Texas health officials on Aug. 18 declared the end of a measles outbreak that had sickened more than 760 people across the state and killed two children. Doctors and public-health officials involved in the outbreak, most of whom had previously never encountered a measles patient, are now taking stock of what they’ve learned about the virus and the best ways to prevent and control outbreaks of the disease.
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Measles, they say, is as contagious as feared, and unvaccinated people are the most vulnerable. But while vaccination remains the best way to prevent measles, Texas public-health officials say they could have adopted a more inclusive approach when engaging with vaccine-hesitant communities about the virus and its risks. More investment is also needed, they say, into building trust between rural communities and health officials.
These insights should be taken to heart as measles cases continue to rise in the U.S., Canada, and Mexico, say public-health experts who fear that measles may now be here to stay. More than 1,300 measles cases have been reported nationally this year, the highest number since the disease was declared eliminated in the U.S. in 2000.
“Even though the Texas outbreak looks to be under control, we’re still seeing a lot of cases,” says Jennifer Nuzzo, director of the Pandemic Center at Brown University School of Public Health. “The measles situation is not over.”
Here are some lessons learned from the Texas measles outbreak.
Measles is as dangerous, contagious, and vaccine-preventable as expected
“What surprised me was how textbook measles is,” says Katherine Wells, the public health director of Lubbock, Texas, where many measles patients were treated during the recent outbreak.
Wells has been in public health for almost 25 years and had never before seen a measles case. But as patients streamed into Lubbock’s hospitals and clinics, a clear clinical pattern—which Wells had learned about in the medical literature—emerged. Unvaccinated people with measles first develop a runny nose and conjunctivitis, then a high fever and rash.
The disease also proved to be as contagious as feared. In Lubbock, an unvaccinated child became ill with the virus after sitting in the same waiting room as someone with measles, Wells says. “Seeing those cases on the ground confirmed what was in the books.”
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About one in five measles cases are severe, says Dr. Leila Myrick, a family medicine and obstetrics physician in Seminole, Texas, who treated more than 20 people with measles this year, most of them children. Several of Myrick’s patients developed pneumonia and required breathing treatments including supplemental oxygen, she says.
Almost 100 people, mostly children, were hospitalized in Texas because of complications from measles. Most people who have contracted measles in the U.S. this year have been unvaccinated.
Throughout the outbreak, U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. downplayed the risk of measles, saying in a Fox News interview in March that it’s “very, very difficult for measles to kill a healthy person.” The two children in Texas who died from the disease were unvaccinated but had no preexisting conditions, officials have said.
“Measles is not a little cold. It can cause very high fever that can become very rapidly life-threatening,” said Richard Plemper, a Georgia State University biomedical scientist whose lab is developing an antiviral treatment for the virus family that includes measles. There is currently no approved treatment for the disease.
About 0.1% of measles cases in developed countries are fatal, Plemper says. “Yes, that’s a small number, but if it’s your child, what comfort is that? Measles is vaccine-preventable. In a country like the U.S., nobody has to die from measles.”
Public-health experts say there is still more to learn about the disease’s longer-term effects on patients who have recovered. Measles can cause yearslong “immune amnesia,” in which the body forgets how to fight other infections. In very rare cases, the disease can also cause a deadly type of brain inflammation that strikes several years after the initial infection.
Better testing and wastewater surveillance can hinder disease spread
At the start of the Texas outbreak, measles testing was a major hurdle, state public-health officials say. It took up to a week for test results to come back, which stymied efforts to curb the spread of the virus.
It wasn’t until about six weeks into the outbreak that testing capabilities improved, and people were able to get test results the next day, says Wells, the Lubbock public-health director.
Wastewater surveillance for measles could also have been instituted earlier, public-health experts say. Such testing, which was started midway through the Texas outbreak, can flag the presence of a disease even before people come forward with symptoms. Recently in Idaho, wastewater surveillance detected measles activity at least a week before the state’s first case in 30 years was reported.
Pushing vaccination is important—but so is meeting people ‘where they are’
The Texas outbreak started in a Mennonite community in Gaines County where vaccination rates are low. State health officials say they pushed hard to get people in the community vaccinated, setting up mobile vaccine clinics and educating people on the safety and efficacy of the shot.
In the end, more than 300 people in the county were vaccinated as part of this campaign, says Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines County.
But officials said they could have done a better job at providing not just vaccines but also information and other resources that could have helped families that chose not to vaccinate and had sick kids at home. Many children showed up to the hospital with dehydration, for instance, and could have benefited from information on the importance of keeping children hydrated, Wells says.
Read More: The Public Health Community Needs to Tell the Whole Truth About the History of Measles
The Texas Department of State Health Services said in an emailthat in future outbreaks, it would continue to share information about the measles, mumps, and rubella vaccine, but it might also introduce more general messaging that does not focus on vaccines, such as when people with measles symptomsshould seek emergency care, sooner.
“We have to meet people where they are,” says Lori Freeman, CEO of the National Association of County and City Health Officials, which represents local health departments across the country.
Freeman says that building trust with communities—and doing so before an emergency strikes—is indispensable. “Our work is only as successful as our ability to partner with communities,” she says.
People do listen to official advice, and the quality of that advice matters
The Texas outbreak demonstrated that the public does heed official recommendations, says Plemper of Georgia State University, and highlights the heavy responsibility that health leaders shoulder when doling out advice.
For instance, Kennedy repeatedly said that supplementing with vitamin A could effectively treat measles. Vitamin A is not an approved measles treatment, and while some research has shown that people with vitamin A deficiencies can get sicker from the disease, there is no evidence that people who aren’t deficient will benefit from it.
Taking too much vitamin A, however, can cause organ damage. Several children in Texas were reportedlyhospitalized earlier this year after taking too much vitamin A.
Nuzzo of Brown’s Pandemic Center says Kennedy—who has long questioned the safety of the MMR vaccine and provided misleading information about the outbreak—did little to help curb the outbreak in Texas.
“We have an HHS Secretary who was pushing false narratives about the vaccine and the virus,” she says. “It was controlled despite him.”