The Journal for Nurse Practitioners xxx (xxxx) xxx

Contents lists available at ScienceDirect

The Journal for Nurse Practitioners

journal homepage: www.npjournal.org

Feature Article

The Resurgence of Measles, Mumps, and Pertussis

e L. Davis, DNP, CPNP-PC
Michelle M. Papachrisanthou, DNP, CPNP-PC, Rene

Although vaccines are one of the greatest scientific innovations to prevent disease and promote well-being, 1
Keywords: in 10 children is not being vaccinated. This has directly contributed to the rise in vaccine-preventable dis-
measles eases. Because of the high contagiousness of measles, mumps, and pertussis, innovative efforts are para-
mumps mount to prevent disease outbreaks in the United States and worldwide. This article reviews measles,
pertussis mumps, and pertussis; explains the resurgence of these vaccine-preventable diseases; and offers evidence-
vaccine-preventable diseases based solutions for increasing vaccination rates.
© 2019 Elsevier Inc. All rights reserved.

Vaccines are one of the greatest scientific inventions available to
prevent illness and death.1 Despite countless vaccine advances over
the past 6 decades, some parents continue to question the safety,
benefits, and necessity of vaccines.1 Some choose to alter, delay, or
decline childhood vaccines, negatively impacting herd immunity
and allowing vaccine-preventable diseases (VPDs) to accelerate.1
The shift from “pro”-vaccine to “anti”-vaccine piques alarming
concerns that decades of successful vaccine programs may be in
jeopardy. Although vaccines prevent approximately 2.5 million
pediatric deaths worldwide annually, the sad fact is that 1 child still
dies every 20 seconds from a VPD.2 Measles, mumps, and pertussis
resurgence will be reviewed, noting their impact both in the United
States and worldwide. Causes for vaccine skepticism and innovative
ideas to increase vaccine uptake will also be presented.
Background
Measles
In 1963, the measles vaccine was introduced to the US and has
reduced measles cases by greater than 99%.1 Because of the high
contagiousness of measles, unvaccinated individuals have up to a
90% chance of contracting it if they are exposed.1 A single dose of
measles, mumps, rubella (MMR) vaccine is 95% effective, and 2
doses of MMR are 99% effective at preventing measles.1
Measles was considered practically eliminated in the US in 2000
with a median of 60 cases reported yearly between 2001 and 2012.3
In 2014, 23 outbreaks in 27 different states totaling 667 cases were
reported, the largest annual disease burden in the US since 1994.4
The 2014 influx of measles cases began in an unvaccinated Amish
congregation in Ohio infecting 383 people.4 The majority of the
other cases reported in 2014 into 2015 were contracted at a Dis-
neyland theme park imported from an index case from the
Philippines.4 Analysis of the Disneyland outbreak concluded that
88% of the individuals infected were unvaccinated or had an un-
identified vaccine status.1
In 2017, Minnesota experienced a measles outbreak that infected
65 individuals ranging from 3 months to 49 years of age.5 The
outbreak was traced back to a 25-month-old hospitalized child who
exposed over 8,200 people from 5 schools, 12 day care facilities, 3
health care centers, and many households.5 Ninety-five percent of
the infected individuals were unvaccinated, and 31% required hos-
pitalization for dehydration or pneumonia treatment.5 This outbreak
shows how rapidly the measles virus spreads in a community lacking
adequate vaccination and reinforces the need for continued educa-
tion to prevent future outbreaks and hospitalizations.
In October 2018, 17 children had confirmed cases of measles in
Williamsburg, NY, and Borough Park, NY, and more than 40 cases
were confirmed in the Jewish community of Rockland County, NY,
from a child who visited Israel.6 This led to a public health notice
that any child within the Village of New Square school district who
was undervaccinated or unvaccinated must be kept home 21 days
after the last confirmed measles case.6 This supports the impor-
tance of vaccine discussions at each and every patient visit and the
need for continued laws regulating school vaccine requirements.
As of December 1, 2018, 292 confirmed cases of measles from 16
different outbreaks involving 26 states and the District of Columbia
have been reported in the US for the 2018 calendar year.4 This is more
than double the cases from 2017 (120) and more than triple the cases
from 2016 (86).4 The majority of the 2018 measles outbreaks have
been in unvaccinated individuals exposed to international travelers.4
Europe is also experiencing the highest measles outbreak in over 2
decades secondary to suboptimal vaccination rates.7 More than
41,000 cases of measles and 37 deaths have been reported in the first
6 months of 2018 in Europe.7 Today, measles still infects 20 million
people worldwide and is responsible for more than 89,000 deaths
annually.8 Through global vaccine initiatives from 2000 to 2017, the
measles vaccine has prevented an estimated 21 million deaths.8

