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County, district and community-level measles transmission in the United States in 2013-2025

Siyu Chen1, Ana I Bento2

  • 1Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.

Nature Medicine
|August 19, 2026
PubMed

Insights

Measles elimination is at risk due to vaccine hesitancy and flawed surveillance. Outbreaks now originate at the school level, invisible to current county-level monitoring, highlighting the need for localized interventions to prevent re-endemicity.

Area of Science:

  • Epidemiology
  • Public Health
  • Infectious Disease Modeling

Background:

  • The United States declared measles eliminated in 2000, but over 3,500 cases in 2025-2026 have triggered a formal review of this status.
  • Vaccine hesitancy, exacerbated by COVID-19 disruptions and misinformation, has weakened herd immunity, increasing measles vulnerability.
  • Current surveillance methods aggregate data at the county level, obscuring localized susceptibility clusters where outbreaks begin.

Purpose of the Study:

  • To assess the current spatial architecture of measles vulnerability in the US.
  • To quantify epidemic risk across multiple spatial scales.
  • To evaluate the effectiveness of current surveillance methods in detecting measles resurgence.

Main Methods:

  • Assembled a nationwide multiscale vaccination database (2013-2025) covering 45 states and DC, including over 50,000 schools, 13,000 districts, and 3,000 counties.
  • Developed a transmission model to quantify epidemic risk at various spatial scales.
  • Analyzed school-level and county-level vaccination data and effective reproduction numbers.

Main Results:

  • Average population susceptibility to measles doubled from approximately 5% to 10% post-pandemic.
  • School-level effective reproduction numbers surpassed the epidemic threshold in 2022-2023, a critical rise undetected by aggregated surveillance.
  • County boundary misalignment was shown to facilitate disease spillover from less-vaccinated to well-vaccinated areas, increasing overall risk.

Conclusions:

  • The spatial dynamics of US measles vulnerability have shifted, with transmission potential now supercritical at the school level but undetectable by current surveillance.
  • Preventing measles re-endemicity necessitates a shift towards school and district-level surveillance and targeted interventions to intercept imported cases early.
  • State-level outcomes are significantly influenced by vaccination exemption policies and the robustness of local vaccination infrastructure.

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