Minnesota's measles outbreak has exceeded the total number of cases reported in the entire United States last year, with no sign of slowing.
Health officials worry that the holy month of Ramadan, which began Friday night and brings Muslims together in prayer and festivities, will accelerate the spread of the highly infectious and potentially deadly disease, which is plaguing the close-knit Somali American community.
Minnesota health officials are working closely with faith leaders in an unprecedented effort to spread the message that parents should get their children vaccinated and keep them home if they show symptoms of the disease.
It's the first time imams in the United States have taken such an active role in a public health crisis, health officials and Somali Americans said.
The imams are up against the anti-vaccine movement, which in recent years has targeted the Somali American community with misinformation linking the measles-mumps-rubella vaccine to autism, a claim that extensive research has disproved.
Somali American children in Minnesota had a vaccination rate of 92 percent in 2004, higher than the state average, but that rate has dropped to 42 percent, leaving children vulnerable to disease.
Faith leaders and health professionals need to work side by side, said Sharif Mohamed, who has been the imam of his mosque in Minneapolis for nearly 20 years.
"The imams emphasize the role of the parent and the role of faith to keep people safe from any disease - not just yourself, but the entire community and also the state - so people have to be responsible citizens and do their part," he said.
"Health professionals can focus on the linkage between the vaccine and the measles. I think we can win the battle."
Health officials say there have been at least 8,250 exposures in day-care centers, schools, hospitals and clinics.
As of June 1, there were 73 confirmed cases, the Minnesota department of health announced, most of them in unvaccinated preschool children. A significant number have been hospitalised. Last year, the United States recorded 70 measles cases.
Although the largest number of cases are in the Somali American community, the disease has begun to spread to the broader community through the Minneapolis public school system, infecting six white children.
Unfounded fears about vaccines have circulated among some in the white community for decades.
"It's white, middle-class parents who have made a decision not to vaccinate and feel very strongly about that choice," said Kris Ehresmann, director of infectious disease epidemiology at the Minnesota Department of Health.
The outbreak in Minnesota has been fueled by local and national anti-vaccine groups that organised meetings in the Somali community. Andrew Wakefield, the founder of the modern anti-vaccine movement, visited Minneapolis at least three times in recent years to talk to parents.
At one meeting, during a smaller measles outbreak in 2011 that also affected Somali children, he downplayed the severity of measles, according to a health official.
In an interview, Wakefield, whose falsified 1998 study purported to link vaccines to autism, has said he feels no responsibility for the current measles outbreak.
At least 50 children have been treated at Children's Hospitals and Clinics of Minnesota, and 20 have been hospitalised, staying an average of five days, said Patsy Stinchfield, who oversees infection control at Children's.
Some of the children are suffering severe dehydration because their mouths are so sore that they can't drink or swallow, she said.
One child was hospitalised for 17 days. Some children who were discharged had to return to the hospital because of continuing respiratory problems.
"We don't see a plateauing," Stinchfield said. "We've geared up for working on this through the summer."
But there have been some encouraging signs. Since the outbreak began in early April, there has been a surge in vaccinations as parents have seen firsthand the severity of the disease.
Statewide, the number of measles-mumps-rubella vaccine doses given before the outbreak was about 2,700 per week. Since the outbreak started, the health department has seen as many as 9,700 doses given in a week.
For ethnic Somali children between 2 and 13 years old, the department typically administered about 30 doses a week before the outbreak. That number began to rise after the outbreak started and reached more than 500 doses a week at the end of April and early May, Ehresmann said.
Despite the worst measles outbreak in the state in nearly 30 years, anti-vaccine groups have stepped up efforts to spread their message there.
At a recent community forum in Minneapolis about the MMR vaccine, an anti-vaccine advocate handed out printouts that claimed the vaccine can cause permanent brain damage and death, according to a Public Radio International report.
"When you have an open community meeting, that does allow a forum for the anti-vaccine groups to come and continue to present their misinformation," Ehresmann said.
Health department officials in Columbus, Ohio, and Seattle, home to other large Somali American communities, worry that the disease or misinformation or both could spread to their areas.
They have increased outreach, adding education forums and programs to air on Somali-language television.
"There is a strong oral tradition in the Somali community, and Somalis in Minnesota have shared the message from the anti-vaccine groups with the community in the Seattle area, so there has been indirect influence from these groups," said Libby Page, who manages the immunisation program for Seattle and King County.
According to the Washington State Department of Health, only 65 percent of infants born to Somali families in 2013 had received one or more doses of MMR by 23 months, even though federal guidelines recommend that vaccinations begin at 12 to 18 months.
Columbus's Somali community of 50,000 to 60,000 people is second only to that concentrated in Minneapolis, with about 90,000. There is much travel between the two communities for family gatherings, such as weddings and graduations, as well as for Ramadan.
The most important message will come from imams, the most trusted community leaders, health officials say. Clinicians from Children's Minnesota and Hennepin County Medical Center are working with a group of 30 imams and mosque executive directors who are eager to participate.
During the group's monthly dinner meeting in late May at the Dar Al-Farooq mosque in suburban Minneapolis, faith leaders sat at tables covered in white tablecloths and listened intently as clinicians explained that there is no medicine for measles.
They showed photos of Somali children covered in rashes, as well as a chart illustrating the drop in MMR immunisation rates.
Clinicians also described the characteristics of autism. The condition is often recognized at the age of 12 to 18 months — around the time the first dose of MMR is recommended. The timing is coincidental, but still makes some families incorrectly assume the vaccine caused autism. (In fact, brain abnormalities associated with autism have been detected much earlier and may emerge during fetal development.)
"They were really listening," said Stinchfield, who led the presentation. "You could hear a pin drop."
Several imams stood up to talk. Some spoke with great passion about their responsibility to make sure children in their community and the broader one do not die of a preventable disease.
"They very much shared our sense of urgency about this topic," Stinchfield said. "They very much confirmed they are allies with us. We are going to work together."
Some of the actions under consideration include suggestions for messaging during each night of Ramadan, immunisation clinics at individual mosques, education forums to explain how the measles virus spreads, and sessions about autism.
For imams such as Mohamed, who is partnering with the Minnesota health department, that additional information will give faith leaders a stronger voice to battle falsehoods.
"I think we will at least reduce the attack from the groups with anti-vaccine message," he said. "They had a very loud voice. But they didn't get a group of strong imams. We will have impact."
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This article was originally published by The Washington Post.