Karen M. Jones, MPH, RN, CIC, FAPIC, clinical program manager

– Infection Prevention in the Clinical Surveillance and Compliance Department for 

. has been an acute care infection preventionist since 2009 and has conducted infection prevention research at hospitals and nursing homes. She has 15 years’ experience as an emergency department nurse in Chicago and Detroit, and her interests are translational research and the mentorship of nursing home infection preventionists.

Karen M. Jones, MPH, RN, CIC, FAPIC

Author’s grandmother with 2 of her children before they were taken by measles.

(Image reprinted with permission from the author) 

It's been said that a visit to a cemetery offers insight into the devastating toll communicable and vaccine-preventable diseases once took on children. For me, I only need to page through my family scrapbook.

My grandmother, Anna, emigrated alone from Germany at age 16, landing in Cleveland, Ohio, before marrying a few years later. Over the next 8 years, they settled in rural Michigan and had 7 children. Then, in early 1926, amid one of the largest measles outbreaks in U.S. history, tragedy struck. Six of their 7 children contracted measles. Sadly, 5 of those children—Esther Marie (6), Walter (4), Margareth (3), Helen (2), and Gertrude (6 months)—died in the span of 8 days, at home or at their local community hospital. Only my Uncle Fred, the oldest at age 9, survived his illness. They were among the 577 measles-related deaths recorded in Michigan and the 8,607 reported across the US that year.

 Their names remain preserved in photocopied newspaper reports, a reminder of a disease that many people today view as a rare possibility.

Anna was widowed 2 years later, remarried, and eventually gave birth to twins, one of whom was my father. I was born 50 years after she lost 5 children. My grandmother was a quiet yet remarkably strong woman who never spoke about the profound grief she must have carried.

Over the past century, advances in medicine, public health, sanitation, and disease prevention have made stories like my family's seem almost impossible, like the plot in a very sad movie. Yet in 2026, measles remains one of the most contagious infectious diseases known. The rise in cases and declining vaccination rates should be a concerning message to us about a disease that really should have been left in the past.

From “Eliminated” to the Highest Case Counts in Decades

In August 2026, the CDC reported the highest number of measles cases seen in the US since 1991, placing the nation's measles elimination status at risk. At the same time, misinformation continues to circulate about where cases originate, how effective vaccination is, and whether natural immunity is preferable to vaccination.

(Image reprinted with permission from the author.) 

The CDC reports that MMR vaccination rates have fallen below levels needed to confidently protect communities from measles. While the decline may appear modest, national kindergarten MMR coverage dropped from 95.2% in 2019-2020 to 92.4% in 2025-2026, creating larger pockets of susceptible individuals.

Of the 3,659 measles cases reported to September 24, 2026, approximately 95% occurred in individuals who were unvaccinated or whose vaccination status was unknown. Hospitalization rates vary by age but average roughly 10% overall. Communities with lower vaccination coverage are particularly vulnerable to rapid transmission. Recent outbreaks affecting hundreds of people, including those in New York City in 2019 and East Texas in 2025, occurred in areas with elevated rates of vaccine exemptions or vaccine hesitancy.

International travel can introduce measles into communities, but it plays a relatively minor role in outbreak activity compared with gaps in vaccination coverage. In many cases, an unvaccinated U.S. resident travels to a country where measles remains common, becomes infected, and returns while still in the incubation period. Because symptoms typically develop 10 to 14 days after exposure, individuals may unknowingly spread the virus through airports, schools, workplaces, healthcare facilities, and social gatherings before realizing they are ill.

 provides weekly updates, but state and local health departments often provide the earliest information about outbreak activity within their jurisdictions.

Before the measles vaccine became available, nearly every child contracted measles by age 15. It’s true that measles-related deaths began decreasing even before the vaccine era because of improvements in medical treatments, antibiotics, nutrition, sanitation, and overall access to health care. In 1941, approximately 894,000 measles cases were reported in the United States, the highest annual total on record, with 2,279 associated deaths. While those improvements significantly reduced mortality, complications, including death, still occurred.

The effectiveness of the MMR vaccine is 97% after 2 doses. Community immunity, often called herd immunity, occurs when enough people are immune to an infectious disease to slow or prevent transmission. This protection is especially important for individuals who cannot be vaccinated, including infants, immunocompromised individuals, and pregnant patients.

