Lessons About Measles & Vaccination Compliance

by Dipti P. Subramaniam

The recent measles outbreak in California and the rise in cases have received considerable media attention, largely due to the debate surrounding the advocacy for child vaccination. The Centers for Disease Control and Prevention (CDC) declared a multistate outbreak in the United States at a record number (since the early 1990s) of 644 measles cases in December 2014. More than 150 additional cases have been reported in 2015.

Infection & Protection Measles is a highly infectious disease that affects all age groups, but the complications can be especially devastating in children who are five years or younger. Although the symptoms of measles may initially appear to be mild and common, this disease also has been known to cause severe complications such as pneumonia and encephalitis. Measles can increase the risk of acquiring long-term complications such as subacute sclerosing panencephalitis (SSPE), which is a fatal disease affecting the central nervous system. Although the measles was eliminated in the United States in 2000, its resurgence can be attributed, in part, as a result of some parents’ refusal to vaccinate their children.

The measles, mumps, rubella (MMR) vaccine provides optimum protection against measles and minimizes the risk of acquiring the associated complications. More importantly, the vaccine reduces infection and transmission. Like any vaccine, the MMR vaccine can cause mild adverse events, such as mild fever, but severe problems are “very rare,” according to the CDC. The CDC in collaboration with organizations such as the American Academy of Family Physicians (AAFP) and American Academy of Pediatrics (AAP) highly recommend that children receive the MMR vaccine based on the suggested schedule to reduce the risk of being infected. Despite noted benefits and recommendations, the lack of MMR vaccine acceptance among parents and their resistance to vaccinate their children are alarming because, although MMR vaccination coverage is at 92 percent, it is still below the threshold for “herd immunity” of 95 percent. Herd immunity (or community immunity) is the concept that, when a critical portion of a community’s residents is immunized (in the case of measles, 95 percent), everyone within this community is protected.

Fears & Facts Parents’ knowledge about vaccinations is a key factor in predicting vaccination compliance. Often, the reported barriers for vaccination compliance include vaccine misconceptions and fear of vaccine-adverse events that result in parental refusal of the vaccine on behalf of the child. The lack of compliance stems from an anti-vaccination movement propelled by parents who are either uninformed, or who consciously choose not to vaccinate due to cultural, philosophical, or religious beliefs. A major point of those who are misinformed is allegations that the MMR vaccine can cause autism, despite the large body of scientific evidence proving otherwise. Some members of the anti-vaccination movement not only propagate fear, but also undermine the parent-physician relationship.

In recognition of this growing public health problem, healthcare providers and professionals are key stakeholders in promoting compliance among community members, specifically parents. The first step in dismissing myths regarding MMR vaccine is education. Public health professionals can collaborate with family physicians in developing educational materials that highlight the benefits of receiving the vaccine. Physicians also should be trained in communicating to parents how the benefits outweigh the side effects of vaccines and the risk of developing measles. Furthermore, physicians should be prepared to address parents who refuse to consent to vaccination for their children – for example, communicating the benefits of vaccination for their child’s long-term health as well as for the health of the community.

Targeting of Future Messages In addition to physicians, public health practitioners should be trained to frame tailored messages for a variety of communities, which have diverse perspectives, social norms, and cultural beliefs affecting how they receive public health messages. Message framing is a key component of influencing behavior and can minimize resistance in communities where healthcare providers are mistrusted. These messages can shift the focus back to the scientifically demonstrated dangers of measles and away from the uncorroborated claims such as the link between vaccination and autism.

Health officials can work with parents toentify and address individual concerns as well as learn more about attitudes and behaviors regarding vaccination. Through this approach, health officials are better able to effectively develop targeted interventions that meet the actual needs of the parents rather than solely perceived needs. Shifting the focus to parents encourages them to take the primary role in the decision-making process, which can alleviate the perceived infringement on parental rights. Likewise, employing the influence of community leaders such as pop culture figures and religious leaders encourages awareness and education among parents.

The solution is not as simple as developing a universal message for parents. Targeted interventions are more effective in encouraging vaccination uptake since they take into account the wide variety of individual, social, and cultural beliefs and concerns of specific communities. However, even with targeted interventions, the anti-vaccination movement will not dissipate overnight. Continual reframing of messages and community engagement are needed to ensure the long-term success of vaccination advocacy.


Dipti P. Subramaniam, Ph.D., has contributed to and led public health projects at the local and national levels, and served faculty, students, and community members in Saint Louis through research, teaching, and practice. In all of these situations, she has had the opportunity to collaborate with diverse stakeholders in order to advocate for targeted groups based on their self-defined health needs. She received her Ph.D. in public health studies and MPH in biosecurity and disaster preparedness from Saint Louis University College for Public Health and Social Justice. At present, she focuses on furthering her research in the area of health promotion and behavior.