https://doi.org/10.1016/j.nurpra.2018.12.028
1555-4155/© 2019 Elsevier Inc. All rights reserved.
2 M.M. Papachrisanthou, R.L. Davis / The Journal for Nurse Practitioners xxx (xxxx) xxx

Mumps health crisis. The solution must involve addressing a myriad of

parental concerns about vaccine safety that includes purported
Before the introduction of the mumps vaccine in the US in 1967, links to autism, immune system overload, and the perception that
about 186,000 cases occurred annually in the US.9 In 1989, the VPDs no longer exist. It is crucial that nurse practitioners (NPs)
Advisory Committee on Immunization Practices recommended remain current on vaccine research and are able to communicate
changing the MMR vaccine from 1 to 2 doses in response to mul- effectively to all parents to aid in vaccine uptake.
tiple measles outbreaks. This resulted in a substantial reduction in
mumps cases in the 1990s.10 However, between 2016 and 2017,
Vaccine Hesitancy
mumps infected over 1.1 million people worldwide with over
12,000 of those cases within the US.11
Parents who delay or decline vaccines are referred to as vaccine
Hundreds of college students from Iowa and Illinois were
hesitant.20 Vaccine-hesitant parents may request an altered vaccine
infected with the mumps in 2015/2016.9 A close-knit community in
schedule, choose to extend intervals between vaccines, or postpone
Arkansas was affected with nearly 3,000 cases of mumps in 2016/
vaccines.20 Some may refuse vaccines entirely.20 Not only is this a
2017.9 Many outbreaks are noted in close-contact settings such as
major contributor to the persistence of VPDs but also puts a strain
schools, colleges, sports teams, and camps.9 As of December 1, 2018,
on the NP who must devise an alternate vaccine schedule and
there have been 2,106 cases of mumps in the US from 47 states and
spend additional time educating parents on the benefits of vac-
the District of Columbia.9 When there are geographic pockets of
cines.20 The NP must also craft a plan to protect other children in
children who are unvaccinated, VPDs, like mumps, can spread
the office that medically cannot be vaccinated and a policy for
rapidly.
possible dismissal of the parent who delays or declines vaccines.20
Because vaccines are given when children are healthy, some par-
Pertussis
ents have a difficult time visualizing the benefits when the risks of
After the introduction of the first pertussis vaccine in the 1940s,
vaccination are so widely publicized.20 The American Academy of
the US saw a decrease in pertussis cases, which lasted until 2004.12
Pediatrics strongly advises against dismissing vaccine-hesitant
However, since 2004, pertussis rates have steadily increased with a
parents because this prevents future revisiting efforts.21 Many
peak of 48,277 cases and 20 deaths reported in 2012.12 Although
vaccine-hesitant parents reevaluate their vaccine decisions;
the acellular pertussis vaccine released in 1997 is considered safer,
therefore, the NP should capitalize on every visit to promote
it wanes rapidly from the initial time of administration compared
parental involvement and vaccine uptake.21 It is clear that vaccine
with the whole-cell pertussis vaccine used in the 1940s.13 McGirr
hesitancy is associated with increased outbreaks of VPDs, hospi-
and Fisman14 found only 10% of children are immune to pertussis
talizations, emergency department visits, morbidity, and
8.5 years after the final dose of pertussis, which increases the
mortality.20
chance of contracting pertussis by 1.3 times each year from the last
Gaps in vaccine rates negatively affect herd immunity. Herd
given dose of pertussis. In 2014, California experienced an epidemic
immunity occurs when most of the population is immune to a
of pertussis that affected over 9,000 individuals.14 A study con-
disease, which helps prevent unvaccinated persons from acquiring
ducted after California’s pertussis epidemic found that, despite high
the disease and also prevents the spread of disease within the
vaccination rates in California adolescents, tetanus, diphtheria, and
community.1 Delaying or refusing vaccinations compromises herd
acellular pertussis only offered 69% protection during the initial
immunity and increases the risk for disease.
year of vaccination, which waned by 35% yearly thereafter, resulting
There are 18 states that allow exemptions for nonmedical rea-
in only 9% of recipients having protection 4 years after vaccina-
