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.

The latest update comes two days after the first death was reported in a school-aged child who lived in the outbreak area.

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