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In late April, Joshua Good got a call from a parent at Ephrata Mennonite School: Two of their children had been diagnosed with measles.

Good, who heads the private religious school in Lancaster County, knew he had to act quickly to prevent further spread of the highly contagious disease. But he was not particularly surprised that measles had turned up at his school.

Ephrata Mennonite, a K-12 school with 375 students, is among the most under-vaccinated schools in the state. Less than half its 27 kindergarten students last school year were immune to measles, which can infect nine in 10 unvaccinated people.

Good, who vaccinated his own children, had watched over the last 10 years as more and more parents in his school and church communities had opted out. He knew firsthand how difficult it had become to change minds.

He contacted a local school district nurse who works closely with Ephrata Mennonite, and then got “right away on a conference call with the state Department of Health.”

In neighboring Lebanon County, three people had arrived at a hospital days earlier with the highly contagious disease. State contact tracers quickly found eight more cases in the county.

Now the outbreak had come to Lancaster.

By this Friday, 53 measles cases had been detected in four counties in Southeastern and Central Pennsylvania, the state’s biggest outbreak in more than 30 years.

The outbreak remains unpredictable as it unfolds in rural counties just west of the Philadelphia metro area, where a recent Inquirer analysis found under-vaccinated pockets pose a rising risk to a region with higher overall vaccination rates.

Lancaster, which has some of the lowest kindergarten vaccination rates in the state, has been a hot spot all year, with 39 of the 65 total measles cases reported in the state.

And healthcare providers there now worry that measles is circulating far more widely than anyone realizes in a county that, like most in the state, lacks a public health department, and where anti-vaccination sentiment runs high.

Good provided information to help state heath officials trace classmates exposed to the infected students in an effort to contain the spread.

The two students at Ephrata Mennonite have recovered, Good said, and there were no more cases at the school. He feels lucky: One of the infected students had never been at the school while contagious, and the school’s classes end around Memorial Day, so the virus no longer has a chance to spread there.

He welcomed a pop-up vaccination clinic on campus, but even measles cases so close to home were not enough to convince many parents who had not previously accepted shots to immunize their children.

“The measles continues to go around here in the Lancaster-Lebanon area,” he said. “Will that move things at all? I’m not sure.”

Vaccination attitudes in Lancaster

Pennsylvania’s first measles scare this year came in February, when eight people contracted measles in Lancaster County in an outbreak that expanded to neighboring Chester and Montgomery Counties, suburbs of Philadelphia. Twelve cases were ultimately reported, the bulk in Lancaster.

Yet few people were aware of the threat at Lancaster’s bustling flea markets and “mud sales” in late February. While area libraries posted signs warning of a measles outbreak, some parents said they believed the risks of vaccination are worse than the prospect of catching measles.

One Amish father, who had never been vaccinated himself, said his 23-year-old son got immunized only because he was born prematurely.

“God will send you what you want anyway,” said the man, who declined to share his name because he was speaking about private medical details.

Only 88.5% of the county’s kindergartners were immune to measles in 2024, the last year for which data are available — well below the 95% threshold scientists consider necessary to protect a community.

Several Lancaster parents said they’d vaccinated their older children and then had opted against immunizations for their younger children. Others said they’d always considered vaccination the best way to protect their children.

Lancaster’s Amish communities have presented a unique concern for health providers, who have long sought to increase their access to vaccination.

In 1991, these communities were at the center of an outbreak of rubella — a virus sometimes called “German measles” that produces a similar rash and fever to measles, and can cause severe birth defects in pregnant women. Today’s measles vaccines provide protection against rubella, too.

Lancaster General Hospital physicians vaccinated hundreds to stop the outbreak, launching the Child Protect Clinic, which provides free vaccines to uninsured children and builds trust in communities that have difficulty accessing medical care.

These days, about 70% of patients at the Child Protect Clinic are from Plain communities, Christian groups like the Amish and some Mennonite sects that adhere to modest dress codes and in some cases avoid modern conveniences.

Some members of Plain communities oppose vaccination, but opinions can vary widely, and the current outbreak is not centered in Amish households, said Pia Fenimore, Lancaster General Hospital’s vice chair of pediatrics.

Anti-vaccination sentiment has spread broadly across Lancaster — and is not confined to Plain communities — in recent years.

At Ephrata Mennonite, Good said, opposition to vaccination has become entrenched in a “significant portion of parents,” with concerns ranging from how vaccines are developed to their safety to resentment over the handling of the immunizations and public restrictions during the COVID-19 pandemic.

“And then you throw in messaging from key health people like RFK Jr.,” he said, referring to Robert F. Kennedy, Jr., the anti-vaccine activist at the head of the country’s public health apparatus.

Higher vaccination rates at Ephrata Mennonite among seventh and 12th graders speak to how “there’s been a big shift in the last 10 years,” Good said.

Good believes that vaccination is a parent’s choice, and supports Pennsylvania’s relatively lax vaccination exemption rules. Parents here can opt out of vaccinating children for religious, personal, or medical reasons.

He vaccinated his own children and recalls how when they were young, he would often try to convince others in his community to do the same.

“I would get into protracted conversations, trying to persuade people. But the amount of success that I’ve had in that has been pretty low,” Good said.

“When someone asks me for my opinion, I’ll provide it to them.”

Tracking cases

As Pennsylvania’s worst measles outbreak in three decades spreads in Lancaster County, Alice Yoder said she remains unable to convince her fellow county commissioners to post details on the county’s website informing residents of the spiraling case counts and urging vaccination.