sons: Arizona, Arkansas, Colorado, Idaho, Louisiana, Maine, Michi-
tion.14 In 2018, pertussis cases have been reported nationwide. For
gan, Minnesota, North Dakota, Ohio, Oklahoma, Oregon,
example, 32 cases have been localized to Flathead City, MT, with 5
Pennsylvania, Texas, Utah, Vermont, Washington, and Wisconsin.22
of these cases being reported in 1 day.15 Colorado and California
In the 2016/2017 school year, nearly 27% of kindergarteners in
have also reported increased pertussis cases for 2018.15
Camas County, ID, were unvaccinated.22 Numerous cities reported
that 5% of their kindergarten population were unvaccinated.22 In
US Vaccination Rates
response to the increased measles cases in 2014, California banned
nonmedical exemptions and now have the highest rate of MMR
Healthy People 2020 has established an overall vaccine goal of
administration and the lowest reported rates of VPDs.22 Herd
90% for children aged 19 to 35 months, 4 to 6 years, and adoles-
immunity thresholds vary by disease; mumps requires that
cents. Each age group has target goals set for the various recom-
approximately 80% of the population be immune, whereas measles
mended vaccines.16 For example, the goals set for the diseases
and pertussis require closer to 95% of the population be immune.1
discussed in this article are 90% of children aged 19 to 35 months of
Strong herd immunity is especially important for infants or those
age will receive 4 doses of diphtheria, tetanus, and acellular
who cannot be vaccinated because of a medical problem.1 These
pertussis (DTaP) and 1 dose of MMR.16 In 2017, 83.4% of US children
populations rely heavily on herd immunity for protection from
were vaccinated with at least 4 doses of DTaP, and 91.1% had
illness.
received at least 1 dose of MMR.17 For children in the kindergarten
age group, the goal states 95% will receive 4 or more doses of DTaP
and 2 doses of MMR.16 For the 2017/2018 school year, 95.1% had Safety and Autism
received 5 doses of DTaP, and 94.3% had received 2 doses of MMR.18
Adolescent goals are set at 80% for 1 dose of tetanus, diphtheria, Safety concerns surrounding thimerosal, a mercury-based
and acellular pertussis.16 In 2017, 88.7% of adolescents had received additive used to prevent the growth of bacteria, surfaced in the
1 dose of tetanus, diphtheria, and acellular pertussis.19 1990s.23 Thimerosal was under scrutiny for suspected ill effects on
brain development and concerns that linked thimerosal to
The Resurgence of VPDs autism.23 Seven studies performed between 2003 and 2007
concluded that there was no relationship between thimerosal and
Although vaccine rates are near or at the goals set by Healthy autism.23 Despite these findings, thimerosal additives were
People 2020, VPDs continue to steadily rise, representing a public removed from routine childhood vaccines in the summer of 2001.23
 M.M. Papachrisanthou, R.L. Davis / The Journal for Nurse Practitioners xxx (xxxx) xxx
A link between the MMR vaccine and autism is the most widely
publicized vaccine safety concern. Intense debates started in 1998
when Andrew Wakefield, a British gastroenterologist, published a
study in The Lancet journal claiming a direct link between the MMR
vaccine and autism.1 The article failed to disclose that Wakefield
had received money from lawyers representing parents in anti-
vaccine lawsuits.1 Additionally, Wakefield personally selected the
subjects, did not obtain human subjects approval, and did not
disclose all of his study’s data.1 In 2010, The Lancet retracted the
article, and Wakefield was stripped of his medical license, but the
damage to the credibility of vaccines was done.1 Parents worldwide
refused to vaccinate their children, and the resurgence of the
measles and the mumps accelerated.
It took 12 years for scientists worldwide to debunk the fraud-
ulent research published by Wakefield. Between 1999 and 2006, 13
studies failed to show an association between receipt of the MMR
vaccine and autism.23 A large study of over 95,000 children per-
formed by Jain et al24 concluded that there is no increased risk of
autism associated with receipt of the MMR vaccine, even in chil-
dren who had an older sibling diagnosed with autism.
Immune System Overload
In the first 2 years of life, a child may receive more than 20 in-
jections against 14 diseases.25 Some parents have concerns that
their child’s immune system will be overloaded as a result of the
number of antigens given within a short period of time.21,25 A cross-
