An outbreak of measles in northwest Texas grew to 146 cases on Friday, two days after health officials reported that a child had died after being hospitalized in Lubbock. Twenty people have been hospitalized for treatment amid the outbreak,

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.