Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle Than Access to Care

Page created by Rhonda Padilla
 
CONTINUE READING
ARTICLES

Underimmunization in Ohio’s Amish: Parental Fears
Are a Greater Obstacle Than Access to Care
AUTHORS: Olivia K. Wenger, MD,a Mark D. McManus, PhD,                   WHAT’S KNOWN ON THIS SUBJECT: Underimmunized
MSSW,b John R. Bower, MD,c and Diane L. Langkamp, MD,                   communities are reservoirs of preventable childhood diseases in the
MPHd                                                                    United States. Many Amish communities have low immunization
Departments of aPediatrics, cInfectious Diseases, and                   rates. Previous research among the Amish has revealed that the
dDevelopmental Behavioral Pediatrics, Akron Children’s Hospital,
                                                                        major barrier to immunization is lack of access to health care.
Akron, Ohio; and bSchool of Social Work, University of Akron,
Akron, Ohio
                                                                        WHAT THIS STUDY ADDS: Among the Amish in Holmes County,
KEY WORDS
                                                                        Ohio, the major barrier to immunization is parental concerns
Amish, immunizations, immunization safety, attitudes, exemption
                                                                        over adverse effects of vaccines. Decision-making about
ABBREVIATION
                                                                        vaccination among Amish parents is complex; many Amish
DoH—Department of Health
                                                                        parents accept some vaccines for their children but refuse
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2599
                                                                        others.
doi:10.1542/peds.2009-2599
Accepted for publication Mar 22, 2011
Address correspondence to Olivia K. Wenger, MD, Department of
Pediatrics, Akron Children’s Hospital, 128 E Milltown Rd, Suite
209, Wooster, OH 44691. E-mail: owenger@chmca.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
                                                                   abstract
                                                                   OBJECTIVE: Holmes County, Ohio, one of the largest Amish communi-
Copyright © 2011 by the American Academy of Pediatrics
                                                                   ties in the world, has persistently low immunization rates. Studies of
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
                                                                   other Amish communities have revealed that parents do not immunize
                                                                   their children because of lack of access to immunizations. Our study
                                                                   explored reasons that Amish parents in the previously uninvestigated
                                                                   Holmes County population exempt themselves from immunizations.
                                                                   METHODS: In January 2007, questionnaires for assessing attitudes re-
                                                                   garding immunizations were mailed to a random sampling of 1000
                                                                   Amish parents in Holmes County.
                                                                   RESULTS: Thirty-seven percent of the parents responded. Among the
                                                                   359 respondents, 68% stated that all of their children had received at
                                                                   least 1 immunization, and 17% reported that some of their children had
                                                                   received at least 1 immunization. Only 14% of the parents reported that
                                                                   none of their children had received immunizations. Eighty-six percent
                                                                   of the parents who completely exempted their children from vaccines
                                                                   stated that the main reason they do not vaccinate their children is
                                                                   concern over adverse effects. Many parents indicated that they allow
                                                                   their children to receive only some vaccines because of concern about
                                                                   the way certain vaccines are produced.
                                                                   CONCLUSIONS: The reasons that Amish parents resist immunizations
                                                                   mirror reasons that non-Amish parents resist immunizations. Even in
                                                                   America’s closed religious communities, the major barrier to vaccina-
                                                                   tion is concern over adverse effects of vaccinations. If 85% of Amish
                                                                   parents surveyed accept some immunizations, they are a dynamic
                                                                   group that may be influenced to accept preventative care. Underimmu-
                                                                   nization in the Amish population must be approached with emphasis
                                                                   on changing parental perceptions of vaccines in addition to ensuring
                                                                   access to vaccines. Pediatrics 2011;128:79–85

