Some Outbreaks of Vaccine-Preventable Disease in Groups with Religious or Philosophical Exemptions to Vaccination

Many children had to live in an iron lung before the polio vaccine was developed. Photo courtesy of the World Health Organization

In 1972 there was an outbreak of polio at Daycroft, a Chris­tian Science boarding school in Greenwich, Connecticut. Eleven children were left with varying degrees of paralysis. The epidemic was not discovered by health authori­ties until twenty days after the first student had become ill with the disease and after five students had been sent to their homes in other states.

“Poliomyelitis Prevention in the United States,” 49 MMWR Recommendations and Reports 05 (May 19, 2000):1-22; Franklin Foote et al., “Polio Outbreak in a Private School,” 37 Connecticut Medicine (Dec. 1973):643-44; Stephen Barrett, The Health Robbers (Philadelphia: George Stickley Co., 1976): 268.
In 1979 Amish communities in Missouri, Iowa, Pennsylvania, and Wiscon­sin had fourteen cases of paralytic polio.

“Epidemiologic notes and Reports Follow-up on Poliomyelitis”—United States, Canada, Netherlands,” 46 MMWR (Dec. 19, 1997):1195-99.

In 1978-79, there were 11 cases of paralytic polio among unimmunized persons in religious groups in Ontario, Alberta and British Columbia. In 1993, 22 asymptomatic persons (primarily children) were found with imported wild poliovirus type 3 among the same Old Netherlands Reformed Church congregation in southern Alberta that had polio cases in 1978-79.

“11. Activities Related to the Elimination of Polio and the Report of Working Group on Polio Elimination,” Canadian National Report on Immunization 1996, vol. 23S4, May 1997.

In 2005 an Amish congregation in central Minnesota had five cases of polio among unvaccinated children. One child had an immune deficiency that made her body unable to rid itself of the virus.

Clusters of unvaccinated people pose great challenges in vaccination programs. The oral polio vaccine (still given in many countries, but not the United States) gives a weakened form of the virus that will confer immunity not only to the vaccinated person, but also to some others in contact with him or her. But if this form of the virus spreads too far among previously unvaccinated people, its genes will change and it will regain its ability to cripple and kill. Such a virus caused an outbreak in Haiti and the Dominican Republic in 2000 and 2001 that crippled 21 people.

Gardiner Harris, “Five Cases of Polio in Amish Group Raise New Fears,” New York Times (Nov. 8, 2005). “Poliovirus Infections in Four Unvaccinated Children—Minnesota, Aug.-Oct. 2005,” 54 MMWR Dispatch (Oct. 14, 2005):1-3.

In 2003 Muslim clerics in Nigeria banned polio vaccination campaigns claiming they were an anti-Muslim plot. In 2005 when polio vaccination began again, 69 Nigerian children became paralyzed by the virus in circulation from the oral polio vaccine itself because it came in contact with such a huge number of unvaccinated people.

Gilbert Da Costa, “Setback for Nigeria’s Polio Fighters,” Time (Oct. 25, 2007).

In 1982, a nine-year-old girl contracted diphtheria at a Christian Science camp in Colorado and then traveled on a bus with many other unvaccina­ted children to Wiscon­sin where she died. Wisconsin and other states had to track down more than 100 children and adults she had come in contact with and culture them.

“Epidemiologic Notes and Reports Fatal Diphtheria—Wisconsin,” 31 MMWR (Oct. 22, 1982):553-5; “A Case of Diphtheria in Wisconsin,” 4 Wisconsin Epidemiology Bulletin (Sept. 1982):1.

In 1994, a four-year-old boy died of diphtheria in Weston, Massachusetts. His mother was a Christian Scientist and had not gotten immunizations for him.

“Current Trends Update: Childhood Vaccine-Preventable Diseases—United States 1994,” 43 MMWR (Oct. 7, 1994):718-20.

Paul Etkind, Susan Lett et al., “Pertussis outbreaks in groups claiming religious exemptions to vaccinations,” American Journal of Diseases of Children 146(Feb. 1992):173-76, report on four pertussis outbreaks in Massachusetts.

