Response to multistate measles outbreak hampered by unique set of challenges

By Deidre McPhillips, Neha Mukherjee and Meg Tirrell, CNN

(CNN) — The US Centers for Disease Control and Prevention is on the ground in Texas for the second time this year, as an ongoing multistate measles outbreak centered in the western part of the state has grown to one of the worst the United States has seen in decades.

The CDC team of three is meeting with state and local officials to assess “the immediate needs to respond to this outbreak,” the agency said, and more staff will be sent once the assessment is complete, after a formal request from Texas Gov. Greg Abbott and an order from US Department of Health and Human Services Secretary Robert F. Kennedy Jr.

But recent threats confronting public health have made the response to the outbreak more challenging than it may have otherwise been, experts say.

Funding cuts create limitations

HHS announced sweeping layoffs last week, including an estimated 2,400 from the CDC. The CDC also pulled back over $11 billion in grants to state and local health departments that were allocated during the Covid-19 pandemic but that local departments say were being used to respond to other public health threats, including the measles outbreak.

As a result of federal funding cuts, New Mexico – which has reported 54 measles cases as part of the outbreak – terminated contracts for 20 temporary workers who were helping order vaccines and check vaccination records.

The cuts “resulted in our agency canceling some contracts with community providers that provide outreach to underserved communities relating to vaccination efforts and education,” said Robert Nott, communications director for the New Mexico Department of Health.

In Dallas, more than 50 immunization clinics had to be canceled after the cuts, according to Dr. Philip Huang, director of the Dallas County Health and Human Services Department. Some of these outreach efforts were in schools that had low rates of measles-mumps-rubella (MMR) vaccination.

Dallas County has not reported any measles cases this year, but as other parts of the state prepare for potential spread of the outbreak, Huang warned that his county’s lab testing capacity may be affected.

As local health officials scramble to increase vaccinations, they say they’re seeing a great deal of vaccine hesitancy among communities affected by the outbreak. Yet efforts to understand this hesitancy and what could promote increased vaccination have also been halted, with at least two dozen research grants related to those topics canceled in the past few weeks by the National Institutes of Health.

“The studies that were cut were really focused on improving the preventative care experience and health outcomes for children and for families,” said Dr. Sophia Newcomer, an epidemiologist at the University of Montana whose grant analyzing CDC data on how and when children get vaccinated was terminated last month.

“What we see today is a big outbreak of measles, and it’s clear that we need now, more than ever, high-quality vaccination services in every corner of the US.”

Trust issues plague public health

Growing vaccine hesitancy has been coupled with a steady decline in trust in public health since the Covid-19 pandemic, which experts say can further hamper the effectiveness of programs and interventions that are central to an outbreak response.

“State and local health departments often build trust one interaction at a time, and that investment is important because it’s the currency that public health operates with,” said Dr. Susan Kansagra, chief medical officer for the Association of State and Territorial Health Officials. “The science and data guide us in how to respond to measles outbreaks, but it’s trust, built over time, that can compel people to listen and act on public health guidance.”

Just over half of US adults have favorable views of state and public health officials, according to a KFF survey from January; about 54% said they trust local health officials “a great deal” or “a fair amount” to make the right recommendations on health, down from 64% in June 2023. Key federal health agencies, including the CDC and the US Food and Drug Administration, also saw similar dips in public opinion over that time.

Kansas has reported 24 confirmed cases of measles, which the state health department said may be linked to the outbreak centered in West Texas. But some patients there are reluctant to be tested for measles, limiting abilities to capture the full scale and epidemiology of the outbreak.

“We are encountering individuals that are apprehensive or are resistant to testing. While the reasons for their decision have not been disclosed to our office, these individuals are willing to engage in discussions about their health status and the steps necessary to prevent the spread of measles,” Kerri Ulrich, health department administrator in Kansas’ Kiowa County, wrote in an email. “During an outbreak, we have two key roles: monitoring and assisting those who are ill, and taking steps to prevent the spread of the disease.”

Experts say it’s important to have a complete epidemiological picture during an outbreak – especially with measles, because it is so contagious.

“One person can infect over a dozen others if everyone is susceptible, so it’s really important to understand the epidemiology of who is infecting who, what potential contact locations might have happened, and where there could have been unknown transmission events,” said Dr. Nina Masters, a senior research scientist at the health care analytics company Truveta and former CDC epidemiologist who has responded to a number of measles outbreaks. “Because it’s an airborne pathogen and can stay in the air for two hours after someone leaves a room, it can be very hard at first glance to identify what those contact points might be” without investigation.

And many are raising the alarm that the ongoing outbreak may be significantly bigger than official case counts suggest.

