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Interviews with Orthodox Jewish moms reveal barriers to measles vaccination
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Findings from a small case series of interviews with Orthodox Jewish mothers revealed several factors that are impacting childhood vaccination rates in New York communities with large Jewish populations. These results may help officials tailor interventions to improve vaccine uptake because Jewish mothers hold important influence among social networks within Orthodox communities
“Our data suggest that establishing trust, influencing social networks as well as media and cultural or religious factors among ultra-Orthodox Jewish mothers may have a favorable impact on the measles vaccination,” Charles H. Hennekens, MD, DrPH, senior author and senior academic advisor at Florida Atlantic University’s Schmidt College of Medicine, said in a press release.
The New York City Department of Health and Mental Hygiene has confirmed 550 cases in the city since September. The city has mandated vaccines in certain zip codes, imposing a potential $1,000 fine on those who have not received the MMR vaccine. Rockland County, New York, has also been struggling to contain the disease, having declared a state of emergency and banning unvaccinated children from public places.
“The situation has raised the specter of ethical concerns about the freedom of parents to choose not to vaccinate, as well as the need to protect the health of the general public,” Hennekens and colleagues wrote in the commentary. “In that regard, the residents of Rockland County have raised a legal challenge temporarily blocking the state of emergency order.”
The authors noted that the outbreaks in New York City and in Rockland County seem confined to ultra-Orthodox Jewish residents who have not had their children vaccinated, and some cases have been linked to travel to Israel, where the prevalence of measles has been increasing.
“Thus, at present, increasing the understanding of barriers to childhood vaccination among the ultra-Orthodox will have important and timely implications for the health of the general public,” they wrote.
Rachael Silverberg, MPH, from FAU, conducted semi-structured interviews with five mothers who self-identified as members of the ultra-Orthodox Jewish communities in Brooklyn and Rockland counties. All five, according to the study, were unwilling to have their children vaccinated. The reasons they gave included suspicion for and animosity toward the vaccine, as well as cultural factors within the community. In some ultra-Orthodox neighborhoods, for example, “religious fatalism,” or the belief that God is in control of the illness rather than a vaccine, contributed to low vaccination rates, Hennekens and colleagues wrote. They also named large family size as a contributing factor, given that ultra-Orthodox families have an average of 8.33 children, which increases the risk for disease transmission between children. Other factors include poverty, limited secular education and domestic overcrowding, according to the study.
Rabbis, health care practitioners, mothers of high social standing and other community members of influence should be identified and recruited as advocates for childhood immunization, they wrote.
“The success of these partnerships would be dependent upon the strength and durability of relationships forged between health officials and the community,” Hennekens and colleagues wrote. “Lack of trust in perceived agents of outside establishment presents a considerable barrier to the success of externally motivated health intervention and highlights the importance of outreach activities that seek to dispel suspicion and fear.”
This week, the CDC reported 971 confirmed cases of measles in the United States thus far in 2019. This is the largest number of cases reported in the U.S. since 1992 — 8 years before measles was declared eliminated in the country. The outbreaks in New York City and Rockland County have dragged on for nearly 8 months, and if they continue through the summer and fall, the U.S. may lose its elimination status, the agency warned. – by Joe Gramigna
Reference:
NYC Health. Measles. https://www1.nyc.gov/site/doh/health/health-topics/measles.page. Accessed May 30, 2019.
Disclosures: Silverberg is currently a medical student at the Charles E. Schmidt College of Medicine at FAU. Please see the full commentary for a list of all other authors’ relevant financial disclosures.
Perspective
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Aaron Glatt, MD, FACP, FIDSA, FSHE
This paper provides an important commentary on the ongoing measles outbreak spreading across the entire globe — present in over 170 countries, encompassing hundreds of thousands of cases worldwide, with thousands of deaths since its onset and no end in sight.
Although the authors focus on one small but important U.S. segment of this raging epidemic, the points they made are generalizable to other populations across the country and the world as well.
Any insular community — especially one with very large numbers of young children in a relatively circumscribed geographic location, with multiple opportunities through school, religious or social contexts for mingling — will be a haven for the spread of a highly contagious disease like measles. This has nothing to do with religion because measles outbreaks have occurred throughout the U.S. and the world in almost every ethnic, religious or nonreligious group. Indeed, as an orthodox rabbi, I can attest to the fact that there is no Jewish opinion that forbids vaccination, and indeed, the vast majority of preeminent rabbis strongly advocate and mandate vaccination. To my knowledge, all of the major religions of the world are also in favor of such immunizations.
The common denominator for trouble in all of these circumstances is suboptimal immunization rates, secondary to strong anti-vaccination influences from nonscientific and unsupported anecdotal positions. This misinformation can easily spread in many different communities, not just poor, uneducated groups. Indeed, there are studies demonstrating that some of the highest incidences of nonvaccination occur in middle to upper socioeconomic, highly educated populations.
Anti-vaxxers are a relatively small but highly visible and vocal group that have no real experts supporting their unscientific position. Yet, they have an inordinate number of supporters in the pop culture and political world, despite their lack of scientific credentials. Their popular appeal is often underestimated, and their influences are sometimes beneath the public health and establishment radar.
One scientific point that is frequently not given the high priority it deserves is that many of the cases in the current outbreak in orthodox Jewish communities were in very young children previously recommended NOT to get vaccinated, ie, children aged younger than 12 to 15 months. Vaccination is delayed to this point in the child's life because of the concern that maternal antibody might still be circulating in these infants and will result in a suboptimal response to vaccination. Likewise, the second MMR vaccination was recommended to be scheduled in children between 4 and 6 years of age, which meant that a small but significant percentage of children vaccinated with only a single dose (having only an approximately 93% chance of acquiring immunity) were, in fact, still at risk for infection.
However, in an epidemic situation, or when traveling to an endemic region, these recommendations are no longer appropriate. Instead, we now recognize that vaccinating at 6 months of age is preferred in such circumstances. Additionally, we recommend that the previously recommended second vaccination dose given between ages 4 and 6 years should now be provided much earlier — as soon as possible — 28 days after the dose given at 1 year. These new recommendations have brought a tremendous increase in vaccinations in the Rockland County outbreak, with over 22,000 doses of vaccine provided in the recent months vs. only 1,000 doses just a year ago. This is truly a phenomenal community and public health response to this epidemic.
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