In Amish country, nurses go door to door to stop deadly spread of measlesWith four measles-related deaths in Pennsylvania, health officials are hoping to get people on board with vaccines in private.6 hrs agoUS & Canada

For the past few months, nurse Dale Weiser has been making unexpected home visits.

As the state battles the deadliest measles outbreak in recent history, the clinical supervisor drives 30 miles (48.3km), sometimes daily, to a rural corner of Pennsylvania where many Amish people live.

Walking into strangers’ homes, Weiser says she tries her best to be respectful and non-intrusive as she vaccinates dozens of family members against the measles, sometimes around the kitchen table.

“A lot of people that I encounter, they don’t have health insurance. They don’t have a lot of interaction with the health system, and they just haven’t seen the need to get these vaccines,” said Weiser, who works for the Chester County Health Department.

The at-home vaccinations are part of the county and state health departments’ strategy to encourage immunisations in the county, which includes an Amish community who abstain from many aspects of modern life, including regular contact with the western medical system.

The state health department told the BBC it has administered nearly 4,300 measles, mumps and rubella (MMR) vaccines at pop-up clinics near the epicentre of the outbreak since it began in late April.

• US measles cases reach 35-year high

But even as health officials see success in their vaccine programmes, the state has reported four deaths from measles complications, marking the most deadly outbreak the US has seen since 1992.

The infections have led to tensions between state and federal health officials, including vaccine-skeptic Health Secretary Robert F Kennedy Jr.

Those politics are back of mind in the Amish community, where people are growing fearful of more deaths as they watch their friends and family fall sick with the disease, which for decades has been eliminated in the US.

“They’re not a community that’s as easy to reach – we can’t just put up a social media post,” Weiser said. “They are suffering at the moment, and we’re trying to reach out and make connections.”

Amish people began coming to the US in the early 1700s, with the first community settling in Lancaster, Pennsylvania. Known as the “Plain People” for the simple clothes they wear, the Amish are a devout Christian community that does not use many forms of technology, relying on horse and buggies instead of cars.

About 90,000 Amish people live in Pennsylvania, with estimates suggesting around only a quarter of Amish people in the Lancaster area have had the MMR vaccine.

There is no particular religious text advising against vaccines, but Amish people do not have regular contact with the western medical system, or have a way to easily travel to appointments, experts said.

“A lot of people who haven’t gotten vaccinated, it’s not because they have a strong stance against getting vaccinated for measles. It’s just that they haven’t gotten around to it. It’s not convenient,” said Braxton Mitchell, a genetic epidemiologist with University of Maryland School of Medicine who runs a research clinic studying the Amish in Lancaster.

Amish people are extremely social, he said, so when the virus hits one church group, it affects everyone who is unvaccinated.

“Measles is rampant in the Amish community,” he said. “People are concerned about it.”

He added the community has been especially concerned about the dangers to babies; so far two newborns have died of measles complications, as well as an 18-year-old and a 40-year-old woman, according to state officials.

Chester County public health officials did not wait long to launch a response to the growing measles outbreak in their community, which shares a border with Lancaster County, the epicentre of the outbreak.

Jeanne Franklin, the director of the health department, said officials have been using some of the strategies they employed during the Covid pandemic – knocking on doors in the community to let them know about the outbreak and offering private settings, like people’s homes, for immunisations.

Since the outbreak started, the county has given 538 MMR vaccines, 340 of which they administered in private settings.

“People have called up and said, ‘I can’t get to your clinic, or, I don’t want people to know I’ve changed my mind,” Franklin said. “‘If you can come to us, that’s a lot easier.'”

The boots-on-the-ground approach has helped the health department dispel misinformation and build trust with the community, local health officials said.

In recent years, childhood vaccination rates have fallen across the country as false theories about the safety of the measles vaccine have proliferated on social media.

Those theories have found roots even in an insulated community with limited access to computers, Weiser said. She has heard people ask if there are heavy metals in the vaccine that could make them magnetic, or if the shot has a computer chip in it.

“You’re clearly getting information from that hard-core group that is promoting that misinformation and disinformation,” she said.

People in this “hard-core group”, who are staunchly against vaccines, are unlikely to be swayed, experts and officials themselves said.

But now, local health officials said, many affected by the Pennsylvania outbreak are seeing their neighbours fall seriously ill and asking thoughtful questions. Weiser said many are parents who are unfamiliar with the shots and are scared to make the wrong choice for their children.

“There is the classically-defined anti-vaxer, versus people who are unaware or their culture feels differently,” Franklin said. “The thinking and the willingness to discuss and possibly change your mind is different between those two bookends.”

The ongoing measles outbreak in Pennsylvania has once again sparked political debate in the US.

After the state health department announced the first two deaths – both in infants – Kennedy, the top health official, took to social media to dispute at least one of the deaths. The BBC has contacted the Department of Health and Human Services for comment.

Democratic Governor Josh Shapiro took aim at Kennedy, saying he told the top US health official that he was spreading misinformation that was worsening the outbreak.

Lancaster County coroner Stephen Diamantoni, a Republican, has said one of the two infants died of a ruptured spleen rather than measles itself. Measles can cause the spleen to enlarge, making it more likely to rupture. Several doctors have said the measles infection made the child vulnerable.

“I think the measles very much contributed to that child’s demise,” said William Moss, a pediatric infectious disease specialist at the Johns Hopkins Bloomberg School of Public Health.

Public health experts said a number of actions taken by Kennedy and the Trump administration have sowed doubts about vaccine safety and worsened outbreaks.

Last month, Trump passed an executive order recommending the MMR shot be split into three separate shots, a move doctors say is costly and unnecessary for a vaccine that is already safe.

“What he’s doing is casting doubt,” said Dr Moss. “He basically said the vaccine could be dangerous in its current combined form.”

The tensions are not helpful for experts working to combat misinformation in a so-far unrelenting outbreak, they said. They worry for the start of the school year, which will provide even more opportunities for the highly contagious virus to spread.

“I think we’re in this for six to 12 months. It does feel like it’s spreading and accelerating,” Weiser said. “We’re in community transmission now. We can’t stop it easily.”