Pennsylvania is bracing for a wave of measles cases, with some public health officials concerned that it’s “only a matter of time” until the disease spreads beyond the outbreak’s epicenter.

Last week the state reported its fifth measles-associated death amid 943 confirmed cases across 39 counties. The outbreak comes amid concerns that public health in the US has been hit by increasing vaccine skepticism, especially due to the power and influence of controversial health secretary Robert F Kennedy Jr.

Contributing to the challenge is that Pennsylvania is one of the few US states where its counties mostly lack their own health department, with only seven of its 67 counties having their own.

Lancaster county, which doesn’t have its own health department, has seen the highest amount of cases, at 381, believed to be mostly among the Amish or similar religious groups who have historically low rates of measles, mumps and rubella (MMR) vaccine uptake. Health officials, doctors and other members of the community in the county are now attempting to establish its own health department to better tackle the outbreak.

Jeanne Franklin, the director of Chester county’s health department, said that her county, which has the third highest number of cases, at 83, is preparing for an influx of cases from neighboring Lancaster.

“We have a very long border with Lancaster county, and these types of disease don’t care about borders,” Franklin said. “It’s going to keep going and find a person who isn’t vaccinated. We’re operating with the assumption that the disease may jump and spread to non-Plain [Amish] community members. Our goal is to prevent that, but we assume that it may happen.”

She added that although many Amish people have not been vaccinated, it’s not because they are anti-vaxxers, but rather because “they were either unaware of it or they don’t seek out healthcare as frequently as other residents”.

She added: “But they’re willing to have the conversation and make a decision on what’s happening today. They’re not making decisions based on the myths out there, but because their neighbors are impacted.”

Amid active surveillance of measles cases, contact tracing and setting up community vaccination centers, the county is also working to dispel misinformation some of its residents have regarding the safety of the vaccine.

“We have people in key positions saying it isn’t an outbreak, it isn’t a problem. We have people who approach our nurses and say that they were told the vaccine will make them sterile, or that there’s a microchip within it,” Franklin said.

But for Franklin, the fact that Chester county is one of the few counties to have its own health department is a clear advantage in the race to stop the spread of the disease.

“By having our own health department [it] means that we already have the infrastructure in place, and we prepare for these things all year round,” Franklin said. “With the number of counties [the state has] to provide support to, they can’t possibly know all the key partners in a geographical area.”

She added: “The state has a finite set of employees, while I can pull my employees away from their normal jobs and say we need help with this. We live here, we know it, and we’re working with the communities and the organizations who know us. I think every county needs a health department, but we’re just not set up that way in Pennsylvania while other states are.”

Dr Richard Lorraine, the medical director of Montgomery county’s office of public health, said that it is a “matter of time” before the third most populous county in Pennsylvania will begin to see measles cases.

“We recognize that essentially it’s all around us, and so a big focus for the county is immunization,” Lorraine said. “It’s the best preventative measure and where the county is focusing its efforts on.”

Working closely with community organizers, Lorraine said the county was making sure that every resident was able to be vaccinated regardless of their insurance status.

“Because we are a public health agency, our mandate is to provide for members of our population for the most part who are underinsured, and there’s a very high percentage who aren’t insured,” Lorraine said. “And through our partnership with pharmacies we’re able to open these clinics for everyone. So whether you have insurance or if you don’t, we can work it out so that someone is able to administer a vaccine.”

Lora Werner, the director of the Delaware county health department, said that her agency is facing several challenges in protecting residents from the virus.

Among them was the collapse of Crozer Health, Delaware county’s largest healthcare system, due to bankruptcy last year.

“They were a huge provider of pediatric care,” Werner said. “And although we do have a high vaccination rate across Delaware county, there are pockets where they aren’t as good.”

For Werner, the newly established local health department has been a gamechanger for promoting public health initiatives in the county.

“We are the newest health department on the block, and we’re so passionate about the fact that we’re now here and can serve our residents,” Werner said. “We’re deeply integrated into the social networks.”

She added: “Creating a new department was very challenging, and we’re a very odd state in this regard,” Werner said. “If you want to have one you need to have a referendum to establish one. But it’s not required, so we have a mishmash of the counties that have taken that step and those that have not.”

The Guardian has approached the Pennsylvania health department for comment.