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Underimmunization in ohio's amish  parental fears are a greater obstacle than access to care peds.2009-2599.full
 

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    Underimmunization in ohio's amish  parental fears are a greater obstacle than access to care peds.2009-2599.full Underimmunization in ohio's amish parental fears are a greater obstacle than access to care peds.2009-2599.full Document Transcript

    • DOI: 10.1542/peds.2009-2599 ; originally published online June 27, 2011;Pediatrics Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp Than Access to Care Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle http://pediatrics.aappublications.org/content/early/2011/06/23/peds.2009-2599 located on the World Wide Web at: The online version of this article, along with updated information and services, is of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point publication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • Underimmunization in Ohio’s Amish: Parental Fears Are a Greater Obstacle Than Access to Care WHAT’S KNOWN ON THIS SUBJECT: Underimmunized communities are reservoirs of preventable childhood diseases in the United States. Many Amish communities have low immunization rates. Previous research among the Amish has revealed that the major barrier to immunization is lack of access to health care. WHAT THIS STUDY ADDS: Among the Amish in Holmes County, Ohio, the major barrier to immunization is parental concerns over adverse effects of vaccines. Decision-making about vaccination among Amish parents is complex; many Amish parents accept some vaccines for their children but refuse others. abstract OBJECTIVE: Holmes County, Ohio, one of the largest Amish communi- ties in the world, has persistently low immunization rates. Studies of 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 AUTHORS: Olivia K. Wenger, MD,a Mark D. McManus, PhD, MSSW,b John R. Bower, MD,c and Diane L. Langkamp, MD, MPHd Departments of aPediatrics, cInfectious Diseases, and dDevelopmental Behavioral Pediatrics, Akron Children’s Hospital, Akron, Ohio; and bSchool of Social Work, University of Akron, Akron, Ohio KEY WORDS Amish, immunizations, immunization safety, attitudes, exemption ABBREVIATION DoH—Department of Health www.pediatrics.org/cgi/doi/10.1542/peds.2009-2599 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). Copyright © 2011 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. ARTICLES PEDIATRICS Volume 128, Number 1, July 2011 79 at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • Despite the efforts of pediatric provid- ers nationwide to advocate for immu- nizations, some parents choose not to vaccinate their children.1,2 Children who live in closed communities with high vaccine-exemption rates are particularly vulnerable to vaccine- preventable diseases.3,4 The Amish, a separatist Christian sect, have had persistently low immunization rates. Multiple outbreaks of vaccine- preventable infections including per- tussis, rubella, measles, and Haemo- philus influenzae type b have been described in underimmunized Amish communities.5–9 Although vaccination is not specifically prohibited by Amish religious doctrine, the reasons for the low immunization rates have not been clearly identified. Authors of a previous study cited lim- ited access to health care as a barrier to immunization among the Amish.10 Among the Amish in Lancaster County, Pennsylvania, investigators found that only 16% of children aged 6 months to 5 years were fully immunized. A survey of Amish families in Lancaster County found that 75% reported that they would immunize their children if vacci- nations were offered locally.9 The gen- eralizability of the Lancaster County findings to other Amish communities has not been determined. Holmes County, Ohio, is one of the largest set- tlements of Amish in the world, yet this population’s attitudes regarding im- munizations have not been re- searched.11 In 2006, 45% of the Holmes County population was reported to be fully immunized, compared with a statewide Ohio immunization rate of 80% and a national rate of 85% (based on children aged 19–35 months who received the 4:3:1:3:3 [Ն4 doses of diphtheria, tetanus toxoid, and any acellular pertussis vaccine, Ն3 doses of poliovirus vaccine, Ն1 dose of mea- sles, mumps, rubella vaccine, Ն3 doses of H influenzae type b vaccine and Ն3 doses of hepatitis B vaccine] series) (Sally Hofsetter, director, per- sonal health services, Holmes County Department of Health, Millersburg, OH, personal