Rubella among the Amish: resurgent disease in a highly susceptible community

Physical health conditions of the Amish and intervening social mechanisms: an exhaustive narrative review

As an ethnic religion, the Amish are of interest to population health researchers due to a distinctive health profile arising from ethnic attributes, including a closed genetic pool and shared culture that shapes lifestyle practices. Amish-focused health research both furthers our knowledge of health conditions by comparing Amish with non-Amish and assists health practitioners in serving this rapidly growing population. Amish health research, now representing approximately a quarter of all Amish-focused publications, is in need of review, to the end of strengthening this knowledge body's coherence, clarifying research directions, and identifying knowledge gaps, lapses, and stagnations. Herein, we synthesize and discuss Amish physical health conditions research, both the population's distinctive health profile and mechanisms shaping this profile. Specifically, we summarize research addressing BMI, physical activity, and body image; diet and supplements; cancer; cardiovascular conditions; communicable diseases; immunity; sleep; genetic disorders; tobacco and alcohol use; periodontal conditions; traumatic injuries; natural treatments for burns; fertility; and sexually transmitted diseases. In reflection, we raise questions about the nature of intervening mechanisms shaping the Amish health profile, the strange omission of several common independent variables commonly used when studying other ethnic groups' health, several recurring methodological complications, and public health policy considerations.

Modeling the Transmission of Measles and Rubella to Support Global Management Policy Analyses and Eradication Investment Cases

Policy makers responsible for managing measles and rubella immunization programs currently use a wide range of different vaccines formulations and immunization schedules. With endemic measles and rubella transmission interrupted in the region of the Americas, all five other regions of the World Health Organization (WHO) targeting the elimination of measles transmission by 2020, and increasing adoption of rubella vaccine globally, integrated dynamic disease, risk, decision, and economic models can help national, regional, and global health leaders manage measles and rubella population immunity. Despite hundreds of publications describing models for measles or rubella and decades of use of vaccines that contain both antigens (e.g., measles, mumps, and rubella vaccine or MMR), no transmission models for measles and rubella exist to support global policy analyses. We describe the development of a dynamic disease model for measles and rubella transmission, which we apply to 180 WHO member states and three other areas (Puerto Rico, Hong Kong, and Macao) representing >99.5% of the global population in 2013. The model accounts for seasonality, age-heterogeneous mixing, and the potential existence of preferentially mixing undervaccinated subpopulations, which create heterogeneity in immunization coverage that impacts transmission. Using our transmission model with the best available information about routine, supplemental, and outbreak response immunization, we characterize the complex transmission dynamics for measles and rubella historically to compare the results with available incidence and serological data. We show the results from several countries that represent diverse epidemiological situations to demonstrate the performance of the model. The model suggests relatively high measles and rubella control costs of approximately $3 billion annually for vaccination based on 2013 estimates, but still leads to approximately 17 million disability-adjusted life years lost with associated costs for treatment, home care, and productivity loss costs of approximately $4, $3, and $47 billion annually, respectively. Combined with vaccination and other financial cost estimates, our estimates imply that the eradication of measles and rubella could save at least $10 billion per year, even without considering the benefits of preventing lost productivity and potential savings from reductions in vaccination. The model should provide a useful tool for exploring the health and economic outcomes of prospective opportunities to manage measles and rubella. Improving the quality of data available to support decision making and modeling should represent a priority as countries work toward measles and rubella goals.

A Measles Outbreak in an Underimmunized Amish Community in Ohio

BACKGROUND

Although measles was eliminated in the United States in 2000, importations of the virus continue to cause outbreaks. We describe the epidemiologic features of an outbreak of measles that originated from two unvaccinated Amish men in whom measles was incubating at the time of their return to the United States from the Philippines and explore the effect of public health responses on limiting the spread of measles.

METHODS

We performed descriptive analyses of data on demographic characteristics, clinical and laboratory evaluations, and vaccination coverage.

RESULTS

From March 24, 2014, through July 23, 2014, a total of 383 outbreak-related cases of measles were reported in nine counties in Ohio. The median age of case patients was 15 years (range, <1 to 53); a total of 178 of the case patients (46%) were female, and 340 (89%) were unvaccinated. Transmission took place primarily within households (68% of cases). The virus strain was genotype D9, which was circulating in the Philippines at the time of the reporting period. Measles-mumps-rubella (MMR) vaccination coverage with at least a single dose was estimated to be 14% in affected Amish households and more than 88% in the general (non-Amish) Ohio community. Containment efforts included isolation of case patients, quarantine of susceptible persons, and administration of the MMR vaccine to more than 10,000 persons. The spread of measles was limited almost exclusively to the Amish community (accounting for 99% of case patients) and affected only approximately 1% of the estimated 32,630 Amish persons in the settlement.

