Hennepin County Public Health Department
Responding to a Vaccine-Preventable Outbreak within a Culturally Vaccine-Hesitant Community
With its staff of 450 professionals, Hennepin County Public Health is the primary provider of public health services to the county's 1.1 million residents. Hennepin County encompasses 46 municipalities within 600 urban and suburban square miles of the greater Minneapolis-St. Paul Twin Cities metropolitan area. Its population includes a diversity of ethnicities and a wide range of household incomes. Hennepin County Public Health works to improve and protect the health of infants, children, adolescents and adults who live, learn, work or play in Hennepin County. One of the key strategic priorities of the department is to prevent and control infectious diseases. We achieve this goal by implementing science-based epidemiological disease investigation and response, aligning and recruiting appropriate resources, and collaborating with communities to make sure our collective resources are leveraged to address health equity.
In 2017, Hennepin County (MN) experienced the largest outbreak of measles in 20 years. From April to July, 70 cases were confirmed among residents of the county, with 9 other associated cases occurring in other counties within Minnesota. Out of the 79 total cases, 90% were unvaccinated, and 22 cases were hospitalized. The outbreak was concentrated in the Somali-Minnesotan community, who had low vaccination rates due to fears about MMR vaccine causing autism. The total cost of the outbreak response to Hennepin County Public Health was in excess of $395,000.
In response, Hennepin County Public Health initiated a model practice, Responding to a VaccinePreventable Outbreak within a Culturally Vaccine-Hesitant Community.â€ The goals of this practice were to: 1) Assure isolation of active cases during their infectious period; 2) Assure compliance with social exclusion among non-immune contacts of actively infectious measles cases; and 3) Promote accelerated vaccination schedule among residents non- and under-immunized residents per state health department guidance. These goals were supported by case investigation and disease control, community outreach, and home visiting. Staff who were from the affected community were recruited to assist with the response effort as they could provide culturally-aware messaging and disease control activities
Over the course of the outbreak, the outreach team of Somali Community Health Workers attended and led approximately 150 community visits to culturally appropriate schools, businesses, homes, apartment complexes, mosques, and community centers across nine cities. Home visits were necessary to contact 31 households who did not answer exclusion phone calls and needed a home visit to discuss the outbreak situation and impact, the disease ramifications on them and their family members and what their options were to protect themselves and others, having been exposed to the disease. These workers listened to families, spoke in their language, and were able to address their concerns. Through the combination of these efforts, the team helped increase the number of vaccines to Somali-Minnesotans in Hennepin County from about 200 to 1,600, a stunning eight-fold increase. During the 13-week period (4/2/17 to 7/1/17) over 25,000 vaccines were given to Hennepin county residents, compared with about 8,000 during the preceding 13-week period, over a three-fold increase.
Through our efforts, we learned that partnership with the community was essential in changing a culture that had been increasingly resistant to vaccine. In addition, home visits were successful for conducting case interviews/making Exclusion recommendations for those resistant to answering our phone calls. With modification to the content and staff resources, this practice can be adapted to addressing outbreaks in other cultural populations that are characterized by vaccine-hesitancy. Going forward, the public health department plans to identify staff across many areas of county government who can be effective in reaching the many cultural groups that may be affected by a public health emergent situation. The experience of responding to the largest measles outbreak in 20 years brought renewed attention from the community and by policy makers to the issues of vaccine coverage and disease control during an outbreak. With ongoing prompting by public health, the community and policy makers can respond with actions that will result in improved immunity, as well as policies and plans that are able to quickly and effectively respond to emerging disease threats.
Measles is a highly infectious vaccine-preventable disease that caused significant morbidity and mortality in the United States prior to the development of a vaccine in 1963. Before that time, close to 500,000 cases were reported annually, with around 48,000 hospitalizations and 500 deaths. Measles was declared eliminated from the United States in 2000 due to vaccine efficacy, coverage and other control measures. However, measles continues to be present in other parts of the world and can be brought to the country by unvaccinated travelers. Recently, several outbreaks of vaccine-preventable diseases have occurred among the residential U.S. population in communities that have low rates of immunization due to vaccine hesitancy. In particular, measles vaccine has been called into question by now-discredited research linking the MMR shot to autism that have caused some communities to reject science-based immunization recommendations. Resultant outbreaks pose a threat to public health and are costly to control.
