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Vaccines & Vaccination Open Access Research Article 33 min read

Addressing Vaccine Hesitancy in the Age of Measles Resurgence: A Mini-Review

Sallam M
ISSN: 2578-5044  10.23880/vvoa-16000178  Received: June 03, 2025  Published: June 17, 2025
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Keywords
Vaccine Hesitancy Measles Resurgence Misinformation Childhood Immunization Behavioral Interventions Public Trust
Abstract

In 2025, the United States is experiencing its most significant measles resurgence since the disease was declared eliminated in 2000. As of June 2025, the Centers for Disease Control and Prevention (CDC) reported 1,168 confirmed cases across 34 jurisdictions, with 96% of cases occurring in unvaccinated individuals or those with unknown vaccination status. This surge correlates with a decline in measles-mumps-rubella (MMR) vaccination coverage, which has fallen below the 95% threshold necessary for herd immunity in many communities. This narrative-based mini-review aimed to examine the complex drivers of vaccine hesitancy, emphasizing the role of misinformation and conspiracy theories propagated through digital platforms. These narratives exploit cognitive biases and erode public trust in health institutions, leading to parental vaccine hesitancy and decreased vaccine uptake. The review incorporates behavioral science insights to understand how social identity, risk perception, and information processing contribute to vaccine refusal. Effective interventions must address these psychological and sociocultural factors. Strategies include empathetic communication by healthcare providers, culturally tailored public health messaging, and community engagement initiatives that involve trusted local leaders. Additionally, implementing “prebunking” techniques—proactively exposing individuals to refuted misinformation—can build cognitive resilience against false narratives. To counteract the spread of vaccine misinformation, collaboration between public health authorities and digital platforms is essential to monitor and mitigate the dissemination of false information. Policy measures should also consider tightening exemption criteria to maintain high vaccination coverage. Rebuilding public trust in vaccines requires a comprehensive approach that combines scientific evidence with culturally sensitive communication and community involvement. Such efforts are critical to safeguarding public health and preventing the resurgence of vaccine-preventable diseases like measles.

Abbreviations

CDC: Centers for Disease Control and Prevention; MMR: Measles-Mumps-Rubella; WHO: World Health Organization’s.

Introduction

Vaccination stands as one of the most valued achievements in modern science—unmatched in its proven role to prevent infectious diseases, save lives, and reduce health care burdens and costs [1, 2, 3]. The impact of vaccination can be appreciated by the sustained absence of once-prevalent infectious diseases such as the global eradication of smallpox and the near-elimination of poliomyelitis exemplifying vaccination success [4]. Yet, as declining immunization rates now precipitate the return of measles in the U.S., history reminds us that progress, when neglected, is rarely permanent [5].

As measles—a disease declared eliminated in the U.S. in 2000—re-emerges in the U.S. among other countries [6, 7, 8, 9, 10], we are reminded that vaccination success can wither under the weight of misinformation and conspiracy ideas [11, 12, 13, 14]. A significant threat to the success of vaccination programs is vaccine hesitancy; a phenomenon that has shifted from the margins to the mainstream, driven by digital misinformation, ideological polarization, and complex sociocultural dynamics [15, 16, 17, 18, 19, 20, 21].

At its core, vaccine hesitancy might be viewed as a manifestation of a corrosion of trust in institutions, science, and collective responsibility [20, 22]. Nowhere is this more dangerous than in childhood vaccination, where parental decisions ripple far beyond the individual to affect the health and well-being of entire communities [23, 24, 25].

As of June 2025, the Centers for Disease Control and Prevention (CDC) reports 1,168 measles cases across 34 U.S. jurisdictions, most in children, most among the unvaccinated [26, 27]. The culprit in this outbreak was not viral mutation, nor international travel, but a collapse in vaccination coverage [11, 28]. Thus, this narrative style mini-review aimed to examine the roots and reach of vaccine hesitancy with an interdisciplinary emphasis [29, 30]. Specifically, the review aimed to dissect the misinformation milieu, and explore behavioral interventions grounded not in abstraction, but in cognitive psychology and sociocultural engagement.

The Epidemiologic Backdrop: Measles Resurgence and the Consequences of Vaccine Hesitancy

Measles is among the most contagious pathogens known to humankind, with a basic reproduction number (R0) as high as 18 [31]. Thus, measles requires vaccination coverage of over 95% to maintain herd immunity [32]. However, CDC data from 2023 and 2024 show that measles, mumps, and rubella (MMR) vaccine coverage among kindergartners has declined from 94.5% pre-pandemic to 90.3% in 2023, falling even lower in states with philosophical or religious exemptions [33].

