Above an image of a child with blotchy skin, the Kent County Health Department asks its Facebook community “Think you might have measles symptoms?”
The department is hoping the county’s answer remains “no”.
Amid the highest number of measles cases in the United States in more than 30 years, Kent County’s kindergarten MMR vaccination rate — measles, mumps and rubella — lags behind the rest of the state at 88%. The CDC reports that more than 95% of the population must be vaccinated to be protected through herd immunity, and Kent is the only county in the state below this threshold.
The MMR vaccine is given in two doses, the first when children are between 12 and 15 months old, and the second at four to six years old. Maryland requires children to have both doses of the vaccine to enroll or attend state schools, but allows for exemptions for religious or medical reasons.
“We’re very concerned about any drop in vaccination rates, especially related to measles, because we know that measles is one of the most infectious viruses that we’re aware of,” said Kent County Health Department Health Officer William Webb. “One of the things I don’t think our community understands is how infectious measles is.”
How contagious is measles?
Measles is extremely contagious. It’s a respiratory virus that can cause serious health complications, especially in children younger than 5 years old.
The disease spreads when an infected person sneezes or coughs. The virus can live for up to two hours in the air after a person with measles leaves the area, according to the CDC.
Nine out of 10 unvaccinated people who come in close contact with a person with measles will also catch it.
James Campbell, a pediatric infectious disease professor at the University of Maryland School of Medicine, said one of the reasons it spreads so quickly is because it’s difficult to recognize early on. Symptoms like fever, cough, runny nose and red eyes are often mistaken for other respiratory viruses, like influenza or the common cold, before the characteristic rash appears, so people often take less precautions.
The CDC reports that measles is contagious 4 days before and after the rash breaks out. There is no treatment against the virus, only help with the symptoms.
Is 88% coverage that low?
As of the 2024-2025 school year, Maryland’s vaccination rate statewide is at 96.4%, only a slight decrease from the year before. But vaccination rates dropped in half of the counties. Excluding Kent, Dorchester, Prince George’s and Garrett counties had the most decrease at about a 2% drop.
Although all the counties, besides Kent, linger at or above the 95% threshold, pockets of unvaccinated populations pose a higher risk of a measles outbreak.
Campbell said that an unprotected population concentrated in a single area can be susceptible to outbreaks, even if the overall coverage is high.
“If you have 95% coverage, that means 5% uncovered … and if those are randomly distributed around the population, then it’s not that likely that any infected person finds a susceptible person,” he said. “But if those 5% are clustered in one school, one district, one zip code, then it’s much more likely.”
The largest measles outbreak this year started in a community with low vaccination coverage in Gaines County, Texas, in January, with 762 cases, 99 hospitalizations and two deaths. The kindergarten MMR immunization rate was at 81%, the lowest in the state.
Why is the vaccination rate low?
Webb said that the Kent County rate is not due to vaccine availability or cost.
All county pharmacies have a supply of the MMR vaccine and children under the age of 18 can get vaccinated for free if they have no insurance or are underinsured under the “Vaccines for Children” program.
He said the county health department also opens vaccination clinics before school starts and publishes information about vaccines through Facebook, local public media and to nonprofit faith-based institutions.
“Really the decline that we’re seeing [is] individuals consciously making a choice not to get their children vaccinated,” Webb said.
Maryland allows medical or religious exemptions to school immunization requirements, and religious exemptions have spiked. Nearly 5% of kindergartners enrolled in Kent County had a religious exemption in the 2024-2025 school year compared to less than 1% medical exemptions, according to the Maryland Department of Health.
This is almost three percentage points above the state religious exemption rate and about one percentage point above the national rate.
It’s not just Kent County
Total exemptions peaked nationally and at the state level in the 2019-2020 school year at the start of the COVID-19 pandemic, before a sharp decline the next year. But they have been steadily increasing since 2021.
At the same time, MMR vaccination coverage has been steadily decreasing at the national level. In Maryland, the rate has declined slightly since the 2022-2023 school year.
According to a series of surveys conducted by the Pew Research Center, support for the MMR vaccine mandate in schools has decreased. In the March 2023 survey, 28% of U.S. adults answered that parents should be able to decide to vaccinate their children, even at the risk of creating health concerns for others. About 16% of adults favored this in the 2019 survey.
The percentage is more stark between Republican and Democrat respondents, the survey reported. About 42% of Republican respondents favored parent approval compared to 14% of Democrat respondents in 2023.
In September, Florida announced plans to be the first state to eliminate vaccine mandates, a significant shift from the medical establishment that vaccines prevent the spread of disease.
“In our current climate, a lot of it has to do with chaos and confusion,” Campbell said of the rise in vaccine distrust. “It is very difficult, I think, for people who don’t live and breathe vaccines like I do to understand ‘Who do I trust?’ and ‘Where’s the best information?’”
The CDC reports 1,544 confirmed measles cases in the United States as of Sept. 30, the highest level since the disease was declared eradicated in the country in 2000.
Maryland has had three measles cases, where residents contracted the disease after traveling. Campbell said these don’t count as outbreaks because the disease didn’t spread from community members, rather from susceptible people travelling to places with large unvaccinated populations.
“But if that changes, like in Kent County, we will see outbreaks,” he said. “Maryland overall tends to do well with vaccination coverage, but there has been some slippage, and I think this is a good time to reinvigorate the messaging.”