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April 15, 2025
Quarterly Opinion
Nahid Bhadelia
Laura White
Lawrence O. Gostin
Apr 14, 2025
Apr 8, 2025
Apr 1, 2025
Back to The Milbank Quarterly Opinion
In 2024, we warned about the potential for measles resurgence in the United States, due to declining vaccination rates and growing religious and other exemptions that threatened our elimination status. Just one year later, our concerns have materialized into the most significant measles outbreak since 2019. The current multistate outbreak, centered in Texas and spreading across state lines, demonstrates the fragility of our public health achievements and the consequences of vaccine skepticism both within and outside of government. We examine here the current measles outbreak’s scope and trajectory, review the enabling factors that have worsened its impact, and explore potential paths forward, including the critical role of modeling resources, community engagement, and depoliticized public health messaging.
As of April 4, 2025, the Centers for Disease Control and Prevention (CDC) had reported 607 confirmed measles cases across 22 jurisdictions, with Texas bearing the heaviest burden at 481 cases (the majority of which were among unvaccinated children). The largest outbreak began in late January in the South Plains and Panhandle regions of Texas, quickly gaining momentum in communities with low vaccination rates, including a Mennonite congregation in West Texas. It has since spread to neighboring New Mexico, Kansas, and Oklahoma.
What distinguishes this outbreak is its rapid expansion through connected transmission chains. According to CDC data, 93% of confirmed cases in 2025 (567 of 607) are outbreak-associated, indicating sustained person-to-person transmission rather than isolated importations.
The human cost of this outbreak has been substantial. By April 4, Texas had reported 56 hospitalizations. Texas recently reported a second death in a child, bringing the nationwide total to three. Nationally, one in five children have been hospitalized for complications, including pneumonia and encephalitis.
Gaines County, Texas, the epicenter of the current outbreak, exemplifies the “perfect storm” conditions that are enabling measles transmission. Its vaccination rates fall well below the 95% threshold needed for community “herd” immunity, with Measles, Mumps and Rubella (MMR) coverage among kindergarteners estimated at just 82%, but ranging from 46% in Loop District to 94% in Seagraves District. Similar deep pockets of under vaccination exist throughout the affected regions, creating “immunity gaps” or clusters of susceptible individuals who provide fertile ground for measles transmission.
These geographic hotspots share several common features: limited health care infrastructure, reduced access to vaccination services, and high rates of vaccine exemptions. Nearly 224 counties in Texas lack primary health care providers within a 50-mile radius, creating significant barriers to routine immunization, while long distances between testing sites and public health laboratories are delaying diagnoses in some affected areas. The current outbreak has also disproportionately affected communities with limited English proficiency or those that have religious or philosophical objections to vaccination.
Multiple factors have led to the growing deadliness of this outbreak. First, the current outbreak occurs against a backdrop of declining vaccination rates nationwide. CDC data shows that kindergarten MMR vaccination coverage has fallen from 95.2% in the 2019-2020 school year to just 92.7% in 2023-2024, with exemptions from childhood vaccinations reaching a record high of 3.3% (93% of which are nonmedical). More alarming is recent research suggesting that actual vaccination rates among children under five may be as low as 71.8%—far below the level needed for community protection. Fourteen states now have exemption rates exceeding 5%, making it mathematically impossible to achieve the 95% coverage needed for herd immunity, even if every non-exempt child were vaccinated. This trend mirrors a broader shift in public attitudes toward vaccination. A recent KFF poll indicates one-quarter of parents now believe the risks of childhood vaccines outweigh the benefits.
Even as the outbreak intensifies, the public health infrastructure needed to respond effectively is being severely weakened by recent funding cuts. In March 2025, the federal government announced the termination of $11.4 billion in grants to state and local health departments—funds that, while originally allocated for COVID-19 response, had been supporting broader infectious disease control efforts. On April 3, a federal judge issued a temporary restraining order against the public health cuts.