These numbers, often dismissed as marginal, are in fact epidemiologically catastrophic as shown in a recent modelling study by Kiang et al. that estimated 11.1 million cases of measles over 25 years in a scenario with a 10% decline in MMR vaccination [34].

In early 2025, an outbreak in southern Texas spread among 74 unvaccinated children, many of whom were below school age [35]. This outbreak was part of a larger resurgence centered in Gaines County, where low vaccination rates— particularly among certain communities—contributed to rapid transmission [36, 37, 38].

By May 2025, Texas reported over 700 measles cases, with two confirmed deaths among unvaccinated school-aged children [26]. Notably, 96% of those infected were unvaccinated or had unknown vaccination status, underlining the critical importance of maintaining high immunization coverage to prevent such outbreaks [35]. National immunization data in the U.S. indicated that MMR vaccine coverage among U.S. kindergartners declined to 93.1% in 2022–2023, with at least 10 states falling below 90% [33]. This reduced childhood vaccine coverage in the U.S. reflects COVID-19 pandemic-related disruptions as well as a sustained rise in vaccine hesitancy [39, 40, 41, 42]. This resurgence of measles in the U.S. illustrates how even modest declines in vaccine coverage—driven in large part by hesitancy—can rapidly erode herd immunity and trigger severe, preventable outbreaks of infectious diseases [43, 44, 45].

Vaccine Hesitancy: Psychological, Sociocultural, and Epistemic Foundations of a Growing Public Health Threat

Vaccine hesitancy is often the product of a rational decision-making process distorted by misinformation, socio-cultural influence, and reduced trust [17, 19, 46, 47]. Understanding vaccine hesitancy as a phenomenon requires comprehensive frameworks that assess the psychological, social, economic, and cultural factors as shown in Figure 1 [48, 49, 50, 51, 52, 53, 54]. The World Health Organization’s (WHO) 3C model— Complacency, Convenience, and Confidence—offers a helpful framework [20]. Among these factors, it is the collapse of confidence that particularly undermines childhood immunization [55, 56].

Figure 1: The psychological, social, economic, and cultural factors associated with vaccination hesitancy. Complacency thrives in the shadow of success in infectious disease containment as follows. In high-income countries, diseases such as measles, diphtheria, and poliomyelitis have become distant memories, their devastation known only through textbooks or grandparents’ stories [57,58]. This absence of direct experience has shifted parental concern away from disease prevention and toward vaccine side effects despite being rare or unfounded [23,59,60]. The psychological calculation is understandable; when the perceived threat of disease disappears, any risk, however minimal, appears excessive [50]. Yet this complacency ignores that the very absence of these diseases is the direct result of sustained population immunity achieved through vaccination coverage [61].
Click to enlarge
Figure 1: The psychological, social, economic, and cultural factors associated with vaccination hesitancy. Complacency thrives in the shadow of success in infectious disease containment as follows. In high-income countries, diseases such as measles, diphtheria, and poliomyelitis have become distant memories, their devastation known only through textbooks or grandparents’ stories [57,58]. This absence of direct experience has shifted parental concern away from disease prevention and toward vaccine side effects despite being rare or unfounded [23,59,60]. The psychological calculation is understandable; when the perceived threat of disease disappears, any risk, however minimal, appears excessive [50]. Yet this complacency ignores that the very absence of these diseases is the direct result of sustained population immunity achieved through vaccination coverage [61].

Figure 1: The psychological, social, economic, and cultural factors associated with vaccination hesitancy. Complacency thrives in the shadow of success in infectious disease containment as follows. In high-income countries, diseases such as measles, diphtheria, and poliomyelitis have become distant memories, their devastation known only through textbooks or grandparents’ stories [57, 58]. This absence of direct experience has shifted parental concern away from disease prevention and toward vaccine side effects despite being rare or unfounded [23, 59, 60]. The psychological calculation is understandable; when the perceived threat of disease disappears, any risk, however minimal, appears excessive [50]. Yet this complacency ignores that the very absence of these diseases is the direct result of sustained population immunity achieved through vaccination coverage [61].