PEDIATRICS Volume 128, Number 1, July 2011                                                                                                79
                                                Downloaded from by guest on November 2, 2015
Despite the efforts of pediatric provid-    and ⱖ3 doses of hepatitis B vaccine]        tory of Amish families living in Holmes
ers nationwide to advocate for immu-        series) (Sally Hofsetter, director, per-    County and its vicinity in 2005.14 The di-
nizations, some parents choose not to       sonal health services, Holmes County        rectory lists the names and birth dates
vaccinate their children.1,2 Children       Department of Health, Millersburg, OH,      of children in each household. Al-
who live in closed communities with         personal communication, July 14,            though addresses were selected at
high vaccine-exemption rates are            2006).12 The Holmes County Depart-          random, only addresses of families with
particularly vulnerable to vaccine-         ment of Health (DoH) has increased          children born after 1980 were used.
preventable diseases.3,4 The Amish, a       the availability of vaccinations by hold-   Such purposeful sampling from a ran-
separatist Christian sect, have had         ing immunization clinics near commu-        dom component of a specific population
persistently low immunization rates.        nity gatherings such as livestock auc-      has been used in other exploratory stud-
Multiple outbreaks of vaccine-              tions and by offering to administer         ies of barriers to immunization.15 A list of
preventable infections including per-       vaccines at parochial schools. Also,        1000 families (5% of the population) was
tussis, rubella, measles, and Haemo-        most physicians provide vaccines            generated. The survey was sent with a
philus influenzae type b have been           through government-supplemented             cover letter and a self-addressed,
described in underimmunized Amish           programs at minimal cost. However,          stamped reply envelope. No incentive
communities.5–9                             low immunizations rates persist,            was offered for survey completion. All
                                            which suggests that the barriers to im-     surveys were anonymous.
Although vaccination is not specifically
prohibited by Amish religious doctrine,     munization among the Holmes County
                                            Amish differ from those described           Statistical Analysis
the reasons for the low immunization
                                            among the Amish in Lancaster County.        The data were analyzed by perform-
rates have not been clearly identified.
                                                                                        ing cross-tabulations, and signifi-
Authors of a previous study cited lim-
                                            MATERIALS AND METHODS                       cant differences were established by
ited access to health care as a barrier
                                                                                        ␹2 statistics using SPSS 15.0.16 Some
to immunization among the Amish.10          Sample and Instrument
                                                                                        respondents did not select answers
Among the Amish in Lancaster County,        This study consisted of a mailed 25-        to all 25 questions. Missing data
Pennsylvania, investigators found that      question survey to Amish parents in         were handled by using available case
only 16% of children aged 6 months to       Holmes County. Survey questions were        analysis so that all available re-
5 years were fully immunized. A survey      designed with input from Amish com-         sponses were used to calculate each
of Amish families in Lancaster County       munity leaders, physicians who serve        statistic, and the number of re-
found that 75% reported that they           Amish families, the Holmes County DoH       sponses varied across analyses.17
would immunize their children if vacci-     staff, and previous studies of parental
nations were offered locally.9 The gen-                                                 We examined the answers to ques-
                                            attitudes toward immunization (Nancy
eralizability of the Lancaster County                                                   tions and comments written by sur-
                                            E. Rosenstein, personal communica-
findings to other Amish communities                                                      vey respondents for thematic trends.
                                            tion, July 14, 2006).13 The questions ex-
has not been determined. Holmes                                                         The end result of this exploration
                                            plored basic demographic informa-
County, Ohio, is one of the largest set-                                                was to provide pertinent themes and
                                            tion, family-specific immunization
tlements of Amish in the world, yet this                                                specific quotes to illustrate the key
                                            status, parental attitudes toward im-
population’s attitudes regarding im-                                                    findings.18,19
                                            munization, religious ideas regarding
munizations have not been re-               immunization, and exposure to poten-        RESULTS
searched.11 In 2006, 45% of the Holmes      tial adverse effects of immunizations.
County population was reported to be        Most questions offered multiple-            Demographics
fully immunized, compared with a            choice answers with an option to write      Of 1000 surveys distributed, 360 com-
statewide Ohio immunization rate of         in comments. A few questions were           pleted surveys were returned and 33
80% and a national rate of 85% (based       open-ended. The survey was reviewed         were returned as undeliverable, which
on children aged 19 –35 months who          by a small group of Amish parents to        resulted in a response rate of 37%. One
received the 4:3:1:3:3 [ⱖ4 doses of         ensure clarity. The study was approved      survey was completed by a Mennonite
diphtheria, tetanus toxoid, and any         by the institutional review board at Ak-    and, thus, was excluded from analysis.
acellular pertussis vaccine, ⱖ3 doses       ron Children’s Hospital. The mailing        Demographic characteristics obtained
of poliovirus vaccine, ⱖ1 dose of mea-      addresses of Amish parents were ob-         from the respondents included gender
sles, mumps, rubella vaccine, ⱖ3            tained from the 2005 Ohio Amish Direc-      (67% female), age (range: 24 – 69
doses of H influenzae type b vaccine         tory, which is a comprehensive direc-       years; mean: 39.1 years), religious af-

