The measles outbreak in Israel in 2018-19: lessons for COVID-19 pandemic

Case Ascertainment of Measles during a Large Outbreak-Laboratory Compared to Epidemiological Confirmation

Measles is a highly contagious viral disease, and hence, sufficient herd immunity is obligatory to prevent infection transmission. Measles is still a cause of considerable disease burden globally, mainly in children. During a national measles outbreak in Israel in 2018-2019, the peak incidence rates occurred in the Jerusalem district. Most measles cases in the Jerusalem district (75.5%, 1702) were observed in children younger than 15 years of age, 49.2% (1109) were in children under 5 years of age, and 18.9% (425) were in infants under 1 year of age. The routine measles vaccination schedule includes two doses at 1 and 6 years of age. Most cases (1828, 81.1%) were unvaccinated (zero measles vaccine doses). These cases comprised the 425 affected infants under 1 year of age, who were ineligible for vaccination, along with the 1403 children over 1 year of age, who were otherwise unvaccinated. This study aimed to describe the epidemiologic and laboratory features of this measles outbreak, and to investigate case ascertainment (laboratory confirmed compared to epidemiologically confirmed cases). The study population included 2254 measles cases notified during the period spanning June 2018 to May 2019 in the Jerusalem district (incidence rate 176 per 10,000 population). Of the 2254 cases, 716 (31.8%) were laboratory confirmed, and 1538 (68.2%) were confirmed as epidemiologically linked. Most laboratory confirmed cases (420, 58.7%) underwent real-time PCR tests. Serological tests (measles IgM and IgG) were used in 189 (26.4%) cases, and a combination of RT-PCR and serology was used in 107 (14.9%) cases. In a multivariate model analysis, the variables significantly associated (after adjustment) with higher odds for laboratory confirmation included month of disease onset (late), additional measles cases in the household (single case), place of medical treatment (hospital; either emergency department, or hospitalization) and vaccination status (at least one prior vaccine dose). The measles outbreak described demonstrates the urgency of addressing vaccination gaps with appropriate outbreak prevention programs. The road to measles elimination needs to be paved with robust public health infrastructure, excellent field epidemiology for outbreak surveillance, investigation, and control, and laboratory proficiency.

Health system barriers to timely routine measles vaccinations in rural southwest China: a qualitative study on the perspectives of township vaccination professionals and village doctors

OBJECTIVES

A well-functioning health system ensures timely routine measles vaccinations for age-appropriate children, minimising measles risk. However, there is limited knowledge about the impact of the performance of immunisation programmes in health systems on the timeliness of measles vaccination. This study aimed to identify health system barriers to timely routine measles vaccination in rural southwest China, integrating the perspectives of township vaccination professionals and village doctors.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study among township vaccination professionals and village doctors in rural Guangxi, southwest China.

METHODS

20 focus group discussions (FGDs) at township level and 120 in-depth interviews (IDIs) at village level, based on a four-theme framework. We used convenience sampling to recruit 60 township vaccination professionals and 120 village doctors in 2015. Instruments used were a semistructured questionnaire and interview outlines. We collected township and village-level data focusing on themes of health resources allocation, pattern of vaccination services, management and supervision of vaccination services, and perceptions of vaccination policy. The FGDs and IDIs were audio-recorded and transcribed. Braun and Clarke's thematic analysis approach was adopted to synthesise findings into meaningful subthemes, narrative text and illustrative quotations.

RESULTS

The health system barriers to timely routine vaccinations were explored across four themes. Barriers in the health resources allocation theme comprised (1) inadequacy of vaccination-related human resources (eg, lack of township vaccination professionals and lack of young village doctors), and (2) incompatible and non-identical information system of vaccination services across regions. Barriers in the pattern of vaccination services theme included inflexible vaccination services models, for example, routine vaccination services being offered monthly on fixed vaccination days, limited numbers of vaccination days per month, vaccination days being set on non-local market days, vaccination days being clustered into a specific period and absence of formal vaccination appointments. Ineffective economic incentive mechanism was identified as a barrier in the management and supervision of vaccination services theme. Low-degree participation of village doctors in routine vaccination services was identified as a barrier in the perceptions of vaccination policy theme.

CONCLUSIONS

We encourage policymakers and stakeholders to apply these findings to improve the timeliness of routine vaccination. Barriers to timely routine vaccination include inadequate allocation of vaccination-related resources and inflexible vaccination service delivery models. Financial and non-financial incentives should be used to retain and recruit vaccination professionals and village doctors. Strengthening information systems with unified data standards enables cross-regional data exchange. Optimising immunisation services and rationalising vaccination days could eliminate health system barriers and improve vaccination timeliness in rural China.