The impact on measles response has been immediate and devastating. In Dallas County, health officials were forced to cancel 50 vaccination clinics, including events targeting schools with low immunization rates. Eleven full-time and ten part-time epidemiology staff who worked on outbreak response lost their jobs. In Lubbock, near the outbreak’s epicenter, funding for an epidemiologist directly responding to the measles outbreak was eliminated.
These cuts have crippled the very capabilities needed to contain the outbreak: laboratory testing, disease surveillance, contact tracing, and vaccination outreach. As Philip Huang, director of Dallas Health and Human Services, recently starkly warned, “This truly is setting us back decades. You cannot just build this back again.”
Compounding these challenges is the proliferation of misinformation about measles treatment and prevention. Most concerning is the promotion of vitamin A as an alternative to vaccination—a narrative that gained prominence when Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. emphasized vitamin A and other unconventional treatments while downplaying vaccination. He posited that childhood vaccination was “a personal choice,” even though unvaccinated children can transmit the infection to others. This is particularly concerning because the KFF poll reports that more Republicans (heavily represented in the affected states) trust the HHS Secretary (81%) compared to their local and state public health officials (46%).
Although vitamin A supplementation can be beneficial for measles patients with a deficiency in this vitamin (generally in low-income countries), it does not prevent infection. But its supporters have led some parents to administer high doses of vitamin A to their children in lieu of vaccination, with reported cases of vitamin A toxicity in Texas.
Circulating misinformation, including misleading claims that the MMR vaccine causes measles-like illnesses and deaths, that tout the superiority of “natural immunity” to vaccination, and that promote “good nutrition” alone as adequate protection against the infection, distract from the fact that the MMR vaccine is safe, effective, and the only reliable way to prevent measles infection. During his confirmation hearings and thereafter, Secretary Kennedy refused to rule out the false claim that MMR vaccine causes autism. Secretary Kennedy recently commissioned an HHS study of the link between vaccinations and autism, led by a long-discredited researcher and vaccine skeptic. The link to autism has been thoroughly studied and rejected by the Institute of Medicine (now the National Academy of Medicine).
The outbreak is unfolding in a political environment where public health measures have become increasingly contentious. In several affected states, legislators have introduced bills to further expand vaccine exemptions even as measles cases rise. Other states, like West Virginia, are considering restoring a religious exemption that had been removed from state statute decades ago. Public health officials report facing political pressure to downplay the severity of the outbreak or to emphasize “parental choice” over community protection and CDC officials were instructed not to publish a public health report stressing the local risk of measles in affected areas and the importance of vaccines.
Measles has a long incubation period, ranging from 10 to 14 days between exposure and symptom onset. Infected individuals transmit the virus for up to four days before developing the characteristic rash, allowing the disease to spread silently before cases are identified. These biological realities, paired with the fact that the measles virus is among the world’s most infectious (one infected person can transmit to 12-18 others in a susceptible population), means that containment efforts are always playing catch-up. A public health official in Texas recently projected that it could take up to a year to fully contain the current outbreak, but this timeline is likely optimistic given recent and ongoing funding cuts and staffing reductions.
During the 2024 Chicago measles outbreak, the CDC’s Center for Forecasting and Outbreak Analytics (CFA) utilized modeling tools to help forecast the outbreak’s trajectory and evaluate effectiveness of intervention strategies in real-time. Modeling showed that timely mass vaccination and active case-finding could reduce the chance of a large outbreak (>100 cases) from 69% to just 1%, and delaying vaccination by even one week would have increased the risk of a larger outbreak by eight-fold. Similar modeling resources may help anticipate and mitigate the current multistate outbreak. However, many affected jurisdictions lack training on and access to modeling resources. And the recent cuts to CDC and state public health agency staffing, including the reassignment of the director of the CDC CFA, may limit timely federal support to states to do this type of analysis.
Even as efforts continue to contain the current outbreak, the risk of new importations is becoming greater. Last year, 57 countries experienced “large or disruptive” measles outbreaks, up from 36 in the previous year. As we previously noted, this global resurgence increases the likelihood of imported cases triggering new outbreaks in under-vaccinated US communities. The risk of imported cases will likely now increase further due to recent cuts in US foreign aid programs that support vaccination and childhood health, including the withdrawal from the World Health Organization (WHO) and defunding of its childhood vaccination programs. The Trump administration has terminated funding for the WHO Global Measles and Rubella Laboratory Network, which consists of over 700 laboratories in more than 150 countries.
