John Goldman had seen only two cases of measles in more than 30 years as a physician. Now, in the midst of the nation’s largest measles outbreak, the infectious-disease specialist in Pennsylvania has helped care for about 50 infected patients in a single year.
And he is seeing the disease manifest in ways he never encountered before: adults with severe pneumonia, pregnant women and babies born infected.
All the patients recovered. But the resurgence of measles is forcing clinicians such as Goldman, 62, to relearn how to recognize and manage a disease that has been largely absent from medical practice since the U.S. eliminated measles in 2000. After years of falling vaccination rates and amid the worst measles outbreak the U.S. has seen in 35 years, doctors are confronting an illness many have never seen in practice.
“There is a tremendous amount of what I would describe as learning on the fly,” said Goldman, an epidemiologist at UPMC Harrisburg.
The magnitude of Pennsylvania’s outbreak — 1,542 cases and seven deaths, including one reported Friday — has made once-rare complications more visible, offering a glimpse of what doctors elsewhere could encounter as measles spreads among susceptible populations.
Some of the greatest unknowns involve the youngest patients — babies infected before birth or in the first months of life. Doctors have far less evidence or knowledge about what infection at such a young age could mean years later.
This week, an independent group of global health experts determined the United States has lost its status as a country that eliminated the continuous spread of measles, a landmark public health achievement attained more than a quarter-century ago. A committee of the Pan American Health Organization, part of the World Health Organization, met this week to determine whether the disease has spread uninterrupted for more than 12 months since a major outbreak in West Texasin January last year, — a conclusion many epidemiologists and infectious-disease experts had said was expected based on publicly available data.
For clinicians in Pennsylvania and elsewhere who have been battling outbreaks, that is a technical marker, and a lagging one. Doctors on the front lines are already seeing the real-life consequences of sustained transmission.
Measles in adults had been rare
For decades, measles was taught in textbooks as a disease that primarily affected children. Historically, most people were infected as children, “so as they got to adulthood, they were immune,” said Robert Hopkins, medical director of the National Foundation for Infectious Diseases who also takes care of adults and children at the University of Arkansas for Medical Sciences hospital in Little Rock.
But now doctors are seeing measles in adults, something they were not expecting.
Measles in adults is often more serious than it is in children, doctors say. One man developed such severe measles pneumonia that doctors placed him on a ventilator to help him breathe, Goldman said. Another, a woman hospitalized with sepsis, a life-threatening reaction to an infection unrelated to measles, turned out to have measles before she even had the characteristic rash.
Nationally, 41 percent of measles cases this year have been among adults 20 and older, up from 29 percent last year, according to data from the Centers for Disease Control and Prevention. There have been more than 5,400 measles cases so far this year, more than double the total reported in 2025.
Years of underimmunization mean there is a population of adults who were neither vaccinated nor infected as children and therefore remain susceptible. Declining vaccination rateshave weakened the community immunity that once protected them by preventing a measles case from spreading.
In Pennsylvania’s outbreak, the shift has been even more pronounced: Two-thirds of the state’s cases have been in adults, some as old as 60.
The outbreak has been heavily concentrated in the state’s Plain community, which includes Amish and conservative Mennonite groups that follow traditional ways of life. Many Amish families do not routinely seek preventive care, are self-insured, and might interact with the health system mainly when someone becomes sick or injured, according to pediatricians who have cared for patients in the community.
As a result, there are people in the community who made the decision not to be vaccinated decades ago and remain susceptible today, said Goldman, who is also the epidemiologist for the system’s hospitals in central Pennsylvania, where the outbreak is centered. The average age of measles patients he has seen in the Pennsylvania outbreak is “probably in the 20s or 30s,” he said.
Goldman has been training younger physicians to recognize measles in people of all ages, starting with the basics. Get vaccinated. Know that you can’t spread the virus to family members unless you are sick. If you are vaccinated and pregnant, there is no risk to the baby.
“And then what we’re really doing is trying to teach them what measles looks like and when to be suspicious of it,” Goldman said.
For example, any rashes that start on the face. A person with a high fever, conjunctivitis or pink eye, and cough are classic measles symptoms. But early on, adults might not have the rash “and it can look like any other viral illness,” Goldman said.
Knowing that measles was spreading in communities with low vaccination rates put clinicians on heightened alert. Sometimes that led to “overcalling who could have measles,” he said. “We had people suspicious of any rash.”
Pregnancy: Another layer of complexity
As more susceptible people reach adulthood, doctors are also confronting a consequence that had become exceedingly rare: women contracting measles during pregnancy, putting them and their babies at risk.
