How the Texas measles outbreak began, spread: See graphics

Texas officials announced the first measles death in the U.S. in a decade Wednesday, a grim milestone in the ongoing outbreak ravishing Texas and nearby New Mexico.

The death, which occurred in a school-age child, is the first of its kind since 2015, according to the U.S. Centers for Disease Control and Prevention. In a statement, Lubbock city and Texas health officials confirmed the hospitalized patient was unvaccinated. 

While Health and Human Services Secretary Robert F. Kennedy Jr. said two deaths have been reported in the outbreak in a Cabinet meeting Wednesday, local authorities and the U.S. Centers for Disease Control (CDC) have confirmed only one death. As of Thursday, the HHS has said only one death occurred.

The Texas Department of State Health Services announced Tuesday that confirmed infections were up to 124, mostly in children. All but five cases were in unvaccinated people or people with unknown vaccination status, and most occurred in far West Texas in Gaines County.

Here’s a look at the area and what the data shows so far about how measles is spreading.

What is a vaccine exemption?

In the U.S., all states require students to have a certain set of childhood vaccines before entering school. The typical vaccine course for a school-age child includes the MMR (measles, mumps, rubella) vaccine, DTap (diphtheria, tetanus, pertussis) vaccine, Hib (H. influenza) vaccine and vaccines for polio, chickenpox, flu, hepatitis A and B, rotavirus, pneumococcal and sometimes RSV or COVID. Requirements vary by state.

If a parent cannot or does not want to vaccinate their child against these diseases, they can submit a request for an exemption, usually on the grounds of medical need or religious and personal beliefs. Different states allow different kinds of exemptions.

In Texas, state law allows exemptions in three cases: If a healthcare provider determines that it is not safe for a student to get a certain vaccine, the student is in the U.S. military or the student has a religious or personal belief that goes against getting immunized.

If it is found medically dangerous for a student to have an immunization, this is called a medical exemption. If the exemption is granted based on religious or personal belief, it is called a conscientious exemption.

Nationwide, childhood immunization rates against serious diseases like measles are declining as more parents request non-medical exemptions from recommended vaccinations, according to the CDC.

Gaines County ground zero in Texas

The epicenter of the outbreak, Gaines County, Texas, encapsulates 10 cities, towns and census-designated locations and had a population of about 22,523 in 2023, according to U.S. Census data. At the seat of the county is Seminole, a small city with a population of roughly 7,231. The same data shows that 31.4% of the population is under 18, the prime population most heavily impacted by measles.

Gaines, which has three school districts that are all public, has an abnormally high conscientious vaccine exemption rate of 13.6% in grades K-12, one of the highest in Texas, 2023-2024 state health data shows. This is more than five times the statewide average of 2.5%.

Two other counties, Crosby and Bell, had even higher rates in 2023-2024 at 23.7% and 18.8%, respectively.

Gaines County school districts report high non-medical exemption rates

Of the school districts located in Gaines County, the Seminole Independent School District, which includes three elementary schools, a junior high school and a high school, had the second-highest conscientious exemption rate at 13.82%, followed by Seagraves Independent School District with just a 1.87% exemption rate.

The Loop Independent School District, which serves a small student population of 157 K-12, had a 47.95% non-medical exemption rate in 2023-2024, the highest known number of any public school in Texas.

When looking over four years of data, the uptick in non-health-related vaccine exemptions at Loop is a snapshot of a larger, statewide trend. The increase was strong and steady, starting at 16.11% in the 2019-2020 school year and jumping up to 34.39% in 2022-2023 before reaching its current total.

Measles coverage in Texas is below the 95% herd immunity threshold

According to CDC data that surveyed 92.4% of Texas kindergarten students in the 2023-2024 school season, 94.3% of students had two doses of the MMR vaccines – just short of the 95% needed for herd immunity. Of all incoming kindergartners surveyed statewide the same year, 3.9% claimed a vaccine exemption of any kind, a 0.4% increase from the previous year.

Herd immunity means enough people in a population are immune to a disease, often through vaccination, that it becomes very difficult for the infection to spread. This protects those who are not yet immune, such as children who are too young to receive vaccines or those with compromised immune systems.

Low vaccination rates among local Mennonite community played a role in outbreak, experts say

While Gaines and Texas at large have followed the nationwide trend of plummeting vaccination rates, the county has another, population-specific factor that contributes to its high exemption status.

The area has a large population of Mennonites, a Christian religious-cultural group established during the protestant reform. Sometimes erroneously mistaken for the Amish due to their cultural practices, the close-knit, under-vaccinated Mennonite community in the area often opts to homeschool children or send them to private schools.

According to the Texas State Historical Association, two groups of Mennonites purchased land in Gaines and Andrews counties near Seminole in the late 1970s, an area they picked partially thanks to the less dense population, large swathes of land and private schools that are not heavily regulated.

Lara Anton, a spokesperson for Texas’ health department, previously told the outbreak was concentrated in this community thanks to “under vaccination.” She likewise pointed to access issues, saying the highly rural nature of the region means people have to travel at least 30 to 40 miles to get preventative care, including vaccinations.

The outbreak, though centralized in Texas, has since spread to multiple other states, though no deaths have yet been reported elsewhere.

Vaccine rates freefall nationwide, not just in Texas

Nationwide, vaccination rates are down and exemption rates are up, having seen an especially large jump after 2020, which is likely tied to COVID-19 vaccines. Another piece of the puzzle is a growing anti-vaccine movement, which has been bolstered by the confirmation of RFK Jr., who has a history of speaking out against vaccines, as health secretary. Despite RFK Jr. saying he isn’t anti-vaccine during confirmation hearings, he has in the past falsely linked vaccines to autism and urged parents to not vaccinate their children.

Exemption rates are not the only factor in the spread of contagious diseases like measles. Exemptions often occur in pockets or are concentrated in certain areas or communities. In areas like Gaines, where school districts and communities with high exemption rates are clustered together and contain a high concentration of the people most susceptible to infection, such as children under 18, the spread is more likely to occur.

Access to resources is also a factor – the area in which the outbreak started in Texas is rural and its residents must travel further to gain access to immunizations and healthcare once they do become ill. This need to travel for care also increases the likelihood of spread to other locales.

More states are hitting a threshold of under 95% for the MMR vaccine specifically, which is required for herd immunity.

With measles holding the distinction of being one of the most contagious of all infectious diseases, according to the CDC, the decline in protective vaccines could spell trouble for states across the U.S. It is so contagious, in fact, that 90% of unvaccinated people who are exposed end up contracting it and one in five of those people end up hospitalized, according to the CDC.

It primarily infects children, a population in which it can become exceptionally deadly. And, due to its nature, it’s likely actual infection rates are much higher than confirmed cases. Even with only one confirmed death thus far, death ratio compared to the state’s 124 known cases is much higher than would be expected, Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, told earlier Wednesday.

“It makes you wonder if it really is 124 cases, or if it is a much larger number of cases.”

Texas health officials are working with counties across the state to hold vaccine drives and encourage higher rates of public vaccination. But experts have warned that once measles starts spreading, it can be hard to stop.

 Contributing: Sara Chernikoff, Eduardo Cuevas, Janet Loehrke,