Cultural Conundrums

From the 43rd Annual Advances and Controversies in Pediatrics, presented by the Department of Pediatrics,
University of California, San Francisco, School of Medicine, and UCSF Children’s Hospital

Educational Objectives

The goal of this program is to improve pediatric health care through a greater understanding of the concerns involved in the antivaccine movement and factors of acculturation. After hearing and assimilating this program, the clinician will be better able to:

1.   Cite the factors that contributed to the birth of the antivaccine movement.

2.   Review key legal cases that influenced current rights for vaccine refusal.

3.   Describe the consequences of the antivaccine movement.

4.   Define acculturation as it applies to pediatric care in the United States.

5.   Recognize child health outcomes that are influenced by acculturation.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or com­mercial interest. For this program, the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Drs. Offit and Fuentes-Afflick were recorded at 43rd Annual Advances and Controversies in Pediatrics, presented June 3-5, 2010, in San Francisco, CA, and sponsored by the Department of Pediatrics, University of California, San Francisco, School of Medi­cine, and the UCSF Children’s Hospital at UCSF Medical Center. The Audio-Digest Foundation thanks the speakers and the spon­sors for their cooperation in the production of this program.

The Antivaccine Movement in America

Paul A. Offit, MD, Professor of Pediatrics and Maurice R. Hilleman Professor of Vaccinology, University of Pennsylvania School of Medicine; Chief, Division of Infectious Diseases, and Director, Vaccine Education Cen­ter, Children’s Hospital of Philadelphia

Birth of the antivaccination movement: began in 1982 with pertussis vaccine

“DPT: Vaccine Roulette”: documentary that attributed childhood epilepsy and mental retardation to pertussis vac­cine; dramatic show by filmmaker Frederick Wiseman; shown to residents of Washington, DC, area; inspired Barbara Loe Fisher, Kathi Williams, and Jeff Schwartz to form group called Dissatisfied Parents Together (DPT; group name later changed to National Vaccine Information Center); spurred Republican senator Paula Hawkins to hold congressional hearing assessing vaccine safety

Legal action: series of lawsuits claimed vaccines caused mental retardation, epilepsy, transverse myelitis, coma,  unexplained coma, sudden infant death syndrome, and Reye syndrome; hundreds of millions of dollars awarded in settlements due to perceived vaccine harm

Scientific literature: 9 studies over 10 yr assessed pertussis vaccine and risk for mental retardation and epilepsy; conclusions negative; study (Berkovic, 2006) revealed neuronal sodium channel transport defects (SCN1A muta­tions) in majority of children allegedly harmed by pertussis vaccine

Impact of lawsuits: price of diphtheria, pertussis, and tetanus (DPT) vaccination rose from $0.19 in 1980 to $12 in 1986 to pay for cost of litigation; number of oral polio vaccine (OPV), measles vaccine, and pertussis vaccine makers declined from 3 to 1, 6 to 1, and 8 to 1, respectively; pertussis vaccine almost lost due to $1.13 million lawsuit against last pertussis vaccine maker; government created National Childhood Vaccine Injury Act and Vaccine Injury Compensation Program in 1986, supported by $0.75 to $2.25 excise tax on every vaccine dose; $2 billion in funds exist today for children truly harmed by vaccines

National Vaccine Information Center: contends infectious diseases replaced by chronic diseases due to vaccines; media-savvy, politically connected, personal injury-backed group; group claims  —  Haemophilus influenzae type B (Hib) vaccine causes diabetes; pneumococcal vaccine causes seizures; hepatitis B vaccine causes multiple sclerosis in adolescents and sudden infant death syndrome; human papillomavirus vaccine causes chronic fatigue syndrome, blood clots, strokes, and heart attacks; vaccines in general (eg, measles, mumps, and rubella [MMR]) cause autism; campaign championed by celebrity Jenny McCarthy