In high-income countries, where access and infrastructure rarely present obstacles, convenience plays only a modest role in vaccine uptake as opposed to low- and middle-income settings [62]. The true challenge lies elsewhere—more insidious, more potent. The surge in vaccine hesitancy is not born from ignorance but from a distortion of information channels [63, 64, 65, 66]. Social media and digital platforms such as YouTube, TikTok, and Facebook facilitated the spread of misinformation [67, 68, 69]. For example, complex immunological concepts, which demand intellectual engagement and deep understanding, were flattened into viral content that is emotionally charged and dangerously persuasive in these platforms [70, 71, 72, 73]. The power of a single mother on TikTok claiming that her child regressed after a routine vaccination far outweighs the weight of a thousand peer-reviewed papers in the court of public opinion [74].

These narratives do not wear the anti-science costume but cloak themselves in intuition, maternal instinct, and a compelling desire to protect children [75]. And therein lies their insidious strength—they do not reject science outright; they supplant it with something that feels more immediate and real [76, 77].

Beneath the storm of misinformation lies a deeper crisis; that of confidence. Confidence in the institutions meant to safeguard public health, science, medicine, and government has eroded [78, 79, 80]. When authorities deliver inconsistent messages, or when they appear beholden to political agendas or pharmaceutical interests, public trust fractures [81, 82, 83]. This was evident during the COVID-19 pandemic, where shifting guidance on masks and vaccines—however rooted in evolving evidence—appeared to many as arbitrariness or deceit [13, 84, 85]. In that epistemic vacuum, conspiracy theories did not merely proliferate—they flourished, offering not just answers, but meaning, identity, and control [86, 87, 88].

Now, we consider the case of the measles outbreaks in the U.S.—a disease once nearly eradicated, rebounding in communities where distrust of vaccines aggravates [28, 89]. The distrust can be attributed to failure of science communication, engagement, of credibility [90, 91, 92]. Facts alone will not suffice. To restore public confidence, we must acknowledge the human dimension of this challenge. Transparency must replace opacity; consistency must replace confusion; humility must replace paternalism [56, 93]. To prevail, health professionals and scientists must engage as partners and build the trust upon which all public health ultimately rests [94]. In sum, vaccine hesitancy is not a knowledge deficit but a complex problem of confidence, fuelled by misinformation and eroded trust. This requires scientific refutation as well as empathetic, culturally aware engagement.

The Misinformation Milieu: Digital Amplification, Narrative Power, and the Crisis of Public Trust

In the current peculiar era of scientific abundance and digital chaos, we confront a phenomenon no less formidable than the viruses we once feared; a misinformation pandemic and the so-called “infodemic” [95, 96, 97, 98]. The infectious agents of the infodemic are not microbes but memes; its vectors are not travelers, but algorithms [99, 100]. The anti-vaccine movement, long relegated to the margins of public discourse, has mutated [101]. It is no longer isolated, but now it functions as a transnational, networked efforts [102, 103, 104]. The anti- vaccine movement use social platforms with manipulation of narrative, targeting the very concept of public trust [105].

It is important to state that vaccine resistance is no novel phenomenon post-COVID-19 pandemic [106]. The suspicion was always there—embedded in political ideology, religious doctrine, and communal memory [107]. What is different now is not the existence of vaccine resistance, but the machinery that amplifies it; the global, instantaneous reach of digital platforms [15, 75]. In the contemporary digital environment, vaccine misinformation has been amplified by algorithmic systems that prioritize engagement over accuracy, resulting in the widespread dissemination of emotionally charged content [71, 108]. These narratives frequently center on alleged adverse effects of vaccines, perceived infringements on personal autonomy, and unverified claims of collusion between governmental agencies and pharmaceutical companies [77, 109]. Their persuasive power lies not in evidentiary rigor, but in their ability to evoke strong emotional responses through anecdotal storytelling, visual immediacy, and rhetorical simplicity [110, 111, 112]. This mode of vaccine information communication stands in stark contrast to the deliberative processes of scientific consensus, which require systematic investigation and deep insightful interpretation [74].

The differential appeal of these competing forms of knowledge production creates an asymmetry. While scientific evidence is inherently complex and often probabilistic, misinformation offers accessible, definitive, and emotionally resonant explanations, particularly in moments of societal uncertainty [113, 114]. These narratives operate as cognitive heuristics—simplified mental models that provide clarity in the face of ambiguity [115, 116]. Importantly, vaccine hesitancy seldom arises in isolation. It is frequently embedded within broader worldviews characterized by skepticism toward pharmaceutical industry motives, concern about government overreach, and mistrust of mainstream media [117, 118, 119]. In this context, parental refusal of vaccines including the MMR vaccines may be better understood as an expression of a deeper, systemic disillusionment with public institutions [47, 60, 120]. This reframing has critical implications for public health strategy.

