Most people do. Then there are those who refuse.
Just last week in Rockland County, New York, which has been battling a persistent outbreak of measles in the Orthodox Jewish community for six months, a contagious person stopped cooperating with local investigators.
"[They] notified us that they were at a Target in Spring Valley, New York," said John Lyon, director of strategic communications for the Office of County Executive in Rockland County, New York.
"But then they stopped returning our phone calls, wouldn't pick up the phone, wouldn't help us narrow down the time they were there," Lyon said.
That's critical information, he said, because measles can live in the air and on surfaces for up to two hours. By narrowing the time of exposure in a public place, he said, officials can reassure fearful residents and keep that "mother with the 2-month old from worrying."
"She can say, 'OK, I went to the store, but I wasn't there at that time, so my baby's OK,' " Lyon said.
In this case, however, the county had to issue a warning of possible exposure over a two-day period, March 10 and 11, Lyon said, "needlessly worrying" that mom and other residents.
That was just one example. Refusing to cooperate was happening so often, Lyon said, that the city said "enough was enough" and took the unusual step Wednesday of banning unvaccinated people under age 18 from going to public places.
Although the county has no plans to "stop and ask people to present their medical records," the new law does have teeth, Lyon said. Anyone under 18 who remains unvaccinated and appears in a public place during the outbreak -- now at 156 cases -- can be referred to the district attorney for possible legal action.
"Now, there's a consequence for not cooperating with our investigators. Now there's a consequence for not being responsible," Lyon said. "We want people to do this on their own, but unfortunately, some of them aren't. And that's a danger to their friends and neighbors and everyone in our community."
Another entrenched outbreak
Rockland's not the only community that's had to force public cooperation during this outbreak. In December, New York City's Department of Health and Mental Hygiene issued exclusion orders for specific zip codes in Brooklyn and Queens. The orders banned unvaccinated children from attending Orthodox Jewish schools, called yeshivas, until they were vaccinated or the outbreak was over.
It didn't entirely work.
"We've had some cases of yeshivas' violating those exclusion orders, which has led to transmission in the schools," said Michael Lanza, spokesman for the department.
As of Wednesday, there were 214 confirmed cases of measles in Brooklyn and Queens, mostly in the Orthodox Jewish neighborhoods of Borough Park (47) and Williamsburg (161). According to the department of health, Williamsburg reported an additional 31 cases in just the past week.
If the yeshivas continue to allow unvaccinated children into their schools, Lanza said, the city may turn to commissioner's orders, which impose a fine on the school's principal of $2,000 a day per unvaccinated child. Why the principal?
"They are in charge of the school," Lanza said. "They should be ensuring the exclusion rules are being followed. And so, if they have a handful of unvaccinated children, that fine would increase in magnitude."
Public health officials in both of these New York communities have taken enormous strides toward getting this outbreak under control. Rockland County has vaccinated 17,000 people during the six-month outbreak; there were 7,000 additional vaccinations since last year in Williamsburg and Borough Park.
Yet new cases of measles continue to pop up.
"It would seem that everyone who's going to get vaccinated probably has," Lanza said.
Fighting misinformation
Blima Marcus lives in Borough Park, Brooklyn, and is a part of the local Orthodox community. She is also a nurse and past president of the Orthodox Jewish Nurses Association. It was in that role that she began to try to educate members of her community who were fearful of vaccines.
Fanning those fears, Marcus discovered, was a slick 40-page booklet being distributed throughout the Orthodox communities in New York and New Jersey about the dangers of vaccines. The booklet was created by a group called PEACH, or Parents Educating and Advocating for Children's Health.
CNN's calls to the organization have not been returned.
The booklet is directly aimed at the Orthodox community, partly written in Hebrew and filled with snippets from the Torah, or Old Testament. Yet local Orthodox Jewish leadership has made it clear that there is nothing in Jewish law that prohibits vaccinations. In fact, it's the opposite.
"It says in the Torah 'V'nishmartem Meod L'nafshoseichem,' that a person must guard their health," said Rabbi David Niederman, president of the United Jewish Organization of Williamsburg and North Brooklyn, in a statement released by the New York City health department. "It is abundantly clear on the necessity for parents to ensure that their children are vaccinated, especially from Measles."
In the same statement, Rabbi Avi Greenstein, CEO of the Borough Park Jewish Community Council, said, "We are also doing everything in our power to stop the disease from spreading further in our community and especially in our yeshivas. It is imperative that every member of our community protect themselves and their families by getting vaccinated."
