Early Vaccination During a Measles Outbreak—The Need to Go Beyond Well-Child Visits

Measles is among the most contagious of vaccine-preventable diseases, and despite elimination being declared in the US in 2000, recent years have seen numerous outbreaks. 1Declining vaccine confidence, geographic clustering of underimmunized children, and widening inequities in access to preventive care have left communities increasingly vulnerable. 1 The 2025 Texas outbreak, the largest in the US in more than 2 decades, offers an important reminder of the fragility of community immunity while also revealing how families, clinicians, and health systems adapt quickly in moments of heightened threat.Goodwin Cartwright and colleagues 2 present compelling evidence that measles-mumps-rubella (MMR) vaccination practices shifted rapidly during the outbreak, particularly through early vaccination of infants aged 6 to 11 months.Using electronic health record data from more than 82 000 children receiving regular outpatient care, the authors found that early vaccination of infants 6 to 11 months old represented only 0.7% of first doses from 2020 through January 2025 but rose sharply to 20.1% by April 2025.Notably, uptake increased even before the Center for Disease Control and Prevention (CDC) Health Alert Network guidance in March recommending early vaccination for children in the affected counties, likely driven by local epidemiology, parental demand, and clinician initiative.Rates were highest among 6-and 9-month-olds, aligning with scheduled well-child visits, while infants outside the routine schedule were vaccinated early less frequently.These results highlight the limits of relying on scheduled preventive visits alone.Well-child visits worked well for vaccinating those children who came in for appointments, but children not scheduled for those visits (eg, aged 7-8 and 10-11 months) were less likely to be vaccinated.At least some children in the affected areas likely contracted measles despite having followed the recommended well child schedule and being up to date on other routine childhood vaccines.As the authors note, strategies such as reminder-recall systems, standing orders, and after-hours clinics have been shown to improve immunization coverage and should play a role in outbreaks such as this one. 2,3Outbreak preparedness should therefore include mechanisms that can rapidly scale vaccine access.Risk perception plays a central role in vaccine decision-making.Parents and clinicians appeared motivated by visible local transmission even prior to national guidance.This aligns with prior research showing that the perception of risk can impact vaccination behavior, with hesitant families sometimes choosing vaccination when disease threat is present and visible. 3,4Whether this represents a durable change in vaccine confidence or a short-term adaptation remains to be seen.Monitoring vaccine uptake in this population would be helpful in determining whether the outbreakdriven uptake we see in this study persists once the outbreak is declared over.One important caveat is that this study was unable to address vaccination equity.By focusing on children with regular health care visits, this study likely overestimates early vaccination in the broader Texas population.Families facing barriers to care such as lack of insurance, transportation challenges, or deep-seated mistrust of health systems are less likely to receive vaccines while at the same time often being most at risk for severe outcomes. 5Historically, outbreaks have disproportionately affected disadvantaged communities.Without targeted outreach, such as mobile vaccination units, school-or church-associated vaccination clinics, or other community partnerships, outbreak-driven early vaccination may widen disparities rather than close them.Equity must therefore be treated as