communication, July 14, 2006).12 The Holmes County Depart- ment of Health (DoH) has increased the availability of vaccinations by hold- ing immunization clinics near commu- nity gatherings such as livestock auc- tions and by offering to administer vaccines at parochial schools. Also, most physicians provide vaccines through government-supplemented programs at minimal cost. However, low immunizations rates persist, which suggests that the barriers to im- munization among the Holmes County Amish differ from those described among the Amish in Lancaster County. MATERIALS AND METHODS Sample and Instrument This study consisted of a mailed 25- question survey to Amish parents in Holmes County. Survey questions were designed with input from Amish com- munity leaders, physicians who serve Amish families, the Holmes County DoH staff, and previous studies of parental attitudes toward immunization (Nancy E. Rosenstein, personal communica- tion, July 14, 2006).13 The questions ex- plored basic demographic informa- tion, family-specific immunization status, parental attitudes toward im- munization, religious ideas regarding immunization, and exposure to poten- tial adverse effects of immunizations. Most questions offered multiple- choice answers with an option to write in comments. A few questions were open-ended. The survey was reviewed by a small group of Amish parents to ensure clarity. The study was approved by the institutional review board at Ak- ron Children’s Hospital. The mailing addresses of Amish parents were ob- tained from the 2005 Ohio Amish Direc- tory, which is a comprehensive direc- tory of Amish families living in Holmes County and its vicinity in 2005.14 The di- rectory lists the names and birth dates of children in each household. Al- though addresses were selected at random, only addresses of families with children born after 1980 were used. Such purposeful sampling from a ran- dom component of a specific population has been used in other exploratory stud- iesofbarrierstoimmunization.15 Alistof 1000 families (5% of the population) was generated. The survey was sent with a cover letter and a self-addressed, stamped reply envelope. No incentive was offered for survey completion. All surveys were anonymous. Statistical Analysis The data were analyzed by perform- ing cross-tabulations, and signifi- cant differences were established by ␹2 statistics using SPSS 15.0.16 Some respondents did not select answers to all 25 questions. Missing data were handled by using available case analysis so that all available re- sponses were used to calculate each statistic, and the number of re- sponses varied across analyses.17 We examined the answers to ques- tions and comments written by sur- vey respondents for thematic trends. The end result of this exploration was to provide pertinent themes and specific quotes to illustrate the key findings.18,19 RESULTS Demographics Of 1000 surveys distributed, 360 com- pleted surveys were returned and 33 were returned as undeliverable, which resulted in a response rate of 37%. One survey was completed by a Mennonite and, thus, was excluded from analysis. Demographic characteristics obtained from the respondents included gender (67% female), age (range: 24–69 years; mean: 39.1 years), religious af- 80 WENGER et al at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • filiation (85% Old Order Amish, 12% New Order Amish, 3% other Amish church), and insurance coverage (95% uninsured). Immunization Trends The parents were asked to state whether all, some, or none of their chil- dren had received immunizations. They were not asked to clarify how many or which immunizations their children had received. Of the 359 re- spondents, 68% stated that all of their children had received immunizations, 17% stated that some of their children had been immunized, and 14% stated that none of their children had been immunized. A majority of the Amish in Holmes County classify themselves as Old Or- der (more traditional) or New Order (less traditional).20 All New Order Amish respondents stated that they had their children immunized. In con- trast, 84% of Old Order Amish had some or all of their children immu- nized, but 16% did not have any of their children immunized (P ϭ .02). To assess familiarity with the technol- ogy of immunization, 1 question asked about immunization of animals. Of the 243 parents who responded that all of their children had received vaccina- tions, 40% immunized their animals. Of the 49 parents who replied that none of their children had received vaccina- tions, only 