The Church as a Vehicle for the Promotion of Immunizations

Richard A. Lane, MD, MPH&TM, FACPM Director, Master of Public Health Program Liberty University

Source: CDC. Measles outbreaks and cases. Accessed June 16, 2014.

Measles Outbreaks • Ohio outbreak began with 4 people returning from a

church mission trip to the Philippines1 • Orange County, California outbreak linked to vaccine

refusal2,3, foreign travel, and a church day care center3

• 2013 Texas mega-church outbreak affected 21 people after exposure to a traveler from Indonesia4

• 58 cases and 3500 exposures from a Jewish community in Brooklyn5

1. CNN staff. Outbreak in Ohio adds to 18-year high of measles cases in U.S. CNN Health. May 13, 2014. 2. Esquivel P. O.C. measles outbreak spurs officials to call for immunizations. Los Angeles Times. April 4, 2014. 3. Zipprich J, Hacker JK, Murray EL, et al. Notes from the Field: Measles — California, January 1–April 18, 2014. MMWR.

April 25, 2014; 63(16);362-363 4. Silverman L. Texas megachurch at center of measles outbreak. NPR. September 1, 2013. 5. Arciuolo RJ, Brantley TR, Asfaw MM, et al. Notes from the Field: Measles Outbreak Among Members of a Religious

Community — Brooklyn, New York, March–June 2013. MMWR. September 13, 2013 / 62(36);752-753

Pertussis • In the first four months of 2014

• 4,838 cases of pertussis reported to CDC by 48 states and Washington, D.C.1

• 24% increase compared with the same time period in 20131.

• California this week declared a state of emergency with over 800 cases2

1. CDC. Pertussis (whooping cough). April 14, 2014. 2. Christensen J. California declares whooping cough epidemic. CNN Health. June 16, 2014.

Factors in the Outbreaks

• Cases are primarily unvaccinated persons • Measles is common in some countries in

Europe, Asia, the Pacific, and Africa • Travelers with measles commonly bring the

disease into the U.S. • Disease spreads if it reaches a community

where groups of people are unvaccinated

California Immunization Rates

• Overall for California – 89.3% • Amador County – 77.45% • Butte County – 82.79% • Mariposa County – 68.48% • Mono County – 78.13% • Nevada County – 67.41% • Santa Cruz - 74.52%

Source: California Department of Health, 2014.

Healthy People 2020 Objectives • 95% Targets for children of kindergarten age

• 2 doses MMR • 4 doses DTaP

• Baselines in 2009-10 school year were at above 95% for all but varicella (91.3%)

• 80% Target for 19-35 month children to receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV

• Baseline in 2008 was 44.3%

Healthy People 2020. Immunizations and infectious diseases.

• 3 doses Hepatitis B • 2 doses Varicella

Vaccination Coverage with Individual Vaccines & Selected Series at 24 months of Age (from VIIS data) – Virginia 2012

District Total no assessed DTAP 4 POLIO 3 MMR 1 HIB 3 HEPB 3 VAR 1 PCV 4 431331 4313314

ALEXANDRIA 245 77.55% 90.61% 86.93% 88.97% 88.97% 85.71% 73.46% 73.87% 67.34%

ALLEGHANY 73 86.30% 89.04% 89.04% 91.78% 82.19% 89.04% 80.82% 69.86% 65.75%

ARLINGTON COUNTY 95 78.94% 88.42% 89.47% 85.26% 87.36% 87.36% 64.21% 74.73% 61.05%

CENTRAL SHENANDOAH 431 75.40% 87.23% 83.06% 86.31% 83.75% 83.29% 73.31% 66.35% 62.41%

CENTRAL VIRGINIA 160 71.87% 83.75% 90% 80% 82.50% 88.75% 65% 65% 58.75%

East Region 820 70.12% 82.19% 87.07% 81.09% 77.07% 85.97% 66.09% 60.48% 55.12%

North Region 1300 73.69% 83.38% 85.46% 84.15% 82.46% 85.15% 66.84% 68.07% 60.15%

Northwest Region 993 72.80% 85.80% 84.18% 84.79% 83.58% 83.68% 67.67% 64.95% 59.01%

Central Region 602 81.22% 91.86% 93.18% 88.53% 91.19% 92.52% 75.08% 77.07% 70.59%

Southwest Region 1015 73.00% 88.07% 87.78% 86.10% 84.13% 87.78% 67.78% 65.51% 58.42%

STATE 4756 73.29% 85.30% 86.48% 84.27% 82.77% 86.01% 67.76% 66.33% 59.67%

Immunizations in Preschoolers

• Pilot study on immunizations in 2013 • Commonwealth of Virginia - Mini-grant • Two surveys of convenience samples

• 32 families with preschoolers as part of a Day of the Child event in Lynchburg

• 15 daycare supervisors prior to Immunization Best Practices in Virginia seminar sponsored in collaboration Liberty University MPH Program and Smart Beginning of Central Virginia

Daycare Supervisors • Centers sizes ranged from 4 to 452 children • Types of center includes

• A home-based family-run facilities • Local non-family run businesses • And religious institution based facilities.

• Only 1 home-based family run program reported being unaware of state immunization requirements

• 13.3% of facilities do not notify parents of the need for vaccines

Parent Survey Findings • 90.3% aware of the existence of immunization

requirements for school entrance • 93.8% of parents reported possession of immunization

records • BUT

• 18.8% do not review these records on at least an annual basis

• 31.3% do not take immunization records to well child check-ups

• 34.4% of families do not receive reminder immunizations notifications from pediatrician office

Immunization Compliance

• 93.7% of parents reported compliance with recommended immunizations

• HOWEVER, when specifically asked • "If not already up-to-date, which of the following

barriers to fully vaccinating your child would apply?"

