How Can the Health Care Community Work With Somali-Americans to Prevent Future Measles Outbreaks?

This April brought the news of an outbreak of measles in the Twin Cities region of Minnesota. In just over a month, the disease spread from 3 children to 70 confirmed cases (as of May 31). 66 were unvaccinated, 1 had one dose of the measles, mumps, and rubella (MMR) vaccine, and 3 had 2 doses of the MMR vaccine. 67 cases were in children, but what is particularly striking is that 59 cases occurred in Somali children.¹ What caused such a significant drop in vaccination rates in one refugee population?

A Community Crisis

When the first Somali refugees arrived in the United States in 1993 after fleeing civil war, many were placed in the Minneapolis-Saint Paul area of Minnesota. Placement is determined by the Refugee Processing Center working with the 10 voluntary agencies (VOLAGS) to assist refugees with their initial resettlement.² The current population of Somalis in Minnesota is approximately 46,300.³

In Somalia, measles outbreaks are fairly common occurrences, despite efforts by various agencies to vaccinate children. A combination of the lack of a functional central government, civil war and factional fighting, natural disasters, and health care service delivery split between national organizations, international non-governmental organizations (NGOs), the World Health Organization (WHO), and other multilateral aid agencies has made it difficult to provide sufficient health care to the entire population.⁴ Initially, this led to newly arrived refugees diligently vaccinating their children against measles. As late as 2004, 92% of Somali-Minnesotan children were vaccinated against measles.⁵

In 2008, the Somali community raised concerns that their children were suffering from autism in higher numbers than average. They had never seen such an affliction in Somalia and linked it to the vaccines their children had received. A 2009 report from the Minnesota Department of Health only fueled the fire when it showed higher numbers of Somali children enrolled in early childhood special education than non-Somali children.⁶

Anti-Vaxxers Listened

The Somali community began to search for answers to the cause of autism, and the anti-vaxxer community quickly stepped in to provide them. Andrew Wakefield, a British researcher whose link between vaccines and autism was proven fraudulent, causing him to lose his medical license, has met privately with gatherings of Somali families in the Twin Cities area on at least three occasions. One meeting took place during a 2011 outbreak of measles that foreshadowed the current outbreak.⁷

Somali families felt that doctors and health department officials weren’t listening, but the anti-vaxxer community did. “It’s something that you’re looking for an answer for how it happened and what happened to your kid,” says Suaado Salah, explaining the community’s fears about autism.⁸ The Somali community wanted an explanation – if vaccines were not the cause of autism, what was? Nobody in the health care community could tell them. Anti-vaxxers supplied them with a satisfactory answer, even if it was not factually accurate. The pamphlets and websites seemed to make sense, and then word passed around the community, “We communicate orally,” says Asli Askir, a senior RN consultant with the Minnesota Department of Health in St. Paul. “The words fly.”⁵

Preventing Future Outbreaks

Minnesota Health Department officials are working diligently to stop the current outbreak of measles, but more efforts are needed across the health care community to increase herd immunity for the future. The health care community must form partnerships and alliances with Somali community members, including Somali health care professionals, parents, and other community leaders. This group can begin to form inroads for peer-to-peer educational outreach that begins with parents in the group. Word of mouth and oral tradition is important in the Somali culture, so it can be a big part of spreading new educational information. ⁶

Reducing the fear and stigma of autism within the Somali community may also increase the MMR vaccination rates. While continuing to educate the community that there is no link between the MMR vaccine and autism, the health care community can help to assuage the fear of an autism diagnosis, because that is a main factor driving families not to vaccinate children. Some families may not even fully understand what autism is, even though their fear of it is greater than measles. Finally, instead of saying that no one knows what causes autism, explain what is known about the causes of autism.⁶

Making sure that Somali families have enough time with clinicians may also increase the likelihood that children are vaccinated. Short appointment times can sometimes discourage Somali parents from asking all the questions they have. They might feel that the doctor is too busy or doesn’t want to answer their questions. Additionally, if they need an interpreter, 15-20 minutes is simply not enough time.⁵ Plenty of time for education at the point of care increases the chances a child will be vaccinated by a trusted clinician.

“The Somali community is resilient and strong, and they’ve gone through a lot of hardships,” says Anab Gulaid, a Somali-American public health researcher at the University of Minnesota’s Institute on Community Integration in Minneapolis. “They just want healthy children. I understand their concerns.”

References

1. Minnesota Department of Health. Measles (rubeola): 2017 outbreak overview. http://www.health.state.mn.us/divs/idepc/diseases/measles/#1. Updated May 31, 2017. Accessed May 31, 2017.
2. American Immigration Council. An overview of U.S. refugee law and policy. https://www.americanimmigrationcouncil.org/research/overview-us-refugee-law-and-policy. Published November 18, 2015. Accessed May 31, 2017.
3. Minnesota State Demographic Center. The economic status of Minnesotans: a chartbook with data for 17 cultural groups. https://mn.gov/admin/assets/the-economic-status-of-minnesotans-chartbook-msdc-jan2016-post_tcm36-219454.pdf. Published January 2016. Accessed May 31, 2017.
4. Kamadjeu R, Assegid K, Naouri B. Measles control and elimination in Somalia: the good, the bad, and the ugly. J Infect Dis. 2011;204 Suppl 1:S312-S317. https://academic.oup.com/jid/article/204/suppl_1/S312/2192343/Measles-Control-and-Elimination-in-Somalia-The. Accessed May 31, 2017.
5. Sohn E. Understanding the history behind communities’ vaccine fears. National Public Radio. May 3, 2017. http://www.npr.org/sections/health-shots/2017/05/03/526595475/understanding-the-history-behind-communities-vaccine-fears. Accessed May 31, 2017.
6. Bahta L, Ashkir A; Minnesota Department of Health. Addressing vaccine hesitancy in a diverse community: MMR vaccine hesitancy in Minnesota Somalis. http://www.mnaap.org/pdf/141209shotatlife/141209shotatlifeMMRVaccineHesitancy.pdf. Accessed May 31, 2017.
7. Lerner M. Anti-vaccine doctor meets with Somalis. Star Tribune. March 24, 2011. http://www.startribune.com/anti-vaccine-doctor-meets-with-somalis/118547569/. Accessed May 31, 2017.
8. Sun LH. Anti-vaccine activists spark a state’s worst measles outbreak in decades. The Washington Post. May 5, 2017. https://www.washingtonpost.com/national/health-science/anti-vaccine-activists-spark-a-states-worst-measles-outbreak-in-decades/2017/05/04/a1fac952-2f39-11e7-9dec-764dc781686f_story.html?utm_term=.24efd2c5bd90. Accessed May 31, 2017.