As the U.S. confronts its worst measles outbreak in three decades, Romania — an eastern European country that has battled large measles surges — offers a cautionary example. Last year Romania reported 30,692 measles cases and 23 deaths; five of those deaths were children under age 1. For a wealthy, EU member nation, those numbers have alarmed public health experts.
Measles hits hardest where vaccination coverage falls. Romania once had coverage above the 95% level needed for herd immunity, but that has collapsed. By 2023 only about 62% of Romanians were fully vaccinated against measles, the lowest rate in the European Union. Outbreaks have continued in 2025, though initial counts are lower than last year’s peaks, reflecting how measles often moves in waves.
Multiple forces drove Romania’s decline in vaccination. Under the country’s authoritarian Communist era, childhood immunizations were mandatory and administered in schools without parental opt-out; the measles vaccine was introduced in 1979 and cases fell by about 90%. After Romania’s 1989 transition to democracy, mandatory vaccination ended and some people embraced the ability to refuse vaccines as an expression of newly won liberty. Distrust of state institutions grew, creating fertile ground for anti-vaccine movements.
Public confidence in vaccines was further eroded by a controversial 2008 human papillomavirus (HPV) vaccination campaign. Negative media coverage and public skepticism about that program spilled over into doubts about other vaccines. Measles coverage declined steadily after the HPV rollout and dropped sharply during the COVID-19 pandemic when routine vaccination services were disrupted.
Systemic weaknesses in Romania’s health system compounded the problem: chronic underfunding, a shrinking primary care workforce, and no mandatory immunization policy created barriers to maintaining high coverage. These gaps affect marginalized groups disproportionately — for example, many Roma communities lack local family doctors and face access and outreach shortfalls, not simple refusal. At the same time, influential clergy and some far-right politicians amplified anti-vaccine sentiment; public figures made high-profile statements opposing vaccination.
The consequences of low coverage are severe. Measles is highly contagious — a single infected person can infect many unvaccinated people nearby — and it can cause pneumonia, severe eye and ear infections, diarrhea, hearing loss, and, years later, the rare fatal complication subacute sclerosing panencephalitis. Regions such as Suceava experienced case rates reminiscent of the pre-vaccine era. Parents of infants too young for the two-dose schedule have faced distress and guilt when their children became exposed or ill.
Romanian clinicians and public health officials have turned to evidence-based strategies to rebuild trust and increase uptake. Many physicians now use motivational interviewing techniques: listening to parents’ concerns without judgment, acknowledging fears, providing tailored information, and helping patients arrive at their own decisions. These approaches have led some hesitant patients to accept vaccination. Public health workers emphasize that overcoming hesitancy requires time, respectful communication, and focused outreach to communities with limited access to care.
Romania’s experience offers clear lessons: loss of high measles vaccine coverage leads predictably to resurgence. Yet relatively well-off countries have not uniformly learned this. Canada recently lost measles elimination status amid sustained transmission, and the U.S. saw more than 1,700 cases in 2025 — its highest annual total in decades. Observers warn that policymakers and health systems must not ignore outbreaks abroad; rising hesitancy and gaps in routine immunization can reverse decades of progress even in high-income settings.
Key takeaways from Romania’s struggle:
– Herd immunity for measles requires about 95% two-dose coverage; falling below that invites outbreaks.
– Distrust in institutions, political shifts, and high-profile controversies can undermine vaccine confidence across multiple vaccines.
– Health system weaknesses — underfunding, workforce shortages, and lack of access — hinder both routine vaccination and targeted outbreak responses.
– Community-tailored outreach and evidence-based communication methods, like motivational interviewing, help address hesitancy.
– Marginalized populations often suffer from access gaps rather than simple refusal; improving access is critical.
Romania’s outbreaks are a reminder: maintaining high routine vaccination coverage and investing in primary care and community engagement are essential to prevent measles’ return. The lesson is universal — when coverage falls, measles will come back.