SEMINOLE — An 8-year-old girl with measles died Thursday morning, the second known measles-related death in an ongoing outbreak that has infected nearly 500 Texans since January. Her funeral was Sunday at a church in Seminole followed by a private burial.

Health and Human Services Secretary Robert F. Kennedy Jr., visited the West Texas town that has been the epicenter of the outbreak Sunday and was expected to meet with the family.

“My intention was to come down here quietly to console the families and to be with the community in their moment of grief,” Kennedy . He went on to describe the resources he deployed to Texas in March after , claiming that the “growth rates for new cases and hospitalizations have flattened” since Kennedy sent a team from the Centers for Disease Control and Prevention. The state reported 59 new cases in three days last week.

The child who died Thursday, Daisy Hildebrand, was not vaccinated and had no known underlying health conditions, said a spokesperson for University Medical Center in Lubbock, where she had been hospitalized. She died from “measles pulmonary failure,” the Texas Department of State Health Services .

“This unfortunate event underscores the importance of vaccination,” Vice President of University Medical Center Aaron Davis said in a statement. “We encourage all individuals to stay current with their vaccinations to help protect themselves and the broader community.”

The death comes about five weeks after unvaccinated 6-year-old Kayley Fehr , the first such death in the country in a decade. Fehr’s that their stance on vaccination did not change after their daughter’s death.

The West Texas outbreak , most of whom are unvaccinated children, according to the state health department.

The outbreak began in Gaines County, located about 90 minutes southwest of Lubbock on the New Mexico border. Since then, cases have been reported in 18 other Texas counties, as far east as Erath County in central Texas.

The CDC has linked the Texas outbreak with measles cases in Oklahoma and New Mexico, where an unvaccinated individual who tested positive for measles died in March. And the World Health Organization reported that cases in Mexico were linked to Texas.

Measles is a highly contagious virus that spreads through respiratory droplets passed through the air by breathing, coughing and sneezing. Vaccination is the safest way to build immunity to the virus. Two doses of MMR vaccine are about 97% effective at preventing measles; one dose is about 93% effective, according to the CDC.

Measles was officially eliminated from the U.S. in 2000 following a highly successful vaccination program. But vaccine skeptics, fueled by misinformation and a disdain for COVID-era mandates, have sown distrust of public health and contributed to declining rates of vaccination. In Gaines County, 82% of kindergarteners are up to date on their MMR vaccine. Experts say communities need a 95% threshold to prevent the spread of measles.

A CDC spokesperson said in an email that Kennedy’s visit to Texas on Sunday resulted in discussions with Texas state health officials to deploy a second CDC response team to West Texas to further assist with the state’s efforts to protect its residents against measles and its complications.

Dr. Manisha Patel, incident manager for the CDC, said their team arrived in Gaines County in March and left on April 1. A spokesperson for the CDC said in light of today’s news and Kennedy’s order to re-deploy, another team will be in the county.

“We’re learning a lot in Gaines County on how we can help other jurisdictions also prepare for measles in their states,” Patel said.

Patel said it’s important to go in with a sensitive approach when it comes to small, close-knit communities that are unvaccinated.

However, she said there are three pieces to their measles control measures: the vaccine, not traveling if you’re exposed, and staying at home.

“MMR is the best way to protect yourself, your families, your communities against measles,” Patel said. “And, if you’re starting to get very sick from measles, not to delay care.”

Patel said for some communities, it’s important to find trusted messengers. In some cases, she said, the federal government might not be the best choice for that and it has to be someone in the community. To work around this, Patel said they’ve worked directly with state and local health departments to find who the trusted messengers are.

“Our role is making sure those trusted messengers have the materials and information they need,” Patel said. “So we translate, for example, materials into a German or Spanish or whatever the community needs.”

State health officials have said that the outbreak could persist for months. It has spread most quickly in pockets of Texas with below-average vaccination rates. In Gaines County, where a large unvaccinated Mennonite community resides, 315 people have been infected.

People infected with measles usually experience symptoms within a week or two of exposure. Early symptoms include high fever, runny nose and watery eyes. A few days later, a rash breaks out on the face and then spreads down the neck to the rest of the body. Infected individuals are contagious about four days before the rash appears and up to four days after, according to state health officials.

