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Why Minnesota lost a battle against anti-vaccine campaigners

A public health official explains how a local Somali community got hit with a measles outbreak.

While Minnesota’s overall vaccination rates remain high, they’ve plummeted in a local Somali community — helping spark a measles outbreak.
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Minnesota is currently battling its largest measles outbreak in nearly 30 years, with 58 confirmed cases. And it’s become a case study in how difficult it can be to slay vaccine misinformation once it takes root.

What makes this outbreak so astounding is that it is nearly a decade in the making. In 2008, anti-vaccine advocates — including the Organic Consumers Association and Andrew Wakefield, a British doctor who falsified data suggesting vaccines are linked to autism — began targeting local Somali Americans who had concerns about autism among their children. The activists saw an opening, offering an explanation of a cause when the health department couldn’t provide one.

Vaccination rates have since plummeted in the community, making its members more susceptible to preventable diseases — such as measles. As of May 16, there were 58 confirmed measles cases in Minnesota, most of them occurring among unvaccinated Somali-American children in Minneapolis.

But how exactly did Wakefield and other anti-vaccine advocates persuade Minnesota’s Somalis to fear vaccines? Why couldn’t the public health community correct their misinformation?

To find out, I called Kristen Ehresmann, director for infectious diseases at Minnesota’s Department of Health. She’s been working with the Somali community for nearly a decade. Five weeks into an outbreak that shows no sign of slowing down, she argues it’s better for the state to address people’s fears than to push vaccines. She also has advice for other communities where vaccine refusal is rising. The conversation that follows has been edited for length and clarity.

Julia Belluz

When did you realize you had a vaccine problem in Minnesota’s Somali-American community?

Kristen Ehresmann

In 2008, there was a news article — based on people’s perception and observation — that a disproportionate number of Somali children were taking advantage of special education services in the Minneapolis public school system. Once that news piece was done, word got out that there appeared to be a disproportionate number of Somalis with autism [which is not true]. And that was the opening point.

Right from the very first meeting that the Department of Health and some community members coordinated, the anti-vaccine folks were there [through public lectures and outreach]. They have been actively working in the community. Andrew Wakefield, the discredited British doctor [who falsified data suggesting vaccines cause autism], has met with the community on at least two occasions.

Julia Belluz

What techniques are the anti-vaccine groups using to influence people?

Kristen Ehresmann

They are very much taking advantage of a vulnerable population. The main groups [promoting an anti-vaccine message here] are the Organic Consumers Association, the Vaccine Safety Council of Minnesota, and National Health Freedom Action. They have really jumped on the fact that this population was concerned about autism, and that has been the focus of their work.

They have redoubled their efforts during this outbreak. They are putting more and more energy ... into promoting their message. They scheduled a community meeting on April 30 — it was “an educational community resource meeting,” but it was really an anti-vaccine meeting. The anti-vaccine groups presented their viewpoints... some Somali parents spoke about their concerns about autism. And a number of physicians got up and refuted the information provided.

Julia Belluz

What impact have their messages had?

Kristen Ehresmann

We can track immunization coverage levels, and when we look at coverage levels of Somali children around 2 years of age and compare them to the rest of the state, up until 2008 their rates ... were equal to or better than the state’s coverage levels. Then in 2008 you see this decline, and every year you see a drop.

Right now we are at 41 percent coverage for the MMR [measles, mumps, and rubella] vaccine among Somali Americans. This outbreak is really driven by low vaccination rates. We are continuing to get new cases each day. We are anticipating we will likely see spread to other unvaccinated communities in Minnesota.

Julia Belluz

What are you doing to fight back against anti-vaccine campaigners?

Kristen Ehresmann

We’ve hired Somali staff to do outreach, and one of the important things is addressing [the community’s] concerns about autism. We have one Somali outreach worker whose job it is to make sure [concerned parents] are aware of resources they can have for their children if they do have [autism] concerns. Then we have an outreach worker who is focused on providing information on immunizations. We have created a Somali health advisers group and pulled together leaders in the Somali community to get their input. The challenge is we need to be doing this 10- or 100-fold more than what we’re able to do.

