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

The EMES Initiative

Alongside these efforts, a local group of Orthodox Jewish nurses felt the need to address the broad misinformation they were encountering in their own communities (Hogan, 2019; Zaltzman, 2019). We formed the Engaging in Medical Education with Sensitivity (EMES) Initiative, a non-profit organization dedicated to bringing evidence-based health information to the Orthodox Jewish community in a culturally-sensitive manner. In Hebrew, "Emes" means truth/honesty. We determined that our first project would be vaccine education, and the Vaccine Task Force was formed.

Our nurses held extensive conversations with community members about concerns related to vaccine safety and their relationships with their pediatricians. We determined that lack of access to evidence-based information, and to providers with the time to review their concerns, were the primary reasons that these parents withheld immunizations for their children. In seeking to rectify these gaps, members of the initiative launched a flexible, multipronged approach: (1) providing evidence directly to parents about vaccine safety and vaccine-preventable diseases via several methods; (2) teaching parents how to discern information from misinformation, including how to read studies and evaluate data; (3) hosting workshops for providers to improve communication with patients, and to provide quick answers to common vaccine myths; and (4) acquiring buy-in from, and offering training to, para-health professionals, such as doulas, therapists, emergency medical technicians (EMTs), and others interested in learning how to combat anti-vaccine misinformation.

EMES chose a fluid approach, depending on the requests and needs of the Orthodox Jewish community in New York. This fluidity was necessary as we engaged in two-way feedback about what would be most helpful to this community. EMES incorporated direct parent and healthcare provider education, print materials, confidential and personal "one-on-one" communication, vaccine fairs, and living room workshops to address vaccine hesitancy in this community.

Parent Education

Several dozen nurses on our team researched and created content to use for educating the Orthodox community about vaccine safety and the importance of immunization. We understood that mistrust of the government, the pharmaceutical industry, and occasionally of the entire medical industry, leads vaccine hesitant parents to reject information from these entities. Therefore, we went to the original sources, using studies and data from scientists who are neither affiliated with pharmaceutical industries, nor with anti-vaccine movements.

All material was written at an 8th grade reading level, and citations were included for every statement. Topics included: how the immune system works; how vaccines work; trends in vaccine-preventable illness; and the risks of not vaccinating. Common concerns about vaccines were addressed and rebutted using data and charts. Side-by-side comparisons were made of gross yearly earnings of the alternative health sector and those from vaccines in the pharmaceutical industry. Flu shot development, hepatitis B seroconversion, autism and its history of diagnostic changes, and many more topics were included in our materials.

Print Materials. This information was woven into an evidence-based magazine, called PIE (Parents Informed and Educated) This was a tongue-in-cheek rebuttal to the anti-vaccine propaganda booklet which circulated in our communities, which is titled PEACH, or Parents Educated and Advocating for our Children's Health. In April, as the outbreak grew, the New York City Department of Health and Mental Hygiene (NYCDOHMH) asked our organization to prepare an abridged version of our magazine for rapid distribution. To date, close to 100,000 copies of our abridged magazine have been mailed and distributed around the United States.

Living-room Workshops. To allow an interactive format, we hosted in-person workshops for mothers in the community. We created electronic presentations geared to parents, and nurses presented the slideshow in intimate "living-room" settings in different communities (Schaffer, 2019b). These took place in actual living rooms and school classrooms. This ensured that groups remained small and allowed for honest dialogue and questions.

We brought several dozen studies with us to every session, which allowed us to review the data in person and provide visual aids. Follow up conversations demonstrated that women appreciated the opportunity to ask questions and learn about vaccine safety. Many women reported new interest in vaccinating their children. One woman took her four children for their first MMR that week, and another mother stated that while her children had been on a delayed vaccine schedule, she now planned for all of them to catch up on the required vaccinations.

Personal Attention. We published a confidential email address and phone number on all materials, giving community members an opportunity to discuss questions and concerns about vaccine safety. Forty healthcare providers have offered their time to engage in conversations with vaccine-hesitant people. To date, we have facilitated over 100 hundred phone calls and over 500 email exchanges.