CONCLUSIONS

The key epidemiologic features of a measles outbreak in the Amish community in Ohio were transmission primarily within households, the small proportion of Amish people affected, and the large number of people in the Amish community who sought vaccination. As a result of targeted containment efforts, and high baseline coverage in the general community, there was limited spread beyond the Amish community. (Funded by the Ohio Department of Health and the Centers for Disease Control and Prevention.).

Modeling Measles Transmission in the North American Amish and Options for Outbreak Response

Measles outbreaks in the United States continue to occur in subpopulations with sufficient numbers of undervaccinated individuals, with a 2014 outbreak in Amish communities in Ohio pushing the annual cases to the highest national number reported in the last 20 years. We adapted an individual-based model developed to explore potential poliovirus transmission in the North American Amish to characterize a 1988 measles outbreak in the Pennsylvania Amish and the 2014 outbreak in the Ohio Amish. We explored the impact of the 2014 outbreak response compared to no or partial response. Measles can spread very rapidly in an underimmunized subpopulation like the North American Amish, with the potential for national spread within a year or so in the absence of outbreak response. Vaccination efforts significantly reduced the transmission of measles and the expected number of cases. Until global eradication, measles importations will continue to pose a threat to clusters of underimmunized individuals in the United States. Aggressive outbreak response efforts in Ohio probably prevented widespread transmission of measles within the entire North American Amish.

Communication and mass vaccination strategies after pertussis outbreak in rural Amish communities-Illinois, 2009-2010

PURPOSE

During January 2010, 2 infants from an Amish community in east-central Illinois were hospitalized with pertussis. The local health department (LDH) intervened to control disease transmission, identify contributing factors, and determine best communications methods to improve vaccination coverage.

METHODS

A retrospective cohort study was conducted using public health surveillance data to determine the extent of the outbreak; the standard Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists case definition for pertussis was used. The standardized Illinois Department of Public Health pertussis patient interview form was used to collect demographic, symptom, vaccination history, and treatment history information. To control disease transmission, LDH staff worked with the Amish community to promote a vaccination campaign during February 6-April 30, 2010.

FINDINGS

Forty-seven cases were identified, with onsets during December 2009-March 2010. Median age was 7 (interquartile range 1-12) years. Nineteen (40%) patients were male; 39 (83%) were aged <18 years; 37 (79%) had not received any pertussis-containing vaccine. Presenting symptoms did not differ substantially between vaccinated and unvaccinated patients. Duration of cough was longer among unvaccinated than vaccinated patients (32 vs. 15.5 days, P = .002). Compared with vaccinated patients, proportionately more unvaccinated patients reported secondary household transmission (30% vs. 72%; P = .012). Through enhanced vaccination campaigns, 251 (∼10%) Amish community members were administered 254 pertussis-containing vaccines.

CONCLUSIONS

Targeted health communication and outreach resulted in a successful vaccine campaign and long-running monthly vaccination clinic. Amish do not universally reject vaccines, and their practices regarding vaccination are not static.

What the world's religions teach, applied to vaccines and immune globulins

For millennia, humans have sought and found purpose, solace, values, understanding, and fellowship in religious practices. Buddhist nuns performed variolation against smallpox over 1000 years ago. Since Jenner developed vaccination against smallpox in 1796, some people have objected to and declined vaccination, citing various religious reasons. This paper reviews the scriptural, canonical basis for such interpretations, as well as passages that support immunization. Populous faith traditions are considered, including Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam. Subjects of concern such as blood components, pharmaceutical excipients of porcine or bovine origin, rubella strain RA 27/3, and cell-culture media with remote fetal origins are evaluated against the religious concerns identified. The review identified more than 60 reports or evaluations of vaccine-preventable infectious-disease outbreaks that occurred within religious communities or that spread from them to broader communities. In multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se. Themes favoring vaccine acceptance included transformation of vaccine excipients from their starting material, extensive dilution of components of concern, the medicinal purpose of immunization (in contrast to diet), and lack of alternatives. Other important features included imperatives to preserve health and duty to community (e.g., parent to child, among neighbors). Concern that 'the body is a temple not to be defiled' is contrasted with other teaching and quality-control requirements in manufacturing vaccines and immune globulins. Health professionals who counsel hesitant patients or parents can ask about the basis for concern and how the individual applies religious understanding to decision-making about medical products, explain facts about content and processes, and suggest further dialog with informed religious leaders. Key considerations for observant believers for each populous religion are described.

