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Underimmunization in Ohios Amish: Parental Fears

Are a Greater Obstacle Than Access to Care

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
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
Americas 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 inuenced 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;128:7985
AUTHORS: Olivia K. Wenger, MD,
Mark D. McManus, PhD,
John R. Bower, MD,
and Diane L. Langkamp, MD,
Departments of
Infectious Diseases, and
Developmental Behavioral Pediatrics, Akron Childrens Hospital,
Akron, Ohio; and
School of Social Work, University of Akron,
Akron, Ohio
Amish, immunizations, immunization safety, attitudes, exemption
DoHDepartment of Health
Accepted for publication Mar 22, 2011
Address correspondence to Olivia K. Wenger, MD, Department of
Pediatrics, Akron Childrens Hospital, 128 E Milltown Rd, Suite
209, Wooster, OH 44691. E-mail:
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 nancial relationships relevant to this article to disclose.
PEDIATRICS Volume 128, Number 1, July 2011 79
Despite the efforts of pediatric provid-
ers nationwide to advocate for immu-
nizations, some parents choose not to
vaccinate their children.
who live in closed communities with
high vaccine-exemption rates are
particularly vulnerable to vaccine-
preventable diseases.
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 inuenzae type b have been
described in underimmunized Amish
Although vaccination is not specically
prohibited by Amish religious doctrine,
the reasons for the low immunization
rates have not been clearly identied.
Authors of a previous study cited lim-
ited access to health care as a barrier
to immunization among the Amish.
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.
The gen-
eralizability of the Lancaster County
ndings 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
populations attitudes regarding im-
munizations have not been re-
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 1935 months who
received the 4:3:1:3:3 [4 doses of
diphtheria, tetanus toxoid, and any
acellular pertussis vaccine, 3 doses
of poliovirus vaccine, 1 dose of mea-
sles, mumps, rubella vaccine, 3
doses of H inuenzae type b vaccine
and 3 doses of hepatitis B vaccine]
series) (Sally Hofsetter, director, per-
sonal health services, Holmes County
Department of Health, Millersburg, OH,
personal communication, July 14,
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.
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).
The questions ex-
plored basic demographic informa-
tion, family-specic 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 Childrens Hospital. The mailing
addresses of Amish parents were ob-
tained fromthe 2005 Ohio Amish Direc-
tory, which is a comprehensive direc-
tory of Amish families living in Holmes
County and its vicinity in 2005.
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 specic population
has been used in other exploratory stud-
ies of barriers to immunization.
A list of
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 signi-
cant differences were established by