Vaccines and the law: 1905 legal case in Cambridge, MA, evaluated legal boundaries for vaccine refusal; occurred after smallpox epidemic killed »200 Boston residents; government mandated smallpox vaccine and charged $5 fine for those who refused; Henning Jacobson refused to pay fine; case heard by Supreme Court; majority (7 to 2) vote upheld Cambridge Board of Health’s right to mandate vaccination; second court case, in 1944 (Sarah Prince vs Massachusetts), began as child labor law case when parent had child perform late-night pamphleteering; ruling judge of Supreme Court said parents cannot claim freedom from compulsory vaccination for child on religious grounds; multiple lawsuits claiming first amendment rights ruled against vaccine exemption based on religion through early 1960s

Vaccines and religion: critical event opened door for vaccine exemptions based on religion in 1966; New York State Assembly voted 150 to 2 requiring polio vaccination for school entry; 2 negative votes resulted from religious lobbying effort, but Old Testament, New Testament, and Koran all written well before vaccines existed

Christian Science: founded by Mary Baker Eddy in 1875; religion based on faith healing; contends illness is spiritual as opposed to physical disorder; prayer used as treatment; founded before Koch’s postulates, virus vi­sualization, antiserum therapy, insulin, and antibiotics; by 1966 vaccines proven effective; speaker attributes religion-based vaccine exemption to wide berth given to religion in United States

Result of religious exemption: 1972 outbreak of polio in Christian Science school in Greenwich, CN; 11 of 128 children paralyzed; spread to surrounding community avoided due to high rate of polio vaccination; New Eng­land Journal of Medicine letter expressed concern over withholding of disease-prevention measures in name of religious freedom; additional court cases solidified religious exemptions in 48 of 50 states; philosophical exemp­tions exist in 21 states

Consequences of antivaccination movement: pertussis outbreaks reported in undervaccinated communities in Cali­fornia and Delaware; epidemiologic pattern similar to outbreaks of prevaccine era (primarily in 5- to 9-yr-olds); 2008 measles outbreak in San Diego, CA, involved »140 people; caused by unvaccinated boy who acquired mea­sles in Switzerland; 4 Hib deaths reported in Minnesota and 3 in Philadelphia due to unvaccinated children; ques­tions raised about rights of individual vs rights of society; speaker’s facility (Children’s Hospital of Philadelphia) mandated influenza vaccination for all employees; 9 of »9300 employees refused vaccination and were fired; edu­cational programs, fairs, giveaways, and declination forms utilized before mandatory vaccinations to improve vac­cination rates; mandatory vaccinations initiated on premise that patients depend on employees to not transmit influenza; facility intends to continue with program, despite loss of several employees; speaker has empathy for cli­nicians trying to balance parent’s desires and risk of substandard care; parents (Celina Yarkin, Stephanie Tatel, Brenda Lee Flint) now initiating vaccination education campaigns

Acculturation and Child Health

Elena Fuentes-Afflick, MD, MPH, Professor of Pediatrics, Epidemiology, and Biostatistics, University of Cal­ifornia, San Francisco, School of Medicine, and Chief of Pediatrics, San Francisco General Hospital

Acculturation: defined by University of California, Los Angeles, group as “the psychosocial adaptation of persons from their culture of origin to a new or host cultural environment”; more recently defined as “the process by which immigrants adopt the attitudes, values, customs, beliefs, and behaviors of a new culture”; addresses changes in im­migrants when they come into contact with new environments; also addresses changes in host country and inhabit­ants (eg, multiple ethnic restaurants, switch in preferred condiment from ketchup to salsa)

Acculturation in United States: at turn of 20th century, most immigrants to United States originated from western Europe; in 1965, changes in US policy resulted in dramatic increases in immigration from Asia and Latin Amer­ica; as of 2004, 58% of US immigrants born in Latin America, 27% born in Asia, and 15% born in Europe; rea­sons for immigration include jobs and educational opportunities; many immigrants’ expectations unrealistic; inner-city poverty, oppression, and discrimination often experienced by immigrants

