Outside the Central Pennsylvania Clinic near Belleville, horse drawn buggies stand hitched to posts while a warning sign covers the front door. Anyone with measles symptoms is told to return to a car and call the office, but many people served by the rural clinic have neither a car nor a cellphone.

Those patients receive different instructions: put on a mask, ring the bell and step away from the entrance. The precautions reflect the growing pressure on a clinic serving many Amish families in Belleville and the surrounding area.

The region and Lancaster County are at the center of a measles outbreak spreading through largely unvaccinated Amish communities. Doctors are trying to contain one of the most contagious viruses while preparing for the possibility that mounting cases will place additional strain on hospitals as flu season approaches.

Dr. Katherine Mascia, a pediatric geneticist at the clinic, described an outbreak that may already be deeply embedded in the community. “I fear that it is very widespread in our area, and I’m seeing so much suffering from our community,” she told MS NOW.

Patients are sometimes gravely ill by the time they reach the clinic. “Many of our patients, by the time they present to us, they’re already so sick that they require hospitalization or even ICU stays,” Mascia said.

Dr. Stanley Martin, an infectious disease specialist at Geisinger Medical Center in Danville, said he has seen “well over 90 cases” of measles this year. Potential complications include pneumonia, secondary bacterial infections and encephalitis, a swelling of the brain that can cause permanent neurological damage.

Pennsylvania’s Department of Health has reported four deaths associated with measles over the past month. The Centers for Disease Control and Prevention initially declined to include those deaths in its count, creating a dispute over the federal government’s recognition of the outbreak’s toll.

On Wednesday, the CDC changed its measles outbreak page to list one measles related death nationwide. The page did not identify where the death occurred or clarify whether it was among the four reported by Pennsylvania.

A note beside the federal figure said it was “subject to change,” and that the agency would “update its reporting as additional information becomes available and relevant reviews are completed.” The CDC did not respond to a request for comment for the report.

As of Wednesday, the CDC had recorded 3,471 confirmed measles cases across the United States this year. More than 300 of those patients had been hospitalized, illustrating the burden already falling on medical facilities.

The federal government’s earlier refusal to count Pennsylvania’s reported deaths prompted a public feud between Health and Human Services Secretary Robert F. Kennedy Jr. and Pennsylvania Gov. Josh Shapiro. Shapiro accused Kennedy of previously minimizing the severity of measles during an appearance in Lancaster and promoting chicken soup and vitamin A as a cure.

Shapiro wrote on X: “Secretary Kennedy has stoked confusion amongst parents and others — and the result has been less protection from measles and more cases.” Kennedy, meanwhile, has maintained that the Trump administration’s response to measles is working.

“Mexico has 11 times the amount of measles cases as we do,” Kennedy said during an August news conference. “I’ve sent the CDC in to cooperate with the state health agencies, and we’ve brought it to an end overnight.”

Medical experts say there is no need to split the MMR shot. They also say there is no evidence that the combined shot is dangerous or that dividing it provides any benefit, while vaccines remain the most effective protection against measles.

When asked whether the federal government had supported their work, Mascia and Martin said they had relied on professional colleagues and Pennsylvania’s Department of Health. Their immediate concern is whether hospitals will retain enough capacity to treat measles alongside other illnesses during the fall.

Measles patients must be isolated in negative pressure rooms designed to keep airborne viruses from escaping. Those specialized rooms are limited, creating a difficult competition for hospital space as severely ill patients arrive.

“Our hospitals have limited rooms, limited negative pressure rooms, and when those rooms are being used by these very very sick measles patients, then that impairs our ability to care for other illnesses,” Mascia said. Both doctors fear that pressure could make treating other patients harder as flu season approaches.

For Martin, the return of a disease that the United States declared eliminated in 2000 has been painful to process. “It’s a real bitter pill,” he said.

The consequences reach patients, their families and the medical workers caring for them. Speaking about those harmed by the outbreak, Martin said, “These are people that should have been living full, normal lives.”