Effective responses to vaccine misinformation cannot rely solely on the provision of accurate information [121]. While fact-based counter-messaging remains essential, it must be embedded within a broader framework that addresses the social, historical, and psychological dimensions of trust [122]. Research has shown that vaccine acceptance is strongly associated with perceived credibility and alignment of values than with knowledge alone [123, 124]. Therefore, rebuilding vaccine confidence requires an approach that includes transparent communication, consistency in public health messaging, and sustained, culturally sensitive engagement with communities [125, 126]. As measles re-emerges in settings where it was once controlled, the need to restore confidence in vaccination becomes urgent [127, 128]. Public health communication must evolve to encompass strategies that prioritize empathy, credibility, and partnership [129]. Addressing vaccine hesitancy in the digital age necessitates an interdisciplinary innovative response—one that integrates epidemiology with behavioral science, strategic communication, and ethical public engagement to rebuild the fractured trust upon which effective immunization programs depend [130, 131, 132]. Combating vaccine misinformation in the digital age demands more than fact-checking; it requires a trust-centered, knowledge-based public health response that is interdisciplinary, emotionally intelligent, and grounded in community engagement.

Understanding and Countering Vaccine Hesitancy: Behavioral, Social, and Ethical Pathways to Rebuilding Trust

The resistance to vaccination, often mistaken for ignorance or defiance, is in fact deeply rooted in the human mind [66]. It is not simply that people misunderstand the science; rather, the way our cognitive system interprets risk makes such misunderstandings almost inevitable [133, 134]. Behavioral science offers crucial insight here, revealing how ancient heuristics, once adaptive for survival, now skew perceptions in ways that hinder public health [135, 136]. For example, the availability heuristic can play a role where a rare vaccine side effect (e.g., an episode of anaphylaxis) is magnified in the public imagination once dramatized in media or shared virally on social platforms [137, 138, 139]. It acquires psychological weight disproportionate to its statistical rarity. A single case, especially when framed with emotion and imagery, overwhelms a thousand safe vaccinations in the mind of a concerned parent [140, 141].

Closely related is the omission bias, the tendency to prefer harms caused by inaction over those caused by action [142]. Many parents would rather accept the risk of measles than feel personally responsible for a perceived vaccine injury, however unlikely [141]. In their calculation, doing nothing feels safer than doing something—even if the science strongly suggests otherwise [143, 144]. Layered upon this is confirmation bias; once an individual has embraced the belief that “vaccines are dangerous,” they become selectively attentive to information that supports that belief and dismissive of anything that contradicts it [145].

On the other hand, vaccine hesitancy is not merely a cognitive distortion; it is also a social phenomenon [19]. Beliefs are rarely formed in isolation. They are constructed and sustained within communities, shaped by cultural identity, religious values, and political ideology [146]. In some cases, rejecting vaccines is less about fear and more about belonging—an expression of solidarity with a particular group or worldview [147]. This is why correcting misinformation cannot rely on facts alone. It must also speak to the social value of belief [148, 149]. Addressing these challenges requires an informed approach that blends behavioral insights with biomedical evidence as shown in (Figure 2) [130, 150].

Figure 2: Key interventions to address parental vaccine hesitancy in the digital era. First, healthcare providers’ communication should be reimagined, since the recommendation of a trusted healthcare professional is a predictor of vaccine acceptance [151]. Yet when that advice is delivered in a top-down, authoritarian manner it often backfires [78]. Studies increasingly support the effectiveness of motivational interviewing, a patient- centered communication strategy that emphasizes empathy, curiosity, and collaborative decision-making [152-155]. When providers listen without judgment and engage parents in a narrative dialogue, they foster trust rather than resistance.
Click to enlarge
Figure 2: Key interventions to address parental vaccine hesitancy in the digital era. First, healthcare providers’ communication should be reimagined, since the recommendation of a trusted healthcare professional is a predictor of vaccine acceptance [151]. Yet when that advice is delivered in a top-down, authoritarian manner it often backfires [78]. Studies increasingly support the effectiveness of motivational interviewing, a patient- centered communication strategy that emphasizes empathy, curiosity, and collaborative decision-making [152-155]. When providers listen without judgment and engage parents in a narrative dialogue, they foster trust rather than resistance.

