Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle Than Access to Care
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ARTICLES
Underimmunization in Ohio’s Amish: Parental Fears
Are a Greater Obstacle Than Access to Care
AUTHORS: Olivia K. Wenger, MD,a Mark D. McManus, PhD, WHAT’S KNOWN ON THIS SUBJECT: Underimmunized
MSSW,b John R. Bower, MD,c and Diane L. Langkamp, MD, communities are reservoirs of preventable childhood diseases in the
MPHd United States. Many Amish communities have low immunization
Departments of aPediatrics, cInfectious Diseases, and rates. Previous research among the Amish has revealed that the
dDevelopmental Behavioral Pediatrics, Akron Children’s Hospital,
major barrier to immunization is lack of access to health care.
Akron, Ohio; and bSchool of Social Work, University of Akron,
Akron, Ohio
WHAT THIS STUDY ADDS: Among the Amish in Holmes County,
KEY WORDS
Ohio, the major barrier to immunization is parental concerns
Amish, immunizations, immunization safety, attitudes, exemption
over adverse effects of vaccines. Decision-making about
ABBREVIATION
vaccination among Amish parents is complex; many Amish
DoH—Department of Health
parents accept some vaccines for their children but refuse
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2599
others.
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).
abstract
OBJECTIVE: Holmes County, Ohio, one of the largest Amish communi-
Copyright © 2011 by the American Academy of Pediatrics
ties in the world, has persistently low immunization rates. Studies of
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
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
PEDIATRICS Volume 128, Number 1, July 2011 79
Downloaded from by guest on November 2, 2015Despite the efforts of pediatric provid- and ⱖ3 doses of hepatitis B vaccine] tory of Amish families living in Holmes
ers nationwide to advocate for immu- series) (Sally Hofsetter, director, per- County and its vicinity in 2005.14 The di-
nizations, some parents choose not to sonal health services, Holmes County rectory lists the names and birth dates
vaccinate their children.1,2 Children Department of Health, Millersburg, OH, of children in each household. Al-
who live in closed communities with personal communication, July 14, though addresses were selected at
high vaccine-exemption rates are 2006).12 The Holmes County Depart- random, only addresses of families with
particularly vulnerable to vaccine- ment of Health (DoH) has increased children born after 1980 were used.
preventable diseases.3,4 The Amish, a the availability of vaccinations by hold- Such purposeful sampling from a ran-
separatist Christian sect, have had ing immunization clinics near commu- dom component of a specific population
persistently low immunization rates. nity gatherings such as livestock auc- has been used in other exploratory stud-
Multiple outbreaks of vaccine- tions and by offering to administer ies of barriers to immunization.15 A list of
preventable infections including per- vaccines at parochial schools. Also, 1000 families (5% of the population) was
tussis, rubella, measles, and Haemo- most physicians provide vaccines generated. The survey was sent with a
philus influenzae type b have been through government-supplemented cover letter and a self-addressed,
described in underimmunized Amish programs at minimal cost. However, stamped reply envelope. No incentive
communities.5–9 low immunizations rates persist, was offered for survey completion. All
which suggests that the barriers to im- surveys were anonymous.
Although vaccination is not specifically
prohibited by Amish religious doctrine, munization among the Holmes County
Amish differ from those described Statistical Analysis
the reasons for the low immunization
among the Amish in Lancaster County. The data were analyzed by perform-
rates have not been clearly identified.
ing cross-tabulations, and signifi-
Authors of a previous study cited lim-
MATERIALS AND METHODS cant differences were established by
ited access to health care as a barrier
2 statistics using SPSS 15.0.16 Some
to immunization among the Amish.10 Sample and Instrument
respondents did not select answers
Among the Amish in Lancaster County, This study consisted of a mailed 25- to all 25 questions. Missing data
Pennsylvania, investigators found that question survey to Amish parents in were handled by using available case
only 16% of children aged 6 months to Holmes County. Survey questions were analysis so that all available re-
5 years were fully immunized. A survey designed with input from Amish com- sponses were used to calculate each
of Amish families in Lancaster County munity leaders, physicians who serve statistic, and the number of re-
found that 75% reported that they Amish families, the Holmes County DoH sponses varied across analyses.17
would immunize their children if vacci- staff, and previous studies of parental
nations were offered locally.9 The gen- We examined the answers to ques-
attitudes toward immunization (Nancy
eralizability of the Lancaster County tions and comments written by sur-
E. Rosenstein, personal communica-
findings to other Amish communities vey respondents for thematic trends.
tion, July 14, 2006).13 The questions ex-
has not been determined. Holmes The end result of this exploration
plored basic demographic informa-
County, Ohio, is one of the largest set- was to provide pertinent themes and
tion, family-specific immunization
tlements of Amish in the world, yet this specific quotes to illustrate the key
status, parental attitudes toward im-
population’s attitudes regarding im- findings.18,19
munization, religious ideas regarding
munizations have not been re- immunization, and exposure to poten- RESULTS
searched.11 In 2006, 45% of the Holmes tial adverse effects of immunizations.
