO data have found only two countries where most children are vaccinated against measles, and many others still have a high rate of infection: The first is Albania, whose government records 99% of the childhood vaccination rates and yet is experiencing a measles epidemic. The other is Israel.

Data show that Israel has seen a slight drop in vaccination rates in recent years, which is believed to have caused the local epidemic: in 2000, 97% of Israeli children in the appropriate age groups were immunized; in 2013, 96% of children were vaccinated, and a similar number of children were vaccinated in 2017.

That means there are more vaccinated children in Israel than in the US, France, the UK, Germany and Italy, for example – but measles seems to hit the Jewish state more strongly.

Dr. Hagai Levine, an epidemiologist at Hadassah School of Public Health and secretary of the Israeli Association of Public Health Physicians, says the measles epidemic in Israel is an anomaly.

Dr. Hagai Levine of the Israel Association of Public Health Physicians (Hebrew University of Jerusalem via Zman Israel)

"Scientific research has undoubtedly proven that exposure to the attenuated measles virus, a species given in the vaccine, results in the almost complete elimination of measles morbidity, both at the individual and population levels. The more people who get vaccinated, the lower their risk of getting measles and the lower the risk of the whole society experiencing the epidemic, ”Levine said.

"Because measles is a highly contagious disease, it only takes a few unvaccinated children in certain parts of society, schools or the neighborhood to get measles, even if most other people are vaccinated. This is exactly the situation in Israel, ”he explained.

Mida's Lotan added that Israel has a unique set of circumstances: It is a very densely populated country with the highest proportion of children among all developed countries. And when it comes to measles, children are the fastest infected and most infected population.

"There are large communities in Israel that are not vaccinated and live in very close proximity. Some are poor and do not have access to vaccines, some oppose immunization, and in some it is a combination of the two, ”she said.

The present data, however, make it difficult to determine where the “foci” of infectious disease are indeed located.

"We do not have enough information to determine whether anthroposophical or democratic schools and communities that serve the places from which the disease spreads," Lotan said, referring to educational developments in which parents were particularly vocal about immunization.

When it comes to measles, children are the fastest infected and most infected population

"There has been a buildup of cases in some schools, but does that mean anything to the communities as a whole? I don’t know, ”she said.

The data, however, is much more convincing compared to the ultra-Orthodox communities.

"When it comes to the Haredi population, the data is clear, because we know that there is a high proportion of anti-vaccines among them," she noted. "Most Haredim are vaccinated and there are rabbinic regulations that support it. On the other hand, some rabbis oppose vaccination, and because of the authority they have, people reject it. [to immunize their children]".

The sign alerts people to measles in an ultra-Orthodox Jewish community in Williamsburg on April 19, 2019 in New York. (Spencer Platt / Getty Images / AFP)

"There are also schools for all boys in the Haredi Society, and the principal may decide that he does not want students to receive vaccines to prevent contact with the sisters. There are solutions to this, but [the schools] he just prefers to skip the vaccine, "Lotan said.

"Some in the Haredi sector do not have access to vaccinations," she continued. "It is not easy for families with 10 children to come to Tipat Halav [maternal-child health clinic], Many Haredi families vaccinate their children when they are two or three years old, instead of when they turn one. Statistically, these children are vaccinated as vaccines, but in reality they do not have protective immunization at exactly the age when they are most susceptible to measles. "

The question remains why, for example, similar religious and spiritual communities in the United States have not become focal points for measles but their Israeli counterparts.

The answer, Lotan said, refers to the basic size of the population. "Communities of this nature in the US have also had a measles epidemic, but they are a relatively small part of a huge American society," which has had 327.2 million people as of 2018. "In Israel, the ultra-Orthodox and other segregated communities form a significant part of society."

Legal impact

The solution to the measles epidemic is seemingly simple – binding vaccination. Many countries have opposed the anti-vaccination trend by passing laws that oblige parents to immunize their children.

In 2015, France passed a law requiring all parents to vaccinate their children against 11 illnesses as a prerequisite for their admission to kindergartens and schools. The result was immediate: the number of vaccinated children increased from 75% in 2013 to 84% in 2017.

Germany has no actual law on the matter, but new parents must attend a series of sessions with a pediatrician explaining why they should vaccinate their child. In 2018, Germany passed a law requiring schools to provide the authorities with a list of unvaccinated children and their parents to attend mandatory pediatric counseling. Parents who fail or refuse to attend these meetings are fined $ 2500 ($ 2,800).

Italy passed emergency laws in 2016 that sought to curb the measles epidemic. The law requires parents to immunize their children with 12 mandatory vaccines; increased state funding for vaccines; ordered mandatory counseling for all parents on the importance of immunizing their children; prohibited unvaccinated children from kindergarten and imposed a fine of 500 euros ($ 560) on parents sending unvaccinated children to school.

In an attempt to combat the measles epidemic, some countries in Europe have enacted mandatory child vaccination laws. (Illustrative. Miriam Alster / FLASH90)

In the UK, parents are not legally required to vaccinate their children. But unlike most countries, British schools are allowed to vaccinate children without parental consent if the children themselves have received and agreed to the proper explanation of the procedure.