When vaccination rates decline, community immunity weakens, increasing the likelihood of outbreaks.

Natural immunity refers to protection acquired after infection and recovery. For measles, infection essentially provides lifelong immunity. Some advocates of natural immunity argue that this protection is superior to vaccine-induced immunity and that there are concerns about vaccine risk.

The question, however, is not whether measles infection produces immunity – it absolutely does. It’s about whether the risk of measles is worth it when a safe preventive option exists.

In 2026, approximately 1 in 10 reported measles cases required hospitalization. Serious complications include pneumonia, encephalitis, and, in rare cases, death. Subacute sclerosing panencephalitis (SSPE) is a rare but fatal degenerative neurological condition that can develop years after measles infection. Even in a world of medical advancements and antimicrobials, measles remains the same pathogen as it was a century ago.

Newspaper article on the loss of the children in the author’s family to measles.

Not Just an Infection Prevention and Control Problem

A single case of measles in a health care facility can overwhelm any facility’s infection prevention and control resources. Exposure investigations and tracing, patient notifications, and operational disruptions will consume significant time and resources. An up-to-date plan developed with multidisciplinary input, tabletop exercises to identify process gaps, and communication with leadership are essential.

In addition to maintaining preparedness plans, infection preventionists can play an important role in preventing outbreaks before they occur:

 Partner with clinical, occupational/employee health, and community teams to reinforce that vaccination remains the most effective way to prevent measles and protect vulnerable individuals.

 Provide health care personnel, patients, and families with understandable information about measles risks, vaccine benefits, and what to expect following an exposure. Equip frontline clinicians with evidence-based communication tools.

Recognize vaccine hesitancy and respond with empathy.

 Distrust, previous negative health care experiences, social influences, misinformation, and safety concerns can all contribute to hesitancy. Make space for people to share their experiences, and don't assume their perspectives aren't valid.

Focus on shared values rather than adherence.

 Conversations about protecting an infant too young to be vaccinated or a patient receiving chemotherapy will be more effective than debates about mandates.

Stay connected with public health partners.

 Strong relationships with local health departments, health care organizations, and community leaders help ensure accurate information reaches the people who need it most at the right time. If contact tracing is needed, encourage participation.

I chose to write about my grandmother after reflecting on the fact that an infectious disease affecting our family 100 years ago is once again in the headlines, despite the resources available to prevent it in 2026. With measles once again appearing in communities across the country, we have an opportunity to help ensure that future generations hear these stories from the past, rather than experience them firsthand.

 US Bureau of the Census. US Government Printing Office; 1929. 

https://www.cdc.gov/nchs/data/vsushistorical/mortstatsh_1926.pdf

Vaccination coverage and exemptions among kindergartners. CDC. SchoolVaxView. Updated August 24, 2026. Accessed September 17, 2026. 

https://www.cdc.gov/schoolvaxview/data/index.html

McDonald R, Ruppert PS, Souto M, et al. Notes from the field: measles outbreaks from imported cases in Orthodox Jewish communities—New York and New Jersey, 2018–2019. 

 2019;68:444-445. doi:10.15585/mmwr.mm6819a4

Texas announces end of West Texas measles outbreak. Texas Department of State Health Services. Published August 18, 2025. 

https://www.dshs.texas.gov/news-alerts/texas-announces-end-west-texas-measles-outbreak

Zucker JR, Rosen JB, Iwamoto M, et al. Consequences of undervaccination—measles outbreak, New York City, 2018–2019. 

 2020;382(11):1009-1017. doi:10.1056/NEJMoa1912514

History of measles. CDC. Updated April 29, 2026. Accessed September 25, 2026. 

https://www.cdc.gov/measles/about/history.html

Measles. Family Practice Notebook. Accessed September 28, 2026. 

https://mobile.fpnotebook.com/ID/Virus/Msls.htm

Measles cases and outbreaks. CDC. Updated September 18, 2026. Accessed September 25, 2026. 

https://www.cdc.gov/measles/data-research/

Articles

In 1926, Karen Jones’s grandmother lost 5 children to measles in 8 days. A century later, Jones connects that devastating family history to vaccination, outbreak preparedness, and the role of infection preventionists in building trust.

