In 2012, the World Health Organization (WHO) generated a global vaccine action plan for the elimination of measles in five of the six WHO regions of the world. However, the WHO's Strategic Advisory Group of Experts on Immunization (2018) concluded that instead of the hoped-for decrease, there was an increase of measles in four of six WHO regions between 2013 and 2017. Dr. Katherine O'Brien, WHO's Director of Immunization, Vaccines, and Biologicals reported there have been substantial measles outbreaks in all WHO regions, and less than 10% of measles cases are reported, thus the numbers are much higher (https://medicalxpress.com/news/2019-02-backsliding-measles-cases-soar.html). This alarming trend includes an increase in measles cases to 634,139 in 147 of 194 countries surveyed (Melegaro, 2019). It is estimated that in 2017, nearly 20 million children worldwide were undervaccinated or not vaccinated.

Measles can be carried into the United States by those who have not been vaccinated and infected in other countries. Based on a Centers for Disease Control and Prevention (CDC) report, in 2018 Venezuela had 68% of measles cases in the Americas, and the majority of measles-related deaths (73 out of 85) (Paniz-Mondolfi et al., 2019). Patel and Orenstein (2019) classified data on measles cases into two major categories. These include (1) being related to being programmatically preventable (i.e., children failed to receive country-specific age-appropriate doses of vaccinations) or (2) nonpreventable related to one of the following factors: (a) did not receive at least two doses of MCV (measles-containing vaccine); (b) were too young to receive a first dose; (c) received one dose of MCV but were too young to receive an additional dose; or (d) were eligible for only one dose according to specific national recommendations. In measles cases during 2013-2017, globally 63% were related to failure of vaccine programs to vaccinate children appropriately (Patel & Orenstein).

Because measles is highly contagious and easily and quickly spread, herd immunity is needed to prevent outbreaks. Herd immunity occurs when a high percentage of people are vaccinated, which prevents the disease from spreading. In the United States in 2000, because of the MCV, the virus was thought to have been eliminated. However, in 2019, outbreaks are occurring in the United States; as of the end of February 2019, >120 people in the United States (mostly young children) have contracted measles (Belluz, 2019). Epidemiologists conclude when measles vaccine coverage drops below 95%, outbreaks are inevitable (Belluz). Although there is significant variation among states, many states allow parents to opt out of vaccinations for their children on religious and moral reasons. These options create conditions in which children who are not vaccinated for medical reasons or are too young to be vaccinated are at risk of contracting the disease and associated complications, including death.

Barriers to immunization need to be overcome with aggressive local and global strategies. Economic commitment to immunization needs to be increased dramatically. Surveillance of cases of measles must be improved to generate robust epidemiological data documenting trends. The WHO is committed to working toward the elimination of measles worldwide through strong vaccination programs. In each country, there should be a surveillance system that fosters detection, investigation, and quick response to any potential cases of measles (Patel & Orenstein, 2019). Nurses can offer education to parents about vaccines and the need to make sure their children are up-to-date with all of the recommended vaccines to keep them safe. Nurses can refer parents to the CDC site on information about vaccines for parents https://www.cdc.gov/vaccines/parents/index.html.

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