Barriers and enablers to vaccination in the ultra-orthodox Jewish population: a systematic review

Background

The Jewish Ultra-Orthodox (UO) population is an under-vaccinated minority group that has been disproportionally affected by outbreaks of vaccine-preventable diseases (VPD) such as measles and polio. Underlying reasons remain poorly characterized. We aimed to identify vaccination barriers and enablers in this population.

Methods

We systematically reviewed the literature (PROSPERO: CRD42021273001), searching Pub-med, Web of science, Medline, PsychNet and Scopus from 1995 to 2021 for quantitative and qualitative primary research in English. Studies published outside the date range, not including barriers or enablers, or that were non-primary research were excluded. We assessed included publications for quality and extracted relevant data based on the 5As taxonomy: access, awareness, affordability, acceptance and activation.

Results

We included nine qualitative and seven quantitative studies from the 125 studies identified. Access barriers included scheduling difficulties, inconvenient opening hours, and logistical difficulties related to having multiple young children. Acceptance barriers included safety concerns. Insufficient knowledge about the importance of vaccine and timely vaccination and the perception of being shielded from infections because of seclusion from wider society were key awareness barriers. Competing priorities, such as work and housework, were the main affordability barriers. Mainstream religious leadership's support for vaccination was an enabler, although recent studies suggest their influence on vaccination behavior is decreasing and influence of anti-vaccination messages is growing.

Discussion

Barriers to vaccination among the UO were mainly logistical, with little religious framing. Safety and efficacy concerns were similar to those reported in the wider community. Decreasing influence of the traditionally pro-vaccine mainstream religious leadership and growing influence of anti-vaccination movements targeting the UO community are new phenomena that require close monitoring. Tailored interventions are required to protect the community and wider society against future VPD outbreaks.

Systematic review registration

PROSPERO: CRD42021273001.

Dynamic Trends in Sociodemographic Disparities and COVID-19 Morbidity and Mortality—A Nationwide Study during Two Years of a Pandemic

Social epidemiological research has documented that health outcomes, such as the risk of becoming diseased or dying, are closely tied to socioeconomic status. The aim of the current study was to investigate the impact of socioeconomic status on morbidity, hospitalization, and mortality outcomes throughout five waves of the pandemic amongst the Israeli population. A retrospective archive study was conducted in Israel from March 2020 to February 2022 in which data were obtained from the Israeli Ministry of Health’s (MOH) open COVID-19 database. Our findings, though requiring careful and cautious interpretation, indicate that the socioeconomic gradient patterns established in previous COVID-19 literature are not applicable to Israel throughout the five waves of the pandemic. The conclusions of this study indicate a much more dynamic and complex picture, where there is no single group that dominates the realm of improved outcomes or bears the burden of disease with respect to morbidity, hospitalization, and mortality. We show that health trends cannot necessarily be generalized to all countries and are very much dynamic and contingent on the socio-geographical context and must be thoroughly examined throughout distinct communities with consideration of the specific characteristics of the disease. Furthermore, the implications of this study include the importance of identifying the dynamic interplay and interactions of sociodemographic characteristics and health behavior in order to enhance efforts toward achieving improved health outcomes by policymakers and researchers.

Are Healthcare Workers Infected with SARS-CoV-2 at Home or at Work? A Comparative Prevalence Study

Prior to the widespread use of vaccinations, healthcare workers (HCWs) faced the double burden of caring for unprecedented numbers of critically ill COVID-19 patients while also facing the risk of becoming infected themselves either in healthcare facilities or at home. In order to assess whether SARS-CoV-2-positivity rates in HCWs reflected or differed from those in their residential areas, we compared the SARS-CoV-2-positivity rates during 2020 among HCWs in Hadassah Hebrew University Medical Centers (HHUMC), a tertiary medical center in Jerusalem, Israel, to those of the general population in Jerusalem, stratified by neighborhood. Additionally, we compared the demographic and professional parameters in every group. Four percent of the adult population (>18 years) in Jerusalem tested positive for SARS-CoV-2 during 2020 (24,529/605,426) compared to 7.1% of HHUMC HCWs (317/4470), rate ratio 1.75 (95% CI 1.57-1.95), with wide variability (range 0.38-25.0) among different neighborhoods. Of the 30 neighborhoods with more than 50 infected HCWs, 25 showed a higher positivity rate for HCWs compared to the general population. The higher risk of HCWs compared to residents representing the general population in most neighborhoods in Jerusalem may be explained by their behavior in and out of the hospital.

