North Carolina preps for potential measles outbreak

By Jennifer Fernandez

As measles cases climb to 400 in Texas, the epicenter of an outbreak of the highly contagious illness, North Carolina is taking steps to prepare for an outbreak here.

Though the state hasn’t recorded any cases this year, officials want to keep it that way. 

“We’ve been able to maintain pretty good [vaccination] coverage, but still, it’s slipping,” North Carolina State Epidemiologist Zack Moore told NC Health News. “And so we are seeing more people who are at risk for a variety of vaccine-preventable diseases.”

Cases of whooping cough, for example, are already 3.6 times higher in North Carolina than last year at this time in the state, federal data shows. That shows signs of becoming a trend, as cases of the respiratory illness also rose sharply between 2023 and 2024. 

The last measles case in North Carolina occurred last September; a child in Mecklenburg County came down with the virus after traveling outside the country, the N.C. Department of Health and Human Services said. It’s not clear if the child was vaccinated. It was the state’s first case since 2018.

In the Texas outbreak, an unvaccinated child died in February after contracting measles. The child lived in a Mennonite community that has low vaccination coverage — about 82 percent for the measles, mumps and rubella combination vaccine, according to data from the Texas Department of State Health Services. That’s well under the 95 percent that Moore said is considered the threshold for preventing an illness from taking hold in a community.

“We’re very concerned about that always, but especially now, given that we’ve had a pretty high number of cases,” Moore said on March 17. “It’s only March, and we’ve already surpassed the 2024 national measles counts.”

The Texas outbreak has been connected to cases in New Mexico and Oklahoma, according to media reports. There are four other separate outbreaks (defined as three or more related cases), with a total of 20 states reporting at least one measles case. In all, the CDC has confirmed 483 cases this year, up from 285 for all of last year.

So what would happen if someone with measles walked into a doctor’s office in North Carolina?

“Oh, that’s a mess, because you have to shut down your office immediately,” said Christoph Diasio, a Moore County pediatrician. “You have to contact everybody who’s been in the office … around when the person was there. You have to talk to the state epidemiologist to see if you can get expedited testing. You have to isolate people.

“There’s a lot you have to do.”

Highly contagious

Measles is an airborne illness spread through coughing and sneezing. It is considered highly contagious. After an infected person leaves a room, the measles virus can survive in the airspace and on surfaces for up to two hours. The infected person doesn’t need to cough or sneeze in that space, only breathe.

The illness, which is marked by a red rash, can be spread by an infected person from as early as four days before the rash appears to four days after it appears; that’s part of what makes it so effective at spreading.

One single measles case is thought to cause on average 12 to 18 secondary cases in a completely susceptible population, according to Amy Winter, a University of Georgia assistant professor who is an infectious disease modeler. For chickenpox, one case can lead to between seven and 10 secondary cases. COVID-19 ranges from two to 10 secondary cases per exposure, depending on the variant, Winter said during a recent webinar.

The first measles vaccine in the U.S. was licensed in 1963. Before the vaccine, measles hospitalized about 48,000 people annually and led to 400 to 500 deaths each year, according to the U.S. Centers for Disease Control and Prevention.

Children younger than 5 years old are particularly susceptible to severe illness, along with pregnant people and those who are immunocompromised.

There are a “whole host of complications and health issues” associated with measles, Moore said.

The most common severe problem is lung infections or pneumonia, he said. Measles can cause ear infections and lead to neurologic complications. A study done in 2019 and published in Science found that measles can compromise the immune system long-term, creating a form of “immunological amnesia” that, in essence, wipes away the ability to fight off diseases.

“Epidemiological evidence has associated [measles virus] infections with increases in morbidity and mortality for as long as 5 years and suggests that in the pre-vaccine era, [measles virus] may have been associated with up to 50% of all childhood deaths from infectious diseases, mostly from non-[measles virus] infections,” that were acquired after a child had measles, the authors found.

“That’s why we take it very seriously and … work really hard to make sure that people are protected … with vaccination, and that we’re responding quickly to stop the spread when we do get cases in our state,” Moore said.

Being prepared

Public health officials are closely monitoring trends in other states and globally, the N.C. Department of Health and Human Services said in a news release.

Since North Carolina’s health system is decentralized, local health departments handle what happens in their area with support from DHHS.

Moore said DHHS is working with local health departments, sharing information about how to prepare for measles cases, including how to collect specimens for testing and how to send specimens to the state lab. DHHS also has been working with school nurses and the N.C. Pediatric Society to share information. 

“We’re reaching out to highlight where we’re seeing pockets of high levels of exemption, low levels of immunization … to make sure everyone has that information and talk about whether there’s any … additional support or resources or engagement that might be helpful in protecting those communities that we know are going to be at really high risk of an outbreak if a case does get introduced,” he said.

