On 4 August, a 22-year-old male tourist from London presented at a hospital in Jerusalem, Israel with general malaise, a high fever and a blotchy maculopapular rash over his face trunk and limbs, including palms and soles. A junior health officer recommended hospitalisation, which the patient refused, partly as a result of there being no definitive diagnosis. Later the same day, the patient visited a private urgent care centre in Jerusalem. Although there was an absence of typical symptoms seen in the early stages of measles, such as Kopliks’ spots, dry cough and conjunctivitis, the physician in the centre suspected measles. He had seen very few cases of measles previously, but as the staff of the clinic are kept informed of infectious disease outbreaks globally by the focused use of Google Health News installed on desktops at the clinic, he was aware of recent outbreaks of measles in parts of the United Kingdom (UK), including London, which had been reported in the British media [1,2]. This, coupled with the patient’s rash and his other symptoms, led to a suspicion of measles, which the man had not been vaccinated against due to adverse reaction in a sibling.

On 7 August, measles was laboratory-confirmed in the Central Virology Laboratory of the Ministry of Health at Tel Hashomer (Sheba Medical Center): serology was strongly positive for rubeola (measles) antibodies (IgM). The virus genotype responsible for the outbreak was D4, the same genotype prevalent in the ongoing outbreak in the United Kingdom [3]. The test was organised by the Public Health Services of the Ministry of Health, to which the suspected case was reported – measles is a notifiable disease in Israel. The patient’s history revealed earlier oral lesions and conjunctivitis. He could not indicate the source of infection, but recalled having visited his General Practitioner in London several weeks earlier, where another patient in the waiting room may have had a rash.

Upon admission, our patient was isolated in a separate room and treated for malaise, fever, cervical lymphadenopathy and dehydration. Intravenous fluids were given daily over a four-day period. He recovered and was discharged two weeks after admission. His eight-month old son was given gamma globulin, while the rest of his household was contacted by the Jerusalem branch of the Ministry of Health and vaccinated where necessary.

On 1 August, the patient had attended a wedding in Jerusalem with an estimated 2,000 guests, almost all of whom were members of the Toldot Aharon (literally ‘generations of Aaron’), also known as the Satmar, an ultra-orthodox Jewish movement with sizeable communities in the United Kingdom (UK), the United States, Belgium, Switzerland, Argentina and Israel. Globally, there are thought to be around 20,000 members of this movement. Guests at the wedding came from Israel, Europe and the United States. Considering the incubation period of measles (10-12 days), these people may have been exposed.

The last cases of measles in the Jerusalem district were in November 2004, following an outbreak that originated in a kindergarten in the ultra-orthodox community. The genotype responsible was D4. There was also an outbreak in the ultra-orthodox community in Jerusalem in 2003, with the index case being a two-year-old unvaccinated child, and 107 cases reported within three months [4]. That outbreak was caused by the D8 genotype, and is thought to have been imported from Switzerland, where there had been a large outbreak involving genotypes D8 and D5 [4,5]. Following these outbreaks, outreach programmes were launched to raise immunisation coverage and achieve herd immunity in the ultra-orthodox communities involved. Taking the success of those campaigns into account, it was not considered necessary to trace all 2,000 guests who attended the wedding on 1 August.

Since August 2007, there have been approximately 50 cases of measles in Israel, the majority of which have been serologically confirmed. Most cases have been concentrated around the Jerusalem area, with almost all patients from the ultra-orthodox community. In the third week of August, a member of the nursing staff at a private urgent care centre in Modiin, 35 kilometres outside Jerusalem, developed measles. Due to comprehensive computerised records of visits to these centres, all contacts were traced within hours of the request by the Ministry of Health, and all those at risk were recalled for measles, mumps and rubella (MMR) immunisation. A three-year-old girl who was hospitalised in Jerusalem in mid-August with measles encephalitis was also ultra-orthodox and non-immunised, but she was neither a tourist nor from the Satmar community. Her contact was traced back to an ultra-orthodox un-immunised child who had travelled from London (with her parents) to a different wedding in Jerusalem that took place earlier in the summer. The three-year-old was treated in an Intensive Care Unit for a few days and appears to have made a full recovery. Two more children were reported to have been hospitalised on 16 September [6], meaning that the infection is now in its third generation, as every two weeks those in contact with an infected person can themselves become infected.

Routine measles immunisation was introduced in Israel in 1967, and a two-dose schedule for the MMR vaccine at the ages of 12 months and 6 years was introduced in 1994 [7]. Israel’s Ministry of Health has estimated that coverage for MMR in the ultra-orthodox community is between 60 and 70% [Y. Amitai, personal communication]. It is likely to be lower in the Satmar, a group who are known not to officially recognise state institutions. Nationally, an estimated 94-95% of the general non-ultra-orthodox population take up the first dose of the MMR vaccine according to Ministry of Health recommendations, and the coverage for the second dose is 95-97% [8].

There is no religious reason for Jews not to vaccinate against disease – in fact, Judaism obliges its followers to prevent illness in themselves and others. The Oral Law specifically states that ‘All of Israel is responsible one for the other’ (Shavuot 39a, Sotah 37a, Rosh Hashanah 29a), the clear message being that one should not rely on others to immunise in order to enjoy herd immunity.

Like most Hassidic sects, the Satmarim are exceedingly disciplined, and the hierarchal structure of the movement can be very successful at motivating large groups of people to one course of action. If the elimination of measles in the World Health Organization European Region by 2010 is to remain a realistic goal, more work will have to be done in future to understand the social structure and establish lines of communication with the key contact points of this and other hard-to-reach communities.

Acknowledgements
We acknowledge the kind assistance of Dr Nitza Abramson, Ministry of Health, Jerusalem; Dr Zahava Grossman, Dept, Virology, Tel Hashomer; Dr Yair Aboudi, Dept Virology, Tel Hashomer; Prof E Mendelson, Head of Virology, Tel Hashomer