Doctors typically recommend all children get two doses of the MMR vaccine, starting with the first dose at 12 through 15 months and the second dose at 4 through 6 years of age.

Parents of infants aged 6 to 11 months living in outbreak areas should consult their pediatrician about getting the measles-mumps-rubella vaccine, Sara Safarzadeh Amiri, chief medical officer for Odessa Regional Medical Center and Scenic Mountain Medical Center, said on Sunday.

Amiri said she was unaware of the second reported death but that it is not unexpected given the continued spread of the outbreak.

So far, 56 measles patients in Texas have been hospitalized, according to state health officials.

This article originally appeared in at . The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.

With schools set to start in a couple weeks, most parents of kindergartners are working to make sure to get required vaccinations for their children before sending them off to school.

But not all parents. Over the last decade, more parents have opted their children out of vaccination requirements through the use of nonmedical religious exemption – especially in recent years following the COVID-19 pandemic.

The number rarely rises above a percent or two of an incoming kindergarten class, typically accounting for no more than a couple hundred children per year. But that means that in the years since 2002, a total of more than 10,000 kindergartners have attended public and private schools without vaccination records, according to historical data from the Maryland Department of Health.

The rising percent of religious exemptions in recent years may point to increasing rates of vaccine hesitancy among families, said Daniel Salmon, a professor and director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health.

“We’ve seen a post-COVID increase,” Salmon said. “With COVID … things got really polarized with more misinformation and disinformation. Vaccinations became a very political topic. And that’s not helpful.”

Maryland law requires that children have a handful of vaccinations when they enter kindergarten, in order to protect themselves and their classmates from transmissible diseases, such as measles, polio and chickenpox, among others. Children can be exempted if there is a medical reason they cannot receive a vaccine or a religious restriction against it.

The process to invoke the religious exemption in Maryland is simple. Parents can just sign a form that says: “Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child.”

Elizabeth Elliott, president of the Maryland Association of School Health Nurses, said she understands the need for exemptions, but she said it is also important that as many children as possible be vaccinated.

“Herd immunity is really important for those of us – kids, staff members, families – in a school community that, for medical reasons, can’t be vaccinated,” Elliott said. “It’s incumbent upon the rest of use to vaccinate ourselves and our children to protect those of use who can’t have the vaccine because it’s unsafe.”

But tracking vaccine hesitancy is a tricky task, according to Salmon, and there are many factors that contribute to why some families don’t get their kids vaccinated.

“It’s really hard to answer that question based on data, based on how you measure vaccine hesitancy,” he said. “So the best measure we have is the proportion of children entering school who have a nonmedical exemption.”

The earliest data readily available from the state is from the 2002-2003 school year, in which 0.2% of kindergartners got a religious exemption, or about 126 kids out of roughly 63,000 entering kindergarten that year.

The rate increased steadily over the years: Ten years later, for example, about 0.6% of kids had religious exemptions, resulting in about 419 kids not receiving vaccinations in 2012-2013.

Religious exemptions spiked in 2019-2020 when 2.7% of kindergartners, or 1,641 kids, opted out of vaccination requirements. The COVID-19 pandemic went into full swing in the spring of 2020, so those families would have opted out prior to the the rise in cases in the United States.

Since the 2021-2022 school year, at least 1 percent of kindergartners in Maryland had a medical exemption – a couple hundred a year.

While the percent and numbers have increased, Salmon believes the numbers are not rising high enough for major concern.

“It’s a pretty small number,” he said. “I guess it’s a big increase by percentage, it’s a fair number of kids, but the absolute numbers are fairly small.”

He also noted that a state average does not tell the entire story of vaccine hesitancy.

“It’s also misleading because the exemptions tend to cluster geographically, socially, and the state average can can’t capture that social, geographical cluster issues,” he said.

In the last school year, there were higher concentrations of religious exemptions in some of Maryland’s more rural counties. The highest rate of religious exemptions were in Worcester (4.21%) and Cecil (3.75%). But Baltimore City also ranked high for religious exemptions, at 2.05% of kindergartners.

