Title : Uncovering predictors of the 2025 measles resurgence in Texas: Ecologic determinants & risk patterns
Abstract:
Background:
Despite measles elimination in the USA since 2000, recent outbreaks of measles have occurred in several Texas counties. The 2025 measles outbreak in Texas, with over 760 confirmed cases, marks the largest resurgence in over three decades. The last large outbreak in Texas occurred in 1992 and was driven primarily by limited vaccine availability and infrastructure gaps. This study explores risk factors for the current resurgence. Identifying county-level factors driving this resurgence is critical for targeted public health interventions.
Objective:
This study aimed to identify key predictors of measles resurgence across Texas counties using data from the Texas Department of State Health Services and the CDC. The lessons learned from this resurgence can be useful in mitigating future outbreaks.
Methods:
In this cross-sectional ecologic study, county-level data from 2024–2025 were compiled from public health sources namely the Texas Department of State Health Services and CDC. Multivariate linear regression was used to analyze associations between predictor variables, including social determinants of health, healthcare infrastructure metrics, vaccination coverage and the incidence of measles in Texas counties.
Results:
As of August 2025, the Texas Department of State Health Services confirmed a total of 762 measles cases statewide, making it the largest outbreak in the state in over 30 years. Of those infected, 99 individuals required hospitalization, representing approximately 13% of all cases. There were two fatalities, both involving school-aged children. Neither had known underlying health conditions. At the individual level, vaccination status remained the most important predictor of contracting measles with 97% of individuals either unvaccinated or under-vaccinated. Linear regression was used to explore county-level risk factors. The adjusted regression model explained 66.1% of the variance in measles incidence (adjusted R² = 0.661, p < 0.001). Higher measles incidence was significantly associated with lower vaccination coverage (β = -0.461, p < 0.001) and higher percentages of individuals without high school education (β = 0.542, p < 0.001). In unadjusted analyses, increased provider density was associated with decreased measles incidence (β = -0.541, p < 0.001), but this was not statistically significant in the final adjusted model. Other factors that were explored including rural/urban status, number of hospitals per county, population density, median income, and percentage of foreign-born residents, were not significant predictors of higher incidence of measles (p > 0.05).
Conclusion: Measles resurgence in Texas was linked to lower vaccination rates and lower educational attainment. Areas with decreased immunization coverage have shown a higher incidence of outbreaks and lower educational attainment can be associated with reduced engagement in preventative healthcare practices, including childhood vaccinations. Individuals with limited formal education may be less likely to access credible health information or to recognize the importance of immunization in preventing highly contagious diseases like measles. These results highlight the importance of equity-focused vaccination efforts and education, alongside improving healthcare provider availability, to mitigate future outbreaks.
