A Measles Outbreak in an Underimmunized Amish Community in Ohio

N Engl J Med. 2016 Oct 6;375(14):1343-1354. doi: 10.1056/NEJMoa1602295.


Background: Although measles was eliminated in the United States in 2000, importations of the virus continue to cause outbreaks. We describe the epidemiologic features of an outbreak of measles that originated from two unvaccinated Amish men in whom measles was incubating at the time of their return to the United States from the Philippines and explore the effect of public health responses on limiting the spread of measles.

Methods: We performed descriptive analyses of data on demographic characteristics, clinical and laboratory evaluations, and vaccination coverage.

Results: From March 24, 2014, through July 23, 2014, a total of 383 outbreak-related cases of measles were reported in nine counties in Ohio. The median age of case patients was 15 years (range, <1 to 53); a total of 178 of the case patients (46%) were female, and 340 (89%) were unvaccinated. Transmission took place primarily within households (68% of cases). The virus strain was genotype D9, which was circulating in the Philippines at the time of the reporting period. Measles-mumps-rubella (MMR) vaccination coverage with at least a single dose was estimated to be 14% in affected Amish households and more than 88% in the general (non-Amish) Ohio community. Containment efforts included isolation of case patients, quarantine of susceptible persons, and administration of the MMR vaccine to more than 10,000 persons. The spread of measles was limited almost exclusively to the Amish community (accounting for 99% of case patients) and affected only approximately 1% of the estimated 32,630 Amish persons in the settlement.

Conclusions: The key epidemiologic features of a measles outbreak in the Amish community in Ohio were transmission primarily within households, the small proportion of Amish people affected, and the large number of people in the Amish community who sought vaccination. As a result of targeted containment efforts, and high baseline coverage in the general community, there was limited spread beyond the Amish community. (Funded by the Ohio Department of Health and the Centers for Disease Control and Prevention.).

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Amish / statistics & numerical data*
  • Child
  • Child, Preschool
  • Disease Outbreaks*
  • Female
  • Humans
  • Infant
  • Male
  • Measles / epidemiology*
  • Measles / transmission
  • Measles-Mumps-Rubella Vaccine / administration & dosage*
  • Middle Aged
  • Ohio / epidemiology
  • Vaccination / statistics & numerical data*


  • Measles-Mumps-Rubella Vaccine