Daniel Feikin, Dennis Lezotte et al., “Individual and community risks of measles and pertussis associated with personal exemptions to immunization,” JAMA 284 (Dec. 27, 2000):3145-50, found that children ages 3-18 with personal belief exemptions were 5.9 times more likely to contract pertussis than vaccinated children.

In 1988 a four-month-old Amish boy died of pertussis in Conewango, New York, and 32 others in his Amish community contracted the disease.

AP, “Whooping cough outreak kills infant in community,” Prescott Courier (Nov. 23, 1988):9A.

The same Amish community had 216 cases of pertussis in 1982 and six in 1985.

In 1993 there were 35 cases of pertussis at two Kauai schools in Hawaii. The disease was brought to each school by children with religious exemptions from immunizations.

Jan TenBruggencate, “Vaccination exemptions increase disease risk,” Honolulu Advertiser (April 6, 1993).

Pertussis outbreaks occurred among unvaccinated persons in Amish communities in Delaware (1986) and Kentucky (1996).

Jaklen Tuyen and Kris Bisgard, “Chapter 10—Community Setting,”

From September, 2004, to February, 2005, there were 345 cases of pertussis among the Amish in Kent County, Delaware. 275 cases were among children under 15 years old.

“Pertussis Outbreak in an Amish Community—Kent County, Delaware, September 2004-February 2005,” 55 MMWR (Aug. 4, 2006):817-21.

In 2008 Winnebago County, Illinois, had 50 cases of pertussis. The index patient was a student with a religious exemption from vaccination who infected 26 students at a private school with a high number of religious exemptions.

Phone conversation with Winnebago County Health Dept.

In 2008 the East Bay Waldorf School in El Sobrante, California, had to close when 16 students were diagnosed with pertussis. The Waldorf schools provide education based on anthroposophy, a philosophy opposed to vaccination.

Henry Lee, “Whooping cough outbreak closes private school in El Sobrante,” San Francisco Chronicle (May 10, 2008).

In 1997 a 12-year-old Amish boy in Pennsylvania contracted tetanus. His medical bills were $600,000. The Amish community refused to apply for Medicaid because of their religious opposition to accepting government assistance and were able to pay only $60,000 of the bill.

“Tetanus: complications and management in a pediatric intensive care unit.”

In 1998 a Montana infant acquired neonatal tetanus because of his mother’s philosophi­cal objections to vaccination.

“Mother has philosophical objection to vaccine for neonatal tetanus,” Infectious Diseases in Children 12 (Jan. 1999):64, 66.

In 2002, Pediatrics reported on eleven children with religious or philosophical exemptions from immunizations who developed tetanus and an infant with tetanus whose mother had refused vaccination on grounds of her beliefs.

Elizabeth Fair, Trudy Murphy, et al., “Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years,” Pediatrics 109 (January, 2002):e1-3.

In 1990 the Followers of Christ in Oregon City, Oregon, had 69 cases of rubella.

“Current Trends in Rubella and Congenital Rubella Syndrome,” 40 MMWR (Feb. 15, 1991):93-99.

In the winter and spring of 1991 there were nine outbreaks of rubella in Amish communities in five states. At least 890 of the nation’s 1093 rubella cases that year occurred among the Amish. In Pennsylvania twelve Amish babies were born with congenital rubella syndrome.

AK Mellinger, JD Cragan, WL Atkinson et al. “High Incidence of Congenital Rubella Syndrome after a Rubella Outbreak,” 14 Pediatric Infectious Disease Journal (1995):573-78.

Measles (rubeola)
Between 1985 and 1994 there have been four large-scale outbreaks of measles at the Principia schools for Christian Scientists in the St. Louis area. The 1985 outbreak at Principia College had 128 confirmed or probable cases of measles with three deaths of young people from complications of measles. In 1989 there were 88 cases of measles at the Principia K-12 school and 12 measles cases at Principia College.

“Epidemiologic Notes and Reports Multiple Measles Outbreaks on College Campuses – Ohio, Massachusetts, Illinois,” 34 MMWR (Mar. 15, 1985):129-30.

Tom Novotny et al., “Measles outbreaks in religious groups exempt from immunization laws,” 103 Public Health Reports (1988):49-54.

