I thought is was because there are enough people not vaccinated for a
reservoir to exist to re infect.
That is why there is a critical number or percentage and why the bad press
of the multiple vaccination system harmed the program.
Brian

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Scientists Thought They Had Measles Cornered. They Were Wrong.
Following intensive vaccination efforts, measles cases plunged across the
world. Now clusters of new infections - some linked, some not - have
confounded health officials.
By Donald G. McNeil Jr., April 3, 2019, NY Times

The measles outbreak that led to a state of emergency in New York's Rockland
County began far away: in an annual Hasidic pilgrimage from Israel to
Ukraine.

It is emblematic of a series of fierce, sometimes connected measles
outbreaks - in places as diverse as Indonesia, the Philippines, Madagascar
and Venezuela - that have shaken global health officials, revealing
persistent shortcomings in the world's vaccination efforts and threatening
to tarnish what had been a signature public health achievement.

In 2001, the United Nations declared war on measles. With help from the
federal government, the American Red Cross and big donors like Ted Turner
and Bill and Melinda Gates, the U.N. began the Measles and Rubella
Initiative and created Gavi, the Vaccine Alliance.

Together, they poured billions of dollars into buying vaccines and helping
countries deliver it safely, which meant building refrigerated storage
facilities, supplying clean needles, training vaccinators and countering
other logistical obstacles common in poor countries.

Public health officials worldwide tracked the results, monitoring cases and
tracking outbreaks. The news was good: Measles declined worldwide by nearly
80 percent between 2000 and 2016, with fatalities - mostly among children
younger than age 5 - plummeting to about 90,000 per year from about 550,000.

But two years ago, measles cases unexpectedly popped upward again, rising 30
percent in a single year. The virus re-invaded countries where it had been
vanquished.

The biggest factor in that increase, World Health Organization officials
said, was poverty: Medical systems in many countries remain too weak to
vaccinate enough children year after year to wall out the virus.

To stop imported cases from spreading, about 95 percent of a country's
citizens must be immune, either through vaccination or because they had
measles as children. As babies are born, new pools of potential victims are
created - unless vaccination is constant.

Anti-vaccine activists, false rumors and serious missteps by some vaccine
companies have all contributed to the global rebound. Jet travel has fueled
the spread, as it has with viruses like MERS and Zika.

So have "diaspora networks," said Dr. Heidi J. Larson, director of the
Vaccine Confidence Project at the London School of Hygiene and Tropical
Medicine - people connected by culture around the world who share beliefs,
and sometimes pathogens.

Israel's measles outbreak began in March 2018, apparently in a small
Orthodox community in Tzfat, in the north, said Dr. Patrick M. O'Connor,
leader of the rapid disease control team at the W.H.O.'s European office,
which oversees Israel.

Resistance to vaccines was not the reason. Orthodox rabbis "have no issue
with vaccination - it's seen as a lifesaving good," Dr. O'Connor said. And
Israel's chief health officer, Yaakov Litzman, is an Orthodox rabbi who grew
up in Brooklyn; his ministry provides vaccines free.

"But there is a mismatch between Israel's health system and the population
it's supposed to serve," Dr. O'Connor added.

The clinics offering vaccines were often not open on convenient days or
couldn't accommodate big groups. Orthodox families may include up to a dozen
children, and ensuring that all have had two measles shots on schedule can
be difficult.

(To comply with Israel's health ministry schedule, a child needs nine doctor's
appointments before age 6 to be fully vaccinated against 14 diseases.
Children get measles shots at ages 1 and 6.)

Vaccination rates among the Orthodox in Israel were in the 80 percent
range - better than in many other countries, but not enough to stop measles.
Another contributing factor: Even if they are sick, children are often
brought to Orthodox weddings or other gatherings.

At first, the virus moved slowly through Orthodox communities in Jerusalem
and Tel Aviv. Then in September, Dr. O'Connor said, a major outbreak in
Ukraine supercharged Israel's modest one - and probably led, indirectly, to
outbreaks in Britain and in the United States.

The Ukraine connection

Ukraine is suffering through a measles outbreak that began in 2017. The
country has had almost 70,000 cases - more than any other country in recent
years.

The infections have not been confined to a particular ethnic group. The
country is at war with pro-Russian separatists on its eastern border,
distrust in government is high, and rumors about vaccines are rife - one of
which began when a 17-year-old died of unrelated causes after getting a
shot.

The Ukrainian government also rejected cheaper Indian and Korean vaccines in
favor of European ones, but they cost more than the government could afford,
Dr. Larson said.

But the real problem appears to have begun at Rosh Hashana.

Each year on the holiday, tens of thousands of Orthodox men travel to Uman,
a Ukrainian city where the grave of Rabbi Nachman of Breslov, founder of one
branch of Hasidism, has become a popular pilgrimage site. (The festivities
have been called the "Hasidic Burning Man.")