18% immunized their ani- mals (P Ͻ .001). Reasons for Acceptance of Vaccination and Selective Immunization Among the 280 parents who vacci- nated at least some of their children, 100% agreed that vaccinations are “protective against disease.” Nearly half of the parents who vaccinated at least some of their children indicated that their physician or nurse recom- mended vaccinations for their chil- dren. More than 30% of the parents who vaccinated at least some of their children stated that they had been vac- cinated as children. Parents who allow some, but not all, recommended immunizations re- ported several explanations for their decision to use selective immuniza- tion. Of the 140 respondents who al- lowed selective immunization, 42% felt that “giving all the shots at once is too hard on a baby,” 27% were concerned that “some shots were manufactured from aborted babies,” 25% were con- cerned that “there are too many rec- ommended shots,” and 19% felt that “babies are too young to handle shots.” Only 6% reported that it was “too hard to get to the doctor’s office/clinic for shots,” and 2% said that they could “not afford to get all the shots.” Re- sponses varied according to parental age; only 14% of parents aged 40 years or older reported that “some shots were manufactured from aborted ba- bies” as a reason for allowing selective immunization for their children com- pared with 39% of the younger parents (P ϭ .001). Reasons for Exemption From Vaccination Table 1 lists the reasons that parents who did not have any of their children immunized indicated to explain their decision. The 3 most commonly re- ported explanations for not allowing immunization were related to con- cerns about adverse effects. Understanding of the Adverse Effects of Immunization To assess understanding of the risks and benefits of immunization, re- spondents were asked to select statements from a list with which they agreed (Table 2). Respondents were then asked if they personally knew anyone who had had a “bad side- effect from baby shots.” Of the 359 re- spondents, 47% replied that they knew someone with a serious adverse effect. More parents aged 40 years or older reported that they knew someone with a serious adverse effect of immuniza- tions than did the younger (Ͻ40-year- old) parents (56% vs 44%; P ϭ .04). Table 3 lists the most common types of adverse effects to immunization reported. TABLE 1 Reasons for Exemption From Immunization (N ϭ 49) Possible Responsesa n (%) Shots have too many side effects to be worth the risk of gettingb 48 (97) Shots could have dangerous chemicals or preservatives in themc 14 (29) Shots inject children with dangerous germs like whooping cough 6 (12) The diseases shots prevent are not a problem in our community 4 (8) Shots are too expensive 3 (6) Other families in my district do not give shots 3 (6) Giving shots means I’m not putting faith in God to take care of my children 3 (6) I have heard some shots are manufactured from aborted babies 2 (4) It is too hard to get to the clinic/office for shots 1 (2) The ministers in my district disagree with giving shots 0 (0) a Participants were asked to circle any response with which they agreed. b Highlighted as the most important singular reason for exempting children from shots in 86% of the cases. c Highlighted as the most important singular reason for exempting children from shots in 10% of the cases. TABLE 2 Understanding of Risks and Benefits of Immunization (N ϭ 304) Possible Responsesa n (%) Shots are safer overall than the diseases our children would get without them 188 (61) Shots would save our community money by preventing illness if everyone got them 110 (36) Shots can cause high fevers more than one week after they are given 97 (32) Shots can cause brain damage 95 (31) Shots can cause too much stress on the system if given at once 91 (30) Shots can cause seizures more than one week after they are given 97 (32) a Respondents were asked to circle any of the statements that they felt were correct. ARTICLES PEDIATRICS Volume 128, Number 1, July 2011 81 at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • Attitudes Regarding the Immunization Schedule Parents were asked whether giving shots at 2, 4, and 6 months was “too early.” Of the 359 respondents, 47% did not feel that physicians gave shots too early, 35% felt that doctors do give im- munizations too early, and 18% were unsure. More parents who reported knowing someone with a serious ad- verse effect from immunizations re- plied that giving shots at 2, 4, and 6 months was “too early” compared