statistics using SPSS 15.0.
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.
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
specic quotes to illustrate the key
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
fromthe respondents included gender
(67% female), age (range: 2469
years; mean: 39.1 years), religious af-
80 WENGER et al
liation (85% Old Order Amish, 12%
New Order Amish, 3% other Amish
church), and insurance coverage (95%
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
A majority of the Amish in Holmes
County classify themselves as Old Or-
der (more traditional) or New Order
(less traditional).
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 .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 .001).
Reasons for Acceptance of
Vaccination and Selective
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 doctors ofce/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 .001).
Reasons for Exemption From
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 benets 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 (40-year-
old) parents (56% vs 44%; P .04).
Table 3 lists the most common types of
adverse effects to immunization
TABLE 1 Reasons for Exemption From
Immunization (N 49)
Possible Responses
n (%)
Shots have too many side effects to be
worth the risk of getting
48 (97)
Shots could have dangerous chemicals
or preservatives in them
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 Im not putting
faith in God to take care of my
3 (6)
I have heard some shots are
manufactured from aborted babies
2 (4)
It is too hard to get to the clinic/ofce
for shots
1 (2)
The ministers in my district disagree
with giving shots
0 (0)
Participants were asked to circle any response with
which they agreed.
Highlighted as the most important singular reason for
exempting children from shots in 86% of the cases.
Highlighted as the most important singular reason for
exempting children from shots in 10% of the cases.
TABLE 2 Understanding of Risks and Benets
of Immunization (N 304)
Possible Responses
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
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)
Respondents were asked to circle any of the statements
that they felt were correct.
PEDIATRICS Volume 128, Number 1, July 2011 81
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 .001).
Sources of Information Regarding
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-
ilys 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 .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 .001).
Addressing Spirituality or Faith in
Decision-Making Regarding
Only a small minority of the parents
reported that their religious or spir-
itual beliefs inuenced 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
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 .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
Factors That Would Inuence
Decision-Making of Exempting
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.
Theanswersif theshotswerecheaper,
if their bishop or elder recommended
them, and if it were easier to get to the
doctorsofceor clinic wereselectedby
only 5%, 3%, and 3% of the respondents,
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 doctors ofce 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
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 cant talk or walk without help
and has a very miserable life.
Couldnt walk anymore
He could never walk again and they said it
was from the shots and his mind was
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
She is crippledcannot walk
Brain damage, though Im not sure how they
know it was due to shots
Severe brain damage caused by high fever
from [the measles, mumps, rubella
Mentally disabled
Crib death
Death, the baby was too weak to handle them
82 WENGER et al
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 -
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 inuenzae 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 nding 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 fewexempting 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 reect 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.
study of antivaccination Web sites
found content claims that vaccines
cause idiopathic illness and erode im-
munity in 95%of sites analyzed.
concerns of Amish parents about the
current immunization schedule, in-
cluding that it is too hard on a babys
system or that infants are too young
to handle shots, reect misconcep-
tions about immunizations that are re-
ected in the views of the mainstream
American public.
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.
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 difcult to
travel to places where vaccinations
were offered.
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
conict with their faith or spiritual be-
liefs. This result aligns with previous
ndings 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 specically
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.)
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-
We aimed to examine non-
quantiable issues such as parental
attitudes, expectations, and beliefs.
The survey was designed to system-
atically gather data that focused on a
specic line of inquiry, but given our
resources, it was difcult to validate
our data with triangulation or re-
spondent validation.
less, our ndings 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
PEDIATRICS Volume 128, Number 1, July 2011 83
similar response rate.
Those investi-
gators reected that the Amish are
not often asked to answer written sur-
vey questions and may not be familiar
with this mode of gathering informa-
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 specic questions in the
Amish population is difcult to inter-
pret without further and potentially
costly investigation.
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 inuenced
by their religious beliefs, many choose
to exempt fromcertain 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,
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.
This research was supported by a
grant from the Akron Childrens Hospi-
tal Foundation.
Special thanks go to Peter Reuman,
Jerry Slabaugh, Marla Sabey, Marne
Woyat, D. J. McFadden, MD, Akron Chil-
drens Hospital Department of Volun-
teers, and the Holmes County DoH.
1. Omer SB, Pan WKY, Halsey NA, et al. Nonmed-
ical exemptions to school immunization re-
quirements. JAMA. 2006;296(14):17571763
2. Smith PJ, Chu SY, Barker LE. Children who
have received no vaccines: who are they
and where do they live? Pediatrics. 2004;
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):31453150
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):
5. Centers for Disease Control and Prevention.
Pertussis outbreak in an Amish community:
Kent Count y, Del aware, Sept ember
2004February 2005. MMWR Morb Mortal
Wkly Rep. 2006;55(30):817821
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;
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):955959
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.
9. Fry AM, Lurie P, Gidley M, et al. Haemophilus
inuenzae type b disease among Amish
children in Pennsylvania: reasons for per-
sistent disease. Pediatrics. 2001;108(4).
Available at:
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):
11. Young Center for Anabaptist and Pietist
Studies at Elizabethtown College. The twelve
largest Amish settlements. Available at:
Settlements_2010.asp. Accessed January 4,
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 I mmunization Survey, 2005.
Q1/2005-Q4/2005. Accessed October 24,
13. Mills E, Jadad AR, Ross C, Wilson K. System-
atic review of qualitative studies exploring
parental beliefs and attitudes toward child-
hood vaccination identies common barri-
ers to vaccination. J Clin Epidemiol. 2005;
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.
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):5566
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
21. Wolfe RM, Sharp LK, Lipsky MS. Content and
design attributes of anti-vaccination Web
sites. JAMA. 2002;287(24):32453248
22. Gellin BG, Maibach EW, Marcuse EK. Do par-
ents understand immunizations? A national
telephone survey. Pediatrics. 2000;106(5):
23. Oft PA, Quarles J, Gerber MA, et al. Ad-
dressing parents concerns: do multiple
vaccines overwhelm or weaken the infants
immune system? Pediatrics. 2002;109(1):
24. Yoder JS, Dworkin MS. Vaccination usage
among an Old-Order Amish community in
Illinois. Pediatr Infect Dis J. 2006;25(12):
25. Hayick L, Moorhead PS. The serial cultiva-
tion of human diploid strains. Exp Cell Res.
26. May T, SilvermanRD. Clusteringof exemptions
as a collective action threat to herd immunity.
Vaccine. 2003;21(1112):10481051
27. Pope C, Zieband S, Mays N. Qualitative re-
search in health care: analyzing qualitative
date. BMJ. 2000;320(7227):114116
28. Mays N, Pope C. Qualitative research in
health care: assessing quality in qualitative
research. BMJ. 2000;320(7226):5052
29. Hurst CE, McConnell DL. AnAmishParadox. Balti-
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 dont 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