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.

Texas health officials say the number of people with measles has increased to 146 in rural West Texas outbreak that led this week to the death of a school-aged child who was not vaccinated.

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