Women who contract measles while pregnant face increased risk of serious illness, including pneumonia, as well as miscarriage, stillbirth and premature delivery, said Kevin Ault, an obstetrician-gynecologist at Penn State Health in Hershey, about 30 miles northwest of Lancaster County, the outbreak’s epicenter.
Scientists at the CDC sought to send an urgent nationwide alert to clinicians about the risks and management of measles during pregnancy as cases increased, but the alert was not approved, The Washington Post previously reported.
Last month, Pennsylvania health officials took the unusual step of issuing a statewide health alert specifically addressing rising cases of measles in pregnancy and measles passed on in utero. The notice urged doctors to immediately report suspected infections and said women should be vaccinated against measles before becoming pregnant. The measles, mumps and rubella (MMR) vaccine cannot be given during pregnancy.
Complications for children born with measles
If a woman contracts measles late in pregnancy, or gives birth prematurely, the baby might be born with congenital measles, Ault said. But much of what physicians know about the condition dates to the middle of the last century, he said. Those data suggest that about 30 percent of babies born to women infected during pregnancy develop congenital measles, he said.
What doctors are seeing in Pennsylvania appears consistent with that estimate, Ault said. In talking to obstetricians in other parts of the state, “I think they are seeing congenital measles about the rate you’d expect, about one-third of the time,” he said.
Still, the estimates of congenital cases predate modern diagnostic tools such as PCR testing and advanced imaging. Physicians might now “find a whole new crop of problems,” Ault said.
Children known to have been infected around the time of birth should be followed closely throughout childhood for developmental delays or learning disabilities, clinicians said. One particularly serious concern is subacute sclerosing panencephalitis, or SSPE, a rare, progressive and almost always fatal brain disorder that typically emerges years after a measles infection.
Since the outbreak began in late April, at least 101 pregnant women in Pennsylvania have been diagnosed with measles as of Friday, an increase of 24 cases in three weeks, according to the state health department. Pennsylvania’s sixth measles-associated death was a 21-year-old woman who died after postpartum complications. The funeral director who handled her arrangements told The Post that her baby was healthy.
It’s unclear how many of the women have miscarried or delivered babies with congenital measles. The department said that state law prohibits it from releasing details of the outcomes of those pregnancies. There is no national database that tracks such cases. True numbers might also be higher because the outbreak has been centered in the Amish community, where many families have not sought conventional medical care.
Pennsylvania does not track congenital measles as a separate category because there is no national case definition or standardized reporting system, state health officials said. The state and CDC are working to develop definitions and tracking tools for measles in pregnancy and congenital measles cases.
Doctors estimate almost two dozen babies have either been born with the infection or became infected after delivery. Goldman, at UPMC in Harrisburg, said the hospital system has treated at least a dozen babies with congenital infections, meaning they tested positive at birth, or neonatal infections, meaning they tested negative at birth but became infected after delivery.
Ericka Hayes, senior medical director of infection prevention at Children’s Hospital of Philadelphia (CHOP), said the Geisinger health system has had six congenital cases. In an email, Geisinger spokesman Joseph H. Stender III declined to comment.
CHOP has treated two infant cases of measles in its network, spokesman Ben Leach said.
Canada’s outbreak last year offers some clues about the potential consequences. In Ontario, 51 women contracted measles during pregnancy and 10 babies were diagnosed with congenital measles, according to a recently published study. Seven of the women experienced premature labor or delivery. One infant, who was born prematurely, died; researchers said measles contributed to the premature birth and death, although the baby had other serious medical conditions.
Alexandra Medoro, a neonatologist and pediatric infectious-disease physician at CHOP, said pediatricians worry there might be other babies whose infections are never recognized because their symptoms are subtle.
Measles in very young babies does not always look like the textbook illness. Maternal antibodies — or immune globulin given after known exposure — can lessen the illness, leaving a baby with a mild or atypical rash instead of the classic measles presentation.
“My biggest concern is not necessarily the loss to follow-up of the kids that we know about,” Medoro said. “It’s the lack of identification of kids that we can’t know about.”
Even when babies recover from the initial infection, doctors have little evidence to tell parents what comes next. Congenital measles has historically been so uncommon that much of the medical literature consists of case reports or small numbers of patients.
The risk is greatest among children infected at very young ages, and the disease can emerge sooner the younger a child was when infected.
Medoro, who is the mother of a 10-month-old, said the uncertainty leaves her unable to answer the questions she said parents ask in almost every difficult consultation: “Is my baby going to make it? And then what’s going to happen to my baby long-term?”
“Those are questions that I wish I had the answers to, too,” she said.
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