County population was reported to be Most questions offered multiple- Demographics
fully immunized, compared with a choice answers with an option to write Of 1000 surveys distributed, 360 com-
statewide Ohio immunization rate of in comments. A few questions were pleted surveys were returned and 33
80% and a national rate of 85% (based open-ended. The survey was reviewed were returned as undeliverable, which
on children aged 19 –35 months who by a small group of Amish parents to resulted in a response rate of 37%. One
received the 4:3:1:3:3 [ⱖ4 doses of ensure clarity. The study was approved survey was completed by a Mennonite
diphtheria, tetanus toxoid, and any by the institutional review board at Ak- and, thus, was excluded from analysis.
acellular pertussis vaccine, ⱖ3 doses ron Children’s Hospital. The mailing Demographic characteristics obtained
of poliovirus vaccine, ⱖ1 dose of mea- addresses of Amish parents were ob- from the respondents included gender
sles, mumps, rubella vaccine, ⱖ3 tained from the 2005 Ohio Amish Direc- (67% female), age (range: 24 – 69
doses of H influenzae type b vaccine tory, which is a comprehensive direc- years; mean: 39.1 years), religious af-
80 WENGER et al
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filiation (85% Old Order Amish, 12% dren. More than 30% of the parents TABLE 1 Reasons for Exemption From
Immunization (N ⫽ 49)
New Order Amish, 3% other Amish who vaccinated at least some of their
Possible Responsesa n (%)
church), and insurance coverage (95% children stated that they had been vac-
Shots have too many side effects to be 48 (97)
uninsured). cinated as children.
worth the risk of gettingb
Parents who allow some, but not all, Shots could have dangerous chemicals 14 (29)
Immunization Trends or preservatives in themc
recommended immunizations re-
Shots inject children with dangerous 6 (12)
The parents were asked to state ported several explanations for their germs like whooping cough
whether all, some, or none of their chil- decision to use selective immuniza- The diseases shots prevent are not a 4 (8)
dren had received immunizations. tion. Of the 140 respondents who al- problem in our community
Shots are too expensive 3 (6)
They were not asked to clarify how lowed selective immunization, 42% felt Other families in my district do not 3 (6)
many or which immunizations their that “giving all the shots at once is too give shots
children had received. Of the 359 re- hard on a baby,” 27% were concerned Giving shots means I’m not putting 3 (6)
faith in God to take care of my
spondents, 68% stated that all of their that “some shots were manufactured children
children had received immunizations, from aborted babies,” 25% were con- I have heard some shots are 2 (4)
17% stated that some of their children cerned that “there are too many rec- manufactured from aborted babies
had been immunized, and 14% stated It is too hard to get to the clinic/office 1 (2)
ommended shots,” and 19% felt that for shots
that none of their children had been “babies are too young to handle shots.” The ministers in my district disagree 0 (0)
immunized. Only 6% reported that it was “too hard with giving shots
a Participants were asked to circle any response with
A majority of the Amish in Holmes to get to the doctor’s office/clinic for
which they agreed.
County classify themselves as Old Or- shots,” and 2% said that they could b Highlighted as the most important singular reason for
der (more traditional) or New Order “not afford to get all the shots.” Re- exempting children from shots in 86% of the cases.
c Highlighted as the most important singular reason for
(less traditional).20 All New Order sponses varied according to parental exempting children from shots in 10% of the cases.
Amish respondents stated that they age; only 14% of parents aged 40 years
had their children immunized. In con- or older reported that “some shots
TABLE 2 Understanding of Risks and Benefits
trast, 84% of Old Order Amish had were manufactured from aborted ba- of Immunization (N ⫽ 304)
some or all of their children immu- bies” as a reason for allowing selective Possible Responsesa n (%)
nized, but 16% did not have any of immunization for their children com- Shots are safer overall than the 188 (61)
their children immunized (P ⫽ .02). pared with 39% of the younger parents diseases our children would get
To assess familiarity with the technol- (P ⫽ .001). without them
Shots would save our community money 110 (36)
ogy of immunization, 1 question asked by preventing illness if everyone got
about immunization of animals. Of the Reasons for Exemption From them
243 parents who responded that all of Vaccination Shots can cause high fevers more than 97 (32)
one week after they are given
their children had received vaccina- Table 1 lists the reasons that parents Shots can cause brain damage 95 (31)
tions, 40% immunized their animals. Of who did not have any of their children Shots can cause too much stress on the 91 (30)
immunized indicated to explain their system if given at once
the 49 parents who replied that none
Shots can cause seizures more than one 97 (32)
of their children had received vaccina- decision. The 3 most commonly re- week after they are given
tions, only 18% immunized their ani- ported explanations for not allowing a Respondents were asked to circle any of the statements
mals (P ⬍ .001). immunization were related to con- that they felt were correct.
cerns about adverse effects.
