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

Vaccine Hesitancy


Vaccines have been so successful at eradicating and reducing illness that many parents are now complacent and unfamiliar with the risk conferred by vaccine-preventable diseases (Calandrillo, 2003). Misinformation about vaccine safety is prevalent on the internet and on social media. Healthcare professionals and evidence-based information are replaced with volunteers without a medical background who devote their time to study an issue in depth, known as "citizen scientists" (Consortium for Science, Policy and Outcomes, 2019). However, lack of medical education reflects a poor understanding of immunology, pharmacology, research methodology, and pathophysiology, leading these volunteer researchers to erroneous conclusions. Personal anecdotes shared by parents who blame vaccines for developmental delays or illnesses are shared and viewed thousands of times. Concerns about vaccine safety, insufficient time to discuss these concerns during short clinic visits, and inadequate responses from pediatricians further contribute to rising vaccine hesitancy (McKee & Bohannon, 2016).

Significance of the Problem

As many as 1 in 5 people believe that there is a link between vaccines and autism. As many as 1 in 5 people believe that there is a link between vaccines and autism (Public Policy Polling, 2013). In 2006, a study by the American Academy of Pediatrics (AAP) found that 75% of pediatricians had encountered vaccine hesitant parents, and by 2013 this figure had increased to 87% (AAP, 2006; Hough-Telford et al., 2016). The providers in these surveys reported that the percentage of parents who refused one or more vaccines increased from 9.1% to 16.7% during this time.

Vulnerable Communities

Over 75% of the recent outbreaks of vaccine-preventable illnesses have occurred in isolated, vulnerable communities (Reddy, 2019). Often, these communities have been targeted by anti-vaccine activists, who sense that communities with knowledge deficits, language barriers, or cultural barriers may be easily infiltrated by anti-vaccine sentiment. After concerted efforts by anti-vaccine activists to undermine faith in vaccines, measles vaccination in Somali communities in Minnesota dropped from 92% in 1994 to 42% in 2014 (Dyer, 2017). In 2010 and 2011, two talks were given in the Somali community by anti-vaccine advocate and former physician Andrew Wakefield (Dyer), and in 2017 the community experienced the biggest measles outbreak in 30 years (Branswell, 2017).

In these cases, traditional methods of reaching the community, by circulating educational videos or handouts, failed. The Minnesota Department of Health learned that the community members wanted to receive information from trusted community sources. Community approaches were initiated with great success. Somali healthcare workers were hired, and small conversations and talks were hosted throughout the communities. Imams began endorsing vaccinations, and suspicion of vaccines slowly decreased (Vaccine Confidence Project, 2016).

In 2014, a measles outbreak occurred in the Amish community in Ohio. It was noted at the time that the immunization rate for the measles, mumps, and rubella (MMR) vaccine in the community was only 88% (Gastañaduy et al., 2016). The World Health Organization recommends community vaccination levels of greater than 95% (Funk, 2017). This undervaccination led to the spread of the measles after two unimmunized individuals returned from the Philippines, causing 178 cases. Again, public health officials involved the local health department, who had established relationships with the community and included bishops and local community members in their efforts to curtail the outbreak (Gastañaduy et al., 2016).

The Role of Pediatric Health Providers

The burden of speaking with vaccine hesitant parents falls primarily on pediatric health providers. One study found that nearly 80% of parents confirmed that their decision to vaccinate was primarily influenced by their provider (Taylor et al., 1997). A more recent study found that a "well-informed pediatrician who effectively addresses parental concerns and strongly supports the benefits of vaccination has enormous influence on parental vaccine acceptance" (Smith, Kennedy, Wooten, Gust, & Pickering, 2006, p. e7). Common barriers to discussions about vaccine safety with concerned parents include time constraints as well as providers' inadequate knowledge about vaccine science and safety. In one study which evaluated how providers (n = 696) communicate with vaccine hesitant parents, 53% of physicians reported spending 10–19 minutes in conversation (Kempe et al., 2011). However, in a telephone survey of 2,000 parents, 70% of parents reported that most child well-visits took under 20 minutes (Halfon, Stevens, Larson, & Olson, 2011). It becomes difficult for pediatric providers to do a comprehensive physical exam, discuss developmental milestones, give vaccines that are due, and have extensive conversations with parents regarding vaccine safety.

Outbreak Causes in New York Orthodox Jewish Community

A Jewish anti-vaccine activist group was identified as the source of myriad instances of misinformation that have slowly spread throughout the Orthodox Jewish community in the form of print magazines and telephone conferences (Pager, 2019). In order to maintain a religious and cultural lifestyle, the ultra-Orthodox Jewish community practices solitary, insular living and rejects modern influences, including secular media. Community magazines, circulars, and dial-in telephone conferences are a common source of "kosher" information for many members. Since 2014, anti-vaccination magazines and dial-in telephone conferences have emerged in the community, rife with misinformation, false experts, and emotional anecdotes (Schaffer, 2019a). These sources of anti-vaccine rhetoric went unchallenged for many years. Left without access to evidence-based information, it is not surprising that vaccination rates in these neighborhoods dropped and that these communities saw a rise in vaccine hesitancy. Large families, insular lifestyles, and low immunization rates primed this community for an outbreak.

Orthodox Jewish Community Response

There were several responses by Orthodox leadership to the growing measles outbreak in the New York communities. Orthodox Jewish physicians, alarmed at the rising number of cases, implored their communities to follow the scientific evidence and help contain the outbreak. Five hundred community physicians signed a letter, distributed to the entire community, asking parents to vaccinate their children (Oster, 2019). Orthodox politicians, from the city to the state level, exhorted their constituents to vaccinate their families (The Yeshiva World, 2019). Hatzalah, a volunteer emergency medical service organization serving mostly Jewish communities, held MMR vaccine drives and placed ads in local circulars, endorsing vaccination (Maimonides Medical Center, 2019). Der Yid, a Yiddish-only language newspaper with a circulation of over 50,000 took the rare step of printing a full-page editorial in English, denouncing community members who do not vaccinate, citing religious mandates to vaccinate children (Der Yid, 2019).