In many parts of the U.S., the share of children vaccinated against measles has fallen below 95 percent, the threshold public health officials say is needed to prevent community outbreaks. Photo credit: iStock
Published April 1, 2025 under Commentary
A fast-moving measles outbreak in Texas, which claimed the life of a young girl in February, has sounded the alarm about an infectious disease that was eliminated in the U.S. in 2002. But measles’ resurgence is not a new phenomenon, nor one isolated to a single part of the country, says a Duke Global Health Institute expert.
Heather Lanthorn, ScD, a political and behavioral scientist who leads the Duke Global Health Innovation Center’s collaborative Health Trust Initiative, says the spike in measles cases is a consequence of growing mistrust of public health guidance. The share of parents who vaccinate their children against measles has been in steady decline over the past several years, leaving more children vulnerable to catching and spreading the infection, she says.
“Where an [outbreak happens] is similar to a forest fire,” says Lanthorn, assistant director of programs and research for Duke GHIC. “It could happen anywhere in the world where there’s a dry forest with insufficient firebreaks and an ember floats in on the wind.”
As of late March 2025, nearly 500 measles cases have been confirmed across 20 states this year, according to the Centers for Disease Control and Prevention. Nearly all of those cases have occurred in children who did not receive the MMR (measles, mumps and rubella) vaccine or were under-vaccinated, according to public health reports.
Lanthorn, whose research focuses on understanding how people make health decisions, says medical authorities aren’t automatically entitled to trust. The Health Trust Initiative is an effort to identify ways that public health officials can foster trust and open dialogues across diverse communities including with those skeptical of vaccines and other medical interventions.
“As social and communication scientists and as practitioners, we must help communicators and champions earn trust while they help people make positive, protective health choices every day and during emergencies,” she says.
DGHI asked Lanthorn to share more about why scientists and health officials have lost trust in recent years and what steps they can take to rebuild it.
What’s driving the measles outbreak?
The vaccination rates have dipped below what we want them to be, which is 95 percent coverage. Measles is super contagious. Once you have a pocket where vaccination rates are too low for community immunity, it's going to spread.
Is this just a Texas problem or are MMR vaccine rates declining elsewhere?
It’s not just a Texas problem. It’s becoming everybody's problem quite quickly. When community immunity breaks down, several people can suffer most immediately: those with compromised immune systems such as folks on chemotherapy for cancer or who have received an organ transplant; children too young for vaccines; and elderly folks with waning vaccine protection. But in the end, it is everyone.
The trend in declining routine childhood immunization, including MMR, precedes COVID. It was almost certainly exacerbated by that experience of public health, how people responded to messaging and programming around vaccines. There are people who feel they were talked down to and not given full information during COVID and now, they are pushing back.
Where can parents find credible information if they have questions about vaccinations?
Their state and local health departments. [COVID] triggered people to think more about wanting to make their own choices. Choice is good but we need to make sure people are fully informed as they make personal benefit-risk trade-offs.
What are some misconceptions about vaccines?
Confusion about the necessity of vaccines stems from people’s understanding of the severity of a disease against which the vaccine protects, their susceptibility to it and how to mitigate that susceptibility. While measles was a predictable, common part of childhood for much of human history, we shouldn’t normalize getting it now. It’s deadly. Once people believe they want to prevent measles, they may still want to go about it in other ways: eating good food, including ramping vitamin A intake and hand washing.
But you can overdo vitamin A intake and in reality, none of these measures fully protect against measles. Only vaccination can do that. It’s good to eat well and practice good hand hygiene but that doesn’t substitute for the full protection you get from vaccination.
How is the Health Trust Initiative working to address vaccine hesitancy?
When Americans face critical health choices – from vaccines, cancer screenings to emergency preparedness – they find themselves navigating a maze of conflicting and chaotic information without trustworthy guides. Meanwhile, those trustworthy guides are disconnected from one another and from suppliers of credible health-related information. In turn, suppliers of high-quality information are disconnected from frontline needs and concerns.
This initiative was born out of Jack Leslie, a senior visiting fellow at DGHI; and Duke GHIC Director Krishna Udayakumar, M.D, hosting a workshop at the Rockefeller Foundation’s Bellagio Center to talk about issues of health trust. We are also working closely with Katelyn Jetelina, who is co-leading the initiative. We're working on both research and practice to advance our understanding of frontline need and to build a functional marketplace where supply and demand can meet.
On the ‘supply side,’ we’re bringing together health and science communicators and organizations to see how coordination and collaboration can get messengers the effective resources they need more efficiently. It’s a bottom-up and demand-driven approach that we haven’t historically seen in the public health establishment. While we’re focused on the US now, our hope is to continue our work more globally.
How do health officials rebuild trust for the public to have confidence in vaccines?
When trust breaks down, it is in part because those with authority are not behaving in trustworthy ways against a rising cacophony in the information environment.
For example, it seems clear we need to stop simply repeating vaccines are ‘safe and effective’ and expect a different response. A promising reframing might be that vaccines are ‘worth it,’ but we should test it out and see whether it changes mindsets and behavior and learn from that. We are building the Health Trust Initiative to equip trusted voices in local communities and online to meet these criteria, which we think will allow more people to make positive, protective health choices.