80   WENGER et al
                                           Downloaded from by guest on November 2, 2015
ARTICLES

filiation (85% Old Order Amish, 12%                dren. More than 30% of the parents          TABLE 1 Reasons for Exemption From
                                                                                                         Immunization (N ⫽ 49)
New Order Amish, 3% other Amish                   who vaccinated at least some of their
                                                                                                        Possible Responsesa                   n (%)
church), and insurance coverage (95%              children stated that they had been vac-
                                                                                              Shots have too many side effects to be          48 (97)
uninsured).                                       cinated as children.
                                                                                                  worth the risk of gettingb
                                                  Parents who allow some, but not all,        Shots could have dangerous chemicals            14 (29)
Immunization Trends                                                                               or preservatives in themc
                                                  recommended immunizations re-
                                                                                              Shots inject children with dangerous             6 (12)
The parents were asked to state                   ported several explanations for their           germs like whooping cough
whether all, some, or none of their chil-         decision to use selective immuniza-         The diseases shots prevent are not a             4 (8)
dren had received immunizations.                  tion. Of the 140 respondents who al-            problem in our community
                                                                                              Shots are too expensive                          3 (6)
They were not asked to clarify how                lowed selective immunization, 42% felt      Other families in my district do not             3 (6)
many or which immunizations their                 that “giving all the shots at once is too       give shots
children had received. Of the 359 re-             hard on a baby,” 27% were concerned         Giving shots means I’m not putting               3 (6)
                                                                                                  faith in God to take care of my
spondents, 68% stated that all of their           that “some shots were manufactured              children
children had received immunizations,              from aborted babies,” 25% were con-         I have heard some shots are                      2 (4)
17% stated that some of their children            cerned that “there are too many rec-            manufactured from aborted babies
had been immunized, and 14% stated                                                            It is too hard to get to the clinic/office        1 (2)
                                                  ommended shots,” and 19% felt that              for shots
that none of their children had been              “babies are too young to handle shots.”     The ministers in my district disagree            0 (0)
immunized.                                        Only 6% reported that it was “too hard          with giving shots
                                                                                              a Participants were asked to circle any response with
A majority of the Amish in Holmes                 to get to the doctor’s office/clinic for
                                                                                              which they agreed.
County classify themselves as Old Or-             shots,” and 2% said that they could         b Highlighted as the most important singular reason for

der (more traditional) or New Order               “not afford to get all the shots.” Re-      exempting children from shots in 86% of the cases.
                                                                                              c Highlighted as the most important singular reason for
(less traditional).20 All New Order               sponses varied according to parental        exempting children from shots in 10% of the cases.
Amish respondents stated that they                age; only 14% of parents aged 40 years
had their children immunized. In con-             or older reported that “some shots
                                                                                              TABLE 2 Understanding of Risks and Benefits
trast, 84% of Old Order Amish had                 were manufactured from aborted ba-                     of Immunization (N ⫽ 304)
some or all of their children immu-               bies” as a reason for allowing selective               Possible Responsesa                  n (%)
nized, but 16% did not have any of                immunization for their children com-        Shots are safer overall than the              188 (61)
their children immunized (P ⫽ .02).               pared with 39% of the younger parents         diseases our children would get

To assess familiarity with the technol-           (P ⫽ .001).                                   without them
                                                                                              Shots would save our community money          110 (36)
ogy of immunization, 1 question asked                                                           by preventing illness if everyone got
about immunization of animals. Of the             Reasons for Exemption From                    them
243 parents who responded that all of             Vaccination                                 Shots can cause high fevers more than           97 (32)
                                                                                                one week after they are given
their children had received vaccina-              Table 1 lists the reasons that parents      Shots can cause brain damage                    95 (31)
tions, 40% immunized their animals. Of            who did not have any of their children      Shots can cause too much stress on the          91 (30)
                                                  immunized indicated to explain their          system if given at once
the 49 parents who replied that none
                                                                                              Shots can cause seizures more than one          97 (32)
of their children had received vaccina-           decision. The 3 most commonly re-             week after they are given
tions, only 18% immunized their ani-              ported explanations for not allowing        a Respondents were asked to circle any of the statements
mals (P ⬍ .001).                                  immunization were related to con-           that they felt were correct.

                                                  cerns about adverse effects.
Reasons for Acceptance of
Vaccination and Selective                         Understanding of the Adverse                spondents, 47% replied that they knew
Immunization                                      Effects of Immunization                     someone with a serious adverse effect.
Among the 280 parents who vacci-                  To assess understanding of the risks        More parents aged 40 years or older
nated at least some of their children,            and benefits of immunization, re-            reported that they knew someone with
100% agreed that vaccinations are                 spondents were asked to select              a serious adverse effect of immuniza-
“protective against disease.” Nearly              statements from a list with which           tions than did the younger (⬍40-year-
half of the parents who vaccinated at             they agreed (Table 2). Respondents          old) parents (56% vs 44%; P ⫽ .04).
least some of their children indicated            were then asked if they personally          Table 3 lists the most common types of
that their physician or nurse recom-              knew anyone who had had a “bad side-        adverse effects to immunization
mended vaccinations for their chil-               effect from baby shots.” Of the 359 re-     reported.