with parents who did not know someone with a serious adverse effect from im- munizations (57% vs 25%; P Ͻ .001). Sources of Information Regarding Vaccines All the respondents were asked to identify who advised them against in- fant immunizations. Of the 154 respon- dents, 38% replied that they had re- ceived such advice from their community and friends, 37% from par- ents/other family members, 16% from books, 19% from articles, 10% from chiropractors, and 6% from their fam- ily’s doctor/nurse. No respondents reported that their ministers advis- ed against immunization. Parents younger than 40 years were more likely to report having received advice against immunizations from parents/ other family members than older par- ents (45% vs 25%; P ϭ .02). The respondents were asked to indi- cate any sources from which they learned about infant immunizations. Of the 327 respondents, 74% wrote that they had learned about immunizations from their doctor/nurse, 64% from their family, 7% in school, 7% from magazines or papers, 5% from their midwife, and 3% from their chiroprac- tor. Parents younger than 40 years were more likely to report that they learned about infant immunizations from their family than were older par- ents (73% vs 52%; P Ͻ .001). Addressing Spirituality or Faith in Decision-Making Regarding Immunization Only a small minority of the parents reported that their religious or spir- itual beliefs influenced their deci- sions about immunization. When asked if “giving shots disagrees with your faith or spiritual beliefs in some way,” 63% replied “no,” 4% indicated “yes,” and 30% did not respond to the question. Addressing Access and Financial Burden of Vaccines The respondents were asked if they knew that the Holmes County DoH of- fered immunization clinics throughout the county at convenient times and lo- cations. Of the 49 respondents who had not had any of their children im- munized, 20% did not know about the DoH vaccine posts in their county. Of the 304 respondents who had had some or all of their children vacci- nated, 11% did not know about the DoH clinics (P ϭ .005). We asked the re- spondents if they knew that immuniza- tions provided by the DoH could be free of charge. A larger proportion of par- ents who had not had any of their chil- dren immunized were not aware that immunizations could be obtained at no cost (37%) compared with only 11% of the respondents who had had some or all of their children vaccinated (P Ͻ .001). Factors That Would Influence Decision-Making of Exempting Parents Parents who exempted completely or partially from vaccines were asked to indicate factors that might alter their decision. Of the 95 respondents, 86% stated that they would be more likely to consider having their children immu- nized if they “knew shots were safe to give,” 20% if “there was a disease out- break,” 11% if “shots were required by the law/government,” and 10% if their “parents or family encouraged them.” Theanswers“iftheshotswerecheaper,” if their “bishop or elder recommended them,” and if “it were easier to get to the doctor’sofficeorclinic”wereselectedby only 5%, 3%, and 3% of the respondents, respectively. None of the 10 exempting parents who were not aware of accessible DoH vac- cine posts stated that they would con- sider having their children immunized if the doctor’s office were “easier to get to.” Only 2 of the 18 exempting par- ents who were not aware that DoH vac- cines could be free indicated that they would consider having their children immunized if “the shots were cheaper.” TABLE 3 Examples of Immunization Adverse Effects Listed by Parents Mild reactions “Swelling, stiffness” “Fever, swelling of the arm” “Our oldest, now 10 years old, was about 6 months when she could not move her leg without screaming for about 12 to 24 hours after getting shots.” “He got a very high fever.” Developmental regression “I have a relative that was a healthy girl. She was walking and talking until she got her shots. She can’t talk or walk without help and has a very miserable life.” “Couldn’t walk anymore” “He could never walk again and they said it was from the shots and his mind was affected.” “I know of three children that were perfectly normal till after receiving baby shots.” “Stunted growth” Neurologic sequelae “Brain damage (they gave her too much for her weight)” “She is crippled—cannot walk” “Brain damage, though I’m not sure how they know it was due to shots” “Seizures” “Severe brain damage caused by high fever from [the measles, mumps, rubella vaccine]” “Mentally disabled” Death “Crib death” “Death, the