Racing to contain the measles outbreak that's killed 60 people amid low vaccination rates, the government of Samoa has turned to a disease-control tactic going back centuries.

Officials told the public Tuesday to hang red flags or cloth outside houses where people have not been vaccinated, to help teams embarking on a massive door-to-door campaign giving free booster shots. The government plans to canvas the entire country of 200,000 over two days later this week while shutting down both the "public and private sectors" — the latest urgent measure in a health crisis that's hit the South Pacific nation's children hardest.

'Basically he's on home detention': Toddler flown back to Samoa without measles vaccine
Samoa measles epidemic: Another day brings two more deaths
Samoa measles: 'The children are deteriorating in front of our eyes'
Samoan family mourns deaths of two children from suspected measles

Vaccination for all Samoans ages 6 months to 60 will be free, the government said, but the top priority is children under age 4 because they are most at risk of deadly complications and also have the lowest vaccination rates.


Of the more than 4000 cases reported so far, the government announced Tuesday, 171 were recorded in the past 24 hours and 90 of those involved children 4 or younger. Most of the deaths to date are from that age group, too.

Prime Minister Tuilaepa Sailele Malielegaoi promised Wednesday to bring vaccination coverage up sharply, from about 55 percent to 90 percent, the BBC reported.

A girl receives a vaccination against measles in Apia, a the toll rises during an outbreak in Samoa. Photo / UNICEF
A girl receives a vaccination against measles in Apia, a the toll rises during an outbreak in Samoa. Photo / UNICEF

"Our children and people will never become immune to any future epidemic unless we have almost 100 percent vaccination coverage," he said on a hospital tour.

Deadly measles outbreak hits children in Samoa after anti-vaccine fears

The red flag system is just part of Samoan officials' efforts to combat an outbreak that has reportedly sickened more than 2 percent of the population. They're sending out mobile clinics and trying to raise awareness with photos of leaders, including the prime minister, getting their shots.

They're battling public mistrust after a faulty vaccine led to two infants' deaths, manslaughter charges for nurses and a drop in immunisations last year, the editor of the Samoa Observer, Keni Lesa, told NPR.

The government hopes the flags will expedite its huge door-to-door undertaking.

"We need all the help we can get," Disaster Advisory Committee Chairman Ulu Bismarck Crawley said, according to the Samoa Observer.


Pictorial; LEADING BY EXAMPLE Prime Minister Tuilaepa Sailele Malielegaoi and the remaining Ministers of Cabinet...

Posted by Government of Samoa on Wednesday, 4 December 2019

There's a long history of using flags to mark places stricken by disease. Fighting an outbreak of yellow fever in 1888, Florida officials flew yellow flags at afflicted houses, posting multiple guards to each one "night and day" and cordoning off "areas of infection" with rope.

An Indiana Board of Health document, also from the late 1800s, describes "flags of warning" posted outside buildings to broadcast the recent presence of scourges such as smallpox and cholera. The markers should stay up for at least two weeks, the health board advised, though it added one week was enough to prevent contagion for measles.

Flags systems have also helped officials inspect incoming ships as they try to curb the spread of infection. In the 1600s, Venice required boats suspected of harboring plague to signal church-tower lookouts with a flag, according to the US Centers for Disease Control and Prevention. The captain would then have to prove the health of all crew and passengers as well as give documentation on any merchandise headed for the Italian commercial hub.

The approach persisted hundreds of years later across the Atlantic, as the U.S. government gained increasing authority to curb incoming disease in the 1900s. A public health vessel brought inspectors aboard ships flying a yellow flag, which didn't come down until the ship was cleared to dock, according to the CDC.