In 2017, Hennepin County (MN) experienced the largest outbreak of measles in 20 years. From April to July, 70 cases were confirmed among residents of the county, with 9 other associated cases occurring in other counties within Minnesota. Out of the 79 total cases, 90% were unvaccinated, and 22 cases were hospitalized. The outbreak was concentrated in the Somali-Minnesotan community, who had low vaccination rates due to fears about MMR vaccine causing autism. In response to the outbreak, Hennepin County Public Health, in collaboration with the Minnesota Department of Health, responded by increasing resources for epidemiological case investigation and community outreach, and partnering in unique ways to ensure the community was quickly and effectively protected from the threat of disease. These activities took place under FEMA Incident Command Structure response model, initiated in the first days following the initial case report.
The local Somali community was particularly affected by the outbreak after an unfounded link between vaccines and autism was deliberately used to fan fears within this large local refugee population in recent years, resulting in a dramatic drop in vaccinations among them and their young children. Specifically, the Somali MMR vaccination rate had dropped from levels that were close to the state average in 2001 to levels around 40 percent due to targeted messages from anti-vaccine groups in the mid 2000's. In the past, this issue had been addressed through outreach through existing public health programs, but in the absence of clear measles risk and ongoing autism concerns, these efforts had limited impact on vaccination rates.
According to the 2010 American Community Survey, there are around 25,000 Somalis living in Minnesota, with the majority living in Hennepin County. Many are concentrated in the Cedar-Riverside neighborhood of Minneapolis, particularly new immigrants, while a significant number of Somalis have settled in the surrounding suburbs throughout the Minneapolis-St. Paul metropolitan area. Among students in Hennepin County school districts, Somali is ranked as the second most-common non-English language spoken at home behind only Spanish, with almost 9,000 students who speak Somali at home during the 2015-16 school year. About 40 percent of these Somali students live in Minneapolis, while the remaining 60 percent live in suburban cities within Hennepin County.
This practice, Responding to a Vaccine-Preventable Outbreak within a Culturally Vaccine-Hesitant Community,â€ is an innovative application of evidence-based practices, including Advisory Committee on Immunization Practices (ACIP) Immunization Recommendations and CDC Community Guide practice Vaccination Programs: Community-Based Interventions Implemented in Combinationâ€. The innovations of these practices involved the application of these practices during an outbreak under Incident Command Structure (ICS), developing specific messaging and response activities within a culturally vaccine-hesitant community, and enhancing capacity by leveraging the expertise of staff from the community to implement intensive outreach and education activities. In addition, the public health model of home visiting was modified to serve the needs of outbreak response by supporting social exclusion of exposed individuals and community outreach and education.
During an outbreak of a vaccine-preventable disease with human-to-human spread, key goals are to mitigate risk by reducing exposure to actively infectious persons, and to increase population immunity by improving vaccination coverage among those at risk. Therefore, the objectives of this practice were to: 1) Assure isolation of active cases during their infectious period; 2) Assure compliance with social exclusion among non-immune contacts of actively infectious measles cases; and 3) Promote accelerated vaccination schedule among residents non- and under-immunized residents per state health department guidance.
The activities undertaken to achieve these objectives involved intense coordination with the Minnesota Department of Health (MDH), and integrating a number of different activities under incident command which normally function in separate parts of Hennepin County Public Health â€“ HCPH (e.g. Epidemiology, Public Health Clinic, and Immunization Registry staff), as well as from other areas of the county government, including Human Services and the Office of Multicultural Health. This allowed us to align unique skills and resources needed to accomplish our goals.
