The Clallam County woman who was the first confirmed measles death in the U.S. in a dozen years was likely exposed to the virus at a Port Angeles tribal health clinic, newly released state emails show.

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New details about the first confirmed measles death in the U.S. since 2003 show that the victim, a 28-year-old woman with underlying health problems, was likely exposed to the virus at a Port Angeles tribal health clinic.

Nearly three dozen other people also were potentially exposed to the highly contagious germ on Jan. 29, 2015, at the Lower Elwha Health Clinic by a 52-year-old man who became the first case of measles confirmed in Clallam County in two decades.

That’s according to emails and documents from Washington State Department of Health (DOH) officials released in response to a Seattle Times Public Records Act request.

Eventually, the man may have exposed at least 149 people to the disease, including a 5-year-old unvaccinated girl whose infection forced the quarantine of a private Christian school last winter, county and state reports show.

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The measles death wasn’t reported to the public until July 2, nearly three months after the woman succumbed to pneumonia linked to the infection. She died April 8 at the University of Washington Medical Center.

It’s not clear whether the woman or the man who likely infected her were vaccinated against measles. In both cases, the vaccination status was unknown, health officials said.

But the newly released details underscore the capriciousness of measles infection and the need for widespread vaccination to protect against it, experts said.

“You don’t know when somebody who is in the same place as you is contagious for measles,” said Chas DeBolt, a DOH senior epidemiologist. “If everybody had a known measles immunity status in this situation, it might have been a very different outcome.”

DeBolt outlined details of the woman’s infection in an email sent June 19, 2015, to state health officials and those at the Centers for Disease Control and Prevention (CDC) who were investigating the death.

Previously released information offered only a broad description of the case, the first confirmed measles death in the U.S. in a dozen years.

The Seattle Times requested the records pertaining to the death in July, but state officials didn’t supply all of them until February.

The woman was likely infected when the 52-year-old Port Angeles man sought care at the clinic. It’s not clear what his symptoms were, though measles can resemble other illnesses in early stages.

“There were 35 possible exposures on 1/29/2015, at the Lower Elwha Clinic,” the state records showed. Thirteen of those present had verified immunity for measles. Ten were vaccinated. One was not vaccinated. Eleven others had unknown immunity, like the man who exposed them, the emails indicated.

The Elwha clinic serves members of the Lower Elwha Klallam Tribe, members of neighboring tribes in the service area and non-Indian patients who are covered by state insurance and can’t get health care from local providers, according to its website.

Officials with the clinic did not respond to questions about the exposure.

Eventually, at least 149 other people may have been exposed to the germ by the man, who was hospitalized but later recovered, a Clallam County report said. Tests showed he was infected with a D9 strain of the virus not linked to previous cases in Washington. The source of his infection remains unknown, DeBolt said.

It’s possible the woman was exposed to measles elsewhere in the community because the virus was circulating widely, but no other source has been documented, DeBolt noted.

The young woman’s health condition was redacted from the public records, but it required her to take drugs that suppressed her immune system. She may have been vaccinated against measles as a child, but her family couldn’t produce evidence, which left her status categorized as unknown, health officials said.

The woman was unable to fight off the infection, which attacked her lungs. She didn’t develop a rash or other symptoms typical of measles, but the virus was present in a lung-tissue sample collected Feb. 2, 2015, the emails showed.

She fell ill about six weeks later and sought care at Olympic Medical Center in Port Angeles on March 19, the emails showed. The young woman’s condition worsened and she developed hypoxia, a condition in which the body doesn’t get enough oxygen. On March 26, she was sent to the University of Washington Medical Center, where she died April 8.

An autopsy later confirmed that the woman died of pneumonia caused by measles, a common side effect of the infection.

The death was the sixth measles case confirmed in Clallam County last year and the 11th in Washington state. In 2015, 189 people from 24 states and the District of Columbia were reported to have measles, the CDC said. Most of those cases were related to an outbreak that began in December 2014 at Disneyland in Southern California. In 2014, a record number of cases, 667, were reported in the U.S., the most since the virus was considered eliminated from the country in 2000. Most of those who fell ill had not been vaccinated against the disease, officials said.

As of Feb. 5, two measles cases have been reported in the U.S. this year, one in California and one in Texas, the CDC reported. No cases have been confirmed in Washington state.

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