Reasons for Acceptance of
Vaccination and Selective Understanding of the Adverse spondents, 47% replied that they knew
Immunization Effects of Immunization someone with a serious adverse effect.
Among the 280 parents who vacci- To assess understanding of the risks More parents aged 40 years or older
nated at least some of their children, and benefits of immunization, re- reported that they knew someone with
100% agreed that vaccinations are spondents were asked to select a serious adverse effect of immuniza-
“protective against disease.” Nearly statements from a list with which tions than did the younger (⬍40-year-
half of the parents who vaccinated at they agreed (Table 2). Respondents old) parents (56% vs 44%; P ⫽ .04).
least some of their children indicated were then asked if they personally Table 3 lists the most common types of
that their physician or nurse recom- knew anyone who had had a “bad side- adverse effects to immunization
mended vaccinations for their chil- effect from baby shots.” Of the 359 re- reported.
PEDIATRICS Volume 128, Number 1, July 2011 81
Downloaded from by guest on November 2, 2015TABLE 3 Examples of Immunization Adverse fant immunizations. Of the 154 respon- had not had any of their children im-
Effects Listed by Parents
dents, 38% replied that they had re- munized, 20% did not know about the
Mild reactions
ceived such advice from their DoH vaccine posts in their county. Of
“Swelling, stiffness”
“Fever, swelling of the arm” community and friends, 37% from par- the 304 respondents who had had
“Our oldest, now 10 years old, was about 6 ents/other family members, 16% from some or all of their children vacci-
months when she could not move her leg books, 19% from articles, 10% from
without screaming for about 12 to 24 hours
nated, 11% did not know about the DoH
after getting shots.” chiropractors, and 6% from their fam- clinics (P ⫽ .005). We asked the re-
“He got a very high fever.” ily’s doctor/nurse. No respondents spondents if they knew that immuniza-
Developmental regression reported that their ministers advis-
“I have a relative that was a healthy girl. She
tions provided by the DoH could be free
was walking and talking until she got her
ed against immunization. Parents of charge. A larger proportion of par-
shots. She can’t talk or walk without help younger than 40 years were more ents who had not had any of their chil-
and has a very miserable life.” likely to report having received advice
“Couldn’t walk anymore”
dren immunized were not aware that
“He could never walk again and they said it
against immunizations from parents/ immunizations could be obtained at no
was from the shots and his mind was other family members than older par- cost (37%) compared with only 11% of
affected.” ents (45% vs 25%; P ⫽ .02). the respondents who had had some or
“I know of three children that were perfectly
normal till after receiving baby shots.” The respondents were asked to indi- all of their children vaccinated (P ⬍
“Stunted growth” cate any sources from which they .001).
Neurologic sequelae
learned about infant immunizations. Of
“Brain damage (they gave her too much for her
weight)” the 327 respondents, 74% wrote that Factors That Would Influence
“She is crippled—cannot walk” they had learned about immunizations Decision-Making of Exempting
“Brain damage, though I’m not sure how they from their doctor/nurse, 64% from
know it was due to shots”
Parents
“Seizures” their family, 7% in school, 7% from
Parents who exempted completely or
“Severe brain damage caused by high fever magazines or papers, 5% from their
from [the measles, mumps, rubella
partially from vaccines were asked to
midwife, and 3% from their chiroprac-
vaccine]” indicate factors that might alter their
“Mentally disabled”
tor. Parents younger than 40 years
decision. Of the 95 respondents, 86%
Death were more likely to report that they
“Crib death”
stated that they would be more likely to
learned about infant immunizations
“Death, the baby was too weak to handle them” consider having their children immu-
from their family than were older par-
nized if they “knew shots were safe to
ents (73% vs 52%; P ⬍ .001).
give,” 20% if “there was a disease out-
Attitudes Regarding the break,” 11% if “shots were required by
Immunization Schedule Addressing Spirituality or Faith in
Decision-Making Regarding the law/government,” and 10% if their
Parents were asked whether giving Immunization “parents or family encouraged them.”