sectional, Web-based survey of 51 parents found that 20% of par-
ents believed too many vaccines may be overwhelming to the
immune system, and 16% of parents agreed vaccines are given
when children are too young.26 However, a case-control study
of 944 children found no significant differences in rates of
nonevaccine-targeted infections in vaccinated and unvaccinated
children through 23 months of age.25
VPDs No Longer Exist
Ironically, vaccines are being hurt by their own success. Many
parents have no experience with and no longer fear VPDs or believe
their child is not susceptible to disease.21 Smith et al27 found par-
ents who delay or refuse vaccines are less likely to believe vaccines
protect their child (70% vs 96%), less likely to believe that their child
will contract a VPD if he or she is not vaccinated (71% vs 90%), and
more likely to view vaccines as not safe (50% vs 85%) compared
with parents who receive vaccines on time. Moreover, many par-
ents believe that natural immunity resulting from disease is more
beneficial to their child’s immune system than vaccination.28
Possible Solutions
Evidence-based solutions are critical in the fight against the
resurgence of VPDs. Detailed discussions with parents in the pre-
natal period, using pictures/videos to educate parents about the
persistence of VPDs, patient reminders and recall, and motivational
interviewing (MI) are ways to reinforce vaccine adherence to the
recommended schedule.
Prenatal Vaccine Education
Parents must be taught that these "common childhood
infections" are not always benign (eg, a mild temperature, sore
throat, or rash). They may lead to severe illness, not only for the
child but also for those with whom they come in contact including
immunocompromised patients or those with decreasing levels of
3
immunity such as the elderly. It may not be the child who dies; it
may be an elderly relative.
Numerous studies have shown that the prenatal period is the
best time to begin vaccine discussions. Providing vaccine education
to pregnant women can increase knowledge, vaccine uptake, and
timeliness of vaccine receipt.29,30 The American Academy of Pedi-
atrics recommends that all pregnant women complete a prenatal
visit to their pediatric provider.31 This provides a good opportunity
to discuss vaccines with expectant parents. One study showed that
parents who refuse or delay vaccines are twice as likely to think
about vaccines while pregnant and 8 times more likely to contin-
ually reevaluate their decision to vaccinate.32 A study performed in
China found 90% of children whose mothers received vaccine
education prenatally were up-to-date on vaccines by 12 months of
age compared with 83% of children whose mothers did not receive
prenatal vaccine education.29 Mothers in the intervention group
were 5.2 times more vaccine knowledgeable, and their children
were 3.4 times more likely to be fully vaccinated and 2.3 times
more likely to be fully vaccinated on time.29 Saitoh et al33 used a
stepwise, interactive approach to vaccine education that delivered
education prenatally, postnatally, and 1 month after birth to
mothers in Japan. The prenatal education took place between 34
and 36 weeks of gestation and centered on the necessity of vac-
cines, VPDs, types of vaccines, and how to search the Internet for
reliable vaccine information.33 The postnatal education occurred 3
to 6 days after delivery and focused on the vaccine schedule, vac-
cines under the Japan system, detailed VPD risk, and first vacci-
nation date.33 The last period of interaction happened at the 1
month well-baby visit and addressed how to vaccinate and adverse
reactions versus serious reactions.33 Compared with the compari-
son group, the intervention group had increased maternal vaccine
knowledge scores over time, higher vaccination completion rates,
and shorter durations between vaccination completion.33 Addi-
tionally, a study performed by Klein et al34 revealed that many
vaccine-hesitant parents prefer their health care provider to supply
them with vaccine education and information before the first well-
baby visit. The prenatal period offers an excellent opportunity to
initiate the conversation because it is a less stressful time because
the baby has not yet arrived. The parents can focus on the vaccine
education and not have to recall all the other topics discussed
during the well visits.
Visually Enhanced Education
One innovative technique to improve vaccine acceptance is
