On Oct. 30, Pennsylvania cleared the 1,400 mark for the number of confirmed measles cases this year, but frontline doctors warn that there are many cases that go unreported. Doctors have found that often when they treat a child for measles, they discover that the entire family has suffered measles-like symptoms, but none of these additional cases are reflected in official statistics.

Many doctors who have never treated a single measles case in their entire medical career are now shocked—not just at the number of cases, but at the severity of the symptoms. The state’s Department of Health reports 268 hospitalizations and 5 deaths related to measles. One in twenty children with measles develops pneumonia, and previously healthy adults need oxygen support or even machines to aid breathing. Dr. Patrick Gavigan at Penn State Health’s Children’s Hospital told the Washington Post that some measles patients developed hepatitis, and other patients developed encephalitis with its risks of seizures, paralysis, and permanent brain damage. Some never fully recover.

State health officials have been requesting better guidance on recognizing and caring for the complications of measles in pregnant women. The disease can lead to pneumonia and death in the mother, and to severe complications in the baby, including brain inflammation and death. One month ago, scientists at the U.S. Centers for Disease Control and Prevention (CDC) sought to notify frontline health workers of these risks through the CDC’s Health Alert Network, but amid the CDC’s internal chaos and conflict, the agency has failed to send any alert, according to a separate report in the Washington Post.