Measles Took 5 Children in 8 Days. A Century Later, Their Story Still Matters

As the COVID-19 pandemic was challenging public health and infection preventionists, multidrug-resistant organisms (MDROs) lurked quietly in the background. Although not as well-known as methicillin-resistant 

(VRE) or as feared as Candida auris, extended spectrum beta-lactamase (ESBL)-producing 

 have been identified by the Centers for Disease Control & Prevention (CDC) as a serious risk to public health. Infection preventionists (IPs) in nursing homes must thus gain a better understanding of how to manage this additional threat.

ESBL-producing Enterobacterales (ESBL-Es) received an unfortunate honorable mention in the 2022 CDC special report 

COVID-19: US Impact on Antimicrobial Resistance

. From 2019 to 2020, the US saw a 32% increase in these infections in hospitalized patients.

 In 2017, there were 197,00 new ESBL cases, which was a 53% rise from 2012.

 Also identified as rapidly spreading through nursing homes were ESBL-producing 

Because the health care continuum involves patient movement between acute care, short-stay rehab, long-term care, and other facilities, it is critical that infection preventionists in nursing homes be aware of this MDRO.

An ESBL is an enzyme produced by certain strains of gram-negative bacteria that protects bacteria from many commonly prescribed antibiotics, which is great news for bacteria but bad news for the patient, clinical treatment options, and public health overall. First identified in Greece in the early 1960s, ESBLs have been expanding their families and geographic reach ever since. The first case in the US was reported in 1988.

 ESBLs continue to strengthen in antibiotic resistance and require treatments other than standard antibiotic regimens.

. Exposure to health care, including hospitals or nursing homes, places individuals at greater risk for developing an ESBL. But even without such exposure, ESBLs have been identified in otherwise healthy people, often manifesting as urinary tract infections.

 ESBLs are resistant to cephalosporins and penicillin, with carbapenems left as one of the only effective treatments. Although these intravenous antibiotics are often the best treatment, they require venous catheters and often a longer stay. If bacteria become resistant to this last-option drug class, even fewer options will be available.

Because nursing homes provide long-term care as well as short-stay rehabilitation, they are affected by various factors. Most of their residents are aged over 65 and have multiple comorbidities that impact their immune system, skin, and mucous membranes. In addition, the atypical infection symptoms seen in them may delay infection identification. Creating a home-like environment is essential for individuals who will spend weeks, months, or even the remainder of their lives at the facility. With more shared residential areas than other settings, nursing homes find it difficult to contain infections. Private rooms, especially in older facilities, are far less common than shared rooms, which may be designed to accommodate up to 4 residents. More than half of them will receive an antibiotic over the course of a given year. Of those, 40% to 75% do not meet the clinical criteria for appropriateness of use or are prescribed an incorrect dose or length of treatment.

As with all MDROs, prevention and containment of ESBLs begins with good hygiene. ESBLs are primarily spread by direct contact with infected body fluids, including those found on surfaces and equipment. Just as hand hygiene is essential in health care workers, residents should also be encouraged to wash their hands, especially after using the bathroom and before meals, as ESBLs live and travel in the gastrointestinal tract. A study at the University of Michigan revealed that residents’ hands are often contaminated with MDROs.

Proper cleaning and disinfection, with periodic audits and feedback, will help build adherence to your prevention program. Obtain buy-in from those individuals doing the work by making infection prevention “everyone’s business” and include others who may be interested to collect data and provide reports to peers. Keep everyone in the prevention program involved and aware that environmental services are far more than merely janitorial, and that infection prevention relies on all the dedicated individuals doing this work. They must understand their role in infection prevention, stay up to date on best practices, and have a voice in the decisions made by Quality Assurance & Performance Improvement (QAPI) and the institution’s antimicrobial stewardship program.

The CDC’s Project Firstline offers virtual learning with interactive resources, educational modules, printed materials, and training toolkits improve infection prevention and control beyond hospitals into nursing homes, and other long-term care facilities.

 These materials are a great way to educate the staff and keep them up to date.

Transmission-based isolation precautions for ESBLs may differ between nursing homes and other health care facilities. Stay connected with and follow recommendations from your health department to stay abreast of current trends.

