As the U.S. confronts its worst measles outbreak in more than three decades, Romania’s recent experience offers a cautionary lesson. Although most large measles outbreaks occur in lower-income countries, Romania — an upper-middle-income member of the European Union — ranked fifth worldwide last year, reporting 30,692 cases and 23 deaths. Dr. Aurora Stanescu of Romania’s National Institute for Public Health says five of those deaths were children under 1.
The scale of Romania’s outbreak has alarmed public health experts. Nina Schwalbe, a senior scholar at Georgetown’s Center for Health Policy and Politics, calls the numbers a “wake-up call,” noting measles deaths “shouldn’t be happening” where vaccines are available.
How Romania got here
Romania’s decline in vaccine coverage is multifactorial. Under the communist regime that ruled for decades, childhood immunizations were compulsory and delivered in schools without parental consent. Vaccination success was visible and politically useful: after measles vaccine introduction in 1979, cases dropped by about 90% and coverage exceeded 95% — the threshold public health experts cite for interrupting measles transmission.
After the 1989 transition to democracy, mandatory vaccination ended. Greater personal freedom and growing distrust of state institutions created space for vaccine refusal. Historian Dora Vargha and physicians such as Dr. Mihai Craiu note that some Romanians came to view immunization mandates as a symbol of authoritarian control; refusing vaccines became a way to assert newfound liberty.
Distrust deepened after a 2008 HPV vaccine campaign. Media coverage and controversy around HPV vaccination for girls appears to have eroded confidence in vaccines more broadly. At the time, measles coverage was near the 95% mark; afterward it fell steadily — dropping by roughly 20 percentage points by 2017 and plunging to about 62% by 2023. A 2024 study found only one of Romania’s more than 40 regions maintained measles coverage above 95%.
The COVID-19 pandemic worsened the decline by disrupting routine immunization services. Structural health system problems also contribute: Romania’s health care remains underfunded compared with other EU countries, the primary care workforce is shrinking from burnout and low pay, and mandatory immunization policies are absent. These issues disproportionately affect marginalized groups, including nearly 2 million Roma people, for whom lack of local family doctors and outreach limits access to vaccines.
Social and political amplifiers
Beyond access, social forces have amplified hesitancy. Clergy in some areas have become vocal against vaccines, in part reacting to public health measures that limited church services during the pandemic. Far-right and populist politicians have seized on mistrust for political gain; one anti-vaccine lawmaker famously declared, “God is not vaccinated.” Such messaging compounds parental fears and normalizes refusal.
Consequences for children and communities
Only about two-thirds of Romanians are currently fully vaccinated against measles — the lowest rate in the EU. Measles is extremely contagious: a single infected person can infect up to 18 nearby unprotected people. The two-dose schedule, with doses typically given at 12 months and again at age 5, protects most children, but infants under 12 months remain vulnerable.
Parents like Ionela Radulescu experienced this firsthand. Her 7-month-old son, too young for his first dose, was hospitalized for pneumonia and exposed to measles. She describes the fear and self-blame she felt watching a spreading rash and worrying whether she had been negligent. Measles can cause pneumonia, eye inflammation, diarrhea and ear infections that can lead to deafness in 5–10% of cases. Even after recovery, children risk a rare, fatal complication called subacute sclerosing panencephalitis (SSPE) that can appear seven to ten years later; Romania has seen about a dozen recent SSPE cases.
Responses and outreach
Romanian clinicians and public health workers are trying evidence-based tactics to counter hesitancy and rebuild coverage. Pediatricians such as Craiu and family doctors like Dr. Gindrovel Dumitra emphasize communication techniques that respect parents’ concerns. Dumitra uses motivational interviewing — an approach that avoids judgment, elicits patients’ own reasons for change, and verifies understanding — which the American Academy of Pediatrics endorses as effective for vaccine discussions. Small, trust-building conversations can persuade hesitant parents; one example Dumitra shares involved addressing a patient’s specific fear about a chronic illness and ultimately arranging vaccination after listening and providing tailored information.
WHO and other public health actors in Romania hope sustained, respectful engagement and improved access will gradually restore confidence. But reversing long declines, limited health infrastructure, and politicized misinformation is a heavy lift.
What this means for other countries
Romania’s outbreak underscores a broader principle: when communities lose high measles coverage, the disease returns. Other relatively well-off countries are showing similar backsliding. Canada recently lost its measles elimination status amid sustained transmission, and the U.S. has reported over 1,700 cases so far in 2025 — the most in more than thirty years.
Experts warn that wealthy countries sometimes assume these problems are confined to “over there,” but Romania’s experience demonstrates how social, political and health-system changes can erode defenses against vaccine-preventable diseases anywhere. The clear lesson is that maintaining high vaccination coverage requires consistent access, adequately funded health systems, trust-building communication, and vigilance against politicized misinformation. Where those conditions falter, measles and other preventable diseases can and will resurge.
Michal Ruprecht is a Stanford Global Health Media Fellow.