Maryland tends to fall behind the national average of religious exemptions, according from the Centers for Disease Control and Prevention. In 2022-2023, the national average for nonmedical exemption was 2.8% of kindergartners, compared to Maryland’s 1.4% for that year.

Salmon notes that there are many factors since the pandemic that have led to more parents seeking out exemptions from vaccination requirements.

“There’s not a simple answer. It’s a mixture of people not being aware of the diseases … people worried about the safety of vaccines, often full of misinformation and disinformation,” he said. “We need to do a better job of communicating to parents more broadly, listen to people’s concerns and be empathetic and address them with the best available science.”

Elliott added that there are other underlying reasons why some families seek a religious waiver.

“What I often see now is families signing the religious objection because it’s too difficult to get to their children their vaccines … It’s not surprising to hear, ‘Well, I just couldn’t get to the clinic.’ So they just signed the religious waiver,” she said, noting that this issue gets more common in middle school.

Elliott agreed with Salmon that the best way to reach families who are hesitant about vaccinating their kids is to be is to be understanding and respectful. She said that as a school nurse, it is part of her responsibility to help families understand why vaccines are important for health and safety in a school setting.

“We are the ones that will view the records and ensure compliance and reach out to families,” she said. “It is a state requirement that students are immunized. And we spend lots and lots and lots of time picking up the phone and having those conversations, politely and respectfully, informing those parents.”

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Child vaccination rates dipped into dangerous territory during the first year of the COVID-19 pandemic, when schools were shuttered, and most doctors were only seeing emergency patients.

But instead of recovering after schools reopened in 2021, those historically low rates worsened, according to new data from the federal Centers for Disease Control and Prevention. Experts fear that the skepticism of science and distrust of government that flared up during the pandemic are contributing to the decrease.

According to today’s data, the percentage of U.S. children entering kindergarten with their required immunizations fell to 93% in the 2021-22 school year, 2 percentage points below recommended herd immunity levels of 95% and lower than vaccination rates , when many schools and doctor’s offices were closed.

“While 1 percentage point might not seem concerning, that one percent represents tens of thousands of children who are inadequately protected from diseases we can easily prevent through immunization,” said Dr. Michelle Fiscus, chief medical officer at the Association of Immunization Managers, a nonprofit group of state officials who direct vaccination efforts. 

“This national trend is alarming, especially as we see outbreaks of measles in Ohio among children who are too young to be vaccinated and those who are inadequately vaccinated. We need all hands on deck to get these children protected,” Fiscus said.

Public health officials warn that unless child vaccination rates for measles, chicken pox, polio and other diseases are quickly brought back to pre-pandemic levels, outbreaks of preventable diseases — like the measles outbreaks in  and  in the fall and the polio case in  last summer — are likely to become commonplace.

While COVID-related disruptions in schools and the health care system may be the primary cause for this recent drop in immunization rates, they’re only part of the reason state-required vaccination rates are trending downward, public health experts say.

They say the politicization of public health and increasing distrust of government have skewed parents’ previously positive attitudes about vaccines for measles, mumps, rubella, chicken pox, tetanus, diphtheria, polio and other childhood diseases that have been all but eradicated. 

“I’m trembling in my anxiety about this,” said Dr. William Schaffner, a professor of preventive medicine at the Vanderbilt University School of Medicine.

“Our own success in immunizing children routinely, uniformly against a whole list of diseases that used to be common has resulted in the current generation of moms and dads not knowing much about these diseases, if anything,” he said.

“If you don’t fear the disease and respect the vaccines,” he added, “you may not adhere to state laws requiring them.”

In general, the public’s willingness to follow public health requirements has been waning since the COVID-19 pandemic began, said Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officers.

The political divisiveness that erupted over COVID quarantines, masking and vaccines, he said, may be spilling over into what has been a widely accepted public health policy of protecting children from infectious diseases.

The CDC  that vaccinating children born from 1994 to 2018 will prevent 472 million illnesses, nearly 30 million hospitalizations and more than a million deaths. The state-run vaccination programs are also projected to save $479 billion in health care and other direct costs.