PEDIATRICS Volume 128, Number 1, July 2011                                                                                                         81
                                             Downloaded from by guest on November 2, 2015
TABLE 3 Examples of Immunization Adverse             fant immunizations. Of the 154 respon-    had not had any of their children im-
          Effects Listed by Parents
                                                     dents, 38% replied that they had re-      munized, 20% did not know about the
Mild reactions
                                                     ceived such advice from their             DoH vaccine posts in their county. Of
  “Swelling, stiffness”
  “Fever, swelling of the arm”                       community and friends, 37% from par-      the 304 respondents who had had
  “Our oldest, now 10 years old, was about 6         ents/other family members, 16% from       some or all of their children vacci-
     months when she could not move her leg          books, 19% from articles, 10% from
     without screaming for about 12 to 24 hours
                                                                                               nated, 11% did not know about the DoH
     after getting shots.”                           chiropractors, and 6% from their fam-     clinics (P ⫽ .005). We asked the re-
  “He got a very high fever.”                        ily’s doctor/nurse. No respondents        spondents if they knew that immuniza-
Developmental regression                             reported that their ministers advis-
  “I have a relative that was a healthy girl. She
                                                                                               tions provided by the DoH could be free
     was walking and talking until she got her
                                                     ed against immunization. Parents          of charge. A larger proportion of par-
     shots. She can’t talk or walk without help      younger than 40 years were more           ents who had not had any of their chil-
     and has a very miserable life.”                 likely to report having received advice
  “Couldn’t walk anymore”
                                                                                               dren immunized were not aware that
  “He could never walk again and they said it
                                                     against immunizations from parents/       immunizations could be obtained at no
     was from the shots and his mind was             other family members than older par-      cost (37%) compared with only 11% of
     affected.”                                      ents (45% vs 25%; P ⫽ .02).               the respondents who had had some or
  “I know of three children that were perfectly
     normal till after receiving baby shots.”        The respondents were asked to indi-       all of their children vaccinated (P ⬍
  “Stunted growth”                                   cate any sources from which they          .001).
Neurologic sequelae
                                                     learned about infant immunizations. Of
  “Brain damage (they gave her too much for her
     weight)”                                        the 327 respondents, 74% wrote that       Factors That Would Influence
  “She is crippled—cannot walk”                      they had learned about immunizations      Decision-Making of Exempting
  “Brain damage, though I’m not sure how they        from their doctor/nurse, 64% from
     know it was due to shots”
                                                                                               Parents
  “Seizures”                                         their family, 7% in school, 7% from
                                                                                               Parents who exempted completely or
  “Severe brain damage caused by high fever          magazines or papers, 5% from their
     from [the measles, mumps, rubella
                                                                                               partially from vaccines were asked to
                                                     midwife, and 3% from their chiroprac-
     vaccine]”                                                                                 indicate factors that might alter their
  “Mentally disabled”
                                                     tor. Parents younger than 40 years
                                                                                               decision. Of the 95 respondents, 86%
Death                                                were more likely to report that they
  “Crib death”
                                                                                               stated that they would be more likely to
                                                     learned about infant immunizations
  “Death, the baby was too weak to handle them”                                                consider having their children immu-
                                                     from their family than were older par-
                                                                                               nized if they “knew shots were safe to
                                                     ents (73% vs 52%; P ⬍ .001).
                                                                                               give,” 20% if “there was a disease out-
Attitudes Regarding the                                                                        break,” 11% if “shots were required by
Immunization Schedule                                Addressing Spirituality or Faith in
                                                     Decision-Making Regarding                 the law/government,” and 10% if their
Parents were asked whether giving                    Immunization                              “parents or family encouraged them.”
shots at 2, 4, and 6 months was “too                                                           The answers “if the shots were cheaper,”
early.” Of the 359 respondents, 47% did              Only a small minority of the parents
                                                                                               if their “bishop or elder recommended
not feel that physicians gave shots too              reported that their religious or spir-
                                                                                               them,” and if “it were easier to get to the
early, 35% felt that doctors do give im-             itual beliefs influenced their deci-
                                                                                               doctor’s office or clinic” were selected by
munizations too early, and 18% were                  sions about immunization. When
                                                     asked if “giving shots disagrees with     only 5%, 3%, and 3% of the respondents,
unsure. More parents who reported                                                              respectively.
knowing someone with a serious ad-                   your faith or spiritual beliefs in some
verse effect from immunizations re-                  way,” 63% replied “no,” 4% indicated      None of the 10 exempting parents who
plied that giving shots at 2, 4, and 6               “yes,” and 30% did not respond to the     were not aware of accessible DoH vac-
months was “too early” compared with                 question.                                 cine posts stated that they would con-
parents who did not know someone                                                               sider having their children immunized
                                                     Addressing Access and Financial           if the doctor’s office were “easier to
with a serious adverse effect from im-
                                                     Burden of Vaccines
munizations (57% vs 25%; P ⬍ .001).                                                            get to.” Only 2 of the 18 exempting par-
                                                     The respondents were asked if they        ents who were not aware that DoH vac-
Sources of Information Regarding                     knew that the Holmes County DoH of-       cines could be free indicated that they
Vaccines                                             fered immunization clinics throughout     would consider having their children
All the respondents were asked to                    the county at convenient times and lo-    immunized if “the shots were
identify who advised them against in-                cations. Of the 49 respondents who        cheaper.”

