Four cases of the measles have been reported in Hawaii this year, but the state’s high vaccination rates will likely prevent an outbreak as severe as the one experienced by the nation of Samoa, state health officials say.

All four cases in 2019 were travel-related, according to Hawaii Department of Health spokeswoman Janice Okubo. The department would not disclose where each case of the disease was acquired.

The measles epidemic in Samoa has claimed 70 lives in a matter of months, and most of those who died were children under the age of five. The outbreak there spread this week to neighboring American Samoa. A delegation of Hawaii doctors and nurses traveled to Apia, Samoa last week for a 48-hour vaccination campaign.

Hawaii students are required to receive the MMR vaccine by the time they enter preschool, childcare or kindergarten to protect them from measles, mumps and rubella.

Hawaii Department of Health Epidemiologist Sarah Park said those requirements and Hawaii’s high vaccination rate will prevent the Aloha State from having an epidemic as severe as Samoa.

But ongoing measles outbreaks in the Philippines, Tonga and now Samoa and American Samoa pose an ever-present risk for imported cases to Hawaii. Hawaii residents have many family ties throughout the Pacific and the Aloha State is a frequent travel stop. Outbreaks in the Pacific Northwest and New York also increase the possibility of exposure.

“There’s a lot going on out there globally, so it really emphasizes the importance for us to maintain a high vaccination status,” Park said. “It would be rare compared with the nation of Samoa but it’s something we want to guard against because it’s something entirely preventable.”

Young infants, pregnant women and people with compromised immune systems are highly susceptible to catching measles. It is one of the most contagious diseases in the world and passed by coughing, sneezing or direct contact.

This year the U.S. had a record number of measles cases — the greatest number since 1992. More than three-quarters of cases were linked to outbreaks in New York, according to the Centers for Disease Control and Prevention.

The federal health agency reports that a spike in measles cases is most frequently related to an increase in the number of travelers who travel home after contracting it abroad. Transmission rates also escalate among communities with “pockets of unvaccinated people,” the CDC reports.

Social media was a huge influence in fueling fear and mistrust around vaccines in both the Philippines and Samoa.

In Samoa, the vaccination-mixing error that took the lives of two infants would be considered malpractice in the U.S., Dr. Park said. The two nurses in Samoa who used an expired muscle relaxant instead of water were ultimately sentenced to five years in prison.

The measles outbreak in the Philippines this year has resulted in 466 deaths, the majority of them among children. The country’s decline in vaccination rates appears to follow a spike in public mistrust after a dengue-vaccine controversy. Children in the Philippines were put at risk for a deadly disorder when the country launched the new dengue vaccine without following its restriction guidelines: That only children ages 9 to 16 with a prior dengue infection should be vaccinated.

“I hope the tragedy that’s happening in Samoa reminds our community of why it is that we do vaccinate,” Park said. “Sometimes no matter how much science is out there, they’re only listening to their heart. I hope parents and others who are on the fence will listen to the science and understand they shouldn’t be getting their information from Dr. Google, they should be talking to their healthcare provider.”