In 2019, a single measles outbreak of 72 cases in Washington state cost $3.4 million, CDC researchers , with most of the costs incurred by local public health agencies.

State immunization rates vary widely. For the 2021-22 school year, Alaska, the District of Columbia, Wisconsin, Georgia, Idaho, Kentucky and Ohio had the lowest rates. New York, Rhode Island, West Virginia, Delaware, California, Massachusetts and Nebraska had the highest rates.

Changing Mandates

All 50 states and the District of Columbia require children to be vaccinated for childhood diseases before entering kindergarten, whether at a public or private school. Every state allows medical exceptions, and most allow parents to seek an exemption for religious or philosophical reasons.

Public health officials argue that the best way for states to boost their child vaccination rates is to enact ironclad vaccine mandates with no exceptions other than for medical reasons, such as for children who are undergoing cancer therapy.

Mississippi and West Virginia, which have such strict vaccine mandates, have had among the highest vaccine rates in the nation for decades. 

California did away with its non-medical vaccine exemptions in 2015, followed by Maine and New York in 2019 and Connecticut in 2021. West Virginia’s vaccine mandate never included non-medical exemptions, and Mississippi’s law was stripped of non-medical exemptions in 1979 after the state Supreme Court ruled them unconstitutional.

California repealed its non-medical exemptions in reaction to high-profile measles outbreaks in 2014 and 2015, including one that started at Disneyland. After the law took effect, measles, mumps and rubella coverage rose by 3.3%, which put California closer to the herd immunity vaccination threshold of 95% for measles.

With most state vaccine mandates in place by the 1980s, the CDC declared victory over measles in 2000.

But in recent years, the diagnosis numbers have crept upward: In 2014, 667 measles cases were reported to the CDC. In 2019, state health departments reported 1,274 measles cases.

Even so, childhood vaccination rates in the United States remained high relative to other developed countries, and public attitudes toward routine childhood vaccines were relatively positive.

But since the COVID-19 pandemic began, state vaccine requirements have met more opposition. In October, a poll conducted by the Harvard Opinion Research Program showed that support for vaccination requirements to enter school had slipped to 74%, compared with 84% in 2019.

A  published by the Kaiser Family Foundation in November showed that 28% of respondents said parents should be able to opt out of vaccinating their school-age children even if it results in health risks for others.

That’s up from only 16% who responded the same way in a 2019 poll conducted by the Pew Research Center. (The Pew Charitable Trusts funds the center and Stateline.)

In the past two years, dozens of bills have been proposed that would make it easier for parents to opt out of routine vaccinations for their school-age children, as well as COVID-19 shots, according to the National Conference of State Legislatures, which tracks state legislation.

In 2021, Kentucky and Florida enacted laws allowing parents to refuse routine vaccinations and still enroll their children in school.

Enforcement and Access

In addition to tightening vaccination mandates, public health officials say some states need to better enforce their rules and increase education and community messaging, so parents better understand the importance of vaccinating their children.

Measles, for example, is far more contagious than COVID-19. It typically infects 9 out of 10 people an infected person encounters, and the contagion can linger in a room for at least two hours after an infected person leaves. 

Although most measles cases resolve within a week, it is a potentially life-threatening respiratory disease that often results in hospitalization. In , for example, 33 of the 82 children with measles last year were hospitalized.

Dr. Anne Zink, chief medical officer for Alaska’s Department of Health and president of the Association of State and Territorial Health Officials, said improving access to pediatricians, family doctors and other health professionals who can administer childhood vaccines is another way states can get more children vaccinated.

Pediatricians and family doctors typically provide immunization shots to children between 12 and 23 months. But for children who miss their vaccinations in their first two years and need to get caught up, some states set up local vaccine drives at schools and use mobile vaccination units to serve local communities.

Matt Guido, research coordinator for Dr. Ezekiel Emanuel at the Department of Medical Ethics and Health Policy at the University of Pennsylvania, said states should consider taking advantage of the infrastructure established for ramping up COVID-19 vaccinations and call on some of the same community leaders to help parents get their kids vaccinated before they start school next year. 

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