A Nursing Approach to the Largest Measles Outbreak in Recent U.S. History

Lessons Learned Battling Homegrown Vaccine Hesitancy

Blima Marcus, DNP, RN, ANP-BC, OCN


Online J Issues Nurs. 2020;25(2) 

In This Article


Trends in Hesitancy

Vaccination rates have been dropping in developed countries. Outbreaks of preventable infectious diseases are increasing, and the rise of anti-vaccination movements is thought to be a major contributing factor to these outbreak clusters. Vaccine hesitancy (VH) is defined by the World Health Organization as "the reluctance or refusal to vaccinate despite the availability of vaccines" (2019, Vaccine Hesitancy section, para. 1). It has been listed by the WHO as one of the top ten threats to global health (WHO, 2019).

Fears related to vaccine safety, vaccine side effects, and perceived associations between vaccines and neurodevelopmental disorders drive fears of vaccines and induce parents to reject vaccination for their children. Studies have demonstrated that in counties in the United States with higher rates of vaccine exemptions (either religious, medical, or personal belief), clusters of vaccine-preventable illnesses rise (Imdad et al., 2013). Other barriers to vaccination include lack of access to immunizations, inconvenience and time constraints, and perceived barriers by parents who believe that vaccines are not covered by insurance (Hendriksz, Malouf, Sarmiento, & Foy, 2013).

2019 Measles Outbreak

The recent measles outbreak of 2018–2019 in the United States occurred primarily in New York State. The disease was brought into the country by an unimmunized international traveler, and as of this publication, over 1,200 cases have been reported to the local and national health departments, with 119 hospitalizations (CDC, 2019).

The epicenters of this outbreak were the ultra-Orthodox Jewish communities in Brooklyn, New York, and in Rockland County, a large religious enclave in northern New York State. Orthodox Jews make up approximately 500,000 people in an 8-county New York area (UJA Federation, 2015), and Rockland County has the largest Jewish population per capita of any U.S. county, with 31.4%, or 90,000 residents, being Jewish (Official Website of NY, n.d.). The median patient age was 5 years, and the measles vaccination coverage in schools in the outbreak area was only 77%, well below the threshold needed to maintain herd immunity (Mcdonald et al., 2019). An active anti-vaccine movement within the community, and widespread vaccine misinformation are thought to have been key contributors to decreased vaccination rates and the outbreak.

The purpose of this article is to describe the concern that vaccine hesitancy presents and provide evidence-based, recommended steps to combat this public health problem. The article also describes the grassroots effort led by a local group of nurses in their battle to address vaccine hesitancy and misinformation in their Orthodox Jewish community. Healthcare providers interested in providing vaccine education and correcting misinformation will find answers to common vaccine concerns, and receive communication tips, tools, and other recommended methods to address vaccine hesitancy.