Key activities that supported this effort were case investigation and disease control, community outreach, and home visiting. Individuals exposed to measles were assessed for immunity to measles (either past measles disease or MMR vaccine), while those who were non-immune to measles and had appropriate post-exposure prophylaxis (MMR vaccine within 72 hours; immune globulin within 6 days) were placed in Symptom Watch. Those in Symptom Watch received an initial phone call describing their exposure, symptoms of measles disease, and phone numbers to call during and outside of business hours if they had concerns. People who were non-immune to measles and did not receive post-exposure prophylaxis were placed in Exclusion. Those in exclusion received an initial phone call with the general information provided during the Symptom Watch call with the additional information that they were voluntarily excluded from childcare/school/public activities for 21 days following exposure to measles. These exclusion recommendations, developed in collaboration with the state health department and CDC, were intended to greatly reduce the risk of ongoing exposure in high-risk settings such as daycares and schools. In many cases, this involved placing the burden of excluding non-immunized children from childcare on families, meaning they needed to make other arrangements for care that did not pose a risk to public health. Some families were referred to a Human Services social worker, to assist with arranging basic needs. This included arranging housing for families living in shelters unable to provide appropriate services. During exclusion, periodic calls were made every few days to assess symptoms. A call was made on the 21st day to inform the individual that their Exclusion period was over. These activities were done in coordination with MDH, who conducted these activities for those exposed in school and childcare settings, while HCPH conducted the Symptom Watch and Exclusion activities for those exposed in health care settings.
Epidemiology case investigation and disease control services had access to in-person language assistance through Community Health Workers (CHWs) when needed to perform interviews. If an exposed individual could not be reached via telephone for an Exclusion call (regardless of place of exposure), Hennepin County Public Health conducted a home visit. The purpose of the home visit was to explain the Exclusion, review measles symptoms, listen to concerns, and answer any questions. A single home visit was attempted, as per MDH recommendations. If the individual was not home, a letter was left at their residence explaining the situation and asking that they call Public Health. Home visit teams were comprised of public health nurses and cultural staff (CHW and PHN's speaking Somali and Spanish languages).
These in-person visits provided the opportunity for staff to provide more in depth assessments of the families' situation that could enable them to target messaging and provide helpful context and empathy to conversations that may not have been possible with a phone call. A cohort of 12 Hennepin County community health workers (CHWs) mobilized the Twin Cities' Somali community to assist with epidemiologic investigation, disease control, and community outreach. Many of these staff were Somali and were recruited from the Hennepin County Office of Multicultural Services to assist in this effort.
Community stakeholders were identified by staff with extensive knowledge of the organizations and were leaders trusted by Somalis in Hennepin County. Staff relationships were used to engage these individuals to provide messaging about the outbreak, updated information as it progressed, and what the community could do to protect themselves from disease. These staff were engaged in roles that brought their experience to the Incident Command meetings that determined overall response strategies, and were further involved in regular meetings to discuss outreach and education updates. Outreach staff also participated in regular conference calls with the state health department and other local public health departments to coordinate efforts and assure consistent messaging.
Costs were traced throughout the outbreak response by tracking staff time spent on response activities. Equipment and supply use and/or purchases that supported the effort were tracked similarly. The total cost of the response to Hennepin County Public Health was in excess of $395,000, the majority of which were costs related to staffing.
Throughout the outbreak response, data were collected from a number of sources, including measles case interviews, social exclusion interviews (phone/in person), interviews to monitor the well-being of those in exclusion, home visit dispositions, feedback from culturally-specific staff on appropriate outreach messages, and community feedback on messaging. Key data were summarized in a data dashboard updated daily that compiled key indicators of the work, such as number of cases, contacts, home visits, and other relevant information. Hennepin County GIS staff were mobilized to develop assessment maps, including MMR vaccination by ZIP code to identify high-risk areas of the County as well as the locations of case residence and schools and daycares with confirmed cases. Qualitative feedback from community conversations was shared at daily briefings to identify gaps in messaging that needed to be addressed. Daily phone conferences with MDH were used to elevate issues that required statewide coordination. MMR Immunization tracking was done through the statewide immunization registry Minnesota Immunization Information Connection (MIIC).
One observation by staff from the Somali community initially was that the community was not responding to new vaccination and outbreak recommendations that she was hoping. She quickly arranged meetings with local Imams to help educate and support this population through the mosque, correctly predicting that they would trust their community and faith leaders with personal health care advice and information. Over the course of the outbreak, the outreach team of CHWs attended and led approximately 150 community visits to culturally appropriate schools, businesses, homes, apartment complexes, mosques, and community centers across nine cities in Hennepin and Ramsey counties. They handed out flyers, provided education, listened to concerned community members and parents, described the county and state public health response to the outbreak, encouraged MMR vaccination, and supported families and individuals to utilize their existing primary care providers for care.