baby was too weak to handle them” 82 WENGER et al at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • DISCUSSION We found that Amish parents in Hol- mes County generally accept some vaccinations; 85% of them have their children at least partially immunized. Amish parents of unvaccinated chil- dren were concerned about adverse effects and the ability of an infant to tolerate vaccines rather than about fi- nancial, accessibility, or religious is- sues. Their concerns about adverse ef- fects and the ability of an infant to tolerate vaccines mirror the concerns of non-Amish parents in the broader American society. Given the low immunization rates in Holmes County, we were surprised by the high proportion of respondents who had accepted vaccines for some or all of their children. In an effort to keep the survey brief, respondents were not asked to specify which vac- cines they accepted. DoH staff re- ported to us that some Amish parents accept immunizations against poliovi- rus or H influenzae type b but not those against varicella or Streptococcus pneumoniae. Thus, although the par- ents had accepted some immuniza- tions, their children would not be “fully immunized” according to Centers for Disease Control and Prevention stan- dards. This finding points to the need to further explore parents’ concerns about individual vaccines rather than vaccination as a general practice. When comparing responses of the par- ents who exempted completely with those of nonexempting parents, con- cern regarding potential adverse ef- fects was the major barrier to immu- nization cited; 82% of the exempting parents stated that they would con- sider vaccinating their children if “they knew the shots were safe to give,” and only a few exempting parents reported that they would have their children im- munized if the shots were cheaper or easier to access. The fact that many parents claimed to know someone who had suffered a “serious adverse effect” from immunization and de- scribed many potential adverse effects may reflect the closeness of their com- munity or the incidence of inherited metabolic disorders in the population. However, surveys of the general Amer- ican public have revealed similar pa- rental misconceptions regarding ad- verse effects of immunization.13 One study of antivaccination Web sites found content claims that vaccines cause idiopathic illness and erode im- munity in 95% of sites analyzed.21 Other concerns of Amish parents about the current immunization schedule, in- cluding that it is “too hard on a baby’s system” or that infants are “too young to handle shots,” reflect misconcep- tions about immunizations that are re- flected in the views of the mainstream American public.22,23 Similar to our study, a survey of an Ar- thur, Illinois, Amish population found that parents were most concerned about vaccine safety rather than avail- ability, cost, prioritization, or align- ment with religious values.24 Thus, the Amish populations of Holmes County and Arthur seem to differ from the Amish population in Lancaster County, where 51% of parents exempting from vaccines did not consider vaccination a priority compared with other activi- ties of daily life, and 29% of exempting parents felt that it was “too difficult to travel” to places where vaccinations were offered.9 Our study shows that the characteriza- tion of religious values in medical decision-making is complex. Amish re- spondents stressed that individual families were responsible for the deci- sion to vaccinate. Only a few respon- dents reported that giving shots would conflict with their faith or spiritual be- liefs. This result aligns with previous findings that most Amish people do not view vaccination as a religious or spir- itual issue. In contrast to the study of the Amish population in Arthur, our study provides further insight into un- derimmunization in Amish communi- ties by revealing the practice of selec- tive immunization. The reticence of parents to accept immunization against rubella and varicella because of the understanding that the immuni- zations “come from aborted babies” suggests an ethical if not specifically religious basis for their decision- making. (Rubella and varicella vac- cines present concern because the at- tenuated viruses in the vaccines are propagated by using a human cell line, WI-38, derived in 1961. The cell line was originally prepared from tissues of an aborted fetus.)25 Further investigation is needed to more fully understand the reasons for selective immunization among Amish families. Understanding separatist