At the Epicenter of Minnesota’s Ongoing Measles Outbreak

For observant Muslims across the country, sunset last Friday brought with it the start of the holy month of Ramadan—a time of prayer, fasting and, once the fast is over each day, social gatherings over food. But for the majority-Muslim Somali-American community in Hennepin County, Minnesota, which includes Minneapolis, this Ramadan comes at a particularly risky time. That community is at the epicenter of the worst outbreak of measles the state has seen in recent memory.

Since the outbreak began in April, there have been 68 recorded cases of the disease—most of which have affected young children in the Somali-American community in Hennepin County—and the outbreak is on track to exceed the number of cases seen in the entire United States in 2016.

Minnesota’s Somali-American community once had a vaccination rate that was on par with the general population. That was before 2008, when a slew of news coverage came out that focused on the prevalence of autism within that particular community.

Groups that tie the autism to the measles vaccine, despite the complete lack of evidence to support those claims, saw their opening and began holding meetings and outreach events for the Somali-American community. The stoking of fears combined with the fact that it’s relatively easy to opt out of vaccination in Minnesota—all you need to do is present a notarized statement saying you don’t want your child immunized—led to a precipitous drop in the rate at which Somali-American children were receiving immunizations.

By 2014, 2-year-olds in the Somali-Minnesotan community received vaccinations at a rate of only 42 percent—that’s compared with 88 percent among non-Somali children.

Minnesota health officials have been fighting back against this misinformation since it first took hold.

“We’ve known for many years now that in Hennepin County we have communities that have lower rates of vaccination,” Dave Johnson, the epidemiology manager for Hennepin County, said in a phone interview with Route Fifty on Tuesday.

“We have staff here and there’s also staff at the Minnesota Department of Health who have been working for years at trying to do education and trying to encourage people to vaccinate.”

But, according to Johnson, since the start of the outbreak, something has changed.

“What we have now that we haven’t had before is really people’s attention,” Johnson said.

And health officials in Hennepin County don’t plan to squander the spotlight on measles and the need to immunize. To that end, the current outbreak and the particular challenges presented by Ramadan have prompted a coordinated effort to craft measles response tools specifically for the community that needs them most.

Culturally Specific Outreach

For the most part, the epidemiological response to measles follows a pattern similar to that of other infectious diseases. When a case is detected, health officials conduct what is called contact tracing, which involves finding everyone who might have encountered the infected person in the hope of mapping all possible directions in which the disease could spread.

Along with contact tracing, during outbreaks such as this one, officials step up their push for vaccinations, encouraging parents to make sure their children are immunized.

And, when exposure to the disease does occur, health workers will take steps to limit the chance for future transmissions. For measles, doctors recommend that if an unvaccinated child is exposed to the disease they must be excluded from school, daycare and other social situations for 21 days.

But, as epidemiologists know all too well, health officials can only do so much without the trust and support of the community involved. After all, vaccinations remain mostly optional and the responsibility to enforce the “exclusion” of children who have been exposed to the disease remains in the hands of the parents.

The campaign to bring the Somali community on board as allies in the fight against measles has been multi-faceted.

Now that it’s Ramadan, Johnson said, “there are more community gatherings and there is more praying at mosques.” So, in response, health officials are working closely with religious leaders to meet the people where they are. Imams have been willingly co-opted as measles educators, helping to stress the need for vaccines and also to reassure community members that Islamic teachings allow for those vaccinations during the holy month.

“And,” Johnson added, “what we’re really trying to make sure we get buy-in on is the exclusion.” That exclusion, Johnson acknowledged can be “a real hardship for families.” Not being able to send a child to daycare for 21 days, or being told that a child should sit out all social gatherings—even religious services—could feel like too drastic of a step for some families.

So, since the outbreak began, Hennepin County has added home visits to their anti-measles strategy. A team of public health nurses, including at least one person fluent in Somali, goes door-to-door to connect with families and hammer home the importance of that exclusion.

Johnson has been pleased with the results of that effort. “Once these home visitors are able to explain the seriousness of the situation and the fact that by doing this a family is really helping protect their friends and their friends’ kids, we’ve really been getting excellent cooperation.”

Along with those home visits and meetings with Imams, Hennepin County has been working closely with Somali health care providers to get information about measles out in the contexts that will have the most reach. Those medical professionals from within the community have been active on community media outlets, including local Somali-language television and radio programming.

And the effort has gotten support from the area’s hospitals as well. One of the largest treatment sites in the region, Children’s Hospitals and Clinics of Minnesota have contributed to the prevention strategy by providing photos of measles rashes that are more easily recognizable to members of the Somali community. It seems simple, but it’s actually a critical step, said Johnson.

“A lot of the images that you see if you google 'measles' are of caucasian individuals,” Johnson acknowledged. “So, when you see a measles rash, oftentimes that doesn’t translate to all skin tones, a rash looks very different on someone who has darker skin.”  

Early detection is critical. There’s no medical treatment for measles and Johnson said many of the cases in the county have become serious. “We’ve had more than 13, 14, 15 kids who have been in hospital, some of them for extended periods of time, some of them who have had to be rehospitalized.”

Signs of Progress

There’s at least one promising piece of news coming out of Minnesota. Using a statewide immunization database, health officials have been monitoring the vaccination rate specifically for the Somali-American community.

The change since before the outbreak has been impressive. Earlier in the year, anywhere from 10 to 30 people might receive a measles vaccination in a week. Now, 400-500 people are getting immunized every seven days.

“It’s a huge increase that we can only attribute to this situation,” Johnson said.