Orange County, New York, is located approximately 50 miles north of New York City and includes a diverse mix of suburban, urban, and rural communities. One of the county’s defining characteristics is the presence of the Satmar community, a rapidly growing Hasidic Jewish population that began moving to Orange County from Brooklyn in the 1970s.  

Over time, the community expanded into surrounding towns and even neighboring counties. This geographic spread, combined with frequent travel back and forth to New York City and internationally contributed to a higher risk for communicable disease exposure and spread, including measles. 

Effective communication required Orange County Department of Health to first understand how the Satmar community functions socially, culturally, and informationally. In this community, religious leadership plays a central role. Religious leaders are highly revered, and their guidance often carries more weight than that of elected officials. Housing is very dense, resulting in close physical proximity among families. The community has its own school system, emergency medical services, and newspaper. While community members do shop, seek medical care, and socialize outside the community, much of daily life remains internally focused. 

Yiddish is the primary language spoken, and traditional media channels like television, radio, and social media are not widely used. Instead, information spreads through telephones and print newspapers. International travel is common, and large religious gatherings can draw tens of thousands of people when Grand Rabbe (Grand Rabbi) visits.  

Demographics further complicate outbreak response. More than half of the community, approximately 56%, is under the age of 18. This is significant because the community has the lowest childhood vaccination rates in both the county and the state. Only 12.2% of two-year-olds, within the zip code, have received recommended vaccinations, as many families delay vaccination until school entry, when immunization is required. Over the past decade, rapid growth and increased multi-family housing have intensified these challenges, increasing the potential for rapid disease transmission. 

The Orange County Department of Health did not begin relationship-building when measles cases started popping up; it began over a decade earlier. During a mumps outbreak in 2009–2010, health department staff met with religious leaders and local pediatricians to identify barriers and challenges. With support from the Centers for Disease Control and Prevention and New York State, vaccination clinics were held to curb transmission. 

In 2013, a measles case in an infant exposed more than 100 individuals. The established trust allowed the health department to enter the community quickly and provide post-exposure prophylaxis to infants, mothers, and staff. 

These early responses created a foundation that proved essential during the 2018–2019 measles outbreak, when Orange County reported more than 55 cases. The scale of this outbreak ultimately contributed to New York State’s decision to remove the religious exemption for vaccines. 

Following the outbreak, the state recommended forming a coalition to strengthen ongoing communication and preparedness. The Hudson Valley Health Coalition was created and included religious leaders, school leaders, community pediatricians, Satmar EMS, and multiple local health departments. 

The coalition aimed to meet twice per year, but the process revealed important challenges. Much of the meeting agenda and content was driven by the health department rather than the community itself. Over time, it became clear that for coalitions to be effective, communities must have space to raise the issues that matter most to them. 

One key lesson was the importance of tailoring engagement. If coalition members preferred data-driven discussions, epidemiologists were included. If concerns centered on religious or cultural alignment, trusted community voices were prioritized. 

One of the most impactful strategies involved identifying and supporting a trusted messenger within the community. With the health department’s collaboration, this individual authored a book that was distributed to community leaders, pediatricians, and mothers. The book framed vaccination through the lens of shared values such as science, protecting health, and the religious and communal obligation to safeguard one another. It emphasized that vaccines align with community beliefs rather than conflict with them. 

After the COVID-19 pandemic, the book was updated, and another publication was created explaining how vaccines are developed and the differences between vaccine types. These materials became trusted sources of accurate public health information. Recognizing the need for more timely updates, the health department now plans to transition from books to a newsletter format to improve responsiveness during future events. 

Several lessons learned that are applicable to any jurisdiction working with insular or hard-to-reach communities: 

• Establish clear points of contact at local medical offices and within community leadership. 

• Hold regular, ongoing meetings even outside of crisis periods. 

• Invest time in understanding cultural norms, communication channels, and trusted information sources. 

• Identify when and how communities are most receptive to outreach.