The Minnesota Department of Health Responds to Measles Outbreak: An Interview with Kristen Ehresmann

August 24, 2017|4:20 p.m.| ASTHO Staff

Kristen EhresmannMeasles is a highly contagious disease that can be prevented with two major vaccinations: the measles, mumps and rubella (MMR) vaccine and the measles, mumps, rubella and varicella (MMRV) vaccine. The rate of measles in Minnesota began to rise in April 2017. As of July 13, 2017, there have been 79 confirmed cases of Measles in the state of Minnesota, 71 of which linked to unvaccinated populations. In response to this outbreak, Kristen Ehresmann, director of the infectious disease epidemiology, prevention, and control division at the Minnesota Department of Health (MDH), worked closely with Ed Ehlinger, commissioner of health, to lead statewide efforts to increase vaccination rates and awareness.

Please briefly describe how the Minnesota Department of Health became aware of a potential measles outbreak.

Measles is a nationally notifiable condition. The Minnesota Department of Health was notified on April 10, 2017, of a measles case in an unvaccinated 25-month-old child who was hospitalized with fever and rash. On April 11, 2017, a second hospitalized, unvaccinated child of 34 months with febrile rash illness was reported to MDH. This child had a younger unvaccinated sibling of 19 months who had a similar illness with onset on March 30, 2017. All three children were Somali Minnesotans. The department was aware of very low MMR vaccination coverage rates in Somali children (42% for 24-35 month olds at the time of the outbreak). Even with just three cases of measles identified, we knew this had the potential to be a big outbreak. We were challenged by the fact that there had been multiple exposures in child care settings serving many unvaccinated children before the outbreak came to the attention of public health.

What major steps were taken to identify and respond to the outbreak in Minnesota?

In addition to promoting vaccination, our outbreak response focused on identifying a potential source of exposure for a case and who may have been exposed. We had a team that focused on healthcare exposures as well as child care and school exposures. Our immunization information system (IIS), MIIC, was invaluable in our response efforts. We were able to check vaccination status for exposed individuals. For those persons not vaccinated, they were offered post-exposure prophylaxis if appropriate. Otherwise, we excluded them from high risk settings (e.g., child care, schools, etc.) for 21 days after their last exposure (the incubation period for measles). This was an incredibly labor intensive activity.

Over the course of the outbreak, over 8,800 exposed individuals were identified. However, we feel it was a critical element for slowing the spread of measles. The value of this activity is shown by comparing the 1990 and 2017 outbreaks. Figure 1 compares the trajectory of the 1990 measles outbreak (460 cases and three deaths) with the 2017 outbreak. In 1990, we did not have the capacity to implement the public health intervention of tracking the vaccination status of exposed contacts and asking susceptible individuals to refrain from public settings. We also were not able to track the uptake of vaccine in the population. As you can see, the 2017 outbreak had a much steeper initial curve (more cases occurring at a faster rate than 1990) but tapered off much more quickly due to the public health interventions.

What partners were critical in assisting with response activities?

Within our agency, we brought together a team that included the public health laboratory, epidemiology and program staff, legal staff, and communications staff. Our key external partners were local public health agencies, healthcare systems (clinics and hospitals), healthcare providers, child care providers, school leadership, our sister agencies of human services and education, and spiritual leaders in the Somali community.

How did you work with your state health official in this effort?

Ed Ehlinger, our commissioner of health, was involved in our response. He met with Somali faith leaders to discuss their concerns about the outbreak and how the faith community could be involved. He also met with elected officials. “This is about unvaccinated children, not specific communities,” Ehlinger said. “There are people of all backgrounds around the state who have chosen not to protect themselves or their children. Often that decision is based on good intentions and inaccurate information. It’s the responsibility of all of us who care about the health of Minnesota children to make sure people have accurate information and take action to protect their families and their communities.”

Are there any resources that would have made response efforts or activities easier or more seamless?

At the peak of the outbreak, we had pulled in 70 staff from across the infectious disease division to assist in the outbreak response. There was no ‘surge fund’ to cover costs of an outbreak response. During the tail end of our legislative session, we had the opportunity to support a public health contingency fund bill which was signed into law. Five million dollars was set aside, with no end date, for response to public health infectious disease emergencies.

In order to be able to respond effectively to outbreak situations, you need to have sufficient existing infrastructure. No system is nimble enough to be able to add staff resources in a crisis. You really can only use existing infrastructure. We were grateful to have a strong infectious disease and public health laboratory infrastructure to allow us to effectively respond. This outbreak did highlight the importance of having a diverse workforce representing the broad range of communities you serve. We could have used more Somali speaking staff to help with the response and community outreach activities.

Minnesota Measle cases over time, 1989-1990 vs 2017

Are there any lessons learned from this outbreak that may be utilized to prevent or respond to future outbreaks?  

Early in the outbreak, we held a meeting of key Somali health leaders to discuss the outbreak and get their input on suggested actions. We found our work with the Somali faith leaders to be very valuable. We were able link a physician with an Imam; they used prayer time during Ramadan to provide important messages to the Somali community on measles and the value of vaccination. These connections helped smooth the way during our response efforts. We were surprised by how many families used multiple child care facilities. Better enforcement of MMR vaccine compliance in child care could have a significant impact on preventing disease going forward. Our experience also supports the general view that community forums to discuss vaccinations, autism, or other purported vaccine injury claims are not useful and can have deleterious effects by highlighting false claims and creating a degree of “false equivalency” for arguments supported by science and those which are not. We recognized that it would be very useful to have statutory language that explicitly outlines exclusion as an action step for unvaccinated child care and school attendees.

Do you have any advice for other states or territories who may experience a similar outbreak?

Make sure you are shaping your communications and outreach to best engage the affected community.  Create relationships with leadership in communities that are at-risk for outbreaks. Our work over the past several years with healthcare providers and religious leaders was vitally important in responding to the outbreak. In general, it is better to build on existing relationships during an outbreak than to start from scratch. Invest in your IIS. Your IIS is your best friend in an outbreak. Maintain a sense of humor and express appreciation for your staff frequently! They make it happen!