The only Democratic county commissioner in Lancaster and a former nurse and executive at Lancaster General, she feels certain the county needs to do more to address the outbreak.

The county’s health advisory website is so outdated that it advertises an April 2025 meeting, ironically on measles preparedness, beside a fact sheet that merely mentions vaccination as a “highly effective” prevention measure instead of the best defense against the disease.

“If it wasn’t for our local newspaper, I don’t know how many people would be aware,” Yoder said.

So far, Lancaster has reported 31 cases in the current outbreak.

Twice in the last month, potential exposures in public places prompted state health officials to issue news releases. At a Kohl’s in Lancaster in late May, shoppers were potentially exposed to measles, which can linger in the air for up to two hours, over four days after an employee tested positive.

And on June 3, a person with measles visiting the Lancaster County courthouse’s marriage license office may have exposed others to the virus between 10 a.m. and 4:30 p.m. The person is now isolating at home, officials said Friday.

Neighboring Lebanon County, where vaccination rates for kindergartners are around 93%, has seen 19 cases. Berks and Dauphin Counties have reported three cases between them.

Last week, state health officials reported that they’d confirmed 20 cases. That alone surpassed the total of 16 cases statewide from all of last year.

The rapid case jump, coupled with Lancaster’s low vaccination rates, concerns Remy Pasco, a research associate at the University of Colorado who helped develop a measles outbreak simulator based on school vaccination rates.

Without more information on when and where patients developed symptoms, he said gauging future case patterns is difficult. Only three patients were still contagious as of Wednesday, according to the state.

Measles can incubate in patients for up to 21 days; more active infections means more residents of the county are currently at risk.

Local physicians fear cases are going unreported, and say communication remains a challenge as the outbreak spreads in a county without a local health agency to lead the response.

“There may be many more cases in the community that don’t come to light because people aren’t getting tested,” said Jeff Martin, a physician who heads the family medicine department at Lancaster General.

In some cases, patients may not appreciate why it’s important for health officials to track the spread of the disease, which typically presents with a fever and a rash but can cause brain inflammation and pneumonia in serious cases.

Others may be afraid that if they report a measles case, “there will be some kind of repercussion,” said Fenimore, a hospital pediatrician.

Could a local health department help?

Yoder has spent years calling for a local health department that could update county residents regularly on health threats and educate about the importance of vaccination and other public health measures. But there is little political will to do so, she said.

Lancaster, like 60 of Pennsylvania’s 67 counties, has no local health department, which makes it difficult for Martin and Fenimore to get the full picture of what’s happening.

State officials, who are largely handling the response, say they’re working diligently to contain the outbreak, by conducting contact tracing and hosting vaccine clinics in hot spots that have drawn residents by the dozens.

Martin tracks cases that come through Lancaster General Hospital and its affiliated provider offices. Despite serving on the county health advisory council, Martin learns of cases elsewhere in the county “through the newspaper just like anyone else.”

Martin said that the health department should give physicians details on cases near them regardless of the health system they are detected in.

And, he said, while state health officials are responsive to local physicians and “doing a very good job” at conducting contact tracing, sometimes residents are more receptive to information that comes from their local physician, instead of a state official.

“From a state level, trying to do this in a local community is a little more difficult. We know the providers really well and the unique cultural variations within the community,” he said.

Department of Health press secretary Neil Ruhland said the state is in regular communication with local health systems, working directly with providers to provide “resources and guidance” when cases are detected in an area. The state operates its own health centers in Lancaster and Lebanon Counties, which have “strong ties to the communities they work in.”

State officials have hosted 12 vaccination clinics across the region as the outbreak has unfolded, and local providers routinely offer immunizations at doctor’s offices, fire departments, and state-run health clinics.

Yet no details about the circulating measles threat have reached State Rep. Russ Diamond, a Republican who represents Lebanon County, even as cases in the community where the outbreak began have risen to 19.

“If folks are worried about it,” he said, “then get your kid vaccinated. That’s your right.”

“I don’t know how the state should respond.”

Encouraging vaccination

Parents who have opted against vaccinating their children because of misinformation about vaccine safety have become a focus for local pediatricians trying to halt the outbreak.

The parents coming to Lancaster General often ask about the long-debunked theory that vaccinations cause autism, or ask whether measles is truly dangerous.

In March, two members of Lancaster County’s health advisory board — a nonbinding group that meets every other month — falsely suggested measles vaccines can be deadly and raised long-debunked concerns about measles and autism, according to local news reports.

Neither of Yoder’s two colleagues on the board of commissioners returned calls for comment on the county’s approach to the outbreak.

As physicians race to increase vaccination rates among children whose parents have avoided immunization, they’re also trying to reassure parents in Lancaster whose children are too young to be vaccinated and concerned about the growing risks from measles.

Typically, children receive two vaccines for measles, mumps, and rubella at 1 and 5 years old, but Fenimore increasingly recommends that young children receive an extra early dose at six months, especially if they’re going to spend time around unvaccinated people.

The state is also considering whether to recommend that physicians deliver this “zero dose” to babies as young as six months old in affected counties, said Ruhland, the health department spokesman.

Physicians in Lancaster say it’s key to take time to listen to parents, hear their concerns, and provide accurate information about vaccine safety. These efforts can take several visits.

“We know scare tactics don’t work. What does work is developing a rapport,” Fenimore said. “The fact that we have a current measles outbreak makes this more imperative.”

Inquirer staff writer Gillian McGoldrick contributed to this article.