Feb. 28, the number of measles cases in West Texas has risen to 146, with 20 hospitalizations, in an outbreak primarily affecting children and teenagers.

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

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.