shots at 2, 4, and 6 months was “too The answers “if the shots were cheaper,”
early.” Of the 359 respondents, 47% did Only a small minority of the parents
if their “bishop or elder recommended
not feel that physicians gave shots too reported that their religious or spir-
them,” and if “it were easier to get to the
early, 35% felt that doctors do give im- itual beliefs influenced their deci-
doctor’s office or clinic” were selected by
munizations too early, and 18% were sions about immunization. When
asked if “giving shots disagrees with only 5%, 3%, and 3% of the respondents,
unsure. More parents who reported respectively.
knowing someone with a serious ad- your faith or spiritual beliefs in some
verse effect from immunizations re- way,” 63% replied “no,” 4% indicated None of the 10 exempting parents who
plied that giving shots at 2, 4, and 6 “yes,” and 30% did not respond to the were not aware of accessible DoH vac-
months was “too early” compared with question. cine posts stated that they would con-
parents who did not know someone sider having their children immunized
Addressing Access and Financial if the doctor’s office were “easier to
with a serious adverse effect from im-
Burden of Vaccines
munizations (57% vs 25%; P ⬍ .001). get to.” Only 2 of the 18 exempting par-
The respondents were asked if they ents who were not aware that DoH vac-
Sources of Information Regarding knew that the Holmes County DoH of- cines could be free indicated that they
Vaccines fered immunization clinics throughout would consider having their children
All the respondents were asked to the county at convenient times and lo- immunized if “the shots were
identify who advised them against in- cations. Of the 49 respondents who cheaper.”
82 WENGER et al
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DISCUSSION who had suffered a “serious adverse the Amish population in Arthur, our
We found that Amish parents in Hol- effect” from immunization and de- study provides further insight into un-
mes County generally accept some scribed many potential adverse effects derimmunization in Amish communi-
vaccinations; 85% of them have their may reflect the closeness of their com- ties by revealing the practice of selec-
children at least partially immunized. munity or the incidence of inherited tive immunization. The reticence
Amish parents of unvaccinated chil- metabolic disorders in the population. of parents to accept immunization
dren were concerned about adverse However, surveys of the general Amer- against rubella and varicella because
effects and the ability of an infant to ican public have revealed similar pa- of the understanding that the immuni-
tolerate vaccines rather than about fi- rental misconceptions regarding ad- zations “come from aborted babies”
nancial, accessibility, or religious is- verse effects of immunization.13 One suggests an ethical if not specifically
sues. Their concerns about adverse ef- study of antivaccination Web sites religious basis for their decision-
fects and the ability of an infant to found content claims that vaccines making. (Rubella and varicella vac-
tolerate vaccines mirror the concerns cause idiopathic illness and erode im- cines present concern because the at-
of non-Amish parents in the broader munity in 95% of sites analyzed.21 Other tenuated viruses in the vaccines are
American society. concerns of Amish parents about the propagated by using a human cell line,
current immunization schedule, in- WI-38, derived in 1961. The cell line was
Given the low immunization rates in
cluding that it is “too hard on a baby’s originally prepared from tissues of an
Holmes County, we were surprised by
system” or that infants are “too young aborted fetus.)25 Further investigation
the high proportion of respondents
to handle shots,” reflect misconcep- is needed to more fully understand the
who had accepted vaccines for some
tions about immunizations that are re- reasons for selective immunization
or all of their children. In an effort to
flected in the views of the mainstream among Amish families.
keep the survey brief, respondents
American public.22,23 Understanding separatist groups
were not asked to specify which vac-
cines they accepted. DoH staff re- Similar to our study, a survey of an Ar- such as the Amish is crucial for pre-
ported to us that some Amish parents thur, Illinois, Amish population found vention of disease epidemics, be-
accept immunizations against poliovi- that parents were most concerned cause underimmunized populations
rus or H influenzae type b but not those about vaccine safety rather than avail- are proven reservoirs of serious in-
against varicella or Streptococcus ability, cost, prioritization, or align- fections.26 We aimed to examine non-
pneumoniae. Thus, although the par- ment with religious values.24 Thus, the quantifiable issues such as parental
ents had accepted some immuniza- Amish populations of Holmes County attitudes, expectations, and beliefs.