Through the combination of these efforts, the team helped increase the number of vaccines to Somali-Minnesotans in Hennepin County from about 200 to 1,600, a stunning eight-fold increase. During the 13-week period (4/2/17 to 7/1/17) over 25,000 vaccines were given to Hennepin county residents, compared with about 8,000 during the preceding 13-week period, over a three-fold increase. The health department also proactively worked with the local media to ensure factual and timely measles information reached the public. The resulting community dialogue has helped mitigate the vaccine myths and supported a significant increase in vaccinations.
Exclusion compliance was assessed through monitoring phone calls. Home visits were necessary to contact 31 households who did not answer exclusion phone calls and needed a home visit. A home visit was also utilized when Hennepin County Public Health was unable to interview two cases of infectious measles residing in the same household. This was the first time the County had sent home visitors in to a home with known infectious measles. The cases were Somali Americans, so we utilized two Somali Public Health nurses who were trained in home visiting. The nurses were screened for measles immunity by titer and were fit tested with an N95 respirator prior to their visit. The home visit was successful and the team was able to conduct the case interview in person, ensure home isolation during the infectious period, and avoid the possibility of legal intervention needed if the person were to refuse. These strategies were modified during the outbreak to address a non-Somali family that was skeptical of both MMR vaccine, as well as school exclusion recommendations. Extensive communication took place involving outreach workers, school staff, and epidemiology, and in the end, the family agreed to exclusion and no legal action was necessary to protect public health. Overall, there were very few instances where families were actively resistant to exclusion. These cases were quickly resolved through home visits or by working with daycare/school administration to assure compliance. In many cases, public health staff offered problem-solving assistance in identifying creative ways to maintain exclusion, for example, by asking families whether daycare could be provided by someone in the family's social network. There were no cases where legal intervention was necessary to enforce recommended exclusion.
Through our efforts, we learned that partnership with the community was essential in changing a culture that had been increasingly resistant to vaccine. Staff from the community were very effective messengers and were crucial in identifying the communications channels that would be most effective in reaching those who were at risk of disease.
In addition, home visits were successful for conducting case interviews/making Exclusion recommendations for those resistant to answering our phone calls. Home visits prevented Public Health from having to consider legal Isolation/Quarantine (IQ) measures. These visits were best done by someone who speaks the individual's native language/is a trusted member of the community. Those needing home visits were from all racial/ethnic groups (i.e., not just from the Somali American community).
With modification to the content and staff resources, this practice can be adapted to addressing outbreaks in other cultural populations that are characterized by vaccine-hesitancy. Going forward, the public health department plans to identify staff across many areas of county government who could be effective in reaching the many cultural groups who may be affected, as well as expanding MRC outreach to ensure a culturally diverse response team. Monitoring vaccination rates through the statewide immunization registry to examine ethnic groups and geographic communities exhibiting under-vaccination will be used to develop potential strategies for response, as well as opportunities for outreach with messaging in the absence of measles to promote vaccine.
Cost of response was tracked by tracking staff time for all individuals who assisted in this effort and related supplies and other expenses, with a total of $395,000 at the county level. A formal cost/benefit analysis has not been performed, however the cost of making home visits offset higher expenses, in that we did not have to place any families in legal quarantine. Legal action in situations such as this has been estimated at $50,000 per occurrence.
The experience of responding to the largest measles outbreak in 20 years brought renewed attention from the community and by policy makers to the issues of vaccine coverage and disease control during an outbreak. Many families re-examined their risk perceptions related to immunization, as exhibited by higher levels of vaccination during the outbreak. Data suggest that while MMR vaccination has dropped since the outbreak was declared over, rates continue to be higher than those prior to measles. With ongoing prompting by public health, the community and policy makers can respond with actions that will result in improved immunity, as well as policies and plans that are able to quickly and effectively respond to emerging disease threats.