Morbidity and Mortality Weekly Report

* A newborn infant tested positive for measles following birth to a mother who
Notes from the Field had measles during pregnancy.
had measles immunity rates of <95% as documented by 2
Measles Outbreaks from Imported Cases in valid doses of measles-mumps-rubella vaccine (MMR) or
serologic evidence of immunity. To provide opportunities for
Orthodox Jewish Communities — New York and vaccination, approximately 20 community vaccination events
New Jersey, 2018–2019 open to all ages were held in Rockland County and two in
Robert McDonald, MD1,2; Patricia Schnabel Ruppert, DO3; Maria Souto,
Orange County.
MPH3; Dylan E. Johns, MS2; Kevin McKay, MPH3; Noelle Bessette,
MPH4; Lissette X. McNulty5; Jennifer E. Crawford, MPH6; Patrick During October 1, 2018–April 30, 2019, Rockland County
Bryant, PhD7; Maria Cecilia Mosquera, MD3; Sonya Frontin, MPH8; administered 19,661 MMR doses. NYSDOH, RCDOH, and
Tatiana Deluna-Evans3; Daniel E. Regenye, MHA6; Elizabeth F. Zaremski, private medical providers held nine informational events and
MPH4; Vanessa J. Landis, MPH8; Bonnie Sullivan3; Brian E. Rumpf, JD6; distributed educational materials focused on measles
Judi Doherty3; Kathryn Sen2; Eric Adler, MPH4; Lisa DiFedele, MPH4; prevention to 45,000 homes. A culturally appropriate and
Stephanie Ostrowski, PhD2; Christine Compton, MD2; Elizabeth Rausch- detailed vaccine education book was distributed to 15,000
Phung, MD2; Irina Gelman, DPM5; Barbara Montana, MD4; Debra Blog,
MD2; Bradley J. Hutton, MPH2; Howard A. Zucker, MD2
Rockland County and 10,000 Orange County homes and
medical providers. Orthodox Jewish leaders were engaged in
On October 1, 2018, the Rockland County (New York) the outbreak response, with rabbinical leaders supporting
Department of Health (RCDOH) alerted the New York State vaccination efforts and community groups advocating for
Department of Health (NYSDOH) of an unvaccinated vaccination. As of April 30, 2019, transmission was ongoing.
teenaged traveler with diagnosed measles. During the next 17 This has been the largest measles outbreak in New York
days, RCDOH learned of an additional six unvaccinated (outside New York City) since 1992 and, at 7 months, the
travelers with measles. On October 24, 2018, the Ocean longest documented outbreak in the United States since
County (New Jersey) Health Department alerted the New endemic measles was eliminated in 2000 (2).
Jersey Department of Health (NJDOH) of a case of measles
in an international traveler, with rash onset October 17. The New Jersey
unvaccinated travelers reported recent travel in Israel, where During October 17–November 30, 2018, 33 measles cases
an outbreak of approximately 3,150 cases of measles is were confirmed in New Jersey, primarily in members of the
ongoing (1). Investigations during October 1, 2018–April 30, orthodox Jewish community in Ocean County. The median
2019, identified 242 laboratory-confirmed and patient age was 10 years (range = 6 months–59 years). In
epidemiologically linked measles cases in New York, Ocean County, unvaccinated students were excluded from
excluding New York City, and during October 17, 2018– school for 21 days after a measles exposure. Some private
November 30, 2018, identified 33 in New Jersey (Figure). The schools excluded unvaccinated students for the duration of
cases of measles were primarily in members of orthodox the New Jersey outbreak. NJDOH worked with local health
Jewish communities. officials and providers to facilitate delivery of >12,500
outbreak response doses of MMR vaccine to Ocean County
New York medical providers. This outbreak was declared over on
The 242 cases in New York (excluding New York City) January 16, 2019. A second outbreak occurred in the same
included 206 in Rockland County and 36 in nearby counties. community in March 2019, with no identified connection to
Most patients resided in orthodox Jewish neighborhoods with the first outbreak.
low school immunization rates. The median patient age was 5 In the New York outbreak, low community vaccination
years (range = 0 days* to 63 years). The 2017–2018 New York rates facilitated widespread measles transmission after
State School Immunization Survey measles vaccination rate introduction of imported measles in unvaccinated travelers.
for students in prekindergarten through grade 12 was 98%; Educational efforts regarding risks associated with
however, documented measles vaccination coverage in undervaccination should be increased in communities with
schools in the outbreak area was only 77%. To prevent disease low vaccination rates. Health departments and clinicians
spread in schools, Rockland County and neighboring Orange should be aware of multiple ongoing measles outbreaks
County have excluded unvaccinated students from school for globally, and travelers should have evidence of measles
21 days after a measles exposure. To further control spread immunity.† All U.S. communities should
after school exposures, in areas of Rockland County with
measles cases, exclusions from school were expanded to
include all nonimmune students at schools that

444 MMWR / May 17, 2019 / Vol. 68 / No. 19 US Department of Health and Human Services/Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
FIGURE. Number of measles cases, by date of rash onset — New York (n = 242)* October 1, 2018–April 30, 2019, and New Jersey (n = 33)
October 17, 2018–November 30, 2018

* Excludes New York City. All authors have completed and submitted the ICMJE form for
disclosure of potential conflicts of interest. No potential conflicts of
maintain ≥95% levels of age-appropriate vaccination interest were disclosed.
coverage with 2 doses of MMR vaccine to ensure herd
immunity (3). References
1. State of Israel Ministry of Health. Measles. Jerusalem, Israel: State of
Acknowledgments Israel Ministry of Health; 2019.
https://www.health.gov.il/English/Topics/
Chanie Sternberg, Corinna Manini, Michael Kaplan, Refuah
Pregnancy/Vaccination_of_infants/Pages/measles.aspx
Health Center; Michael Gronostaj, CDC.
2. Gastañaduy PA, Budd J, Fisher N, et al. A measles outbreak in an
Corresponding author: Robert McDonald, [email protected], 518-402-5901. underimmunized Amish community in Ohio. N Engl J Med
2016;375:1343–54. https://doi.org/10.1056/NEJMoa1602295
1Epidemic Intelligence Service, CDC; 2New York State Department of Health; 3. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS; CDC. Prevention
3Rockland County Department of Health, New York; 4New Jersey of measles, rubella, congenital rubella syndrome, and mumps, 2013:
Department of Health; 5Orange County Department of Health, New York; summary recommendations of the Advisory Committee on
6Ocean County Health Department, Toms River, New Jersey; 7New York Immunization Practices (ACIP). MMWR Recomm Rep 2013;62(No.
State Department of Health, Wadsworth Center; 8Metropolitan Area RR-04).
Regional Office, New York State Department of Health.
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