Underimmunization in Ohio's Amish: parental fears are a greater obstacle than access to care

OBJECTIVE

Holmes County, Ohio, one of the largest Amish communities 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 regarding 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 vaccination 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. Underimmunization in the Amish population must be approached with emphasis on changing parental perceptions of vaccines in addition to ensuring access to vaccines.

Feasibility of a rubella screening and vaccination programme for unvaccinated young women

The feasibility of a rubella screening and vaccination programme for unvaccinated young women was assessed after the 2004/2005 epidemic in The Netherlands. All 640 young women in two villages with low vaccination coverage were invited for a rubella seroprevalence test. Information on vaccination status was gathered by written questionnaire. Women testing seronegative were offered free rubella vaccination. The feasibility of the programme was evaluated in terms of participation, rubella susceptibility, and acceptance of the vaccination offer by seronegative women. The participation rate was 48% [95% confidence interval (CI) 44–52] with 108 unvaccinated participants. Eleven per cent (95% CI 6–19) of the women were identified as susceptible to rubella, of whom 17% (95% CI 2–48) accepted the vaccination offer. In the end only 0·9% (95% CI 0·1–2·5) of the target population was given protection by the programme. Under the present conditions this programme proved to be an inefficient strategy for rubella protection.

Vaccination usage among an old-order Amish community in Illinois

The Old-Order Amish have low rates of vaccination and are at increased risk for vaccine-preventable diseases. A written survey was mailed to all Amish households in the largest Amish community in Illinois inquiring about their vaccination status and that of their children. In this survey, the Amish do not universally reject vaccines, adequate vaccination coverage in Amish communities can be achieved, and Amish objections to vaccines might not be for religious reasons.

Case series: outbreak of conversion disorder among amish adolescent girls

OBJECTIVE

Outbreak investigations are challenging in a cross-cultural context, and outbreaks of psychiatric disease are rare in any community. We investigated a cluster of unexplained debilitating illness among Amish girls.

METHOD

We reviewed the medical records of cases, consulted with health care providers, performed active case finding, administered open-ended and structured interviews, and met with Amish community members. A case-patient was defined as a resident of the county who was bedridden for more than 3 weeks with otherwise unexplained systemic weakness and anorexia from January 2000 to February 2002.

RESULTS

Five case-patients were identified. All were Amish girls aged 9 to 13 years. All five had debilitating voluntary motor deficits, anorexia, and weight loss. Four experienced neck weakness with inability to hold up their heads. Thorough medical evaluations failed to identify an organic etiology. All five patients met the diagnostic criteria for conversion disorder. Substantial social conflict within the Amish community preceded illness onset. Family behavioral interventions were recommended. Three months after the investigation, four of five patients demonstrated some improvement.

CONCLUSIONS

Clinicians should be aware of the potential for outbreaks of psychogenic illness and work to address the challenges of developing effective intervention strategies, particularly in the cross-cultural context.

Haemophilus influenzae Type b disease among Amish children in Pennsylvania: reasons for persistent disease

OBJECTIVE

To identify reservoirs of Haemophilus influenzae type b (Hib) pharyngeal carriage and assess barriers to vaccination among 2 Amish communities in Pennsylvania.

METHODS

We investigated recent cases, performed community surveys for Hib vaccination coverage and pharyngeal carriage, and administered a questionnaire assessing vaccination knowledge and attitudes to 298 members of 2 Amish communities (A and B) in Pennsylvania and, as a comparison group, 136 non-Amish family members who participated in state immunization clinics. From December 1999 to February 2000, 8 cases of invasive Hib disease occurred among children who were 5 years of age or younger in Pennsylvania. Six of the case-patients were from Amish communities. None of the children had been vaccinated.

RESULTS

Among children who were 5 years of age or younger, Hib vaccine coverage was low in the 2 Amish communities: A (9 [28%] of 32) and B (3 [7%] of 41) compared with the non-Amish group (19 [95%] of 20). Hib carriage prevalence was higher in both Amish communities than in the non-Amish group (A: 3%; B: 8%; non-Amish: 0%). More households in community B had 1 or more Hib carriers than in community A (8 [28%] of 29 vs 3 [9%] of 32). Among Amish parents who did not vaccinate their children, only 25% (13 of 51) identified either religious or philosophical objections as a factor; 51% (26 of 51) reported that vaccinating was not a priority compared with other activities of daily life. Seventy-three percent (36 of 49) would vaccinate their children if vaccination were offered locally.

CONCLUSIONS

Undervaccinated communities in the United States still exist and allow circulation of Hib strains, resulting in disease among susceptible children. Identification of undervaccinated populations, such as the Amish, and targeted education and vaccination campaigns are essential to achieving elimination of Hib disease.