South Carolina hospitals are not required to disclose measles-related admissions. This leaves doctors in the dark.

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

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

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

Then she started getting sick. And sicker. She was tested for measles and, to their surprise, it came back positive. It was apparently one of the very rare breakthrough infections.

Scared, 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 this for what? This…this is absolute madness.”

Dr. Leigh Bragg, a pediatrician working in a remote county, didn’t even know that someone in South Carolina had been hospitalized for measles-related illnesses until shortly after she logged onto Facebook and saw someone relaying her husband’s distraught comments.

Part of the reason Bragg didn’t know is that South Carolina doesn’t require hospitals to report measles admissions, which could mask the severity of the illness. In the absence of mandatory reporting rules, she and other doctors often have to rely on rumors, colleagues and the scraps of information that the state’s public health agency is able to piece together and is willing to share.

With 973 cases reportedSouth Carolina’s measles outbreak has become the nation’s largest since the virus was declared eliminated in the United States 25 years ago. Yet since state health officials confirmed the outbreak on Oct. 2, hospitals across the state have reported only 20 measles-related admissions, or about 2% of cases. Some infectious disease experts say the real figure is likely much higher.

Hospitalization rates can vary greatly depending on where the measles outbreak occurs and who is infected. But the Centers for Disease Control and Prevention estimates about 20% of measles cases will result in admissions.

“A 2% hospitalization rate is ridiculous,” 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.

“This is a vast underestimate,” Offit said. “Measles makes you sick. »

Measles is one of the most contagious viruses. So far in 2026, nearly half of states have reported cases. Yet it is largely up to each state to decide what level of infectious disease reporting to require on this subject.

“We don’t think we have a clear picture of the impact of these diseases on our community,” Linda Bell, South Carolina’s state epidemiologist, said during a press briefing last month. “We just don’t have a sense of that right now, given the small number of hospitalizations that we have.”

Bell said the state Department of Public Health urges 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 can’t force them to do so. Bell also said the agency, which sets reporting requirements for infectious diseases, has not considered adding hospitalizations to the list because the primary goal of public health surveillance is to understand disease transmission, frequency and distribution, not to track complications.

That leaves doctors like Bragg counseling patients, including vaccine-resistant parents, without the benefit of real-time confirmed data on the number of South Carolinians hospitalized with measles. Serious complications include pneumonia, dehydration and a potentially fatal brain swelling called encephalitis.

“It’s a great disservice to the public to not report the complications that we see in hospitals or even emergency rooms,” Bragg said. “Measles is not just a cold.”

ProPublica contacted health agencies in Southern states and found that most do not require hospitals to report measles-related admissions. Alabama does. Virginia does too, although it does not release this data to the public. Like South Carolina, North Carolina and Texas do not require reporting of hospitalizations, but epidemiologists can identify them during case investigations.

During the measles outbreak in Texas last year, 99 people out of 762 cases were hospitalized.

This represents a rate of approximately 13%. In South Carolina, the reported rate is 2%.

Real-time hospitalization data can inform where to target resources and help hospitals prepare for an influx of patients. “As vaccination rates decline, this could also really help us understand how the epidemiology of measles is changing in the current context,” said Gabriel Benavidez, a professor of epidemiology at Baylor University in Texas.

When ProPublica asked hospitals in Upstate, the northwest quadrant of South Carolina where the outbreak is concentrated, whether they were reporting their measles-related admissions in the state and the number of patients they had treated, few responded. Only Spartanburg Regional Health System shared that total. (As of mid-February, that number was four.)

A spokesperson for Prisma Health, a Greenville-based nonprofit that owns eight acute care hospitals in the upstate, said its hospitals “report everything we’re supposed to report.” She would not say how many measles patients were hospitalized at Prisma hospitals or how many the system reported to the state.

Doctors in the dark

Bragg, board certified in pediatrics and pediatric infectious diseases, works in the region of South Carolina where the outbreak is concentrated. It’s a highly religious tract with the lowest student vaccination rates in the state. She recently met a parent who was wondering about the recommended vaccines for a 1-year-old, which include a first dose of measles vaccine.

“We are in the middle of a measles epidemic,” thought Bragg.

She then began a 30-minute discussion about the extreme safety of the vaccine and its 97% lifetime effectiveness when two doses are administered. She explained that 95% of people in South Carolina who contracted measles were not vaccinated. She spoke of the historical risks of complications linked to measles.

Still, Bragg couldn’t tell the relative how seriously ill his fellow South Carolinians were because of the epidemic that was making people around them sick.