82     WENGER et al
                                                    Downloaded from by guest on November 2, 2015
ARTICLES

DISCUSSION                                        who had suffered a “serious adverse         the Amish population in Arthur, our
We found that Amish parents in Hol-               effect” from immunization and de-           study provides further insight into un-
mes County generally accept some                  scribed many potential adverse effects      derimmunization in Amish communi-
vaccinations; 85% of them have their              may reflect the closeness of their com-      ties by revealing the practice of selec-
children at least partially immunized.            munity or the incidence of inherited        tive immunization. The reticence
Amish parents of unvaccinated chil-               metabolic disorders in the population.      of parents to accept immunization
dren were concerned about adverse                 However, surveys of the general Amer-       against rubella and varicella because
effects and the ability of an infant to           ican public have revealed similar pa-       of the understanding that the immuni-
tolerate vaccines rather than about fi-            rental misconceptions regarding ad-         zations “come from aborted babies”
nancial, accessibility, or religious is-          verse effects of immunization.13 One        suggests an ethical if not specifically
sues. Their concerns about adverse ef-            study of antivaccination Web sites          religious basis for their decision-
fects and the ability of an infant to             found content claims that vaccines          making. (Rubella and varicella vac-
tolerate vaccines mirror the concerns             cause idiopathic illness and erode im-      cines present concern because the at-
of non-Amish parents in the broader               munity in 95% of sites analyzed.21 Other    tenuated viruses in the vaccines are
American society.                                 concerns of Amish parents about the         propagated by using a human cell line,
                                                  current immunization schedule, in-          WI-38, derived in 1961. The cell line was
Given the low immunization rates in
                                                  cluding that it is “too hard on a baby’s    originally prepared from tissues of an
Holmes County, we were surprised by
                                                  system” or that infants are “too young      aborted fetus.)25 Further investigation
the high proportion of respondents
                                                  to handle shots,” reflect misconcep-         is needed to more fully understand the
who had accepted vaccines for some
                                                  tions about immunizations that are re-      reasons for selective immunization
or all of their children. In an effort to
                                                  flected in the views of the mainstream       among Amish families.
keep the survey brief, respondents
                                                  American public.22,23                       Understanding separatist groups
were not asked to specify which vac-
cines they accepted. DoH staff re-                Similar to our study, a survey of an Ar-    such as the Amish is crucial for pre-
ported to us that some Amish parents              thur, Illinois, Amish population found      vention of disease epidemics, be-
accept immunizations against poliovi-             that parents were most concerned            cause underimmunized populations
rus or H influenzae type b but not those           about vaccine safety rather than avail-     are proven reservoirs of serious in-
against varicella or Streptococcus                ability, cost, prioritization, or align-    fections.26 We aimed to examine non-
pneumoniae. Thus, although the par-               ment with religious values.24 Thus, the     quantifiable issues such as parental
ents had accepted some immuniza-                  Amish populations of Holmes County          attitudes, expectations, and beliefs.
tions, their children would not be “fully         and Arthur seem to differ from the          The survey was designed to system-
immunized” according to Centers for               Amish population in Lancaster County,       atically gather data that focused on a
Disease Control and Prevention stan-              where 51% of parents exempting from         specific line of inquiry, but given our
dards. This finding points to the need             vaccines did not consider vaccination       resources, it was difficult to validate
to further explore parents’ concerns              a priority compared with other activi-      our data with triangulation or re-
about individual vaccines rather than             ties of daily life, and 29% of exempting    spondent validation.27,28 Neverthe-
vaccination as a general practice.                parents felt that it was “too difficult to   less, our findings provide insight for
When comparing responses of the par-              travel” to places where vaccinations        future studies involving the same
ents who exempted completely with                 were offered.9                              and comparison populations.
those of nonexempting parents, con-               Our study shows that the characteriza-      The response rate to our survey was
cern regarding potential adverse ef-              tion of religious values in medical         only 37%, which introduces a risk of
fects was the major barrier to immu-              decision-making is complex. Amish re-       sampling bias. Survey recipients who
nization cited; 82% of the exempting              spondents stressed that individual          view health care providers and vacci-
parents stated that they would con-               families were responsible for the deci-     nations favorably may have been more
sider vaccinating their children if “they         sion to vaccinate. Only a few respon-       likely to complete and return our sur-
knew the shots were safe to give,” and            dents reported that giving shots would      vey. We speculate that parents who
only a few exempting parents reported             conflict with their faith or spiritual be-   completely exempt from immunization
that they would have their children im-           liefs. This result aligns with previous     may have been less likely to respond to
munized if the shots were cheaper or              findings that most Amish people do not       our survey. Another study that used
easier to access. The fact that many              view vaccination as a religious or spir-    written surveys of an Amish population
parents claimed to know someone                   itual issue. In contrast to the study of    about health care issues obtained a

