Two seven year old twins arrived at Mission Hospital in Asheville in the early hours with fever, cough, a rash, pink eye and cold symptoms. They sat in one emergency room after another, and it was more than two hours before any isolation measures began.

An ER physician called the state epidemiologist around dawn and described the boys’ symptoms. "Shortly after that call, the patients were diagnosed." It was measles.

Investigators found that the virus exposure reached at least 26 other people within the hospital that January day. They concluded that the twins’ symptoms should have triggered an isolation procedure that Mission Hospital staff had trained to perform seven months earlier. The hospital was designated in "Immediate Jeopardy" for exposures and other issues, one of the most severe penalties a facility can face.

A Mission spokesperson said the staff were trained to manage airborne illnesses and are following federal rules. Nancy Lindell, Mission’s spokesperson, said, "Our hospital has been working with state and federal health officials on proactive preparedness, and we are following guidance provided by the CDC."

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Health care leaders warn that the rising frequency of measles makes recognition by frontline workers more critical, and many admit they lack a uniform, real time picture of the disease. "There’s a word, ‘morbilliform’ — it means measles-like, and there are lots of viruses that can cause a rash that looks like a measles rash in children," said Theresa Flynn, a pediatrician in Raleigh and the president of the North Carolina Pediatric Society. In 30 years in health care, she’s never seen a measles case, she said.

North Carolina has reported more than 20 measles cases since mid-December, and more than 3,000 people nationwide have been infected since the start of 2025.

With two doses of the measles vaccine, a person has about a 3 percent chance of contracting the virus after exposure, according to the CDC. An unvaccinated person has about a 90 percent chance of infection.

But for the past year, the administration has sown doubt about vaccine effectiveness. Health and Human Services Secretary Robert F. Kennedy Jr. was a longtime anti vaccine activist before taking office, and under his leadership the Centers for Disease Control and Prevention has reduced the number of shots recommended to children. Kennedy publicly recommended unconventional and unproven treatments for the virus, including steroids, antibiotics, and cod liver oil.

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Infectious disease experts and doctors said federal policies have left health care workers to lean on their own experience or guidance from their state public health systems to fight a disease that many are preparing to see for the first time and that initially may behave like the common cold. "As measles becomes more common, all of us are leveling up in our ability to recognize and immediately respond to suspected measles," Flynn said.

Officially, the U.S. has maintained "measles elimination status" since 2000, meaning the nation has avoided significant spread of the virus. After outbreaks in Texas, Arizona, Utah, and now South Carolina, the country is on track to lose that designation before the year is out. Its own adopted regulations tie elimination status to a lack of a continuous viral spread persisting for 12 months.

One county in South Carolina, an hour’s drive from Asheville, has had more than 900 cases in the current outbreak — more than Texas reported in all of 2025.

Symptoms of measles, a virus that attacks the lungs and airways, can include fever, cough, a blotchy rash, and red, watery eyes. Researchers consider measles among the most contagious diseases, and the virus may remain active for up to two hours after an infected person leaves a room.

It can be lethal, with 1 to 3 deaths per 1,000 cases in children. In 2025, two children in Texas and one adult in New Mexico died of measles.

Along with tracking data, the CDC provides detailed summaries on its website for diagnosing measles. State public health agencies and some counties have developed dashboards tracing the disease as it surfaces in such places as hospitals, schools, grocery stores, and airports. Large hospital systems developed staff training protocols last year and shared them with area clinics. Look for the three C’s, that guidance said: cough, coryza (cold symptoms), and conjunctivitis (pink eye). According to CMS inspection records, HCA Healthcare, which owns Mission Hospital, trained Mission staff on the three C’s early last year. On top of failing to isolate the twin patients right away, Mission staff didn’t have a designated area for patients with respiratory symptoms, federal inspectors found.

The CDC advises health workers to immediately place patients with measles or suspicious symptoms in a special isolation room, where airflow is controlled inward. The Mission patients were separated from other patients only by plastic partitions, according to CMS records.

Mission spokesperson Nancy Lindell said the hospital was equipped and staffed to manage airborne illnesses like measles. "Our hospital has been working with state and federal health officials on proactive preparedness, and we are following guidance provided by the CDC," Lindell said.

Most U.S. clinics and hospitals have never experienced measles cases, said Patsy Stinchfield, a former president of the National Foundation for Infectious Diseases and a nurse practitioner. She called CMS’ Immediate Jeopardy penalty for Mission "extreme," given the virus can be so difficult to identify. "In the middle of winter right now, measles looks like every other viral respiratory infection that kids come in with," Stinchfield said.

The CDC has been less communicative in the past year with clinics about their response to outbreaks, and this disconnect has been noted by health workers and infectious disease experts. This challenge comes as clinics struggle to coordinate with federal agencies, and several sources say a robust information campaign has been lacking.

“We certainly do not feel the support or guidance from the CDC right now,” said Brigette Fogleman, a pediatrician at Asheville Children’s Medical Center, where staff members have devised their own method of screening patients by phone and in cars before visits.

In response to questions about how the CDC is supporting health care organizations during the measles resurgence, spokesman Andrew Nixon said that "state and local health departments have the lead in investigating measles cases and outbreaks" and that the CDC provides support "as requested." Jennifer Nuzzo, an epidemiologist and director of the Pandemic Center at Brown University, acknowledged that diagnosing measles remains a major challenge and emphasized that coordination among public health agencies is critical.

Stinchfield attributed the spread of measles to CDC leaders’ lack of communication to clinics and to the public — no ads on buses, no social media campaigns, no sense of urgency. "When you are at the highest level of measles cases in 30 years, we should be seeing lots more from our federal government," Stinchfield said. "And I think it’s harming kids and causing an inordinate amount of work and expense that really doesn’t belong in health care right now."

In Buncombe County, officials had counted seven measles cases by mid-February and anticipated many more, according to state epidemiologist Zack Moore. "We are preparing for a future in which we follow a trajectory like South Carolina," Moore said, "where we see sort of a gradual accumulation of cases, and then all of a sudden it reaches kind of a tipping point, and we see a more explosive growth in the outbreak and spread across the state."

Fogleman, who is also a pediatrician, and Buncombe health department director Jennifer Mullendore spoke during a county Facebook livestream urging families to get their children vaccinated, debunk vaccine misinformation, and update parents on local case numbers. A local private school quarantined about 100 students after an exposure; only 41 percent of students there were immunized, according to state data. Kennedy handpicked the committee members who made those recommendations. One parent recently told a nurse, "It’s only measles. It doesn’t kill anybody," Fogleman said.

We cannot change the past, but local clinicians say the real test is how we respond now and how we educate families going forward. "We can’t change the past," Fogleman said. "All we can do is try to educate and move forward."