Figure 2: Key interventions to address parental vaccine hesitancy in the digital era. First, healthcare providers’ communication should be reimagined, since the recommendation of a trusted healthcare professional is a predictor of vaccine acceptance [151]. Yet when that advice is delivered in a top-down, authoritarian manner it often backfires [78]. Studies increasingly support the effectiveness of motivational interviewing, a patient- centered communication strategy that emphasizes empathy, curiosity, and collaborative decision-making [152, 153, 154, 155]. When providers listen without judgment and engage parents in a narrative dialogue, they foster trust rather than resistance.

Second, cultural competence must become the cornerstone of vaccine messaging. One-size-fits- all approaches are ineffective in a pluralistic society. Interventions must be tailored to reflect the language, values, and belief systems of specific communities via community- led, culturally embedded message delivery as a durable path forward [156]. Third, pre-bunking grounded in inoculation theory should be invested in [157]. Just as vaccines introduce harmless antigens to prime the immune system, exposing individuals to weakened forms of misinformation can build psychological resilience [158]. Fourth, digital platforms must be held accountable. Current efforts at content moderation are sporadic and insufficient. While some platforms demote or label anti-vaccine content, enforcement is uneven, and algorithms continue to prioritize engagement over accuracy [65, 159]. Public health must advocate for algorithmic transparency, and must also proactively seed social media with engaging, accurate narratives that compete with misinformation on equal environment [75, 160]. Finally, it is important to contend with the legal and ethical dimensions of vaccine policy. The tension between individual liberty and communal health is longstanding, but in the context of infectious disease, it is ethically untenable to treat vaccination as a purely personal choice [161, 162, 163]. In the U.S., the States with lenient exemption laws consistently exhibit lower vaccination rates and higher outbreak incidence [164, 165]. Respect for autonomy must be balanced with the collective right to health [166]. Vaccine refusal, unlike most other health decisions, endangers others—especially those who cannot be vaccinated for medical reasons [167]. Public health, therefore, must not only inform—it must protect. In this moment of measles resurgence and rising skepticism, the public health tools must be as sophisticated as the challenges faced. The response to vaccine hesitancy must be interdisciplinary, evidence-based, and rooted in a profound understanding of the human condition. Only then can we rebuild the trust on which the success of all immunization efforts depends.

Conclusion

We are living through a paradox; at a time of unparalleled scientific advancement, trust in science is declining. The reemergence of measles in 2025 in the U.S. is not a failure of immunology but of sociology and communication. Vaccine hesitancy, driven by misinformation, now represents one of the greatest threats to child health in the developed world. Public health must evolve. This requires a shift from information transmission to meaning-making, from paternalism to partnership, and from reactive to anticipatory communication. Only through a fusion of science, empathy, and cultural literacy can we hope to rebuild the public trust upon which vaccination depends.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare they have no competing interests.

Author contributions

Conceptualization: Malik Sallam Data Curation: Malik Sallam, Saja Al-Baidhani, Mohammed Sallam Investigation: Malik Sallam, Saja Al-Baidhani, Mohammed Sallam Methodology: Malik Sallam, Saja Al-Baidhani, Mohammed Sallam Project administration: Malik Sallam Supervision: Malik Sallam Visualization: Malik Sallam Writing – Original Draft Preparation: Malik Sallam Writing – Review & Editing: Malik Sallam, Saja Al- Baidhani, Mohammed Sallam

Availability of Data

The data presented in this study are available in the References section.

Further Disclosure

None.

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@article{sallam2025,
  title   = {Addressing Vaccine Hesitancy in the Age of Measles Resurgence: A Mini-Review},
  author  = {Sallam M},
  journal = {Vaccines & Vaccination Open Access},
  year    = {2025},
  volume  = {10},
  number  = {1},
  doi     = {10.23880/vvoa-16000178}
}
Sallam M (2025). Addressing Vaccine Hesitancy in the Age of Measles Resurgence: A Mini-Review. Vaccines & Vaccination Open Access, 10(1). https://doi.org/10.23880/vvoa-16000178
TY  - JOUR
TI  - Addressing Vaccine Hesitancy in the Age of Measles Resurgence: A Mini-Review
AU  - Sallam M
JO  - Vaccines & Vaccination Open Access
PY  - 2025
VL  - 10
IS  - 1
DO  - 10.23880/vvoa-16000178
ER  -