PEDIATRICS Volume 128, Number 1, July 2011                                                                                          83
                                             Downloaded from by guest on November 2, 2015
similar response rate.10 Those investi-            ten permit their children to receive                  study. Our results indicate that con-
gators reflected that “the Amish are                only certain vaccines. Although most                  cerns about immunization practice
not often asked to answer written sur-             Amish parents report that decisions                   among Amish populations are similar
vey questions and may not be familiar              about immunization are not influenced                  to the concerns of mainstream Ameri-
with this mode of gathering informa-               by their religious beliefs, many choose               cans and that concerns about vaccine
tion.”10 Lack of familiarity with this type        to exempt from certain vaccines on the                safety represent the major barrier to
of instrument may have contributed to              basis of ethical values. The Amish may                immunization. Efforts of health care
some reticence among Amish parents                 require different approaches to ad-                   providers working with Amish families
to respond to our survey. However,                 dressing misconceptions about vacci-                  must focus on redirection of parental
other means of assessing parental                  nation than the general population, be-               misconceptions about vaccine safety
opinions in the general population (eg,            cause the religious principles of the                 rather than simply improving access
telephone surveys) cannot be used ef-              Amish, who value separation from the                  to vaccines.
fectively in the Amish community. The              secular world, prevent exposure to
issue of nonresponse to the entire sur-            many avenues that are used to educate
vey or to specific questions in the                 the public about vaccines, such as tele-
                                                                                                         ACKNOWLEDGMENTS
Amish population is difficult to inter-             vision or radio. Because Amish fami-                  This research was supported by a
pret without further and potentially               lies are less likely to seek preventive               grant from the Akron Children’s Hospi-
costly investigation.                              health care,29 peer educators within                  tal Foundation.
                                                   the Amish community who are sensi-                    Special thanks go to Peter Reuman,
CONCLUSIONS                                        tive to the traditions and culture of the             Jerry Slabaugh, Marla Sabey, Marne
More Amish parents in Holmes County                Amish community may be needed to                      Woyat, D. J. McFadden, MD, Akron Chil-
reported accepting vaccines than we                address the common misconceptions                     dren’s Hospital Department of Volun-
expected, but these Amish families of-             about immunizations reported in this                  teers, and the Holmes County DoH.
REFERENCES
 1. Omer SB, Pan WKY, Halsey NA, et al. Nonmed-          ease in a highly susceptible community. Pe-           www2a.cdc.gov/nip/coverage/nis/nis_iap.
    ical exemptions to school immunization re-           diatr Infect Dis J. 1992;11(11):955–959               asp?fmt⫽v&rpt⫽tab09_24mo_iap&qtr⫽
    quirements. JAMA. 2006;296(14):1757–1763        8.   Sutter RW, Markowitz LE, Bennetch JM,                 Q1/2005-Q4/2005. Accessed October 24,
 2. Smith PJ, Chu SY, Barker LE. Children who            Morris W, Zell ER, Preblud SR. Measles                2006
    have received no vaccines: who are they              among the Amish: a comparative study of         13.   Mills E, Jadad AR, Ross C, Wilson K. System-
    and where do they live? Pediatrics. 2004;            measles severity in primary and second-               atic review of qualitative studies exploring
    114(1):187–195                                       ary cases in households. J Infect Dis.                parental beliefs and attitudes toward child-
