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Spatial Clustering of School Susceptibles Drives Divergent US Measles Outbreaks

Chen, S.; Hupert, N.; Bento, A. I.

2026-02-27 epidemiology
10.64898/2026.02.25.26347103 medRxiv
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The two largest US measles outbreaks in over two decades (2025 Gaines County, Texas: 414 cases, contained; 2025-2026 Spartanburg County, South Carolina: 923+ cases, ongoing) occurred in counties with similar sub-threshold K-12 MMR coverage (85.1% vs 88.8%), yet their trajectories diverged dramatically. Using kernel density estimation with a common bandwidth and bootstrap uncertainty quantification, we compared sub-county vaccination data at the district level for Texas (3 districts, 3,560 students) and the school level for South Carolina (93 schools, 57,281 students). Peak susceptible density in Spartanburg County was 5.7 times that of Gaines County (23 vs. 4 unvaccinated students per square mile; 95% CI 2.4-12.5, non-overlapping). In Texas, a single isolated cluster around Seminole ISD limited spatial connectivity, producing self-limiting spread. In South Carolina, a northwest corridor of under-vaccinated schools created overlapping catchment areas that sustained transmission chains. These findings demonstrate how county-level aggregates can mask nearly six-fold differences in local risk, underscoring the need for school-level spatial surveillance.

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