We triage these calls and emails based on provider specialty. The EMES Vaccine Task Force has on call experts, including a gynecological oncologist who is most adept at speaking about the Human Papillomavirus (HPV) vaccine; a pediatric pulmonologist who is fluent regarding the flu vaccine as well as allergic conditions which are a common concern for parents; a pediatric emergency department physician who is available to discuss many childhood illness and their inherent risks; and another three dozen providers available to discuss a wide range of topics with men and women who have vaccine-related questions. Several providers are Yiddish-speaking, which has been useful considering the population we serve.

Vaccine Fairs. Rockland County, the seat of the 2018–2019 outbreak, continued to have difficulty containing the outbreak. In June 2019 we decided to host a large educational event in one Orthodox Jewish hamlet in this county. To respect the gender-segregated nature of this community, we invited women only. We used community leaders and activists as our guides when planning this event, to ensure that we met the religious and cultural standards set by this ultra-Orthodox community.

We reached out to local pediatricians, nurses, primary care providers, immunologists, allergists, and rabbis, requesting their support and attendance. The participating EMES nurses and physicians hosted different "vaccine booths" organized by topic. This allowed the women to have discussion with specific providers based on their concerns. All providers were required to have participated in an EMES provider workshop and were sent materials to review prior to the event. This ensured that providers were fluent in their subject matter, including autism, sudden infant death syndrome (SIDS), aluminum in vaccines, the Hepatitis B vaccine, the flu shot, and many more topics. Women moved from table to table, interacting with the providers and each other, and gathering handouts to read at home. Approximately 200 women attended this event with much positive feedback.

In June 2019, New York State passed Public Health Law S2164, (Public Health Law S2164, 2019) removing religious exemptions for vaccination as an option for schoolchildren. Many Orthodox Jewish families had used religious exemptions as a way to avoid vaccinating their families. As the summer ended, many families who had hoped for a reversal or a stay found themselves highly anxious at having to vaccinate their children or remove them from school.

We elected to hold another vaccine fair, this time in Brooklyn, the second hotbed of the measles outbreak. We followed the format of the event in Rockland County, adding some topics such as "What the Vaccine Law Means", the HPV vaccine, and immunizations for pregnant women. This event, attended by 250 women, was an overwhelming success. Anecdotal feedback demonstrated relief from community members who appreciated unlimited time with providers who were well-versed in vaccine topics and who maintained empathy and respect throughout these conversations.

Important components of our work in this community included working with key community members who guided the work. Women from within these communities advised us about appropriate advertising, event incentives, and dress code of healthcare volunteers. This demonstrated a respectful approach to the community we were serving.

Provider Training

While we engaged with parents using the above methods, we also received requests from providers requesting training to be able to better answer patient questions and provide vaccine education. In response, we developed a workshop geared to interested healthcare providers. The content was approved for two continuing education credits by the Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

We hosted several provider workshops, both in-person and via livestream. These were attended by dozens of physicians, residents, interns, students, nurses, nurse practitioners, doulas, and community members who wanted to be better prepared to speak to vaccine-hesitant people in their communities (Sun, 2019). One large medical center in the Orthodox community offered us their conference space for any vaccine-related workshop we wanted to hold, even having their technical team remain late to help us livestream our event.

At these meetings, we emphasized that the crucial element in choosing to vaccinate is with the provider. A 2006 study reported that while providers indicated that they were seeing more and more vaccine-hesitant families, they also stated that they were able to convince 30% of the vaccine hesitant parents who had initially refused vaccines (AAP, 2006; Hough-Telford et al., 2016). We reviewed methods for communication as well as answers to common concerns.

Anecdotal feedback from providers demonstrated that the information provided was useful while talking to vaccine hesitant parents. Our workshops were featured in the Washington Post (Sun, 2019) and we received requests to lecture for residents at large teaching hospitals in New York City. We continued to receive positive feedback about our approach, methodology, and practical, factual presentation.


We were able to proceed with many of our projects due to generous funding from four private donors who became aware of our efforts to combat vaccine hesitancy in our community and wanted to help expand our efforts. The NYCDOHMH became a helpful ally in our work, offering to assist with printing and distribution of our magazine. The providers of the EMES group have been working on a volunteer basis and continue to do so, without remuneration.