 Enhanced Barrier Precautions (EBP) offer direction on how to handle MDRO infection and colonization. If CDC contact precautions don’t apply to a resident with an ESBL per the facility’s protocol, CDC guidelines list them as an “epidemiologically important MDRO,” for which EBP is recommended. The EBP strategy was designed with input from a CDC Healthcare Infection Control Practices Advisory Committee expert group in 2019 and updated in 2022. Besides MDRO infection and colonization for residents when contact precautions don’t otherwise apply, EBP is recommended to be followed with residents who have indwelling medical devices or wounds during “high-contact resident care activities.”

 Because EBP does not require a private room or exclude residents from activities, it may be the ideal option.

The prompt and accurate sharing of information during care transitions or resident transfers is an essential component of infection prevention and resident safety. When residents are moved between nursing homes, acute care, outpatient clinics, and home care, infection and colonization status information should be prioritized. Have there been times when information about residents coming to your facility has not been provided directly to the clinical staff? Does a physician's office always communicate lab or clinical findings after the resident returns to your facility? On the flip side, can hospital emergency department staff easily discern whether a resident is being treated for an infection or has a history of MDRO colonization? Developing working relationships between the staff responsible for transfers and IPs can bridge the communication gap. Not only is the sharing of infection information best practice, but it can also alert you to current practices and challenges at nearby facilities.

Nursing homes are one of several health care settings that must have antibiotic stewardship programs in place. A 2015 study by Daneman et al found a great deal of variability among 600 nursing homes with respect to antibiotic prescribing and the high antibiotic use associated with increased individual-level risk, even among residents who did not receive antibiotics. Nonrecipients are at an increased risk simply by being at that facility.

 Recognizing where the facility stands in terms of antibiotic prescribing, zeroing in on opportunities for improvement, and engaging a multidisciplinary team to address problems create a safer environment for everyone. The CDC’s 

Core Elements of Antibiotic Stewardship for Nursing Homes

 is a comprehensive toolkit for institutions starting from scratch or looking for materials to address a specific issue related to antibiotic stewardship.

COVID-19: U.S. impact on antimicrobial resistance, special report 2022.Centers for Disease Control and Prevention. June 2022. Accessed Nov 21, 2022. 

https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf

Castanheira M, Simner PJ, Bradford PA. Extended-spectrum β-lactamases: an update on their characteristics, epidemiology and detection. JAC Antimicrob Resist. 2021;3(3):dlab092. doi:10.1093/jacamr/dlab092

ESBL-producing Enterobacterales in healthcare settings. Centers for Disease Control and Prevention. Updated Nov 22, 2019. Accessed Nov 21, 2022. 

https://www.cdc.gov/hai/organisms/ESBL.html

Ghafourian, S., Sadeghifard, N., Soheili, S., & Sekawi, Z. Extended spectrum beta-lactamases: Definition, classification, and epidemiology. Curr Issues Mol Bio. 2015;17:11-22.

Antibiotic resistance threats in the United States, 2019.Centers for Disease Control and Prevention. Reviewed December 2019. Accessed Nov 21, 2022. 

https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf

Montoya A, Cassone M, Mody L. Infections in Nursing Homes: Epidemiology and Prevention Programs. Clin Geriatr Med. 2016 Aug;32(3):585-607. doi:10.1016/j.cger.2016.02.004. PMID: 27394025.

Core elements of antibiotic stewardship for nursing homes. Centers for Disease Control and Prevention. Reviewed Aug 20, 2021.Accessed Nov 15, 2022. 

https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html

Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands: a missed opportunity. JAMA Intern Med. 2016;176(5):705-706. doi:10.1001/jamainternmed.2016.0142

Project Firstline.Centers for Disease Control and Prevention. Updated July 20, 2022. Accessed November 15, 2022. 

https://www.cdc.gov/infectioncontrol/projectfirstline/index.html

Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings.Updated May 2022. Accessed November 15, 2022. 

https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

Implementation of personal protective equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). Centers for Disease Control and Prevention. Updated July 12, 2022. Accessed November 15, 2022.

https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf

Daneman N, Bronskill SE, Gruneir A, et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Intern Med. 2015;175(8):1331-1339. doi:10.1001/jamainternmed.2015.2770

Information for infection preventionists to manage ESBL-producers even while fighting against COVID-19. 

Karen M. Jones, MPH, RN, CIC, FAPIC

Articles

Measles Took 5 Children in 8 Days. A Century Later, Their Story Still Matters

Considerations for Extended Spectrum Beta-Lactamase (ESBL)-Producers in Nursing Homes