As the U.S. continues to face its worst measles outbreak in three decades, another country that has struggled with measles offers a telling case study: the eastern European nation of Romania.
While most countries hardest hit by measles are lower-income countries in the Global South, wealthier countries have also seen significant outbreaks. Romania is one of them. The country ranked fifth on the measles outbreak list last year, reporting 30,692 cases and 23 deaths.
According to Dr. Aurora Stanescu, an epidemiologist at the National Institute for Public Health in Romania, five of those deaths were children under age 1.
Nina Schwalbe, a senior scholar at the Georgetown Center for Health Policy and Politics, calls those figures a "wake-up call."
"That's a lot of cases of measles, and that's a lot of deaths from a disease that really shouldn't be killing anybody at this point," Schwalbe says.
Unlike many lower-resource countries where measles takes a toll — such as the Democratic Republic of the Congo, Pakistan and Yemen — Romania is an upper-middle-income country and part of the European Union.
Even now, the consequences of low vaccine rates linger. The country continues to report measles cases in 2025. However, initial tallies are significantly lower than those of last year. According to public health specialists in Romania, the current numbers reflect how measles tends to come in waves.
Amid a growing trend of vaccine hesitancy around the world, Romania's experience paints a cautionary tale.
An authoritarian past
"The outbreaks aren't only a matter of poverty and not understanding the importance of immunization," says Dr. Mihai Craiu, a pediatrician at Carol Davila University of Medicine and Pharmacy in Romania. "It's multifactorial."
One of the forces driving the measles surge is Romania's political transition. Under the repressive Communist government that ruled for more than four decades, vaccines for childhood diseases were required.
Immunizations were given to kids at school without parental consent, Craiu says. "Virtually all children were immunized," he recalls.
"Prevention of infectious diseases by vaccination were ideal terrains in which the Communist state could demonstrate its power and legitimate its authority," historian Dora Vargha wrote in a book about vaccines. "If vaccination worked, the result would be immediate and visible."
The measles vaccine was introduced in 1979. The result: a 90% reduction in cases, according to a report from the U.S. Centers for Disease Control and Prevention. And an immunization rate above 95%.
That's the magic number for measles. "If 95% of people are vaccinated, the measles virus can't find a home for itself in those people, and eventually it gives up," Schwalbe says.
Then came political — and vaccine — upheaval. When Romania adopted a democratic form of government in 1989, citizens gained more freedom — including the ability to decline the recommended but no longer mandatory vaccine.
Like others in post-Communist countries, Romanians grew more distrustful of their government — and the immunizations it was recommending. This laid the foundation for anti-vaccine groups to step in and take advantage of the public mindset.
"Part of the perception of democracy in Romania was the liberty of not obeying the rules," Craiu says, noting that some Romanians view immunization as a form of Communist-era state control. When Romanians refuse vaccines, he says it's their way of asserting independence after decades of authoritarian leadership.
The impact of an HPV vaccine campaign
But vaccine refusal wasn't just about asserting personal freedom. People began doubting the benefits of vaccines.
"This decline [in vaccination] is partly due to decreased public confidence in vaccination benefits, reflected in parental refusal to vaccinate their children," read a report published in October by Romania's National Institute for Public Health — their equivalent of the CDC.
This trend was exacerbated by growing skepticism about vaccines, exacerbated by the 2008 campaign to vaccinate girls against HPV, the virus that can cause cervical cancer. That campaign deepened public skepticism about all vaccines, as headlines from various Romanian media outlets demonstrate.
At the time of the HPV vaccine rollout, measles vaccine coverage stood at the recommended 95% rate. In subsequent years, it declined steadily, dropping by 20 percentage points by 2017 and further declining to just 62% in 2023.
A study conducted by Stanescu and her colleagues last year found that only one of Romania's more than 40 regions had measles vaccine coverage above 95%.
The pandemic exacerbated that sharp nosedive in vaccine coverage, the National Institute for Public Health report observes, noting disruptions in routine vaccination.
As the share of those protected against measles decreased, outbreaks pummeled the country.
"Some saw the outbreaks in the 2010s as a wake-up call, but others didn't," says Dr. Gindrovel Dumitra, the vice president of the Romanian National Society of Family Medicine. "Some people simply refuse vaccines — and even an outbreak won't convince them."
A health system struggles to keep up
Along with Romania's growing anti-vaccine movement, the country faces systemic barriers that contribute to its low vaccination rates. Dumitra points to three main factors: a fragile health system that remains one of the most underfunded in Europe, a shrinking number of primary care providers — driven by burnout and low compensation — and the absence of mandatory immunization policies.