“My understanding is that there are many, many, many more cases than are being reported,” said Dr. Adam Ratner, a pediatric infectious diseases physician in New York City and author of a book warning about the resurgence of measles.

At least 631 measles cases have been reported in the US since the start of the year, according to a CNN tally using data from the CDC and state health departments. There have been dozens of hospitalizations, and two children have died.

According to the CDC, at least 1 in every 1,000 children who become infected with measles may die. At that rate, there are probably now at least twice as many cases as have been reported – and perhaps thousands more.

“I think that the confirmed case numbers that we see are a lower bound,” Ratner said. “They’re almost certainly an underestimate of the actual number of cases, and the fact that we’ve seen two pediatric deaths already makes me worry that there are potentially many more cases than we know of.”

Mixed messaging about vaccines

The MMR vaccine is highly effective, with one dose offering 93% protection against measles and a second shot raising it to 97%.

But messaging around the importance of the vaccine – and the severity of the situation, in general – has been highly disjointed among various leaders.

“There has to be an absolutely clear and unambiguous and repeated message to families that what they should do is get their children vaccinated. And we haven’t seen that,” Ratner said.

In February, the Texas Department of Health Services declared Gaines County to be a designated measles outbreak area, invoking new vaccination guidelines. Infants ages 6 months to 11 months are recommended to immediately get an early dose of the MMR vaccine, with two other doses following the regular vaccination schedule: one between 12 to 15 months and one between 4 and 6 years.

Children ages 1 to 4 who have received a dose should get their next MMR dose immediately, as long as it’s 28 days after their first one, according to the guidelines. Children who have had no shots should also get two MMR doses 28 days apart.

By Monday, the state health department had expanded the designated measles outbreak area to include 10 counties.

“Increasing MMR coverage is a statewide priority. DSHS encourages all eligible individuals to be up to date on MMR vaccination to limit and prevent measles outbreaks,” the agency said in a health alert.

In 2019, the worst year for measles since it was declared eliminated in the US a quarter-century ago, health officials also recommended early doses of the MMR vaccine for infants – and a new report from Truveta says that there was a bump in vaccinations that year.

“It shows a positive signal that parents are listening to their providers. They are listening to public health. They’re aware of these travel-based recommendations,” Masters said.

But Kennedy’s stance on the MMR vaccine and his messaging around it have been mixed.

In March, he wrote in an opinion piece in Fox News that “the decision to vaccinate is a personal one.”

“Vaccines not only protect individual children from measles, but also contribute to community immunity, protecting those who are unable to be vaccinated due to medical reasons,” he wrote, and parents should consult with health-care providers “to understand their options to get the MMR vaccine” for their children.

On Sunday, after the death of a second unvaccinated school-age child, Kennedy arrived in West Texas “quietly to console the families and to be with the community in their moment of grief,” according to a social media post. In the same post, he wrote that “The most effective way to prevent the spread of measles is the MMR vaccine.”

But many experts stress the importance of more direct messaging.

“He still hasn’t said the thing he should say, which is that parents should get their children vaccinated,” Ratner said, and this is more concerning as Kennedy touts the use of vitamin A and the other unconventional therapies for measles.

“Kennedy is in a position now where people take his words seriously, and he is in over his head. This is not an area in which he has expertise, and the things that he says can be dangerous,” Ratner said, citing reports of children with liver toxicity from too much vitamin A.

“Many people have interpreted his comments to mean that people should use vitamin A to prevent measles. It does not work for that. We do sometimes give vitamin A to children who already have measles, but vitamin A is not the thing that you should be talking about to stop a measles outbreak,” he said. “The thing that stops a measles outbreak is vaccination, which is also the thing that prevents the measles outbreak from happening in the first place.”

In March, the CDC buried a measles forecast that stressed the need for vaccinations, according to internal records reviewed by ProPublica. Leaders ordered staff to not release an expert assessment that found that the risk of catching measles is high in areas near outbreaks where vaccination rates are lagging, ProPublica reported.

And on Sunday, President Donald Trump downplayed the size of the outbreak and the need for action.

“It’s so far a fairly small number of people relative to what we’re talking about,” he said.

“This is not something new,” he said. “And we’ll see what happens, but certainly, if it progresses, we’ll have to take action very strongly.”

The key elements of a successful outbreak response for measles include case identification and investigation, isolating cases and quarantining those with possible exposure, and supporting vaccination, as well as post-exposure prophylaxis, Masters said.

But the “backbone” of ensuring that it all works well is trust, she said.

“If communities lose that trust in public health, in their health departments, in science, in institutions, it just makes it that much harder for the teams on the ground, for the state and local health departments, for the physicians, for everyone involved in this response,” Masters said.

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