 3. Feikin DR, Lezotte DC, Hamman RF, Salmon             1991;163(1):12–16                                     hood vaccination identifies common barri-
    DA, Chen RT, Hoffman RE. Individual and         9.   Fry AM, Lurie P, Gidley M, et al. Haemophilus         ers to vaccination. J Clin Epidemiol. 2005;
    community risks of measles and pertussis             influenzae type b disease among Amish                  58(11):1081–1088
    associated with personal exemptions to im-           children in Pennsylvania: reasons for per-      14.   Wengerd M. 2005 Ohio Amish Directory. Wal-
    munization. JAMA. 2000;284(24):3145–3150             sistent disease. Pediatrics. 2001;108(4).             nut Creek, OH: Carlisle Press; 2005
                                                         Available at: www.pediatrics.org/cgi/           15.   Mills EJ, Montori VM, Ross CP, Shea B, Wil-
 4. Rodgers DV, Gindler JS, Atkinson WL,
                                                         content/full/108/4/e60                                son K, Guyatt GH. Systematically reviewing
    Markowitz LE. High attack rates and case
    fatality during a measles outbreak in          10.   Dickinson N, Slesinger DP, Raftery PR. A              qualitative studies complements survey
                                                         comparison of the perceived health needs              design: an exploratory study of barriers to
    groups with religious exemption to vaccina-
                                                         of Amish and non-Amish families in                    paediatric immunisations. J Clin Epidemiol.
    tion. Pediatr Infect Dis J. 1993;12(4):
                                                         Cashton, Wisc. Wis Med J. 1996;95(3):                 2005;58(11):1101–1108
    288 –292
                                                         151–156
 5. Centers for Disease Control and Prevention.                                                          16.   SPSS [computer program]. Release 15.0
                                                   11.   Young Center for Anabaptist and Pietist               Chicago, IL: SPSS Inc; 2006
    Pertussis outbreak in an Amish community:
                                                         Studies at Elizabethtown College. The twelve
    Kent County, Delaware, September                                                                     17.   Little RJA, Rubin DB. Statistical Analysis
                                                         largest Amish settlements. Available at:
    2004 –February 2005. MMWR Morb Mortal                                                                      With Missing Data. 2nd ed. Hoboken, NJ:
                                                         www2.etown.edu/amishstudies/Largest_
    Wkly Rep. 2006;55(30):817– 821                                                                             Wiley; 2002
                                                         Settlements_2010.asp. Accessed January 4,
 6. Jackson BM, Payton T, Horst G, Halpin TJ,            2011                                            18.   Pottie C, Sumarah J. Friendships between
    Mortensen BK. An epidemiologic investiga-                                                                  persons with and without developmental
                                                   12.   Centers for Disease Control and Prevention.
    tion of a rubella outbreak among the Amish                                                                 disabilities. Ment Retard. 2004;42(1):55– 66
                                                         NIS data table: estimated vaccination cover-
    of northeast Ohio. Public Health Rep. 1993;          age with individual vaccines and selected       19.   Crabtree B, Miller W. Doing Qualitative Re-
    108(4):436 – 439                                     vaccination series by 24 months of age by             search. Thousand Oaks, CA: Sage; 1999
 7. Briss PA, Fehrs LJ, Hutcheson RH, Schaffner          state and immunization action plan area US,     20.   Nolt SM. A History of the Amish. Intercourse,
    W. Rubella among the Amish: resurgent dis-           National Immunization Survey, 2005.                   PA: Good Books; 1968

