22 cases of measles infected Minnesota children this fall. Credit: Illustration by Aala Abdullahi

Before physician assistant Mohamed Adan can start explaining the importance of the measles vaccine, parents tell him they don’t want their child receiving the shot. 

Mistrust of the vaccine among many Somali community members goes back many years, setting the stage for measles to reach Minnesota’s East African community this fall. Low vaccination rates combined with travel to countries where the disease is endemic led to 14 unvaccinated children contracting measles while traveling abroad. The children likely caught the disease in Somalia, Kenya, or Denmark, according to data Sahan Journal requested from the Minnesota Department of Health. 

“I have a son who’s 8, and I explain to them that I gave it to my kid and he’s fine,” said Mohamed, who works with many Somali families at Axis Medical Center. “But word-of-mouth between families is stronger than what we say.”

The 14 measles infections in Minnesota spread to eight additional unvaccinated children in the state, leading to 22 total infections. At least nine of the children were hospitalized. All have since been discharged from the hospital. 

Of the 22 cases, 21 were among non-Hispanic Black patients and the race of one is unknown, according to the state health department. The state doesn’t track measles infections by specific ethnic communities, but health department officials and staff say that they have directed measles vaccination outreach efforts toward the Somali community. The outbreak poses a delicate balancing act for state health officials as they work with the Somali community while trying to avoid stigmatizing any one group.

The state also doesn’t usually track vaccine rates by specific ethnic communities, but health officials have followed measles trends in the Somali community since a local 2011 outbreak was linked to a Somali American child who had traveled to Kenya. Measles has sickened at least 8,435 people in Somalia this year, according to the U.S. Centers for Disease Control and Prevention. 

The rate for the measles, mumps and rubella vaccine, known as the MMR vaccine, for 2-year-old Somali Minnesotans has dropped from 92 percent in 2004 to about 35 percent in 2021. The state’s overall measles vaccination rate was 89 percent for children entering kindergarten in 2021, according to state vaccination records.

State health officials urge all Minnesotans to vaccinate their children and to take extra precautions when traveling to countries where the disease is prevalent. Measles is not isolated to any particular group of people, they said. But community health advocates working to increase childhood immunization note that underprivileged communities can be vulnerable to misinformation.

“It’s not a Somali problem—it’s an unvaccinated problem,” said Minnesota Department of Health spokesman Doug Schultz. 

State health officials and community advocates are hopeful that community-based outreach will turn the tide. If there are no more new measles cases by December 23, the Minnesota Department of Health said, it can be assumed that the current clusters of infections have ended. But public health officials warn that traveling to countries where measles is endemic will continue to pose a risk to unvaccinated Minnesotans as long as vaccination rates remain low. 

Other states are also currently battling measles: The Minnesota Department of Health said it was contacted recently by the U.S. Centers for Disease Control and Prevention about an outbreak of 59 cases in central Ohio. None of the 59 children had been fully vaccinated.

“We were asked by CDC to participate in a call with Ohio to help them with their outbreak, to share what we knew about our cases, just in case there were any similarities or possible connections, but we have not been having regular contact with Ohio,” Schultz said.

Ohio health officials have not disclosed the backgrounds of the people infected in their state.

Measles cases are rare in Minnesota

Measles is a respiratory virus that can cause symptoms ranging from a cough, rash, fever, and runny nose to pneumonia and permanent brain damage. People are often contagious before a tell-tale rash appears on the skin, and the disease spreads much more readily than most respiratory viruses such as colds, flu, and COVID-19, said Gwantwa Mwakalundwa, who teaches biology and virology at Metro State University.

At least 95 percent of the general population needs to be vaccinated against measles in order to protect the remaining five percent because the disease is so contagious, she said. The number is higher than “herd immunity” rates for other diseases, she added, referring to the percentage of people that needs to be protected from a disease in order to prevent spread within a community. 

“Measles spreads so easily through the air,” said Mwakalundwa, who is a member of the The American Association of Immunologists. “A lot of people think it’s transmitted through contact because of rashes, but it’s air. If someone is not vaccinated and they never had it before, they have a 95 percent chance of developing the disease if they come into contact with it.”

The World Health Organization declared that the United States eliminated measles in 2000. But that doesn’t make Minnesota safe from outbreaks, which can start from travel to countries where the disease is endemic. 