tions, their children would not be “fully and Arthur seem to differ from the The survey was designed to system-
immunized” according to Centers for Amish population in Lancaster County, atically gather data that focused on a
Disease Control and Prevention stan- where 51% of parents exempting from specific line of inquiry, but given our
dards. This finding points to the need vaccines did not consider vaccination resources, it was difficult to validate
to further explore parents’ concerns a priority compared with other activi- our data with triangulation or re-
about individual vaccines rather than ties of daily life, and 29% of exempting spondent validation.27,28 Neverthe-
vaccination as a general practice. parents felt that it was “too difficult to less, our findings provide insight for
When comparing responses of the par- travel” to places where vaccinations future studies involving the same
ents who exempted completely with were offered.9 and comparison populations.
those of nonexempting parents, con- Our study shows that the characteriza- The response rate to our survey was
cern regarding potential adverse ef- tion of religious values in medical only 37%, which introduces a risk of
fects was the major barrier to immu- decision-making is complex. Amish re- sampling bias. Survey recipients who
nization cited; 82% of the exempting spondents stressed that individual view health care providers and vacci-
parents stated that they would con- families were responsible for the deci- nations favorably may have been more
sider vaccinating their children if “they sion to vaccinate. Only a few respon- likely to complete and return our sur-
knew the shots were safe to give,” and dents reported that giving shots would vey. We speculate that parents who
only a few exempting parents reported conflict with their faith or spiritual be- completely exempt from immunization
that they would have their children im- liefs. This result aligns with previous may have been less likely to respond to
munized if the shots were cheaper or findings that most Amish people do not our survey. Another study that used
easier to access. The fact that many view vaccination as a religious or spir- written surveys of an Amish population
parents claimed to know someone itual issue. In contrast to the study of about health care issues obtained a
PEDIATRICS Volume 128, Number 1, July 2011 83
Downloaded from by guest on November 2, 2015similar response rate.10 Those investi- ten permit their children to receive study. Our results indicate that con-
gators reflected that “the Amish are only certain vaccines. Although most cerns about immunization practice
not often asked to answer written sur- Amish parents report that decisions among Amish populations are similar
vey questions and may not be familiar about immunization are not influenced to the concerns of mainstream Ameri-
with this mode of gathering informa- by their religious beliefs, many choose cans and that concerns about vaccine
tion.”10 Lack of familiarity with this type to exempt from certain vaccines on the safety represent the major barrier to
of instrument may have contributed to basis of ethical values. The Amish may immunization. Efforts of health care
some reticence among Amish parents require different approaches to ad- providers working with Amish families
to respond to our survey. However, dressing misconceptions about vacci- must focus on redirection of parental
other means of assessing parental nation than the general population, be- misconceptions about vaccine safety
opinions in the general population (eg, cause the religious principles of the rather than simply improving access
telephone surveys) cannot be used ef- Amish, who value separation from the to vaccines.
fectively in the Amish community. The secular world, prevent exposure to
issue of nonresponse to the entire sur- many avenues that are used to educate
vey or to specific questions in the the public about vaccines, such as tele-
ACKNOWLEDGMENTS
Amish population is difficult to inter- vision or radio. Because Amish fami- This research was supported by a
pret without further and potentially lies are less likely to seek preventive grant from the Akron Children’s Hospi-
costly investigation. health care,29 peer educators within tal Foundation.
the Amish community who are sensi- Special thanks go to Peter Reuman,
CONCLUSIONS tive to the traditions and culture of the Jerry Slabaugh, Marla Sabey, Marne
More Amish parents in Holmes County Amish community may be needed to Woyat, D. J. McFadden, MD, Akron Chil-
reported accepting vaccines than we address the common misconceptions dren’s Hospital Department of Volun-
expected, but these Amish families of- about immunizations reported in this teers, and the Holmes County DoH.
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1097–1102 25. Hayflick L, Moorhead PS. The serial cultiva- health care: assessing quality in qualitative
23. Offit PA, Quarles J, Gerber MA, et al. Ad- tion of human diploid strains. Exp Cell Res. research. BMJ. 2000;320(7226):50 –52
dressing parents’ concerns: do multiple 1961;25:585– 621 29. Hurst CE, McConnell DL. An Amish Paradox. Balti-
vaccines overwhelm or weaken the infant’s 26. May T, Silverman RD. “Clustering of exemptions” 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 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
PEDIATRICS Volume 128, Number 1, July 2011 85
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Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp
Pediatrics 2011;128;79; originally published online June 27, 2011;
DOI: 10.1542/peds.2009-2599
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 2, 2015Underimmunization in Ohio's Amish: Parental Fears Are a Greater Obstacle
Than Access to Care
Olivia K. Wenger, Mark D. McManus, John R. Bower and Diane L. Langkamp
Pediatrics 2011;128;79; originally published online June 27, 2011;
DOI: 10.1542/peds.2009-2599
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/128/1/79.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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