• 9 parents (28.1%) provided reasons for non-immunization

• Responses suggest that the compliance rate is likely lower than the self-reported frequency.

Reasons for Non-immunization

• Fear of side effects (12.6%) • Time (12.6%) • Finances (6.2%) • Religious views (6.2%) • Reason not specified (3.1%).

Vaccination Advocates

• Parents not keeping track of records • 13.3% of daycare centers in pilot study not

notifying parents • 34% of parents not reminded by pediatricians • The church?

Fear of Side Effects

• Local pain and swelling, headache • More serious effects - rare • Allergy • Autism – no evidence to support • Mercury neurotoxicity

Mercury • Methyl mercury

• Neurotoxicity in large amounts • Bioaccumulates in fish / shellfish • Led to concern about other forms of organic mercury

• Ethyl mercury = Thimerosal • Used as a preservative in some vaccines since 1930 • Removed from most vaccines in 1999 as a precaution • Continues to be used in multi-dose flu vaccines for

older children and adults

Mercury in Tuna* • Tested 42 samples of canned tuna • Every sample contained measurable levels of mercury • EPA limit for mercury consumption is 0.1 µg/kg body weight • White tuna

• Averaged 0.427 ppm (0.217 to 0.774 ppm) of mercury • Equals 30.3 µg (15-55 µg) • The average woman of childbearing age eating 2.5 oz. (~71 grams) of the

average white tuna would exceed the daily mercury intake established by EPA

• Light tuna • Averaged 0.071 ppm (0.018 to 0.176 ppm) of mercury • Equals 5.04 µg (1.3 -12.5 µg) • The average woman of childbearing age eating 2.5 ounces of the average

light tuna would get less than the EPA’s limit • Eating 5 ounces would exceed the limit with half the tested samples

• The FDA can pull products containing over 1 ppm from the market Consumer Reports. January 2011.

Immunization Tensions • Divergent goals

• Protect individual liberty • Safeguard public’s health

• Controversies • Efficacy • Safety • Morality of compulsory immunization

Blum JD. 2006

Morality • No scriptural objections1

• Judaic principles based on Leviticus 19:16 emphasize the community benefits of disease prevention1

• Vatican position on the use of vaccines derived from aborted fetuses2

• Use alternatives if they exist • Where they do not exist, the use is lawful to protect

the health of children and pregnant women • Principle of licit cooperation in evil – remote and

passive material 1. Grabenstein JD. What the world’s religions teach, applied to vaccines and immune globulins. Vaccines

2013; 31:2011-2023. 2. Pontifical Academy of Life. Moral Reflections on Vaccines Prepared from Cells Derived from Aborted Human Foetuses. Vatican City. 2005.

References • CDC. Measles outbreaks and cases. 2014. http://www.cdc.gov/measles/cases-outbreaks.html

Accessed May 27, 2014 • CNN staff. Outbreak in Ohio adds to 18-year high of measles cases in U.S. CNN Health. May

13, 2014. http://www.cnn.com/2014/05/13/health/measles-ohio-cases/ • Esquivel P. O.C. measles outbreak spurs officials to call for immunizations. Los Angeles Times

April 4, 2014. http://www.latimes.com/local/la-me-measles-20140405-story.html#axzz30UHK7OM3

• Zipprich J, Hacker JK, Murray EL, et al. Notes from the Field: Measles — California, January 1–April 18, 2014. MMWR. April 25, 2014; 63(16);362-363

• Wallace G, Redd S, Rota J, et al. Measles — United States, January 1–August 24, 2013. MMWR. September 13, 2013 / 62(36);741-743. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm?s_cid=mm6236a2_w

• CDC. Pertussis (whooping cough). April 14, 2014. http://www.cdc.gov/pertussis/outbreaks/trends.html

• Christensen J. California declares whooping cough epidemic. CNN Health. June 16, 2014. http://www.cnn.com/2014/06/13/health/whooping-cough-california/

• Silverman L. Texas megachurch at center of measles outbreak. NPR. September 1, 2013. http://www.npr.org/2013/09/01/217746942/texas-megachurch-at-center-of-measles-outbreak

• Arciuolo RJ, Brantley TR, Asfaw MM, et al. Notes from the Field: Measles Outbreak Among Members of a Religious Community — Brooklyn, New York, March–June 2013. MMWR. September 13, 2013 / 62(36);752-753. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a5.htm

• Healthy People 2020. Immunizations and infectious diseases. 2020 Goals and Objectives. Department of Health and Human Services. Updated June 16, 2014. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23

• 2013-2014 Child Care Assessment Results. California Department of Health, Immunization Branch; 2014. http://www.cdph.ca.gov/programs/immunize/pages/immunizationlevels.aspx

• Mercury in canned tuna still a concern. Consumer Reports. January 2011. http://www.consumerreports.org/cro/magazine-archive/2011/january/food/mercury-in-tuna/overview/index.htm

• Blum JD. Balancing individual rights versus collective good in public health enforcement. Medicine and Law. 2006;25:273-281

• Grabenstein JD. What the world’s religions teach, applied to vaccines and immune globulins. Vaccines 2013; 31:2011-2023.

• Pontifical Academy of Life. Moral Reflections on Vaccines Prepared from Cells Derived from Aborted Human Foetuses. Vatican City. 2005. http://www.cogforlife.org/vaticanresponse.htm