Global Aspects of Social and Behavioral Health – Final Exam: Measles Outbreak Among Somali Community in Minneapolis, 2017
Please read the following case, accompanying data tables, the attached MMWR article, the slideset from the Minnesota state demographic center, and the news article from the Star-Tribune. In formulating your answers you can draw upon any of the readings from the course (required or supplemental) or the accompanying material. Although not required for this exam, if you elect to cite sources beyond these please be sure to use reliable sources and cite all sources fully in endnotes or footnotes. Your final exam should be submitted on NYU Classes as a Word document, and it should be titled “[LAST NAME_FIRST NAME_final exam.doc]”.
In April 2017 the Minnesota Department of Health initiated an outbreak investigation when it was notified of a suspected measles case in a 2-year old child in Minneapolis in Hennepin County. In less than two months, 65 confirmed measles cases were reported to the state health department, 85% of them among American-born Somali children. This was the second outbreak among the Somali community in Minneapolis within six years. (V Hall et al., MMWR 2017).
Immunization for Measles, Mumps and Rubella (MMR) had declined precipitously among Somali children over the prior decade. Public health officials generally regard 92% MMR vaccination coverage to be sufficient to generate “herd immunity” protection for a local population. In 2004, 94% of US-born Somali children were vaccinated. By 2014, although the immunization rate for non-Somali children remained constant at about 91%, the vaccination rate for Somali children had plummeted to 35.6% (see CDC figure to the right).
Nationally, MMR vaccination rates had remained constant over time, although they did vary by insurance status (see Table 1 below). Minnesota public health officials pointed to concerns among the Somali community that vaccines caused autism as the source of the vaccination reluctance. In 2007 a
Table 1. CDC Data, National Immunization Survey (2017)
MMR Vaccination Rates by Year MMR Vaccination Rates by Insurance Status
2013
2014
2015
2016
2017
91.9%
91.5%
91.9%
91.1%
91.5% Private insurance
Medicaid
Other insurance
Uninsured
93.7%
90.4%
91.0%
74.6%
group of Somali parents had been concerned about the numbers of Somali children who were being treated for autism spectrum disorder in the schools, although public health officials later determined that the autism rates among Somali children were the same as among all other children. The Somali community invited a number of anti-vaccination advocates to speak to their community. A Washington Post article published in the midst of the 2017 measles outbreak chronicled this antipathy to immunization:
“Fear of autism runs so deep in the Somali community that parents whose children have recently come down with measles insist that measles is preferable to risking autism. One father, who did not want his family identified to protect its privacy, sat helplessly by his daughter’s bed at Children’s Minnesota hospital last week as she struggled to breathe during coughing fits.
The 23-month-old was on an IV for fluids and had repeatedly pulled out the oxygen tube in her nose. Her older brother, almost 4, endured a milder bout. Neither had received the MMR vaccine.
The children now have antibodies to protect against measles, but they still need the vaccine to prevent mumps and rubella. Their father, who is 33 and studying mechanical engineering while working as a mechanic, wants to wait. His worry: autism. A colleague has a son “who is mute.”
“I would hold off until she’s 3 . . . or until she fluently starts talking,” he said.
His wife no longer harbors doubts, however. As soon as both children are well, she said, “they are going to get the shot.”
The pervasive mistrust was evident Sunday night during a meeting, sponsored by several anti-vaccine groups, that drew a mostly Somali crowd of 90 to a Somali-owned restaurant here. Patti Carroll, a member of the Vaccine Safety Council of Minnesota, described its goal as giving parents more information, including about their right to refuse to vaccinate. People have been “bullied big-time” by doctors and public health officials, she said.
The presentation by anti-vaccine activist Mark Blaxill drew cheers and applause. Blaxill, a Boston businessman whose adult daughter has autism, played down the threat of measles and played up local autism rates.
“When you hear people from the state public health department saying there is no risk, that [vaccines] are safe, this is the sort of thing that should cause you to be skeptical,” Blaxill said.
Two pediatricians in the audience stepped up to a microphone to denounce the claims.
“I am very concerned, especially in the midst of a measles outbreak, to have folks come into a community impacted by this disease and start talking about links between MMR and autism,” said Andrew Kiragu, interim chief of pediatrics at Hennepin Medical Center in Minneapolis. “This is a travesty.”
He and the other doctors were interrupted by boos and yelling.
“For God’s sake, I want to know if vaccines are safe!” Sahra Osman shouted. She has a nearly adult son who received an autism diagnosis when he was 3. “My people are suffering! We’re not ignorant. I read a lot. I know a lot. I educate myself. . . . You don’t know what you are talking about.”
[“Anti-vaccine activists spark a state’s worst measles outbreak in decades,” Lena Sun, Washington Post, May 5, 2017]
COVID-19 in Hennepin County, Minnesota
Minneapolis is the county seat for Hennepin County, and it has recently experienced a significant and alarming rise in COVID-19 cases in the county (see the graphic below). In a recent survey of likely Minnesota voters, 43% reported that they would not take a COVID-19 vaccine when it was initially made available (see attached article from the Minneapolis Star-tribune).
Exam questions
1. Which social determinants may be influencing the health behaviors observed among the Somali community in Minneapolis? Explain how and why you believe these determinants are influencing the problem. Provide evidence from the course readings or lectures to explain your answer. (~250 words)
2. Propose an intervention that could address the problem. Specify what level (individual or community) is being targeted, why you have selected that level, and how your intervention addresses the social determinant you identified in question 1. Explain the appropriateness of your level of intervention for your community and any evidence that could justify the use of this intervention. (~250 words)
3. How would you evaluate the intervention? Describe the data you would need to collect, and how you might apply the RE-AIM evaluation framework to your proposed intervention. (~250 words)
4. Draw a conceptual model that clearly demonstrates the relationship between social determinants of health, mediators/moderators, behavioral risk factors and the health outcome. Include your intervention and clearly identify the factors your chosen intervention would target.
5. Repeated national surveys during the pandemic suggest that between 15-20% of the US population continue to refuse to take a COVID-19 vaccine. To what extent does the conceptual framework that you developed for the Somali measles hesitancy apply broadly to COVID-19 vaccine hesitancy in the United States? What additional determinants would you add to your conceptual framework to account for other causes of vaccine hesitancy, and why? Identify one possible intervention to address this vaccine hesitancy. (250 words)