Julia Belluz

Despite all this work, though, you haven’t yet seen an inflection point with the vaccine coverage rates, right? It looks like coverage rates just keep going down. Have you learned what doesn’t work in terms of pro-vaccine messaging?

Kristen Ehresmann

Over time, we have modified our approach. First we were focusing a great deal on vaccines, and we realized that it’s not enough to say vaccines aren’t the problem. You really have to address the concerns about autism as well. Over time we’ve increased the involvement of the [Somali] community as well as made sure we’re addressing both issues.

One of the big challenges we face is that autism is extremely complex and there are multiple factors that have been identified and that may play a role. And the community really wants an answer — they want to know that X causes autism. We try to explain the level and type of research that’s needed [and that we don’t have answers about the causes of autism], and that was perceived of as, “You don’t care about us.” I don’t think we did a good enough job of conveying that we did care.

Julia Belluz

The University of Minnesota did a research project in response to autism worries among Somali Americans in Minnesota and found no difference in prevalence of the disorder among Somali children compared to white kids. Did that make a dent?

Kristen Ehresmann

The perception is so strong [that autism rates are higher] in the [Somali] community there was almost a distrust — “You’re just saying the rates are the same.” So that [report] didn’t make a huge difference. I think this outbreak has really provided a good opportunity to try and clarify messages and get more concerted messaging from within the community and from community leaders.

Julia Belluz

Is there any sense of whether the FBI’s targeting of Somali Americans has contributed to the mistrust of government in this community?

Kristen Ehresmann

Yes, we have heard this as a concern. Somalia doesn't have a strong, reliable government, which may also contribute to mistrust.

Julia Belluz

Minnesota could be a case study in how difficult — and resource-intensive — it is to debunk anti-vaccine views once they’ve taken off, particularly in a community that has become skeptical of government.

Kristen Ehresmann

Absolutely. It’s very frustrating that this community has been targeted.

We did some projections [about the cost of this measles outbreak] and calculated the cost for the first 21 days — $207,000 — and that was just for the Minnesota Department of Health, not for [county health departments], all the health care facilities that had to ramp up staffing. It doesn’t include direct medical costs that have been incurred. We’re in week five, and if the outbreak lasts three months, it’ll be close to $900,000 — so just under a million for the State Health Department alone.

Julia Belluz

Is Minnesota more permissive in terms of allowing vaccine exemptions?

Kristen Ehresmann

Yes, so this is part of why we’re seeing this problem. Currently in Minnesota law, there is language that allows for conscientious objection to vaccination. So vaccines are required, but you can have a medical exemption, a religious exemption, and there’s philosophical exemption.

Julia Belluz

That’s interesting. We know states with more lax vaccine laws tend to suffer more with preventable outbreaks, which some public health officials worry are on the rise across the US. Do you have any messages for other communities that may soon be dealing with preventable outbreaks of their own?

Kristen Ehresmann

The most important thing is to make sure you’re working with the affected community and that you have staff from that community. For us, the Somali outreach staff have been critical, and the Somali health advisers group has been important. The most important thing is that community has been engaged and can provide information about what can be successful.

What was very interesting [about the April 30 anti-vaccine meeting] was that the original venue they had scheduled the meeting for is right in the heart of the Somali community here, and Somali leaders pushed back and said, “We don’t want this in our community; we don’t want this targeting.” They pulled the contract so the meeting couldn’t be held there, and the groups rescheduled to a different venue. So there was some pushback in the community, and we are seeing more and more of that, which is good.

Julia Belluz

Do you think Minnesota will consider tougher vaccine laws as a result of this outbreak, like California did after their big Disneyland measles outbreak in 2015?

Kristen Ehresmann

As the current situation shows, unvaccinated children have caused a significant outbreak of measles. We welcome a discussion on the current Minnesota school and child care immunization requirements. The concept came up at a legislative hearing today, so I certainly think it is possible there will be further legislative discussion on this issue.

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