She’d heard about pneumonia, intensive care admissions – even a case of encephalitis. But she could not confirm it, nor know if it was a child, and even less how the patient was doing. (Shortly afterward, Bell announced that the national health agency had become aware of cases of encephalitis in children, but it did not provide the number of patients or their results.)

As president of the South Carolina chapter of the American Academy of Pediatrics, Dr. Martha Edwards is in contact with doctors across the state. “All I hear about is ‘complications of measles,'” which can mean a lot of different things, she said.

Communicating the risks of serious illness is all the more important as few of today’s parents have seen measles up close. Neither do most practicing doctors.

Early in his career, Dr. William Schaffner, a Vanderbilt University professor specializing in infectious disease prevention, worked with the CDC to implement the measles vaccine. When he tells medical students today that in the 1960s, before the advent of the measles vaccine, 400 to 500 children died each year from measles and its complications, “they are amazed.”

“If the severity of the illness cannot be determined — if it cannot be determined — it cannot be communicated appropriately to the public,” Schaffner said. “And the public might get the false impression that measles is milder than it actually is. »

At a briefing, Dr. Robin LaCroix, an infectious disease pediatrician at Prisma, said the organization’s doctors “have seen the full range of acute and post-measles infections that have affected these children. They are sick.” Children became listless and suffered rashes, coughs and coughing spasms, dehydration and secondary infections, including pneumonia.

Measles infections are particularly dangerous for babies who cannot yet be vaccinated and young children who have not received the second dose. Infections during pregnancy also pose serious risks for mothers who are not vaccinated or immunized, including miscarriage and a tenfold increase in deaths from pneumonia. Mothers can pass the virus to their babies, “which can be catastrophic,” said Dr. Kendreia Dickens-Carr, an OB-GYN at Prisma.

More than 900 confirmed cases of measles have already been reported nationwide in 2026, compared to 2,281 for all of 2025. Most of this year’s cases are in South Carolina, but Florida has reported 63 cases and neighboring North Carolina, 15, including one hospitalization.

“We really need to think about how we report these things, because viruses and bacteria don’t respect state borders,” said Dr. Annie Andrews, a pediatrician running for Democratic U.S. Senate in South Carolina. “Public health professionals across states should compare apples to apples and oranges to oranges. »

The most advanced pediatric care in the state is provided on the campus of the Medical University of South Carolina in Charleston, several hours upstate on the coast. So far, its children’s hospital has not admitted any measles patients, doctors said.

Dr. Danielle Scheurer, chief quality officer at MUSC, praised the state’s low hospitalization rate and said she doubted hospitals would object to mandatory reporting of measles-related admissions if the state health agency were to change its rules.

“The transparency here is going to help other states,” Scheurer said. “The more transparent we are about all of our statistics, the better any other state will be able to prepare.” »

Political pressures

Across South Carolina, large health systems have been buying up local hospitals and medical practices. Through this control, they can exert influence over what these doctors and hospital employees say publicly, especially when it comes to potentially controversial topics like vaccines. At the same time, they face pressure from Republican lawmakers and a growing segment of vaccine-wary patients.

This often results in highly controlled information sharing, or lack of information sharing.

“There’s this level of caution that wasn’t there before,” Edwards said. She understands that hospitals don’t want to offend patients who doubt vaccines. Bragg agreed but said that since 93% of the state’s students are vaccinated, she worries hospitals will “pander to a small group.”

A pending invoicesponsored by several state representatives from Spartanburg County, seeks to prevent hospitals and doctors from questioning or interfering “in any way” with a patient’s right to refuse treatments or vaccines. During COVID-19, the bill asserts, federal agencies collaborated with medical organizations and others “to orchestrate a coordinated and coercive propaganda campaign” to shame people who refused COVID-19 vaccines. Doctors and hospitals say they must balance public health risks with people refusing to get vaccinated.

The state’s Republican governor, Henry McMasterand major Republican candidates to replace it have largely structured their response to the measles epidemic around the concept of medical freedomespecially when discussing vaccination mandates.

Andrews, the pediatrician running for U.S. Senate, said she has felt the “chilling effect” of the Republican Party’s “anti-science movements” on health systems and individual doctors. “If you speak out, you risk being censored,” Andrews said. “If you speak out, you might lose your job. So everyone’s just trying to keep their heads down and do what’s best for their patients.”

Bragg is among the dwindling ranks of doctors who run their own independent practices. She has the freedom to post whatever she wants on social media and wear pro-vaccine T-shirts that say things like: “I have polio? Neither do I because I got the vaccine.”

But one recent day, her 10-year-old son asked her why she insisted on wearing T-shirts. “Even a 10-year-old can tell you how polarizing vaccines have become,” Bragg said. Despite this, she continued to wear them.