Early acculturation study (Marmot, 1976): evaluated Japanese-American men in California; interviewed subjects about style of upbringing (acculturation) and separated subjects into categories of traditional and nontraditional; categories largely based on diet; assessed coronary heart disease and separated findings by age; traditional up­bringing associated with lower rates of coronary heart disease, compared with nontraditional upbringing; lower acculturation considered protective in this case; adjusting for diet failed to fully explain effect

Acculturation of adult Latino immigrants: early study of acculturation and health outcomes in Latinos (Markides, 1986) focused on mental health; evaluated rate of use of health services for mental health problems in Latinos in 1950s and 1960s; researchers anticipated high rates of use due to socioeconomic risk factors; study revealed low rates of utilization; displaced model that associated  socioeconomic risk with poor outcomes 

Acculturation and Latino immigrant children: early study (Powell-Griner, 1982)  —  evaluated rates of Latino neo­natal mortality in Texas in 1970s, compared to black and white neonates; study revealed overall decreasing inci­dence of neonatal mortality due to advances in neonatology and prenatal care; rates of black neonatal mortality found to be consistently higher, compared to Latino and white women; rates of Hispanic neonatal mortality also surprisingly low, considering socioeconomic status; researchers attributed low Latino neonatal mortality rates to underreporting of neonatal deaths; follow-up study (Selby, 1984; Harris County, TX)  —  revealed similar results (ie, low neonatal and postneonatal mortality rates in Latino and white infants, compared with blacks); researchers con­cluded infant mortality rate not valid indicator of health status in this population; more recent study (Hessol, 2000)  —  evaluated California data from early 1990s; similar results again reported, despite adjusting for potential confounders; study of intrauterine growth retardation (Fuentes-Afflick, 1997)  —in Arizona; revealed 20% in­creased risk for intrauterine growth restriction (IUGR) in infants of United States-born white women, compared to foreign-born counterparts; greater acculturation appeared disadvantageous for perinatal outcomes; analysis of low birth weight (Fuentes-Afflick, 1999)  —  revealed comparable birth weights in infants of white and Latino women; acculturation also affects child health outcomes, including growth and development, immunization status, use of health services, and body mass; study (Gibson, 2005) found higher rates of breastfeeding among Latino women with low acculturation status, compared to those with high acculturation status and white women; study (Anderson, 1997)  —  of families in Los Angeles revealed 30% increased risk for inadequate immunization among infants of La­tino women with high acculturation scores, compared with Latino women with low acculturation scores; findings consistent with observed pattern of association of higher acculturation with greater risk for adverse outcomes; exception  —  found in study (Foster, 2009) which revealed that Latino families interviewed in Spanish reported lower rates of having usual source of care,  compared with Latino families interviewed in English; factors such as access to care, language, and understanding of preventive care may play role; study (Fuentes-Afflick, 2008)  —  of body mass in Latino children revealed 43% incidence of overweight by age 3 yr; self-reported “Americanized” La­tino women twice as likely to have overweight children; reasons currently unknown; overweight or obese mothers were 2 to 3 times more likely to have overweight children; mothers reporting children’s’ weight as “too high” were 12 times more likely to have overweight children; “too high” response rarely reported; question may represent method of initiating conversation

Mechanisms of acculturation: strongly linked to socioeconomic status; perinatal outcomes influenced by multiple factors; behavioral factors (eg, smoking, drug use, drinking alcohol) have large impact on perinatal outcomes; nutri­tional status and micronutrient intake (eg, folic acid) also important; obesity during pregnancy and risk for early childhood obesity needs further study; “healthy immigrants” either healthier than population of origin or healthier than receiving population; obstetric and reproductive factors also important (ie, innate reproductive health); social support and community factors require evaluation in longitudinal studies