Lack of funding for health care disproportionately affects minority groups like the country's nearly 2 million Roma people. Minorities are often blamed for low vaccination rates, but Craiu says a deeper look reveals that the problem stems from inadequate outreach and lack of access to care.
"If you don't have a family doctor in your village, then first of all, it's difficult to get information and then it's also difficult to access vaccines," says Dr. Silvia Gatscher, the health operations manager at the World Health Organization Country Office in Romania.
As the years passed, the clergy became influential in advocating against vaccines — some say as a reaction to the government limiting church services during the early years of the pandemic.
Simultaneously, far-right politicians capitalized on growing mistrust toward vaccines. One of those anti-vaccine lawmakers is Diana Sosoaca. She said, "God is not vaccinated" during a brief speech on the floor of the European Parliament last year.
A free fall in immunization coverage
Currently, only two-thirds of Romanians are fully vaccinated against measles. That's the lowest measles vaccination rate in the European Union.
The shortfall has serious consequences. Researchers estimate that one person who contracts the virus can infect up to 18 unvaccinated people nearby. The risk is especially dire for children too young to have completed the two-dose vaccination protocol, which is administered first at 12 months and then again at age 5.
That includes babies like Ionela Radulescu's son. Last year, the 7-month-old was hospitalized for pneumonia and came into contact with a child infected with measles.
"He had a rash on his face. It was pinkish and very small," the 31-year-old mother says through an interpreter. "Then it started going down onto his chest and palms. It even went down to the soles of his feet. He had it everywhere."
Radulescu lives in Suceava, in northern Romania. Last year, the area recorded the sixth-highest rate of measles cases among more than 40 regions. The frequency of cases in Suceava mirrored levels seen in countries before the measles vaccine became widely available.
Although her son was too young to be vaccinated, the mother says: "I felt bad. It was very hard. I started questioning myself and asking questions like, Was I too negligent? Was I not careful enough? You start to blame yourself. It's a really ugly feeling."
And measles can be far more than an uncomfortable rash. The virus can lead to pneumonia, eye inflammation, diarrhea and ear infections, which can result in deafness in approximately 5 to 10% of cases.
Even after recovering from the illness, children remain at risk for a rare and fatal complication called subacute sclerosing panencephalitis. It typically appears about seven to 10 years after the initial infection. Stanescu estimates there have been about a dozen cases in Romania in recent years.
"Just because you're OK from that infection at the time doesn't mean that that infection doesn't have very serious consequences for you later in life," Schwalbe explains.
A different way to talk to parents
While Craiu and Dumitra admit it's an uphill battle, they've taken an evidence-based approach to combating misinformation and encouraging vaccination. "It's a huge difference in what we learned in medical school and what I'm doing now," Craiu explains.
When speaking with parents, Dumitra uses motivational interviewing, a technique that helps patients adopt changes when they decide the change matters to them — not because a doctor said so. It also encourages physicians to listen without judgment, exploring a patient's ambivalence. The American Academy of Pediatrics praises the method as an effective way to improve communication about vaccines.
"Yesterday, when I recommended a woman to be vaccinated against the flu, she told me, 'I'm scared of the vaccine.' I asked her, 'Why?'" Dumitra recalls.
The woman explained she was worried the vaccine would worsen a chronic illness. "After acknowledging her concerns, I offered her information and then verified if she understood it. She eventually got vaccinated."
Lessons from Romania's outbreaks
Gatscher is optimistic that evidence-based approaches to vaccine hesitancy will chip away at the mistrust and misinformation surrounding vaccines in her country.
Yet the global measles count this year indicates that other relatively well-off countries aren't drawing any lessons from Romania. This month, Canada lost its measles elimination status due to sustained transmission, with 5,000 cases so far this year. The U.S. has confirmed 1,723 cases in 2025 so far, according to the CDC — the highest annual number in more than three decades.
While the U.S. has much to learn from what has happened in Romania, Schwalbe says America exists in its "own bubble" and often looks away from examples like Romania.
"I think we are incredibly good in America at thinking, 'That's what's happening over there, and it has nothing to do with us,'" Schwalbe says.
"I don't think that Romania will teach us any lessons, unfortunately, even though it's such a clear lesson. The lesson to everybody — all over the world — is that when you lose high coverage of [vaccination against] measles, the disease comes back."
Michal Ruprecht is a Stanford Global Health Media Fellow.
Copyright 2025 NPR