Additionally, the administration has ended US funding for Gavi, the Vaccine Alliance, which procures affordable vaccines for children in poor countries. These cuts will lead to decreased vaccination rates globally followed by more measles outbreaks in countries with already fragile health systems. Dismantling both global surveillance for measles and the vaccination infrastructure simultaneously threatens domestic health security.
The convergence of declining vaccination rates, increasing exemptions, geographic clustering of unvaccinated individuals, public health funding cuts, and widespread misinformation creates a perfect storm that will make this outbreak exceptionally difficult to end. However, there is one reason for cautious optimism in the longer term. The MMR vaccine is highly effective and provides long-lasting, durable immunity. Increasing vaccination rates in at-risk areas through concerted outreach efforts will result in effective future protection, if political and social barriers to its use can be overcome.
Containing the current outbreak and preventing future ones will require decisive action at multiple levels. State and local health departments must be well-resourced to implement aggressive vaccination campaigns and surveillance in the affected communities. Hence, restoring funding to departments must be an immediate priority to rebuild response capacity. Additionally, interstate coordination mechanisms, such as standardization of data sharing protocols and joint response teams that can work across jurisdictional boundaries (which is generally led by CDC), may need strengthening.
Addressing vaccine hesitancy requires building trust through sustained community engagement. Health care professionals in affected communities play a crucial role in this process, with polls showing the positive impact of recommendations from trusted clinicians.
Interpersonal interactions can help dispel misinformation in ways that mass media or digital campaigns cannot. Religious leaders, community organizations, and other trusted voices can play important roles in promoting vaccination as a community responsibility rather than a parental choice or a political statement. These leaders can evoke shared values, such as protecting vulnerable children and preserving community health, that transcend the political divides. The question is who will fund and lead these cadres of public health workers in an environment of overall hostility against public health and skepticism of science.
Interstate organizations like the Association of State and Territorial Health Officials (ASTHO), the National Governors Association (NGA), the National Conference of State Legislatures (NCSL), and the National Association of County and City Health Officials (NACCHO) are uniquely positioned to bridge the political and public health divides to possibly create neutral forums where state policymakers from across the political spectrum can develop consensus approaches to measles response.
Finally, depoliticizing public health messaging in media about measles vaccination is crucial. And political leaders at HHS, CDC, the Food and Drug Administration (FDA), and their state partners need to instill confidence in vaccines and, particularly, routine childhood immunizations.
The current measles outbreak serves as a stark reminder that public health achievements are fragile and require ongoing investment and vigilance. Measles elimination in the United States must not be a one-time accomplishment. Sustaining it requires commitment and investment from policymakers, health care providers, and the general public. Without this commitment, we face the very real prospect of measles and other childhood diseases becoming endemic once again in the United States, resulting in preventable suffering and death.
Nahid Bhadelia, MD, MALD, is the founding director of BU Center on Emerging Infectious Diseases. She is a board-certified infectious diseases physician and an associate professor at the BU School of Medicine. Bhadelia’s research focuses on operational global health security and pandemic preparedness, including medical countermeasure evaluation and clinical care for emerging infections, diagnostics evaluation and positioning, infection control policy development, and healthcare worker training. She served as the senior policy advisor for Global COVID-19 Response for the White House COVID-19 Response Team in 2022-2023 and the interim testing coordinator for the White House MPOX Response Team.
Laura White, PhD, is a professor of biostatistics at the Boston University School of Public Health. She co-directs the Data Science and Surveillance Core of the Center on Emerging Infectious Diseases and is the associate director of the Population Health Data Science Program at Boston University. Her research focuses on developing better statistical and modeling tools to understand infectious disease transmission and burden.
Lawrence O. Gostin, JD, is university professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.
