The measles outbreak in Texas has reached nearly 150 cases, according to a Friday morning update from the state health department. The agency said 146 cases have been identified since late January. Twenty of those patients have been hospitalized, and one school-age, unvaccinated child has died.

Vaccine hesitancy has been rising for years in the United States. Doctors and parents in one rural county are confronting the consequences.

Declining vaccination rates, decreasing trust in government and a political unwillingness to endorse vaccines is shaping Texas’ measles response.