'It's pretty easy to plant fear'
Dr. Sean O'Leary, a pediatric infectious disease specialist who researches vaccine hesitancy at the University of Colorado School of Medicine, recognizes much of the misinformation in the booklet.
"I don't know how much of this pamphlet that's circulating is playing on their religious concerns or playing on just the usual misinformation we see from the anti-vaccine advocates," he said. "Because most of the pamphlet looks to be lifted from other pamphlets that these groups have put together before."
Regardless, he says, the misinformation is effective.
"The outbreaks we're seeing now with measles in the United States are absolutely driven by parents refusing vaccines," O'Leary said. "Myths about vaccine dangers are very hard to get out of people's minds, because the more you say it's a myth -- for example, vaccines don't cause autism -- the more you risk reinforcing the myth by associating the two even though it's completely false.
"It's pretty easy to plant fear into people's minds," O'Leary continued, "but it's much harder to get that fear out of their minds."
From front cover to back cover, the booklet is full of misinformation about vaccines, said Shevi Rosner, a neonatal ICU nurse who has worked closely with Marcus at the nurses association. She is now the current president.
"It's so well-produced and written that it looks professional and factual," Rosner said. "But it's filled with cherry-picked snippets of articles that appear to prove that vaccines are dangerous, yet when you look at the article, it's saying the exact opposite."
In addition to myths about vaccine dangers, the booklet has sections on SIDS (sudden infant death syndrome), polio and vaccines for pregnant women. It attempts to cast doubt on the dangers of several of the diseases vaccines aim to prevent. Tetanus, hepatitis B and human papillomavirus (HPV) are discussed under a section labeled "Irrelevant Diseases."
A full two pages argue that unvaccinated children are not endangering their peers; another section discusses "medical atrocities" by the Nazis. One headline over a colorful graphic chart declares: "Sanitation, Nutrition and Improved Living Conditions, NOT Vaccines, Reduced Disease Incidences."
"Because so many in the Orthodox community don't use internet and television," Rosner said, "books are important. And they will read those and believe them unless otherwise persuaded."
Countering the message
To counter the impact of PEACH's anti-vaccination propaganda, Marcus, Rosner and more than 20 other nurses say they have spent hundreds of hours of their own time to research and refute each piece of misinformation in the PEACH booklet.
"Every single statement, every so-called fact they wrote, has been researched," Rosner said, "and we put the real facts next to that misinformation. Our goal is to provide proper education, research and information on this matter."
The group, which calls itself the Vaccine Task Force, plans to publish its rebuttal within the next few weeks, Rosner said, and to distribute the book throughout the New York and New Jersey Orthodox communities.
"The influence of peers is very, very strong," O'Leary said. "And that's why it's particularly important that the countering of this information comes from within this community."
More difficult, he said, will be countering a vaccine conference hotline that frequently invites guests who have written about the dangers of vaccines to speak to the assembled listeners. The call is organized by the same PEACH group that created the booklet. Anonymous members tweet about the calls just hours before they occur.
The vaccine conference call is part of an overall parenting hotline that says it is "A Right Hand for the Jewish Mother," providing recipes, religious, nutritional, weight loss and parenting advice.
"If that's a source of a lot of their parenting information, they're being fed complete misinformation about vaccines directly from anti-vaccine activists," O'Leary said. "And I think the bigger point here is just how these things can spread within a close-knit community where you get most of your information by word of mouth."
A different approach
Outbreaks in close-knit communities are not unusual, O'Leary says. A 2014 outbreak in an Ohio Amish community lasted four months with 383 cases of illness. A 2017 outbreak in a Somali-American community in Minnesota, that was fueled by misinformation from anti-vaxers about dangers of the vaccine that prevents the illness, lasted three months and caused 79 cases of illness. Most of those who were sick were unvaccinated children, as in the current outbreak in New York.
To counter such strong personal connections, O'Leary says, public health officials may need to learn better ways to provide medical information to the public, especially those with entrenched beliefs that run counter to the health message.
"I think for many years the walking paradigm has been you simply provide the factual information and people will make the right decision," he said. "But that assumes that human decision-making is always rational.
"We're not rational creatures in many situations, and emotions play a role," O'Leary continued. "When you get a parent who strongly believes that vaccines have harmed their child, it's a very compelling story for a lot of parents. So yes, I think we need to do a better job on how to communicate science to the public, particularly around vaccines."
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