groups such as the Amish is crucial for pre- vention of disease epidemics, be- cause underimmunized populations are proven reservoirs of serious in- fections.26 We aimed to examine non- quantifiable issues such as parental attitudes, expectations, and beliefs. The survey was designed to system- atically gather data that focused on a specific line of inquiry, but given our resources, it was difficult to validate our data with triangulation or re- spondent validation.27,28 Neverthe- less, our findings provide insight for future studies involving the same and comparison populations. The response rate to our survey was only 37%, which introduces a risk of sampling bias. Survey recipients who view health care providers and vacci- nations favorably may have been more likely to complete and return our sur- vey. We speculate that parents who completely exempt from immunization may have been less likely to respond to our survey. Another study that used written surveys of an Amish population about health care issues obtained a ARTICLES PEDIATRICS Volume 128, Number 1, July 2011 83 at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • similar response rate.10 Those investi- gators reflected that “the Amish are not often asked to answer written sur- vey questions and may not be familiar with this mode of gathering informa- tion.”10 Lack of familiarity with this type of instrument may have contributed to some reticence among Amish parents to respond to our survey. However, other means of assessing parental opinions in the general population (eg, telephone surveys) cannot be used ef- fectively in the Amish community. The issue of nonresponse to the entire sur- vey or to specific questions in the Amish population is difficult to inter- pret without further and potentially costly investigation. CONCLUSIONS More Amish parents in Holmes County reported accepting vaccines than we expected, but these Amish families of- ten permit their children to receive only certain vaccines. Although most Amish parents report that decisions about immunization are not influenced by their religious beliefs, many choose to exempt from certain vaccines on the basis of ethical values. The Amish may require different approaches to ad- dressing misconceptions about vacci- nation than the general population, be- cause the religious principles of the Amish, who value separation from the secular world, prevent exposure to many avenues that are used to educate the public about vaccines, such as tele- vision or radio. Because Amish fami- lies are less likely to seek preventive health care,29 peer educators within the Amish community who are sensi- tive to the traditions and culture of the Amish community may be needed to address the common misconceptions about immunizations reported in this study. Our results indicate that con- cerns about immunization practice among Amish populations are similar to the concerns of mainstream Ameri- cans and that concerns about vaccine safety represent the major barrier to immunization. Efforts of health care providers working with Amish families must focus on redirection of parental misconceptions about vaccine safety rather than simply improving access to vaccines. ACKNOWLEDGMENTS This research was supported by a grant from the Akron Children’s Hospi- tal Foundation. Special thanks go to Peter Reuman, Jerry Slabaugh, Marla Sabey, Marne Woyat, D. J. McFadden, MD, Akron Chil- dren’s Hospital Department of Volun- teers, and the Holmes County DoH. REFERENCES 1. Omer SB, Pan WKY, Halsey NA, et al. Nonmed- ical exemptions to school immunization re- quirements. JAMA. 2006;296(14):1757–1763 2. Smith PJ, Chu SY, Barker LE. Children who have received no vaccines: who are they and where do they live? Pediatrics. 2004; 114(1):187–195 3. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with personal exemptions to im- munization. JAMA. 2000;284(24):3145–3150 4. Rodgers DV, Gindler JS, Atkinson WL, Markowitz LE. High attack rates and case fatality during a measles outbreak in groups with religious exemption to vaccina- tion. Pediatr Infect Dis J. 1993;12(4): 288–292 5. Centers for Disease Control and Prevention. Pertussis outbreak in an Amish community: Kent County, Delaware, September 2004–February 2005. MMWR Morb Mortal Wkly Rep. 2006;55(30):817–821 6. Jackson BM, Payton T, Horst G, Halpin TJ, Mortensen BK. An epidemiologic investiga- tion of a rubella outbreak among the Amish of northeast Ohio. Public Health Rep. 1993; 108(4):436–439 7. Briss PA, Fehrs LJ, Hutcheson RH, Schaffner W. Rubella among the Amish: resurgent dis- ease in a highly susceptible community. Pe- diatr Infect Dis J. 1992;11(11):955–959 8. Sutter RW, Markowitz LE, Bennetch JM, Morris W, Zell ER, Preblud SR. Measles among the Amish: a comparative study of measles severity in primary and second- ary cases in households. J Infect Dis. 1991;163(1):12–16 9. Fry AM, Lurie P, Gidley M, et al. Haemophilus influenzae type b disease among Amish children in Pennsylvania: reasons for per- sistent disease. Pediatrics. 