Federal law in the United States prohibits children who are not vaccinated from entering educational institutions. However, the law is only adopted in some states and is implemented only in public schools and not in private schools.

As a result, some states tolerate the fact that certain sectors choose not to vaccinate children for "religious or conscientious objection". It is these communities that have experienced embarrassment in the case of measles in the last few months.

Eastern European countries are also trying to make it difficult for parents not to vaccinate their children.

Georgia, for example, passed a law banning children who have not been vaccinated in schools. It has also established a national parent education program and has recently taken the aggressive step of criminalizing refusal to immunize children. All this has resulted in a steady increase in the number of children vaccinated.

However, such laws are not always successful.

Ukraine passed a law prescribing immunizations, but this gave birth to an industry of doctors selling cheap false vaccination certificates

The Ukrainian government has passed a law that makes immunization of children compulsory, but according to WHO research, it has given birth to an industry of doctors selling parents false vaccination certificates for a price lower than the vaccine.

"Ministry of Health does nothing"

One would think that given the increase in measles in Israel, the government would be proactive, but that was not the case. There is no law that mandates vaccination, there is no law that prohibits unvaccinated children from attending school, there are no disciplinary measures against anti-vaccines, and no educational effort directed at parents.

Israeli law, which allows the government to close schools in the event of an epidemic of measles, has so far been applied to only two schools, in Jerusalem and Harris, near Haifa. But stopping the epidemic requires more than just isolating the patient – it also requires mass vaccination. The government has so far done nothing to promote this.

"The shafts are expanding because there is no policy to prevent that from happening," Lotan said. "There is no law enforcement, little or no education on the importance of the vaccine, and there are also no moves to vaccinate adults between the ages of 40 and 60 who have not been vaccinated in childhood. Other than a PR campaign and fire fighting, the Ministry of Health is doing nothing. "

Last year, former MKs Yoel Hasson (Zionist Camp), Shuli Moalem-Refaeli (Jewish Home) and Meirav Ben Ari (Kulanu) introduced a bill that would both encourage vaccination and give authorities the power to ban unvaccinated children from all educational backgrounds. because it also obliges the Ministry of Health to promote immunization and punish parents who resolutely refuse to immunize their children for anything other than medical reasons.

The proposal almost unanimously passed its preliminary and first readings on the Knesset and was referred, as required by the legislative procedure, to the responsible parliamentary committee – in this case the Knesset Health Committee. But then the general election in April came with their political stalemate, which led to the September elections.

It is currently unclear whether a government will be formed after the election and nonetheless, none of the three lawmakers who drafted the vaccination bill has been elected, so a move forward will have to be accepted by another MK.

The baby is receiving the vaccine at Tipat Halav Maternal and Child Health Clinic. (Illustrative. Noam Moskowitz / FLASH90)

But even if this bill becomes law, it is unlikely that it will materially change the scope of vaccinations for the simple reason that it does not impose a large legal obligation to immunize children, nor does it allow schools to remove unvaccinated children.

Lotan, whose organization drafted the bill, said many colleagues "criticized her if she was too weak." "But the point was not to target anti-hackers – the point is to make a law that can be implemented in the Israeli language a reality. If you remove unvaccinated children from school, they will not get vaccinated – they just stay home."

If you remove unvaccinated children from school, they do not get vaccinated – they just stay home

The Israeli Maternal and Child Health Clinic Tipat Halav, whose nurses administer vaccines for infants and children through kindergarten, suffers from a constant budget cut and staff loss.

"It is quite clear that a much wider spread of measles has been avoided thanks to Tipat Halav," Levine observed. "But this system suffers from severe erosion. It's hungry for budget, manpower and additional locations, as long as the population grows rapidly."

According to Levine, providing this public health care provider with the budgets it needs will go a long way toward increasing vaccination rates, thus improving the morbidity and mortality rates in Israel.

For its part, the Ministry of Health says it spares no efforts to combat the measles epidemic.

"In recent years, measles has spread in Europe, the US and elsewhere," the statement read. "The large number of reported cases in Israel can be traced back to 'imported' cases of measles combined with the 'pockets' of unvaccinated people among the general population."

The Ministry attributed the high figures cited by the WHO to an acute increase in cases in the last four months of 2018 (up to 900 new patients were reported monthly at the time). In recent months, it has been claimed, there has been a significant decline in disease reports.

Eliminating the disease "requires complete coverage for the entire population, especially children," the ministry said, noting that the laws do not currently make vaccination mandatory, although the possibility of punishing parents who do not immunize their children is still being considered.

"It should be noted that most countries that passed the compulsory vaccination law had lower vaccination rates than Israel before and after the passage of the said legislation. In addition, countries with mandatory immunization laws continued to record the measles epidemic, ”the ministry says.

"During the outbreak, the Ministry of Health stepped up staff at Tipat Halav clinics and vaccination stations across the country," the ministry said, "as well as managing a mobile vaccine station to increase immunization among the general population, especially in the ultra-Orthodox sector."

A version of this article first appeared in Hebrew on the sister site of The Times of Israel, Zman Yisrael.

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