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Romania’s measles outbreak has eased since last year, but the country remains a clear hotspot in the European Union and European Economic Area (EU/EEA), with young children still accounting for a large share of cases and vaccination gaps proving difficult to close.

Romania accounted for well over half of all 7655 reported measles cases across 30 EU/EEA countries in 2025, according to recent data from the European Centre for Disease Prevention and Control (ECDC).

The figures point to two linked problems: Romania still has large immunity gaps among young children, and the systems designed to close those gaps remain fragile. The result is a country where measles continues to find susceptible children early in life — despite signs that emergency vaccination efforts and catch-up campaigns are beginning to have an effect.

Young Children Bear the Burden

Eight in 10 people who fell ill with measles in 2025 had not been vaccinated, said Sabrina Bacci, MD, MSc, head of vaccine-preventable diseases and immunization at the ECDC, who noted marked differences in age distribution across EU/EEA countries.

“In Romania, over one third of all cases were in children aged 1 to 4 years,” she said.

This contrasts with countries that have higher childhood immunization rates, including Italy, Spain, France, and Poland, where the majority of cases were in adults older than 30 years because of missed vaccinations in the past, said Bacci.

Europe’s 2025 figures are substantially better than 2024’s, when there was a 10-fold rise over the previous year to more than 35,000 cases. Linked to declining vaccination rates during and after the pandemic, 87% of all European cases came from Romania as did 22 of the 23 measles deaths in children.

“Romania’s sharp drop in coverage of the first and second doses of measles-containing vaccines over recent years, especially among young children, likely facilitated early-age transmission,” said Bacci.

By 2023, just 62% of Romanian children had received a second dose of measles-containing vaccine, compared with the European average of 88.8%; the lowest rate in the EU/EEA.

Although the case numbers have dropped significantly since 2024, Bacci warned against complacency. Recent measles rates are still double those of 2023.

The burden is clearly falling on Romania’s very young, said Anna Riatti, United Nations Children’s Fund (UNICEF)’s representative in Romania. “The most affected age group were children under 1 year of age who are not eligible for a measles vaccination,” she said. Unvaccinated children under 5 are also at an increased risk, as measles can develop several severe complications in this age group, she added.

How Romania’s Immunization System Became Vulnerable?

The decline in vaccination coverage in Romania has pre-pandemic roots. A mandatory vaccination law drafted in 2017 was withdrawn from parliamentary debate after facing strong opposition, both at political and public levels. Structural changes within Romania’s primary healthcare system mean routine immunization is no longer conducted through the school system. School doctors are authorized to vaccinate but only do so during special campaigns. The lion’s share of vaccinations, therefore, falls on family doctors, who are in short supply.

“Heavy reliance on family doctors — who have no performance obligations — insufficient access points for vaccination, communication gaps, and persistent vaccine hesitancy make the national situation uniquely vulnerable compared to other countries in the region,” said Riatti.

Associate Professor Gheorghe Gindrovel Dumitra, MD, is a family physician, coordinator of the Vaccinology Working Group, and vice president of the Romanian National Society of Family Medicine/General Medicine Association in Bucharest, Romania. He said there have fortunately been no severe outcomes in his practice. “I have had measles cases, but only in children who were under the vaccination age and came into contact with other sick children,” he said. “My team works very actively to maintain high vaccination coverage. My involvement in this field is national.”

Vaccine Hesitancy Remains Central

Dumitra said the bigger challenge is not the shrinking family medicine workforce, but the need for clinicians to adapt how they communicate with vaccine-hesitant parents.

His research into hesitancy traces its earliest signs to Romania’s introduction of human papillomavirus vaccinations in 2008. For the first time, the authority and importance of vaccination were questioned, he said. “An anti-vaccination campaign was instantly triggered, leaving both the authorities and family doctors — the primary vaccinators — stunned.

The pandemic revived these anti-vaccine campaigns, further eroding trust in prevention, the medical community, and the state’s authority in general, he added. Myths surrounding measles, mumps, and rubella vaccine’s links to autism still circulate among parents despite the debunking of this association more than 15 years ago.

Signs of Progress, but Gaps Persist

The decline in rates since 2024 does indicate progress, said UNICEF. In 2023, Romania finalized a national vaccination strategy that propelled the country’s health authorities to intensify targeted communications and launch catch-up campaigns within communities a year later. From 2024, vaccine procurement and reserve stock procedures began to be updated, in addition to surveillance of postvaccination adverse reactions and quality assurance measures.

Romania’s family doctors are now implementing new communication techniques to address false or misleading anti-vaccination arguments.

One approach under study is the empathetic refutational interview, which uses a series of steps to elicit parent concerns, affirm their values and beliefs to the extent possible, refute the reasoning behind misinformed beliefs in a way that is tailored to their psychological motivations and, finally, provide factual information about vaccines.

Dumitra’s research on the technique, conducted in Romania’s seventh largest county Dolj, suggests trainings on this technique produced a greater increase in commitments to vaccination than motivational interviewing, another four-step technique tested in the US, Canada, and France.

But it’s the lack of consequences for parents who refuse vaccination that remains a serious issue, said Dumitra.

“Children are integrated into school communities even if they are not vaccinated,” he said. “In fact, it has even become ‘cool’ to refuse to vaccinate your child. There are social media groups heavily promoting vaccine refusal and, unfortunately, this includes even some doctors or nurses.”

Riatti agreed that zero-dose and under-immunized children are still the biggest challenge according to UNICEF research in two other counties. “These children often face multiple deprivations that extend beyond health, making isolated interventions insufficient,” she said.

What Comes Next?

To help boost rates, UNICEF has recommended establishing vaccination hubs within community centers to bridge the gap caused by the shortage of rural doctors, reducing travel costs for patients, increasing the number of community nurses in isolated or disadvantaged areas, using social workers and community nurses for one-on-one home counselling, or even partnering with local priests to build trust.

To close immunity gaps, the ECDC’s Bacci said that better surveillance quality, ensuring rapid detection, diagnosis, and outbreak control are required, as well as upgraded digitalized immunization information systems to identify and reach the unvaccinated. “This is also critical and should form an integral part of national efforts to improve the performance and management,” she said.

Bacci and Riatti reported having no relevant financial relationships.

Tatum Anderson is a global health and medical journalist. For more than 20 years, she has placed articles in publications including the Bulletin of the World Health Organization, The Lancet, The BMJ, BBC News, and The Economist.