2001;108(4). Available at: www.pediatrics.org/cgi/ content/full/108/4/e60 10. Dickinson N, Slesinger DP, Raftery PR. A comparison of the perceived health needs of Amish and non-Amish families in Cashton, Wisc. Wis Med J. 1996;95(3): 151–156 11. Young Center for Anabaptist and Pietist Studies at Elizabethtown College. The twelve largest Amish settlements. Available at: www2.etown.edu/amishstudies/Largest_ Settlements_2010.asp. Accessed January 4, 2011 12. Centers for Disease Control and Prevention. NIS data table: estimated vaccination cover- age with individual vaccines and selected vaccination series by 24 months of age by state and immunization action plan area US, National Immunization Survey, 2005. www2a.cdc.gov/nip/coverage/nis/nis_iap. asp?fmtϭv&rptϭtab09_24mo_iap&qtrϭ Q1/2005-Q4/2005. Accessed October 24, 2006 13. Mills E, Jadad AR, Ross C, Wilson K. System- atic review of qualitative studies exploring parental beliefs and attitudes toward child- hood vaccination identifies common barri- ers to vaccination. J Clin Epidemiol. 2005; 58(11):1081–1088 14. Wengerd M. 2005 Ohio Amish Directory. Wal- nut Creek, OH: Carlisle Press; 2005 15. Mills EJ, Montori VM, Ross CP, Shea B, Wil- son K, Guyatt GH. Systematically reviewing qualitative studies complements survey design: an exploratory study of barriers to paediatric immunisations. J Clin Epidemiol. 2005;58(11):1101–1108 16. SPSS [computer program]. Release 15.0 Chicago, IL: SPSS Inc; 2006 17. Little RJA, Rubin DB. Statistical Analysis With Missing Data. 2nd ed. Hoboken, NJ: Wiley; 2002 18. Pottie C, Sumarah J. Friendships between persons with and without developmental disabilities. Ment Retard. 2004;42(1):55–66 19. Crabtree B, Miller W. Doing Qualitative Re- search. Thousand Oaks, CA: Sage; 1999 20. Nolt SM. A History of the Amish. Intercourse, PA: Good Books; 1968 84 WENGER et al at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • 21. Wolfe RM, Sharp LK, Lipsky MS. Content and design attributes of anti-vaccination Web sites. JAMA. 2002;287(24):3245–3248 22. Gellin BG, Maibach EW, Marcuse EK. Do par- ents understand immunizations? A national telephone survey. Pediatrics. 2000;106(5): 1097–1102 23. Offit PA, Quarles J, Gerber MA, et al. Ad- dressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109(1): 124–129 24. Yoder JS, Dworkin MS. Vaccination usage among an Old-Order Amish community in Illinois. Pediatr Infect Dis J. 2006;25(12): 1182–1183 25. Hayflick L, Moorhead PS. The serial cultiva- tion of human diploid strains. Exp Cell Res. 1961;25:585–621 26. MayT,SilvermanRD.“Clusteringofexemptions” as a collective action threat to herd immunity. Vaccine. 2003;21(11–12):1048–1051 27. Pope C, Zieband S, Mays N. Qualitative re- search in health care: analyzing qualitative date. BMJ. 2000;320(7227):114–116 28. Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ. 2000;320(7226):50–52 29. HurstCE,McConnellDL.AnAmishParadox.Balti- more,MD:JohnsHopkinsUniversityPress;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 ARTICLES PEDIATRICS Volume 128, Number 1, July 2011 85 at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from
    • DOI: 10.1542/peds.2009-2599 ; originally published online June 27, 2011;Pediatrics Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp Than Access to Care Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle Services Updated Information & /peds.2009-2599 http://pediatrics.aappublications.org/content/early/2011/06/23 including high resolution figures, can be found at: Citations /peds.2009-2599#related-urls http://pediatrics.aappublications.org/content/early/2011/06/23 This article has been cited by 1 HighWire-hosted articles: Permissions & Licensing ml http://pediatrics.aappublications.org/site/misc/Permissions.xht tables) or in its entirety can be found online at: Information about reproducing this article in parts (figures, Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml Information about ordering reprints can be found online: rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly at Univ Of Arizona on April 25, 2014pediatrics.aappublications.orgDownloaded from