"We've all got the virus inside us now": Disaggregating public health relations and responsibilities for health protection in pandemic London

The COVID-19 pandemic has disproportionately impacted ethnic minorities in the global north, evidenced by higher rates of transmission, morbidity, and mortality relative to population sizes. Orthodox Jewish neighbourhoods in London had extremely high SARS-CoV-2 seroprevalence rates, reflecting patterns in Israel and the US. The aim of this paper is to examine how responsibilities over health protection are conveyed, and to what extent responsibility is sought by, and shared between, state services, and 'community' stakeholders or representative groups, and families in public health emergencies. The study investigates how public health and statutory services stakeholders, Orthodox Jewish communal custodians and households sought to enact health protection in London during the first year of the pandemic (March 2020-March 2021). Twenty-eight semi-structured interviews were conducted across these cohorts. Findings demonstrate that institutional relations - both their formation and at times fragmentation - were directly shaped by issues surrounding COVID-19 control measures. Exchanges around protective interventions (whether control measures, contact tracing technologies, or vaccines) reveal diverse and diverging attributions of responsibility and authority. The paper develops a framework of public health relations to understand negotiations between statutory services and minority groups over responsiveness and accountability in health protection. Disaggregating public health relations can help social scientists to critique who and what characterises institutional relationships with minority groups, and what ideas of responsibility and responsiveness are projected by differently-positioned stakeholders in health protection.

Poor Uptake of MMR Vaccine 1-year Post-Measles Outbreak: New York City and Israel

BACKGROUND

In 2018-2019, large outbreaks of measles occurred in Israel and in New York City, driven in part by travel of unimmunized children between the 2 communities.

METHODS

A retrospective chart review was conducted for children tested for measles (March 2018-September 2019) at NYU Langone Health in New York, NY, and in Ramla subdistrict, Israel. Vaccination records were reviewed to determine vaccination status for measles, mumps, and rubella (MMR) at the time of measles testing and 1-year post-testing.

RESULTS

A total of 264 children were tested for measles, and 102 (38.6%) had confirmed measles. Only 20 (19.6%) of measles-positive cases received a full 2-dose course of vitamin A. 82.4% of children with measles were ≥1 year at the time of diagnosis and fully eligible for MMR vaccine. Of the 100 measles-positive cases with available vaccine records, 63 were unvaccinated at testing, and 27 remained unimmunized against MMR 1 year later. At testing, measles-negative children were significantly more likely to have received MMR than measles-positive children (65.4% vs 37%, P < .01). One year later, 70.4% of measles-negative cases and only 57.1% of measles-positive cases had received MMR vaccine (P = .18).

CONCLUSIONS

The majority of measles cases occurred in unimmunized children eligible for vaccination, and >25% of children in both measles-positive and -negative groups remained unimmunized for MMR 1-year post-outbreak. Our results suggest the need for novel, longitudinal vaccination strategies and increased awareness of the role of vitamin A.

Is stronger religious faith associated with a greater willingness to take the COVID-19 vaccine? Evidence from Israel and Japan

Achieving high vaccination rates is important for overcoming an epidemic. This study investigates the association between religious faith and intentions to become vaccinated against COVID-19 in Israel and Japan. Most of Israel's population is monotheistic, whereas most Japanese are unaffiliated with any religion. Therefore, our findings might be applicable to various countries that differ in their religions and levels of religiosity. We conducted almost identical large-scale surveys four times in Israel and five times in Japan from March to June 2020 to obtain panel data. We found that intentions of getting vaccinated depend on people's level of religiosity in a non-linear way. Those who have strong religious beliefs are less likely to become vaccinated than those who say they are less religious. Two other factors that play a role in this relationship are religious denomination in Israel and identifying with a religion in Japan.

Trust in COVID-19 policy among public health professionals in Israel during the first wave of the pandemic: a cross-sectional study

BACKGROUND

The COVID-19 pandemic has highlighted the important role of professionals in designing and communicating effective policies. The purpose of this study was to evaluate the level of trust in the COVID-19 national public health policy among public health professionals in Israel and its correlates during the first wave of the pandemic.

METHODS

A purposive sampling of public health professionals in Israel, through professional and academic public health networks (N = 112). The survey was distributed online during May 2020. Level of trust was measured by the mean of 18 related statements using a 5-point Likert scale, where 1 means not at all and 5 means to a very high extent, and grouped as low and high trust by median (2.75).