In 2017, an outbreak in Minnesota led to 78 cases, mostly in the Somali community. In a typical year in Minnesota, there are zero infections, or one or two cases of measles contracted through travel. There were two cases total in Minnesota between 2018 and 2021. 

It’s not a Somali problem—it’s an unvaccinated problem.

Minnesota Department of Health spokesman Doug Schultz

So how exactly does the measles vaccine work? 

The vaccine is administered in two shots and innoculates against measles, mumps, and rubella, three different viruses that can infect anyone but that are more serious in children, Mwakalundwa explained.

Like many vaccines, the measles vaccine is made from “live, attenuated” virus, or a virus that has been modified so that it is unable to cause infection, she said. 

“We call it an empty virus,” Mwakalundwa said, because it “is just strong enough to wake the immune system. That is what causes a defense in us.”

Think of it, she said, as the vaccine prompting your immune system to make soldiers that are primed to fight when they encounter one of the viruses they were exposed to in the vaccine itself. 

“If you ever encounter a real virus, it will mount a response and fight the enemy,” she said.

Mistrust in measles vaccine

Somali Minnesotans widely accepted the measles vaccine after they fled political instability and civil war in their home country and settled in Minnesota. In 2004, 92 percent of Somali children in Minnesota were vaccinated against measles, according to the “British Medical Journal.”

The rate started falling after a discredited British doctor, Andrew Wakefield, targeted the Somali community in Minnesota in 2010 and 2011. Wakefield had published a fraudulent paper in 1998 connecting the measles vaccine to autism. It took 12 years for Britain’s General Medical Council to fully retract and denounce that paper. During that time, Wakefield and other anti-vaccine activists visited vulnerable communities to perpetuate the myth, including Minnesota’s Somali community.

The community had recently become alarmed by reports that autism appeared to be more prevalent among Somali children. (A later report by the University of Minnesota showed that Somali and white children in Minneapolis were about equally likely to be diagnosed with autism.) 

Wakefield used effective strategies to gain the trust of East Africans; in fact, his techniques are similar to the strategies that the Seward Vaccine Equity Project used to successfully promote the COVID-19 vaccine in the community, said Ramla Bile, who helped coordinate the Seward project.

“He started doing small, community-based meetings at mosques and even creating a space for women specifically,” Ramla said. “His campaign was really successful, and to this day, WhatsApp chats go viral around the spread of autism and linking it to the vaccine.”

Michael Osterholm, director of the the Center for Infectious Disease Research and Policy at the University of Minnesota, and Kris Ehresmann, former infectious disease director at the state health department, have previously said that Wakefield and others are to blame for the falling vaccine rates in the Somali community.

That should give health officials a deeper sense of urgency about reaching Somali community members, Ramla said, adding that some people are more vulnerable than others to misinformation because of wealth gaps, a lack of health literacy, and language barriers.

Years of research published since Wakefield was discredited shows that there is no connection between the measles vaccine and autism. The first dose of the measles vaccine is administered to children at 15 months of age, around the time when autism is often diagnosed. That coincidence likely helped fuel the false belief that the vaccine is linked to the neurobehavioral condition, Mwakalundwa said. (The second and last dose of the vaccine is administered around ages 4 and 6, and inoculates children for life. Adults who have never received the vaccine can also be vaccinated.)

But official retractions weren’t enough to erase the misinformation from communities that prioritize storytelling and oral communication, Ramla said, adding that many people in the Somali community still fear a connection between autism and the measles vaccine.

Mohamed, the physician’s assistant, said he battles those viral stories at the vast majority of check-up visits with Somali families when it’s time for children to receive the measles vaccine. 

“I always show them pictures of what the diseases do, and I explain to them that the vaccine gives a high chance they won’t get that specific condition, but 90 percent of Somali families don’t want it,” he said. “And I wasn’t able to convince them.” 

Mohamed said he doesn’t have enough time or resources during a child’s check-up to spend most of it discussing one vaccine, since other health issues must also be covered.

Lessons from past outbreaks and COVID-19

Childhood vaccination rates across all racial demographics dropped during the pandemic as routine clinic visits were canceled and postponed. In 2021, almost 40 million children worldwide missed a measles vaccine dose, according to the World Health Organization.