84    WENGER et al
                                                  Downloaded from by guest on November 2, 2015
ARTICLES

21. Wolfe RM, Sharp LK, Lipsky MS. Content and        immune system? Pediatrics. 2002;109(1):               as a collective action threat to herd immunity.
    design attributes of anti-vaccination Web         124 –129                                              Vaccine. 2003;21(11–12):1048–1051
    sites. JAMA. 2002;287(24):3245–3248           24. Yoder JS, Dworkin MS. Vaccination usage           27. Pope C, Zieband S, Mays N. Qualitative re-
22. Gellin BG, Maibach EW, Marcuse EK. Do par-        among an Old-Order Amish community in                 search in health care: analyzing qualitative
    ents understand immunizations? A national         Illinois. Pediatr Infect Dis J. 2006;25(12):          date. BMJ. 2000;320(7227):114 –116
    telephone survey. Pediatrics. 2000;106(5):        1182–1183                                         28. Mays N, Pope C. Qualitative research in
    1097–1102                                     25. Hayflick L, Moorhead PS. The serial cultiva-           health care: assessing quality in qualitative
23. Offit PA, Quarles J, Gerber MA, et al. Ad-         tion of human diploid strains. Exp Cell Res.          research. BMJ. 2000;320(7226):50 –52
    dressing parents’ concerns: do multiple           1961;25:585– 621                                  29. Hurst CE, McConnell DL. An Amish Paradox. Balti-
    vaccines overwhelm or weaken the infant’s     26. May T, Silverman RD. “Clustering of exemptions”       more, MD: Johns Hopkins University Press; 2010

  BEAR MYTHS: We recently had a visitor from Western Canada who regaled us
  with stories about the dangers of black bears. While all adult black bears can be
  dangerous, he was emphatic that mothers protecting their cubs are by far the
  most hazardous. Like many, I had heard this refrain many times and always
  assumed it was true. However, according to an article in The Journal of Wildlife
  Management (Wiley Online Library: May 2011), black bear attacks rarely result
  in human death. In fact, between 1900 and 2009 a total of 63 people were killed
  in 59 incidents by non-captive black bears with almost 90 percent occurring
  between 1960 and 2009. Contrary to popular belief, mothers were rarely in-
  volved in fatal attacks. Most fatal black bear attacks involved males acting as
  predators. Why do mothers have such a bad reputation? It may be because
  mother black bears act aggressively when threatened. They may make bellig-
  erent gestures or charge at people but almost always stop before causing any
  harm. The goal is to chase the intruder away. On the other hand, black bears
  acting as predators do not feel threatened by a human presence and are trying
  to decide if the person is worth eating. Those are the bears that are most
  dangerous. The situation with the black bear is a bit different from that of the
  grizzly bear. Grizzlies have evolved in more open areas and don’t climb trees to
  escape threats the same way that black bears do. So while black bears outnum-
  ber grizzlies by 15 to one, grizzly bears have killed more than twice as many
  people. And, to further complicate matters, about half of fatal grizzly bear at-
  tacks have involved mothers with cubs. So what is a hiker or camper confronted
  with a bear supposed to do? Most experts recommend not running away. Back
  away from a mother bear defending a cub. Convince a predatory bear that you
  are not easy prey by yelling and by throwing rocks and sticks. As for me, I doubt
  my brain will function too well if confronted by an angry bear. I hope to avoid
  such confrontations so I never leave food around the camp and make plenty of
  noise when I hike in remote areas.
                                                                                Noted by WVR, MD

PEDIATRICS Volume 128, Number 1, July 2011                                                                                                               85
                                             Downloaded from by guest on November 2, 2015
Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle
                            Than Access to Care
 Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp
       Pediatrics 2011;128;79; originally published online June 27, 2011;
                        DOI: 10.1542/peds.2009-2599
Updated Information &               including high resolution figures, can be found at:
Services                            /content/128/1/79.full.html
References                          This article cites 20 articles, 6 of which can be accessed free
                                    at:
                                    /content/128/1/79.full.html#ref-list-1
Citations                           This article has been cited by 2 HighWire-hosted articles:
                                    /content/128/1/79.full.html#related-urls
Subspecialty Collections            This article, along with others on similar topics, appears in
                                    the following collection(s):
                                    Infectious Disease
                                    /cgi/collection/infectious_diseases_sub
                                    Vaccine/Immunization
                                    /cgi/collection/vaccine:immunization_sub
Permissions & Licensing             Information about reproducing this article in parts (figures,
                                    tables) or in its entirety can be found online at:
                                    /site/misc/Permissions.xhtml
Reprints                            Information about ordering reprints can be found online:
                                    /site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

                           Downloaded from by guest on November 2, 2015
Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle
                            Than Access to Care
 Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp
       Pediatrics 2011;128;79; originally published online June 27, 2011;
                        DOI: 10.1542/peds.2009-2599

The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
                              /content/128/1/79.full.html

 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
 publication, it has been published continuously since 1948. PEDIATRICS is owned,
 published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
 Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
 of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

                        Downloaded from by guest on November 2, 2015
You can also read