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In mid-January, an unassuming man in khakis and a button-down shirt walked to a wooden lectern at a school board meeting in Spartanburg County, South Carolina. Most chairs in the audience were empty. The man, Tim Smith, was the only person signed up to speak during public comments. He had five minutes.

“I trust that each one of you had a good Christmas and New Year’s,” he began. “Unfortunately, I can’t say the same thing.”

His wife is an assistant teacher at a public elementary school in the county, epicenter of the state’s historic measles outbreak, and shortly before winter break she’d received a notice that a child in her classroom had measles. Given his wife is fully vaccinated, he wasn’t worried.

Then, she began to get sick. And sicker. She got a measles test and, to their shock, it came back positive. She was apparently among the very rare breakthrough infections.

Frightened, they took her to the hospital that night. “My wife was throwing up,” Smith said at the meeting. “She had diarrhea. She couldn’t breathe. All for what? This is — it’s absolute insanity.”

Measles Infection Count in January Topped Total Cases in 2023 and 2024 Combined

Dr. Leigh Bragg, a pediatrician working a county away, wasn’t even aware that anyone in South Carolina had been hospitalized with measles-related illnesses until a short time later when she logged on to Facebook and saw someone relay the distraught husband’s comments.

Part of the reason Bragg didn’t know is that South Carolina doesn’t require hospitals to report admissions for measles, potentially obscuring the disease’s severity. In the absence of mandatory reporting rules, she and other doctors are often left to rely on rumors, their grapevines of colleagues, and the fragments of information the state public health agency is able to gather and willing to share.

With 973 reported cases, South Carolina’s measles outbreak has ballooned into the nation’s largest since the virus was declared eliminated in the U.S. 25 years ago. Yet, since state health officials first confirmed the outbreak on Oct. 2, the state’s hospitals have reported only 20 measles-related admissions, or about 2% of cases. Some infectious disease experts say that the true number is likely much higher.

Hospitalization rates can vary greatly by a measles outbreak’s location and who is getting infected. But the Centers for Disease Control and Prevention estimates about 20% of measles cases will result in admissions.

“A hospitalization rate at 2% is ludicrous,” said Dr. Paul Offit, director of the Vaccine Education Center and an infectious disease physician at Children’s Hospital of Philadelphia who served on the Centers for Disease Control and Prevention’s immunization advisory committee.

“It’s vast underreporting,” Offit said. “Measles makes you sick.”

Measles is among the most contagious of viruses. In 2026 so far, almost half of states have reported cases. Yet it’s left largely to each state to decide how much infectious disease reporting to require about it.

“We don’t think we are getting an accurate picture at all of how these illnesses are impacting our community,” Linda Bell, the South Carolina state epidemiologist, said at a briefing last month. “We’re just not getting a picture of that now with the small number of hospitalizations that are known to us.”

Bell said the state Department of Public Health is urging hospitals to report their measles-related admissions, and seven hospitals have done so. (There are at least a dozen acute care hospitals in the Upstate alone.) But the state cannot force them to do so. Bell also said that the agency, which sets infectious disease reporting requirements, hasn’t considered adding hospitalizations to the list because........

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