Two Florida children have contracted measles after the state’s top health official defied federal guidance to contain an outbreak at an elementary school.

Six children at Manatee Bay Elementary School, in Westin near Fort Lauderdale, caught the disease over a week ago. New state health data show two more cases in Broward County, of a child younger than 5 and another between ages 5 and 9.

The newly reported infections bring the total to eight, just days after Florida Surgeon General Joseph Ladapo contradicted federal and medical professional guidance to contain the spread of the highly contagious and preventable disease that’s resurging globally and in the U.S. Florida is one of 11 states that have seen cases this year.

It’s unclear if Florida’s two new cases are connected to the school outbreak. Broward County Public Schools haven’t identified new cases since Tuesday, when there were six, district spokesperson John Sullivan said.

The state Department of Health said there was no additional information at this time.

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In a letter Tuesday, Ladapo said Manatee Bay parents and guardians could decide whether to send their children back to school, a statement that conflicted with federal and medical professional recommendations that children from the school should remain at home to prevent the spread of measles. The U.S. Centers for Disease Control and Prevention recommends that unvaccinated children exposed to measles be isolated for three weeks. Ladapo appeared to agree with this assessment before he concluded that children’s attendance was up to parents or guardians because of the “high immunity rate” and the burden of healthy children missing school, but he said the state’s recommendation could change.

Health experts are concerned by his lax attitude.

“This is a state surgeon general saying that he is not going to enforce any of the tenets of public health in the name of freedom,” said Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, which has worked to contain a recent measles outbreak among children in the Pennsylvania city. “He wants freedom at the expense of putting children in harm’s way.”

The only freedom Ladapo is upholding is the “freedom to harm,” Offit said.

Florida Gov. Ron DeSantis tapped Ladapo to be surgeon general in 2021, in part because of his vocal opposition COVID-19 vaccine mandates and school closures. Last month, Ladapo said the mRNA COVID-19 vaccines pose health risks, defying federal approvals and scientific consensus.

With the measles outbreak, Ladapo again stands apart. Experts say that isolation and vaccination are the best way to stop the spread.

“This is a vaccine-preventable disease,” Dr. Thresia Gambon, president of the Florida chapter of the American Academy of Pediatrics, told USA TODAY. “There are very strict guidelines as to what to do in an outbreak in order to contain it quickly.”

Gambon’s organization, which represents pediatricians in the state, supports CDC’s recommendation that children at the school should have been told to isolate. 

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Measles can come with serious risk. About 1 in 5 children who become ill end up in the hospital, the CDC said. And 1 in 1,000 can develop encephalitis, or brain swelling that can have neurological effects. Between one and three children in a thousand will die.

A full-dose regimen of the vaccine is about 98% effective against measles. About 90% of unvaccinated people who come in contact with the virus will get it. Measles can be transmitted without physical contact. A person can catch it from droplets lingering in the air or on surfaces.

At Manatee Bay Elementary, 33 of the school’s 1,067 students don’t have the measles, mumps and rubella vaccine, said Sullivan, of Broward County Schools. That means about 97% have been given some percentage of their measles vaccine. Sullivan declined to say whether the six students who contracted measles had previously been vaccinated, citing privacy concerns.

Less than 92% of Broward County kindergartners had been immunized as of 2022, in line with state figures. This is below national averages, which have shown declines in recent years, and the U.S. goal of 95% coverage with the measles vaccine.

In the meantime, parents at Manatee Bay have pulled their children out of school. On Tuesday, 219 students did not attend class in person, Sullivan said. By Friday, some had returned and 159 students remained at home.

In January, the CDC warned health providers they needed to do more to detect a potential measles spread in their communities amid a global rise in cases. The lack of large U.S. outbreaks so far signals there is still good immunization against measles through vaccines, said Dr. William Moss, executive director of Johns Hopkins Bloomberg School of Public Health’s International Vaccine Access Center.

But outbreaks could worsen in the right circumstances, Moss said, if enough unvaccinated children are exposed to the virus and they spread measles into a community.