Vaccination is 1 of the most important public health achievements in history, but nonmedical vaccine exemption laws permit parents in 45 states and Washington, District of Columbia, to exempt their children from vaccines required for school or day care entry.1  Recent measles outbreaks have been linked to clusters of unimmunized children, and researchers attribute the mounting public health consequences and financial costs to nonmedical exemptions.2  In this context, the Annual Leadership Forum of the American Academy of Pediatrics (AAP) asked the Board of Directors to advocate for the “development of a toolkit that highlights successful chapter strategies for the purpose of helping chapters work with their state legislatures to eliminate/reduce non-medical exemptions that have allowed immunization refusals.”3  Eliminating nonmedical vaccine exemption laws was the Annual Leadership Forum’s top priority for 2019.

How should the AAP create this toolkit? What principles should it consider? Clearly, any efforts will necessarily involve a variety of key stakeholders. Yet, because nearly every state allows religious vaccine exemptions, the AAP will need to navigate the complex intersection of religion and vaccination to find and engage religious stakeholders. Clergy members are influential leaders who impact the health practices of their congregations and work toward creating safe, flourishing communities. Chapter efforts to eliminate or reduce nonmedical exemption laws may hinge on their support.

Historically, major faith traditions have espoused principles supporting the public health goals of vaccination.4  However, at critical junctures in the history of vaccination work, individual clergy members have aided or opposed vaccination efforts.5  Recent data suggest clergy members still hold variable vaccination views. In 2016, we surveyed 109 Denver religious leaders, finding 54% of the clergy agreed with the existence of Colorado’s religious vaccine exemption law, 25% of the clergy were vaccine hesitant, and 21% of clergy parents used alternative vaccination schedules.6  Most respondents were Christian clergy members, although we recruited religious leaders from a dozen faith traditions. Using key informant interviews, we are in the early stages of a follow-up qualitative study aimed at gaining a deeper understanding of interfaith clergy vaccine attitudes (Table 1). Our goal is to interview religious leaders using rigorous grounded theory methodology, sampling from vaccine-hesitant and nonhesitant survey respondents. We will create a grounded theory describing how religious leaders form vaccine attitudes and whether they feel responsible to promote vaccines in their congregations and communities. We hope to use our qualitative insights to develop clergy-specific vaccine educational materials and derive best practices for engaging them as vaccination advocates.