through the use of visually enhanced education (VEE), which
combines verbal education with visual education.35 VEE uses pic-
tures of children infected with VPDs to educate parents on diseases
that do occur by delaying or declining vaccines.35 This study found
that parents who received VEE versus the control group parents
were significantly more adherent to the recommended vaccine
schedule between the 2- and 6-month visits.35 Horne et al36 also
found that focusing on disease risk education through maternal
written perspectives, pictures, and 3 warnings rather than refuting
myths surrounding vaccines had more positive effects on maternal
attitude responses to vaccines. Overall, this study showed signifi-
cant vaccine attitude change scores related to disease risk and
autism compared with the control group.36 In a randomized
controlled study involving vaccine-hesitant parents, Williams
et al37 used an educational video and written handout in the
intervention group compared with usual care in the control group.
It was found that the intervention group had significantly lower
Parent Attitudes about Childhood Vaccines (PACV) scores at 2
months, which translates into reduced vaccine hesitancy.37
4 M.M. Papachrisanthou, R.L. Davis / The Journal for Nurse Practitioners xxx (xxxx) xxx
Patient Recall
Patient reminders and recall can be in the form of postcards,
phone calls, audiodialer calls, text messages, e-mails, letters, or a
combination of the aforementioned. It is an area that has a plethora
of research supporting its use. Jacobson Vann et al38 analyzed 55
studies using over 138,000 subjects and found strong evidence that
postcards, text messages, and autodialer reminders improve vac-
cine uptake. Thompson et al39 studied the efficacy of reminder
prompts. Children who attended health care facilities with active
reminder systems were 5 times more likely to receive the influenza
vaccine, and children who received vaccine postcard reminders
were 2.5 times more likely to be vaccinated versus those who did
not receive a vaccine postcard.39
MI
MI is a widely used patient-centered approach that strives to
change health behaviors by using negotiation rather than conflict.27
MI involves listening, reflecting, clarifying, and supporting, with
the goal of motivating patients through change by subtle negotia-
tions.27 In a quasi-experimental cohort study by Gagneur et al,40 an
MI educational session was administered to postpartum women
while in the maternity unit about 2-, 4-, and 6-month vaccines
compared with the control group who received no MI educational
session. The MI sessions addressed VPDs, vaccine effectiveness,
vaccine importance, and vaccine fears/side effects.40 Results
showed that the MI group had significantly higher vaccine coverage
at 3 months (91.3% vs 88.1%), 5 months (83.2% vs 78.3%), and 7
months (75.9% vs 68.6%) compared with the control group.40
Joseph et al41 performed a pilot study using mother-daughter dyads
examining human papillomavirus (HPV) intent to vaccinate and
knowledge gained through a brief MI behavioral intervention.
There was no difference noted between dyads receiving their first
HPV vaccine (56% vs 51%), although the intervention dyad mothers
did significantly increase their knowledge of HPV by almost 2 times
the standard deviation.41
Conclusion
Although vaccine rates are near or at the Healthy People 2020
goal of 90%, VPDs are on the rise in the US and worldwide sec-
ondary to parental misconceptions, vaccine hesitancy, waning
immunity, and negative effects on herd immunity. NPs need to
continue addressing the gaps in parental knowledge through
detailed educational efforts and effective communication tech-
niques. NPs should give information to parents that clearly outlines
the risks and benefits of vaccination; NPs should also take into
consideration the parent’s decision-making process and avoid
conflict causing communication. Addressing parental concerns
early, even during pregnancy, is crucial and can both enhance the
patient-provider relationship and improve early childhood vacci-
nation rates.
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Both authors are affiliated with Saint Louis University School of Nursing in St Louis, MO.
Michelle M. Papachrisanthou, DNP, CPNP-PC, is an assistant professor. She is available at
michelle.papachrisanthou@slu.edu. Rene
e L. Davis, DNP, CPNP-PC is an assistant
professor.
In compliance with national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.