But state health officials said they learned a lot about effective ways to promote vaccines from the COVID-19 pandemic and the 2011 and 2017 measles outbreaks in Minnesota’s Somali community.

After the 2011 outbreak resulted in 26 measles cases, the Minnesota Department of Health prioritized connecting with the Somali community. That intensified during the 2017 outbreak, which resulted in 75 measles cases. The COVID-19 pandemic made it clear that community connections are essential in public health emergencies, said several staffers at the state health department. 

“We have more connections with the Somali community, more Somali staff at MDH (Minnesota Department of Health), and with the community connections we made during COVID, it does change our capacity to do things differently,” said Jennifer Heath, supervisor of the Education and Partnerships Unit at the state department of health’s Vaccine Preventable Disease Section. 

The state department has about 13 staff members in its Infectious Disease Epidemiology, Prevention and Control division whose positions involve outreach to the Somali community, said Schultz, the state health department spokesperson.

The staffers who work as community liaisons come from the communities they’re working with, said Okash Haybe, an African Immigrant Community Liaison who joined the department in 2020. 

“We understand the language and the culture and the norms, and that has helped us strengthen our relationships,” he said. 

Community liaisons work with about 12 community partners, including the Somali Nurses Association, African Immigrant Community Service, KALY Radio, and Somali TV Minnesota. Connecting with those “front-facing” community organizations is critical in learning the best ways that communities receive messages about health, said Hafsa Ali, who joined the state department of health in 2019 in the environmental health division and became a community liaison during the pandemic. 

“The main difference is now we have such a built-in network with community partners,” said Aisha Galaydh, an African Immigrant COVID Community Coordinator and Contract Manager and an African Immigrant Community Liaison with the department. “We were already addressing hesitancy for the COVID vaccine; that work was already being done and we developed strategies to address that hesitancy. So we knew immediately who to reach out to.”

As the COVID-19 work at the health department shifted to returning to recovering from gaps in health care that formed during the pandemic, the work of restoring and improving childhood immunization rates began, Aisha said.  

“We’re empowering the community organizations to lead the conversations, listening to what they’ve been hearing, and allowing them to teach us how to tailor the message,” she said, adding that “their expertise has been invaluable.”

Specifically, the state health department’s outreach can include testimonials from faith leaders and parents about why they vaccinated themselves and their children. It could also include hosting events at community centers, mosques, and schools. 

“What we found works best is having people who are trusted and well-known, like imams and health professionals, or those who were hesitant and changed their mind about getting vaccinated,” Aisha said. “It’s powerful to have a mother share she got vaccinated and then got her children vaccinated.”  

Outreach can’t just happen when there’s a new outbreak.

Ramla Bile, Seward Vaccine equity Project organizer

It’s also time-consuming, resource-intensive work. There’s also been in shift toward not calling undue attention to any one community

“We have been very deliberate in not calling out the Somali community based on what we learned in 2017 and in discussion with community leaders this time around to avoid stigmatization of the community,” said Schultz, the state health department’s spokesperson.

“I saw discourse change from shaming—‘Oh, these people are anti-vaxxers’—and things that don’t help families overcome vaccine hesitancy,” Ramla said.

But she also worries that state health officials aren’t doing enough for the Somali community.

“Outreach can’t just happen when there’s a new outbreak,” she said. 

During COVID, Ramla’s work with the Seward Vaccine Equity Project found success with one-on-one conversations and repeated discussions, as has the state health department and other advocacy organizations.

“I appreciated the clinics at the mosques and at different community spaces—they were way more accessible,” Ramla said of COVID vaccination efforts. “We also had folks giving rides to people, we ordered Ubers, etc. The pandemic was a big experiment in community-based public health, and I hope we can lean into those successful strategies for other public health emergencies like a measles outbreak.”

Still, when it was time to vaccinate her own daughter for measles, Ramla faced difficulty telling her mother that the girl had gotten the shot. Ramla and her siblings had many conversations with their mother, reminding her, “We got vaccinated and we’re fine. This is evidence-based. We don’t know what causes autism, but there’s no reason to suspect that this is it.”

Sheila Mulrooney Eldred writes stories about health equity for Sahan Journal. As a freelance journalist, she has written for The New York Times, the Washington Post, FiveThirtyEight, NPR, STAT News and...