Implications for pediatrics: assess families’ and children’s acculturation status during visits; consider cultural fac­tors that may influence health beliefs and behaviors; adolescent patients wavering between parents’ belief system and personal worldview may have unique issues related to acculturative stress and other forms of health-risk behav­iors; greater understanding of mechanisms behind acculturation and adverse outcomes necessary to preserve posi­tive influences of individual cultures

Question-and-answer session: how is the American culture defined, as compared to other cultures?  —  acculturation usually defined by birthplace; United States-born individuals typically defined as more acculturated; other indices include language use, diet, and beliefs; what prepregnancy and pregnancy acculturation issues are anticipated in Latino and black populations?  —acculturative stress (eg, crowding, risk for prosecution due to lack of documenta­tion) virtually unstudied; psychologic and physiologic stress (eg, cortisol) need further exploration; difficult to ex­trapolate findings from one ethnic group to another; is the issue of “buen cuidado” (obesity as sign of good care) encountered during obesity studies in Latino families?  —  longitudinal approaches useful; parents who experienced undernutrition, diarrhea, and death may overfeed children; advise parents that food not equal to comfort; educate parents on good nutrition and other ways to nurture children; what should be done about the pediatric workforce?  —  differences in practice patterns between minority and nonminority pediatricians observed; minority pediatricians more likely to serve minority patients, but pediatric populations changing dramatically; all pediatri­cians need training to enhance adaptability

Suggested Reading

Anderson LM et al: Maternal acculturation and childhood immunization levels among children of Latino families in Los Ange­les. Am J Public Health. 1997 Dec;87(12):2018-21; Berkovic SF et al: De-novo mutations of the sodium channel gene SCN1A in alleged vaccine encephalopathy: a retrospective study. Lancet Neurol. 2006 Jun;5(6):488-92; Feikin DR et al: Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA. 2000 Dec;284(24):1345-50; Foster BA et al: An analysis of the association between parental acculturation and children’s medication use. Pediatrics. 2009 Oct;124(4):1152-61; Fuentes-Afflick E, Lurie P: Low birth weight and Latino ethnicity. Examining the epidemiologic paradox. Arch Pediatr Adolesc Med. 1997 Jul;151(7):665-74; Gibson MV et al: Prevalence of breastfeeding and acculturation in Hispan­ics: results from NHANES 1999-2000 study. Birth. 2005 Jun;32(2):93-8; Glanz JM et al: Parental refusal of pertussis vaccina­tion is associated with an increased risk of pertussis infection in children. Pediatrics. 2009 Jun;123(6):1446-51; Hessol NA, Fuentes-Afflick E: The perinatal advantage of Mexican-origin Latina women. Ann Epidemiol. 2000 Nov;10(8):516-523; Markides KS, Coreil J: The health of Hispanics in the southwestern United States: an epidemiologic paradox. Public Health Rep. 1986 May-Jun;101(3):253-265; Marmot MG, Syme SL: Acculturation and coronary heart disease in Japanese-Americans. Am J Epidemiol. 1976 Sept;104(3):225-247; Omer SB et al: Nonmedical exemptions to school immunization requirements: sec­ular trends and association of state policies with pertussis incidence. JAMA. 2006 Oct;296(14):1757-63; Powell-Griner E, Streck D: A closer examination of neonatal mortality rates among the Texas Spanish surname population. A J Public Health. 1982 Sept;72(9):993-9; Salmon DA et al: Health consequences of religious and philosophical exemptions from immunization laws: in­dividual and societal risk of measles. JAMA. 1999 Jul;282(1):47-53; Selby ML et al: Validity of the Spanish surname infant mor­tality rate as a health status indicator for the Mexican American population. Am J Public Health. 1984 Sept;74(9):998-1002; Wells KB et al: Acculturation and the probability of use of health services by Mexican Americans. Health Serv Res. 1989 Jun;24(2):237-57.