Fine-scale spatial clustering of measles nonvaccination that increases outbreak potential is obscured by aggregated reporting data

Nina B. Masters*, Marisa C. Eisenberg, Paul L. Delamater, Matthew Kay, Matthew L. Boulton, Jon Zelner

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


The United States experienced historically high numbers of measles cases in 2019, despite achieving national measles vaccination rates above the World Health Organization recommendation of 95% coverage with two doses. Since the COVID-19 pandemic began, resulting in suspension of many clinical preventive services, pediatric vaccination rates in the United States have fallen precipitously, dramatically increasing risk of measles resurgence. Previous research has shown that measles outbreaks in high-coverage contexts are driven by spatial clustering of nonvaccination, which decreases local immunity below the herd immunity threshold. However, little is known about how to best conduct surveillance and target interventions to detect and address these high-risk areas, and most vaccination data are reported at the state-level—a resolution too coarse to detect community-level clustering of nonvaccination characteristic of recent outbreaks. In this paper, we perform a series of computational experiments to assess the impact of clustered nonvaccination on outbreak potential and magnitude of bias in predicting disease risk posed by measuring vaccination rates at coarse spatial scales. We find that, when nonvaccination is locally clustered, reporting aggregate data at the state- or county-level can result in substantial underestimates of outbreak risk. The COVID-19 pandemic has shone a bright light on the weaknesses in US infectious disease surveillance and a broader gap in our understanding of how to best use detailed spatial data to interrupt and control infectious disease transmission. Our research clearly outlines that finer-scale vaccination data should be collected to prevent a return to endemic measles transmission in the United States.

Original languageEnglish (US)
Pages (from-to)28506-28514
Number of pages9
JournalProceedings of the National Academy of Sciences of the United States of America
Issue number45
StatePublished - Nov 10 2020
Externally publishedYes


  • Measles | epidemiology | simulation model | disease dynamics | vaccination clustering

ASJC Scopus subject areas

  • General


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