“Measles Outbreak Over, Doctor Says,” St. Louis Post-Dispatch (Oct. 13, 1989):18A

Linda Eardley, “Five Schools Bar 140 who Lack Measles Shots,” St. Louis Post-Dispatch (Jan. 18, 1989):3A.

Martha Shirk, “Outbreaks among Religious Groups,” St. Louis Post-Dispatch (May 8, 1994):6A.

Later in 1985 there were more than 50 cases of measles at a Christian Science camp near Buena Vista, Colorado. The camp was closed, and all the campers sent home. State health departments in 16 states had to implement control measures to prevent secondary spread.

“Measles in a Population with Religious Exemptions to Vaccination – Colorado,” 34 MMWR (Nov. 29, 1985):718-20.

Also in 1985 a child with a religious exemption from immunizations was the index patient for a measles outbreak that spread to 137 persons at the Blackfoot Indian Reservation near Glacier National Park.

“Measles in a Population with Religious Exemptions to Vaccination,” op cit.

In 1989, 55 children got measles while attending a camp for Christian Scientists in Lebanon, Missouri, and triggered several mini-outbreaks when they returned to their home states.

Martha Shirk, “Outbreaks among Religious Groups,” St. Louis Post-Dispatch (May 8, 1994):6A.

In the fall of 1989, 241 cases of measles were reported among the 800 Amish residents of Audrain, Randolph, and Monroe Counties in Missouri.

Martha Shirk, “Outbreaks among Religious Groups,” St. Louis Post-Dispatch (May 8, 1994):6A.

In February and March, 1991, Philadelphia had 492 cases of measles and six deaths among children of the Faith Tabernacle Congregation and the First Century Gospel Church.

Desiree Rodgers et al., “High attack rates and case fatality during a measles outbreak in groups with religious exemption to vaccination,” 12 Pediatric Infectious Disease Journal (Apr. 1993): 288-92.

In 1994 a Christian Science youth at Principia schools in St. Louis was the index patient for an outbreak that spread to 247 children, including many in public schools. It is the nation’s largest measles outbreak since 1992 and cost St. Louis County more than $100,000.

“Outbreak of Measles Among Christian Science Students – Missouri and Illinois, 1994,” 43 MMWR (July 1, 1994):463-5.

Martha Shirk, “How 1 Case of Measles Became 176,” St. Louis Post-Dispatch (May 8, 1994):1A.

Also in 1994 a measles outbreak started in a Salt Lake County, Utah, polyga­mous community and spread to another polygamous community in White Pine County, Nevada. There were 134 cases in Utah, and 12 in Nevada. The patients were not immunized because of their families’ anti-government beliefs.

“Measles—United States, 1994,” 44 MMWR (July 7, 1995):493-94.

In 1996 there were 107 cases of measles in Washington County, Utah, where the percentage of schoolchildren claiming religious exemptions from immunizations is seven times the national average. The county has the polygamous Fundamentalist Latter-Day Saints Church, which opposes immunizations. Sixty-four of the 99 measles patients eligible for vaccination (meaning that they were older than one year and born after 1956) had received no doses of measles vaccine. The index patient and a total of 45% of the measles patients had religious or philosophic exemptions. Fifteen other unvaccinated measles patients were between one and four years old.

Daniel Salmon, et al., “Health Consequences of Religious and Philosophical Exemptions From Immunization Laws,” 282 JAMA (July 7, 1999):47-53.

“Measles Outbreak – Southwestern Utah, 1996,” 46 MMWR (Aug. 12, 1997): 766-69.

In 1999-2000 the Netherlands had 3,292 cases of measles. Three children died and 72 were hospitalized due to the disease. The outbreak began at a Dutch Orthodox Reformed school where only 7% of the students were vaccinated. The Netherlands Orthodox Reformed Church opposes vaccinations. While only about 2% of the Dutch belong to that church, they “form a strongly coherent social group” with their own schools and have large families. The Netherlands also had outbreaks of measles among unvaccinated persons in 1976, 1983,1987-88 and 1992-94.

Susan van den Hof et al., “Measles Outbreak in a Community with Very Low Vaccine Coverage, the Netherlands,” 7 Emerging Infectious Diseases (June 2001)

In 2004 Iowa had three cases of measles. Two of them were among Maharishi students who were unvaccinated because of their religious beliefs. The third case was a vacci­nated adolescent who rode next to an infectious Maharishi student on a plane. The outbreak cost the state $142,000 to manage.

