Measles is spreading in the United States, and so is the risk of exposure and infection at child care facilities, which often serve kids too young to be vaccinated against the highly contagious disease.

Children’s health is the most immediate challenge amid an exposure, but not the only one. Parents may face three weeks of quarantine that requires them to keep their child at home, leaving them scrambling to figure out how to work without reliable child care.

A mother in Iowa is highlighting just how complicated things can get. Martha Martin has been posting on social media about the ripple effects after a person who visited her 9-month-old son’s day care in Cedar Rapids later tested positive for the illness. The individual was vaccinated and is among seven cases of measles in Iowa as of July 15. Not all of the infections appear to be connected. 

It took public health officials several days to notify the day care of the exposure, but Martin’s son — who had not yet received his first dose of the measles-mumps-rubella (MMR) vaccine because of his age — was able to receive a post-exposure antibody known as immunoglobulin. The alert came too late for her son to get an emergency MMR shot, which can be available within 72 hours of exposure.

Martin said she and her husband took their son to an emergency room for the antibody treatment, and she has received some mixed messaging about whether the couple will be on the hook to pay out of pocket. Other children from the day care were given immunoglobulin shots through a clinic organized by UnityPoint Health – St. Luke’s Hospital and the local county public health department. A spokesperson for the hospital system confirmed those details but did not respond to questions about the cost of the shots.

“Day cares can be a terrible place to have a measles outbreak,” said Dr. Tina Tan, a pediatric infectious diseases physician and president of the Infectious Diseases Society of America. “There’s going to be babies there that are too young to receive a measles vaccine. And they are at very high risk, if they get measles, to get a severe case.”

The state of Iowa has a 21-day measles quarantine protocol for non-immune people, a typical period in part because of how long a person may be able to spread the disease. But Martin said the day care instructed the couple to keep their son at home for 28 days because the antibody extends that period. 

“I’m not sure what we’re going to do about that, not sure what we’re going to do about me going to work, my husband, everything like that,” Martin said in one post on TikTok that has now been viewed 2.5 million times.

Martin initially responded to an interview request from The 19th but later stopped communication.

A senior staff member who answered a call at the Iowa day care directed inquiries to local and state public health officials. A spokesperson for the public health department in Linn County, Iowa, said it continues to monitor the day care and other places of exposure as needed after “hours and hours” of contact tracing. A spokesperson for the Iowa Department of Health and Human Services confirmed that the day care is open and highlighted its protocol document. 

Martin said her son appears to be fine for now, but she knows symptoms can take some time to emerge. She said while her employer has been understanding, she will use vacation days and her husband will take unpaid time off to care for their son. Throughout her posts, Martin hammered one point a few times.

“Get your kids vaccinated,” she said, adding: “Your kids, you yourself not getting vaccinated — you are harming everybody else.”

In late March, a measles outbreak in West Texas reached a day care in Lubbock, where a child with measles infected several children, according to news reports. Some parents were told to keep their kids at home for 21 days of quarantine.

A representative for the Texas day care did not immediately respond to a request for comment, but its co-owner told a local news outlet that the facility took a mix of precautions in order to keep its doors open. That meant sending some children home and isolating vulnerable children into a classroom while they still attended day care.

“Sending an infant home for 21 days is a huge burden on working families so there was the need to balance risk of exposure vs the need for income,” said Katherine Wells, director of the Lubbock Health Department, in an email.

America’s child care system runs under different levels of regulations, with varying rules by state when it comes to handling infectious disease outbreaks. 

Ruth Friedman is a senior fellow at The Century Foundation, a progressive think tank, and former director of the Federal Office of Child Care (OCC). She said day cares work under tight financial margins, and infectious diseases like measles could be a major financial blow, a dynamic that has parallels to the COVID-19 pandemic when some centers had to reduce services or close.

“If you destabilize the attendance and enrollment of children in child care, it can very quickly lead to programs closing their doors and child care broadly becoming unavailable to a community,” she said.

Wells said some parents expressed anger about their child being quarantined, while others said they were simply fearful about their children being exposed to the disease, which can make people very sick: complications include pneumonia, brain swelling and death. Children under 5 and pregnant people are among those more likely to suffer complications. And according to the Centers for Disease Control and Prevention, about 1 in 5 unvaccinated people with measles are hospitalized.

The first MMR shot is typically administered to a child between 12 and 15 months of age, with a second dose between the ages of 4 and 6. Children between 6 months old and a year are eligible for an earlier shot if they live in or travel to an outbreak area or are traveling internationally.

Iowa health officials have begun to recommend that parents consider an accelerated shot schedule for their children, which can include receiving the second MMR shot as early as 28 days after the first dose. Two doses are 97 percent effective against measles, which is at a 30-year high around the country.

The risk of measles at day cares is not new. Between December 2023 and January 2024, a day care in Philadelphia reported an outbreak that spread in part because a parent sent a quarantined child to day care despite knowing the child, who was not vaccinated, had been exposed to measles. The child, as well as the parent, later tested positive for measles.

Dr. Ericka Hayes, an attending physician and senior medical director of infection prevention at Children’s Hospital of Philadelphia, said the chances of more outbreaks in child care settings will depend on factors like vaccination rates within the facility and how it adheres to its policies around illness. She noted that children are contagious with measles for several days prior to the onset of a rash — often a primary symptom — but other early signs of infection can look a lot like a common viral infection: fever, cough, runny nose, and red and watery eyes.

“So equally important is if a child is sick they should be excluded from day care,” she said via email.

Friedman said the case out of Philadelphia previews a potential conflict that could emerge as parents reckon with health considerations amid work responsibilities that ensure they can pay their daily and monthly expenses. Federal law does not require employers to offer paid sick leave to its workers, leaving such options up to states. In some cases, states are rescinding those policies despite voters’ wishes.

“There’s this tension — what are you supposed to do with your child if you need to work?” she said. “From a family perspective and from a child care sector perspective, I think the implications could potentially be really, really troubling.”