The measles outbreak in West Texas didn’t happen just by chance.

The easily preventable disease, declared eliminated in the U.S. in 2000, ripped through communities sprawling across more than 20 Texas counties in part because health departments were starved of the funding needed to run vaccine programs, officials say.

“We haven’t had a strong immunization program that can really do a lot of boots-on-the-ground work for years,” said Katherine Wells, the health director in Lubbock, a 90-minute drive from the outbreak’s epicenter.

Immunization programs nationwide have been left brittle by years of stagnant funding by federal, state and local governments. In Texas and elsewhere, this helped set the stage for the measles outbreak and fueled its spread. Now cuts to federal funding threaten efforts to prevent more cases and outbreaks.

Health departments got an influx of cash to deal with COVID-19, but it wasn’t enough to make up for years of neglect. On top of that, trust in vaccines has eroded. Health officials warn the situation is primed to get worse.

Recent cuts by the Trump administration have pulled billions of dollars in COVID-19 related funding — $2 billion of it slated for immunization programs for various diseases. Overseeing the cuts is Health Secretary Robert F. Kennedy Jr., who rose to prominence leading an anti-vaccine movement. While Kennedy has said he wants his agency to prevent future outbreaks, he’s also declined to deliver a consistent and forceful message that would help do so — encouraging people to vaccinate their children against measles while reminding them it is safe.

At the same time, lawmakers in Texas and about two-thirds of states have introduced legislation this year that would make it easier to opt out of vaccines or otherwise put up barriers to ensuring more people get shots, according to an analysis by The Associated Press. That further undercuts efforts to keep infectious diseases at bay, health officials said.

The more than 700 measles cases reported this year in the U.S. have already surpassed last year’s total. The vast majority — more than 540 — are in Texas, but cases have popped up in 23 other states. Two Texas children have died. A 6-year-old girl from Gaines County, the center of the outbreak, died in February, the first measles death in the U.S. in a decade. An 8-year-old girl from the same town, Seminole, died earlier this month.

Children in the U.S. are generally required to be vaccinated to go to school, which in the past ensured vaccination rates stayed high enough to prevent infectious diseases like measles from spreading. But a growing number of parents have been skipping the shots for their kids. The share of children exempted from vaccine requirements has reached an all-time high, and just 92.7% of kindergartners got their required shots in 2023. That’s well below the 95% coverage level that keeps diseases at bay.

Keeping vaccination rates high requires vigilance, commitment and money.

Though the outbreak in Texas started in Mennonite communities that have been resistant to vaccines and distrustful of government intervention, it quickly jumped to other places with low vaccination rates. There are similar under-vaccinated pockets across the country that could provide the tinder that sparks another outbreak.

“It’s like a hurricane over warm water in the Caribbean,” said Dr. Peter Hotez, co-director of the Texas Children’s Hospital Center for Vaccine Development in Houston. “As long as there’s warm water, the hurricane will continue to accelerate. In this case, the warm water is the unvaccinated kids.”

Lubbock receives a $254,000 immunization grant from the state annually that can be used for staff, outreach, advertising, education and other elements of a vaccine program. That hasn’t increased in at least 15 years as the population grew.

It used to be enough for three nurses, an administrative assistant, advertising and even goodies to give out at health fairs, Wells said. “Now it covers a nurse, a quarter of a nurse, a little bit of an admin assistant, and basically nothing else.”

Texas has among the lowest per capita state funding for public health in the nation, just $17 per person in 2023, according to the State Health Access Data Assistance Center.

Vaccines are among the most successful tools in public health’s arsenal, preventing debilitating illnesses and lowering the need for expensive medical care. Childhood vaccines prevent 4 million deaths worldwide each year, according to the U.S. Centers for Disease Control and Prevention, which says the measles vaccine will save some 19 million lives by 2030.

U.S. immunization programs are funded by a variable mix of federal, state and local money. Federal money is sent to every state, which then decides how much to send to local health departments.

The stagnant immunization grant funding in Texas has made it harder for local health departments to keep their programs going. Lubbock’s health department, for example, doesn’t have the money to pay for targeted Facebook ads to encourage vaccinations or do robust community outreach to build trust.

The health departments millions of Americans depend on for their shots largely rely on two federal programs: Vaccines for Children and Section 317 of the Public Health Services Act. Vaccines for Children mostly provides the actual vaccines. Section 317 provides grants for vaccines but also to run programs and get shots into arms.

About half of kids qualify for Vaccines for Children, a safety-net program created in response to a 1989-1991 measles epidemic that sickened 55,000 people and killed 123. Section 317 money sent to state and local health departments pays for vaccines as well as nurses, outreach and advertising.

Health departments generally use the programs in tandem, and since the pandemic they’ve often been allowed to supplement it with COVID-19 funds.

The 317 funds have been flat for years, even as costs of everything from salaries to vaccines went up. A 2023 CDC report to Congress estimated $1.6 billion was needed to fully fund a comprehensive 317 vaccine program. Last year, Congress approved less than half that: $682 million.

Facing these headwinds, things got much worse in March when Kennedy’s health department canceled billions of dollars in state and local funding. After 23 states sued, a judge put a hold on the cuts for now in those states but not in Texas or other states that didn’t join the lawsuit.

But local health departments are not taking chances and are moving to cut services.

HHS said the money, allocated through COVID-19 initiatives, was cut because the pandemic was over. But CDC had allowed the money to be used to shore up public health infrastructure generally, including immunization programs.