RESULTS

A moderate level of trust in policy was found among professionals (Mean: 2.84, 95% Cl: [2.70, 2.98]). The level of trust among public health physicians was somewhat lower than among researchers and other health professionals (Mean: 2.66 vs. 2.81 and 2.96, respectively, p = 0.286), with a higher proportion expressing low trust (70% vs. 51% and 38%, respectively, p < 0.05). Participants with a low compared to high level of trust in policy were less supportive of the use of Israel Security Agency tools for contact tracing (Mean = 2.21 vs. 3.17, p < 0.01), and reported lower levels of trust in the Ministry of Health (Mean = 2.52 vs. 3.91, p < 0.01). A strong positive correlation was found between the level of trust in policy and the level of trust in the Ministry of Health (rs = 0.782, p < 0.01). Most professionals (77%) rated their involvement in decision making as low or not at all, and they reported a lower level of trust in policy than those with high involvement (Mean = 2.76 vs. 3.12, p < 0.05). Regarding trust in the ability of agencies to deal with the COVID-19 crisis, respondents reported high levels of trust in the Association of Public Health Physicians (80%) and in hospitals (79%), but very low levels of trust in the Minister of Health (5%).

CONCLUSIONS

This study shows that Israeli public health professionals exhibited moderate levels of trust in COVID-19 national public health policy and varied levels of trust in government agencies during the first wave of COVID-19. The level of trust in policy was lower among most of the participants who were not involved in decision making. The level of trust found is worrisome and should be monitored, because it may harm cooperation, professional response, and public trust. Professionals' trust in policy-making during early stages of emergencies is important, and preemptive measures should be considered, such as involving professionals in the decision-making process, maintaining transparency of the process, and basing policy on scientific and epidemiological evidence.

Viral Entanglements: Bodies, Belonging and Truth-claims in Health Borderlands

This article contributes to anthropological debates surrounding borderlands and biosecurity by tracing the multiple pursuits of protection that emerge between the state and minorities during infectious disease outbreaks. Drawing on an ethnographic study of child health in Jerusalem following epidemics of measles and COVID-19, the article demonstrates how responses to public health interventions are less about compliance or indiscipline than a competing pursuit of immunity to preserve religious lifeworlds. The voices of Orthodox Jews are situated alongside printed broadsides that circulated anonymous truth-claims in Jerusalem neighborhoods. These broadsides cast state intervention against historical narratives of deception and ethical failures. Borderland tensions, like a virus, mutate and influence responses to authority and biosecurity, and they reconfigure vernacular entanglements of religion, state, and health. The article encourages anthropologists to consider responses to public health interventions and non-vaccination beyond a COVID-19 silo, as part of situated relations between states and minority populations.

Promoting a Culturally Adapted Policy to Deal with the COVID-19 Crisis in the Haredi Population in Israel

COVID-19 has caused high morbidity and mortality in Israel but, as in other countries, not all groups were equally affected. Haredi Jews (often called ultra-Orthodox), a religious minority, were disproportionately harmed by the pandemic. This group has distinctive cultural, lifestyle, and demographic characteristics, which may be related to these higher COVID-19 rates and call for policies specifically adapted for this community. This paper describes in detail the steps the Israeli Ministry of Health (MoH) took to try to improve the quality of care and prevent morbidity in the Haredi population through working in cooperation with the leadership and members of the Haredi community and strengthening mutual trust in order to increase adherence to government regulations and recommendations. This case study is based on the unique perspective of the two people who worked in the Israeli MoH and led the initiative as well as a review of relevant government documents and statistics. It discusses to what extent the initiative seemed to have been successful and what lessons can be learned not only for Haredim but for other religious and/or minority groups and closed communities in Israel and elsewhere.

"If a rabbi did say 'you have to vaccinate,' we wouldn't": Unveiling the secular logics of religious exemption and opposition to vaccination

Maintaining 'faith' in vaccination has emerged as a public health challenge amidst outbreaks of preventable disease among religious minorities and rising claims to 'exemption' from vaccine mandates. Outbreaks of measles and coronavirus have been particularly acute among Orthodox Jewish neighbourhoods in North America, Europe and Israel, yet no comparative studies have been conducted to discern the shared and situated influences on vaccine decision-making. This paper synthesises qualitative research into vaccine decision-making among Orthodox Jews in the United Kingdom and Israel during the 2014-15 and 2018-19 measles epidemics, and 2020-21 coronavirus pandemic. The methods integrate 66 semi-structured informal interviews conducted with parents, formal and informal healthcare practitioners, and religious leaders, as well as analysis of tailored non-vaccination advocacy events and literature. The paper argues that the discourse of 'religious' exemption and opposition to vaccination obscures the diverse practices and philosophies that inform vaccine decisions, and how religious law and leaders form a contingent influence. Rather than viewing religion as the primary framework through which vaccine decisions are made, Orthodox Jewish parents were more concerned with safety, trust and choice in similar ways to 'secular' logics of non-vaccination. Yet, religious frameworks were mobilised, and at times politicised, to suit medico-legal discourse of 'exemption' from coercive or mandatory vaccine policies. By conceptualising tensions around protection as 'political immunities,' the paper offers a model to inform social science understandings of how health, law and religion intersect in contemporary vaccine opposition.