For the past few months, nurse Dale Weiser has been making unexpected home visits. As the state battles the deadliest measles outbreak in recent history, the clinical supervisor drives 30 miles (48.3km), sometimes daily, to a rural corner of Pennsylvania where many Amish people live. Walking into strangers' homes, Weiser says she tries her best to be respectful and non-intrusive as she vaccinates dozens of family members against the measles, sometimes around the kitchen table.
"A lot of people that I encounter, they don't have health insurance. They don't have a lot of interaction with the health system, and they just haven't seen the need to get these vaccines," said Weiser, who works for the Chester County Health Department. "When you start talking and you answer their questions, and build that trust, a lot of times they will make a different decision." The at-home vaccinations are part of the county and state health departments' strategy to encourage immunisations in the county, which includes an Amish community who abstain from many aspects of modern life, including regular contact with the western medical system.
The state health department told the BBC it has administered nearly 4,300 measles, mumps and rubella (MMR) vaccines at pop-up clinics near the epicentre of the outbreak since it began in late April. But even as health officials see success in their vaccine programmes, the state has reported four deaths from measles complications, marking the most deadly outbreak the US has seen since 1992. The infections have led to tensions between state and federal health officials, including vaccine-skeptic Health Secretary Robert F Kennedy Jr.
Those politics are back of mind in the Amish community, where people are growing fearful of more deaths as they watch their friends and family fall sick with the disease, which for decades has been eliminated in the US. "They're not a community that's as easy to reach - we can't just put up a social media post," Weiser said. "They are suffering at the moment, and we're trying to reach out and make connections." Amish people began coming to the US in the early 1700s, with the first community settling in Lancaster, Pennsylvania.
Known as the "Plain People" for the simple clothes they wear, the Amish are a devout Christian community that does not use many forms of technology, relying on horse and buggies instead of cars. About 90,000 Amish people live in Pennsylvania, with estimates suggesting around only a quarter of Amish people in the Lancaster area have had the MMR vaccine. There is no particular religious text advising against vaccines, but Amish people do not have regular contact with the western medical system, or have a way to easily travel to appointments, experts said.
"A lot of people who haven't gotten vaccinated, it's not because they have a strong stance against getting vaccinated for measles. It's just that they haven't gotten around to it. It's not convenient," said Braxton Mitchell, a genetic epidemiologist with University of Maryland School of Medicine who runs a research clinic studying the Amish in Lancaster.
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