That preparation includes:

• Reaching out to providers to remind them of what to look for (many doctors no longer know what measles looks like), how to reach state health officials and how to report a case.
• Providing materials and resources.
• Preparing to help county health departments with specimen collection or diagnostic testing through the state lab.
• Talking to health departments about staffing and how to reallocate resources to respond.

“If you do find yourself with a case, even one case, [it’s] a pretty massive response and takes a lot of staff,” Moore said.

The state is prepared with vaccines as well as immunoglobulin, which can be used if infants or pregnant women, who can’t take the vaccine, have been exposed to measles, Moore said. He added that they can get more vaccine doses if needed.

“North Carolina does a good job with public health,” said Diasio, who is a past president of the North Carolina Pediatric Society. “I have every confidence that if we have to deal with it, that [we] will do a good job.”a Pediatric Society. “I have every confidence that if we have to deal with it, that [we] will do a good job.”

MMR vaccination coverage US and NC by Jennifer Fernandez

US at inflection point?

Measles takes a greater toll in underdeveloped nations where poverty and poor nutrition, along with low vaccination rates, make children more vulnerable, according to the World Health Organization.

Before a vaccine was created and vaccination became widespread, measles claimed some 2.6 million lives worldwide each year with major epidemics taking place every two to three years, the organization said.

About 107,500 people — mostly unvaccinated or undervaccinated children younger than 5 — died from measles in 2023, WHO said.

Global vaccination coverage, which is much lower than in the U.S., has also been declining in recent years. In 2023, 83 percent of children worldwide had received a first dose of the measles vaccine. Four years earlier, 86 percent had their first dose, WHO said.

Based on trends in vaccination coverage and cases, measles elimination across the globe is under threat, according to the WHO Strategic Advisory Group of Experts on Immunization. The group noted that the disease has resurged in numerous countries that achieved, or were close to achieving, elimination.

Moore said public health officials are worried that the U.S. is at “an inflection point.”

Measles has been considered eradicated in the country since 2000, with only localized outbreaks occurring. But now, vaccination rates are declining and exemptions are rising — and not just with measles.  

North Carolina requires all children — with some exceptions — to be vaccinated against several illnesses before attending child care or school, whether public or private. If students don’t have the required vaccinations, or are exempted, they won’t be allowed at school. 

The percentage of incoming kindergartners who are considered fully vaccinated against these illnesses has dropped statewide from 94.2 percent in 2020 to 92.5 percent in 2023, according to the state’s immunization dashboard. 

At the county level, coverage ranged from 83.7 percent in Cherokee County to 97.9 percent in Richmond County in 2023, the latest data available.

Cherokee County’s vaccination coverage also ranged widely among the six public schools with kindergarten students. At Martins Creek Elementary in Murphy, 72.7 percent of students were up to date on their vaccinations in 2023. At Ranger Elementary, also in Murphy, 94.3 percent of students were up to date that year.  

Communities need to know their vaccination rates because contagious illnesses like measles spread at the local level, said David Higgins, an attending physician at Children’s Hospital Colorado Anschutz Medical Campus.

“I like to say that when vaccination rates drop in a community, it is not a question of if, it’s a question of when measles is going to come because it is so incredibly contagious,” he said in a recent webinar.

Vaccination exemptions by Jennifer Fernandez

Getting the word out

Talking with families about vaccination is a core part of being a pediatrician, Diasio said. With the measles outbreak keeping the illness in the national conversation, he’s not seeing concerns about getting the measles vaccine now. But there are still people who aren’t sure they want the flu vaccine or the human papillomavirus vaccine. HPV protects against genital warts and several cancers.

“The science and the data on our opportunity to protect children against terrible diseases is really solid. I mean, it stands on a mountain of data,” Diasio said. “We have more proof about this than basically anything a family is going to ask us about.”

Vaccine hesitancy is never about one thing, Diasio said. Sometimes it’s about someone they know having a bad experience. It can be bad information they saw on the internet or social media.

Not everyone looks at data the way that doctors do to see the benefits of vaccination, he said. But sharing personal stories can provide that connection.

“Sometimes it is just as simple [as], ‘You know, I have a family whose kid did not get this vaccine and had this terrible outcome, and I don’t want that ever to be you,’” he said.

Diasio said vaccines are a victim of their own success.

When no one has ever heard of any friends having whooping cough, for example, then they’re not that interested in that vaccine, he said.

“There were a whole lot of folks who didn’t think measles was a big deal,” he said. “But now that they’re seeing the stories and … people actually have died of measles in America in 2025, which is just horrifying … they’re much more interested in doing it.”

He encouraged parents to talk to their doctors if they have questions about childhood vaccines.

“It’s just an unbelievable blessing that we can protect children against these horrible diseases,” he said.

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