“Madagascar started with a few cases; now, we are almost close to 60,000 and the cases are still increasing,” said Richard Mihigo, coordinator for the World Health Organization’s immunization and vaccine development program at its regional office for Africa. “I think societies like the U.S. and western Europe should ring the bell and see … this is something that could also happen to them.”

The outbreak in Madagascar is due in large part to weak infrastructure that has made it difficult to achieve widespread vaccination. Both there and elsewhere, health workers face extraordinary circumstances, and at times take immense personal risks, to deliver vaccines to vulnerable communities. In 2013, health workers in northern Nigeria were wrapping up an immunization drive to help vaccinate children against the polio virus when armed gunmen appeared and opened fire, killing at least nine of them.

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Targeted killings of health-care workers are even more common in Pakistan, where medical staff have also been killed while delivering vaccines to rural areas or conflict zones in an attempt to control the spread of polio.

“When we see that a society where this is not the case sees it as something to take for granted, it’s very sad,” Mihigo said of the United States and Europe.

Even outside of high-risk areas or conflict zones, delivering vaccines in developing countries can pose serious logistical challenges.

Natalie Roberts, emergency operations manager at Doctors Without Borders, said that in parts of Congo, where a measles outbreak is ongoing, staff with the nonprofit group will travel days by motorbike or canoe to access isolated villages. “You can spend five days going from one place to the next area and then spend eight hours trying to get the car out of a hole and reach the village you’re trying to access, and you notice there are maybe 100 children in the village,” she said. “And you’ve spent days and days to get there.”

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In places like Madagascar, health workers face similar logistical challenges while delivering vaccines. For measles herd immunity to be effective, public health experts recommend that at least 95 percent of the general population be vaccinated. In Madagascar, the estimated immunization rate was just 58 percent as of 2017. In Washington state, the immunization rate is around 90 percent.

“The reasons that children aren’t vaccinated in Congo are very different from the reasons children aren’t vaccinated in America or Europe,” Roberts said. “But in the end, the result is the same.”

In addition to areas with poor infrastructure, measles and other contagious, preventable diseases often break out in conflict zones, when children are not being vaccinated on schedule. In recent years, outbreaks have occurred in Syria, Yemen and Ukraine.

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But in the United States, vaccines that can prevent the spread of measles and other deadly diseases are readily available, stirring frustrations in the public health community over why those who have access to vaccines would refuse them.

“You have at your disposal all the benefits of modern life that are supposed to make your life healthy and strong and long,” said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “And then a segment of the population rejects that. It’s exasperating.”

This year, the WHO named “vaccine hesitancy” one of the top threats to global health. Measles has increased by 30 percent globally, the group’s report said, adding that “some countries that were close to eliminating the disease have seen a resurgence.”

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In 2017, the number of measles cases reported grew dramatically, with the largest surge occurring in Europe, the Americas, and the eastern Mediterranean region, the WHO said.

That year, 110,000 people died from measles. Most of them were younger than 5. In 2000, about five times as many people died from the disease, and medical professionals want to ensure they continue to keep the death rate low.

Morrison stressed that in the United States and Europe, where some parents have lost confidence in the science behind vaccines, “you have to win the trust and confidence of people and fight back deliberately against this paranoia.”

In Congo, Roberts said, such paranoia around the measles vaccine is far less common. Outbreaks there are frequent enough that the communities most susceptible to measles have memories of the toll the virus can take on them and urgently want their children to be vaccinated.

“They understand what a real measles epidemic means,” she said. “Maybe in the U.S. and Europe, we’ve forgotten.”