Last year, Rosh Hashana fell in early September. Later that month, measles
cases exploded in Israel, rising to a peak of 949 in October. The cause?
Numerous pilgrims came back from Ukraine with the virus, experts believe.

New York's outbreak began in October; the first patient was a child in the
Bensonhurst section of Brooklyn who had visited Israel. At the same time, a
measles outbreak began among Orthodox Jews in London.

The Israeli government responded rapidly, recruiting Orthodox Jews onto
vaccine advisory groups and sending mobile clinics into their neighborhoods.

"Coverage improved immensely, and the numbers are getting smaller," Dr. O'Connor
said.

Orthodox Jews in Britain and the United States also have big families and
may struggle to keep everyone vaccinated. But vaccine skepticism is more
common in the United States than in Israel and much more common in Britain.

The false rumor that measles vaccines cause autism was started in 1998 by
Andrew Wakefield, a British doctor whose medical license was later revoked.

Many outbreaks, many triggers

Several other measles outbreaks are crisscrossing the globe. They follow
similar patterns but have unique triggers and pose individual public health
challenges.

Many countries are having outbreaks bigger than Israel's. Madagascar has
seen 66,000 cases of measles, with more than 900 dead. India has had 63,000
cases; Pakistan, 31,000; Yemen, 12,000; Brazil, 10,000; and Venezuela,
5,700.

Most of these countries have chronically low vaccination rates. But some are
worsened by unique constellations of challenges.

Yemen is in the middle of a civil war. Venezuela's medical system has broken
down; part of Brazil's outbreak is in refugees from Venezuela.

Madagascar is one of the world's poorest countries. It is an island with a
high birthrate, and there had been no measles outbreak since 2003, so it had
a huge pool of susceptible children and teenagers. And many of those
children are dangerously malnourished.

In wealthy countries, measles kills about one in every 1,000 victims. But
when children are malnourished, and when they cannot get hospital care for
complications like pneumonia or encephalitis, measles can kill one in 10
children, sometimes even more in refugee camps, said Dr. Katrina Kretsinger,
a W.H.O. medical officer.

Since 2000, when the United States eliminated domestic measles, all cases
here have come from overseas. In the early 2000s, most arrived from Japan,
where the government had made measles shots voluntary after a locally made
vaccine was blamed for cases of meningitis.

In 2011, American tourists brought back 13 cases from a major outbreak in
France. An outbreak in North Carolina in 2013 originated in India.
Most recently, a long-lasting measles epidemic in the Philippines caused an
outbreak in Amish communities in Ohio in 2014, started by a returning
missionary, and the infamous 2015 "Disneyland outbreak," which led
California to tighten its vaccine laws.

The Philippines has long had difficulty vaccinating its people, said
Katherine O'Brien, the W.H.O.'s director of immunization.

The country has a population of 100 million spread out over more than 2,000
islands. Its health care system is decentralized, inept in places and bad at
tracking children's medical records. Some islands have armed conflicts.

The risks of an outbreak were compounded in 2017, when the rollout of the
world's first promising dengue vaccine backfired spectacularly.

The vaccine, Dengvaxia, was withdrawn after evidence emerged that it had the
same sinister drawback as the dengue virus itself: The vaccine appeared to
make a second infection more deadly.

Angry Filipinos rebelled against all vaccines; vaccination rates fell to 60
percent, the country's health ministry said.
Something similar happened there in the early 1990s, said Dr. Larson of the
Vaccine Confidence Project.

A conservative Catholic group heard that a new injectable contraceptive
would include a protein used in tetanus vaccine. Misunderstanding the
science, the group spread the alarm that tetanus vaccine was secretly a
birth-control method.

The mayor of Manila banned the vaccine, and the rumor spread through
Catholic anti-abortion networks as far as East Africa and South America.
Ultimately, the W.H.O. had to ask the Vatican to intervene and say the
vaccine was safe.

The next country in line for an epidemic that could spread to the United
States, Dr. Larson predicted, is Poland.

It was the lowest-ranked European Union country on her organization's recent
"vaccine confidence survey." Respondents are asked, for example, whether
they feel vaccines are safe, effective and compatible with their religious
beliefs.

Poland has a vocal anti-vaccine movement called "Stop Nop," and its
immunization rates have dropped steadily since 2010. And, Dr. Larson noted,
Poland has many Ukrainian refugees, any one of whom could import the virus.

Poles in Scotland are already echoing attitudes in their homeland, she said.

"I would not be surprised if the negative sentiment and consequent vaccine
refusal spread to the Polish communities in the U.S."

https://www.nytimes.com/2019/04/03/h...ne-israel.html