Gustavo Dayan et al., “The Cost of Containing One Case of Measles: Economic Impact on the Public Health Infrastructure—Iowa, 2004,” 116 Pediatrics (July 2005):e1-e4.

“Postexposure Prophylaxis, Isolation and Quarantine To Control an Import-Associated Measles Outbreak—Iowa, 2004,” 53 MMWR (Oct. 22, 2004):969-71.

In 2004 a North Carolina girl with a religious exemption from immunizations infected an 11-month-old baby, who then was taken to a summer camp where he potentially had contact with 234 persons who traveled to five states and five foreign countries. Multistate and multinational investigations and control efforts were undertaken.

“Preventable Measles Among U.S. Residents, 2001-2004,” 54 MMWR (Aug. 26, 2005):817-20

In 2005 Indiana had 34 cases of measles. Thirty-three of the cases were among families who belonged to the Upper Room Christian Fellowship; 32 of them had not received any dose of MMR vaccine. Many had religious exemptions from immuniza­tions. The outbreak cost more than $167,000 to manage.

“Import-Associated Measles Outbreak—Indiana, May-June 2005,” 54 MMWR (Oct. 28, 2005):1073-75.

In 2007 two cases of measles among religious objectors cost Oregon, Lane County, and a hospital $170,000 including the cost of tracking down hundreds of people whom they might have exposed.

Paige Parker, “Oregon’s low vaccination rate causes health concerns,” The Oregonian (Aug. 27, 2008); conversation with Betsy Meredith of Lane County Health Department.

In 2008 twelve children in San Diego were confirmed with measles. All were unvaccinated, either because of their parents’ beliefs or because they were too young to receive the vaccine. Seventy children had to be quarantined for two weeks or more and their health continuously monitored by the County Public Health Staff. In many cases the children had to be quarantined not because of their parents’ beliefs but because they had been exposed by unvaccinated carriers and were too young to be vaccinated or were medically fragile.

“Update: Measles—United States, January-July 2008, 57 MMWR (Aug. 22, 2008):893-96;

In April, 2008, sixteen Washington schoolchildren with belief exemptions from vaccination got measles. Several appear to have contracted the disease while attending a conference of Generations Church, which believes in divine healing of the body.

“Vaccine Exemptions Linked to Spike in Measles Cases,”;

In 2008 the U.S. had 140 cases of measles. Of the 127 U.S. residents who got measles, 67 were unvaccinated because of personal or religious beliefs, 17 were babies too young to be vaccinated, and 32 were unvaccinated for unknown reasons or their vaccination status was unknown. Only seven of the 127 had received the recommended two doses of measles-mumps-rubella vaccine; another four had had one dose.

Thomas Skinner, Centers for Disease Control and Prevention, e-mail April 14, 2009.

Haemophilus influenzae, type b
In 2008 Minnesota had five cases of Hib disease including one death. Three of the children, including the seven-month-old baby who died, were unvaccinated because of their parents’ beliefs. Another child was too young to have completed the series of shots, and a fifth had an immune-compromising disorder.

“Invasive Haemophilus Influenzae type B disease in Five Young Children—Minnesota 2008,” 58 MMWR (Jan. 23, 2009):1-3.

Pennsylvania had seven cases of Hib disease, including three deaths between August, 2008, and March, 2009. Six of the children had received no doses of Hib vaccine; the seventh child had received only one. One of the deaths occurred in the Faith Tabernacle church, and another in the First Century Gospel Church. Both denominations oppose vaccination and medical treatment. Four of the unvaccinated children who contracted Hib disease and survived are believed to be Amish children in Lancaster and Perry Counties.

“Health Advisory: Fatal Case of Meningitis Due to Haemophilus Influenzae Type B in Philadelphia,” Philadelphia Dept. of Public Health, Division of Disease Control (March 13, 2009); conversation with Division Director Dr. Carolyn Johnson.

Information compiled by CHILD, Box 2604, Sioux City IA 51106, Ph. 712-948-3500

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