TABLE 1

Selected Responses From Clergy Interviews With Corresponding Question Prompts

QuestionResponse
What are your general impressions about vaccines? “I resist taking the flu vaccine. I don’t really know how effective they are. And, I don’t know what’s in them. Why would I want to put that in my body, when I don’t really know what’s in it? Or what other effects it might have?” (CO-1) 
 “I would assume they’re good things; they help us health-wise. But, I haven’t really thought too much about it.” (CO-2) 
 “They help. They help. It’s hard for me to imagine that we had a president of the United States who had polio, but we did. … And we eliminated it! It counts as one of the modern miracles.” (CO-3) 
How does your understanding of your sacred texts influence your view of vaccines? “Scripture doesn’t address vaccinations or anything like that because Edward Jenner was still several millennia away. That said, I think we gain insight about human flourishing and the responsibilities we have for each other.” (CO-4) 
“In order for us to live together peaceably in community, we’ve got to look after one another’s needs. Sacred texts that point toward the community looking after one another, whether Ruth or Boaz or various other texts that we might find, deal with the community actually living together.” (CO-3) 
What is your responsibility to address vaccines in your congregation? “I’ve never felt like I was called to step out front with vaccinations because of my ecclesial role or that the community was pushing me as a pastor: ‘Pastor, get yourself together on this because we need you!’ … The quagmire is that there’s always more to do. I never felt like I was hurting for stuff to do, so it’s about prioritizing as well.” (CO-3) 
 “I did a sermon series on [science and faith], and in one sermon, I mentioned some examples. One of them was the anti-vaccination thing that did not rely on science because of faith considerations. … Intellectual development and scientific knowledge are the outcomes of God’s gift of a mind.” (CO-4) 
What do you think about religious vaccine exemptions? “I’m completely opposed to [religious vaccine exemptions]. Government exists for the common good. … To make an exception based on religion when it concerns the public health, I have problems with that.” (CO-4) 
 “I believe in having a religious exemption for [required vaccinations], but I believe it should be a high bar. ‘Please show us and share with us your participation in this religious community or philosophy,’ not just check a box and not do it.” (CO-5) 
 “I think [religious vaccine exemptions] would be fine. I would say, in general, it would be good to give people an option for that. … I would always want to sign on to people having the ability to make their own choices for themselves.” (CO-2) 
QuestionResponse
What are your general impressions about vaccines? “I resist taking the flu vaccine. I don’t really know how effective they are. And, I don’t know what’s in them. Why would I want to put that in my body, when I don’t really know what’s in it? Or what other effects it might have?” (CO-1) 
 “I would assume they’re good things; they help us health-wise. But, I haven’t really thought too much about it.” (CO-2) 
 “They help. They help. It’s hard for me to imagine that we had a president of the United States who had polio, but we did. … And we eliminated it! It counts as one of the modern miracles.” (CO-3) 
How does your understanding of your sacred texts influence your view of vaccines? “Scripture doesn’t address vaccinations or anything like that because Edward Jenner was still several millennia away. That said, I think we gain insight about human flourishing and the responsibilities we have for each other.” (CO-4) 
“In order for us to live together peaceably in community, we’ve got to look after one another’s needs. Sacred texts that point toward the community looking after one another, whether Ruth or Boaz or various other texts that we might find, deal with the community actually living together.” (CO-3) 
What is your responsibility to address vaccines in your congregation? “I’ve never felt like I was called to step out front with vaccinations because of my ecclesial role or that the community was pushing me as a pastor: ‘Pastor, get yourself together on this because we need you!’ … The quagmire is that there’s always more to do. I never felt like I was hurting for stuff to do, so it’s about prioritizing as well.” (CO-3) 
 “I did a sermon series on [science and faith], and in one sermon, I mentioned some examples. One of them was the anti-vaccination thing that did not rely on science because of faith considerations. … Intellectual development and scientific knowledge are the outcomes of God’s gift of a mind.” (CO-4) 
What do you think about religious vaccine exemptions? “I’m completely opposed to [religious vaccine exemptions]. Government exists for the common good. … To make an exception based on religion when it concerns the public health, I have problems with that.” (CO-4) 
 “I believe in having a religious exemption for [required vaccinations], but I believe it should be a high bar. ‘Please show us and share with us your participation in this religious community or philosophy,’ not just check a box and not do it.” (CO-5) 
 “I think [religious vaccine exemptions] would be fine. I would say, in general, it would be good to give people an option for that. … I would always want to sign on to people having the ability to make their own choices for themselves.” (CO-2) 

Quoted clergy were lead pastors of Catholic, Presbyterian, United Church of Christ, United Methodist Church, and Unity congregations. Their median age was 54 (range 37–64) years. Four clergy members were men, 3 were married, and 3 had children. One clergyman was African American, and 4 were white. Two clergy members had doctoral degrees, 2 had professional degrees, and 1 held a high school diploma. Using the previously validated Opel short scale,7  3 clergy members qualified as minimally vaccine hesitant, 1 was moderately vaccine hesitant, and 1 was highly vaccine hesitant. All had served as religious leaders for >5 years. CO, Coloradan.

So far, we have found complex views from Christian clergy members who cite secular vaccine concerns, struggle to interpret centuries-old scriptures, have disparate perceptions regarding their own responsibilities to promote vaccines, and espouse all possible positions on nonmedical vaccine exemption laws (uphold, uphold but strengthen, and eliminate). It is clear that clergy members care for their communities, but interviews suggest vaccine hesitancy and variable interest in vaccination (amid a host of competing interests for their time) may impede vaccine-related partnerships with pediatricians. Furthermore, our preliminary work in this arena arises out of a single-faith tradition. Forthcoming interviews with clergy from other traditions will likely reveal further diversity of vaccine opinion and perceived policy responsibility at the bustling interstices of religion and vaccination.

How then should chapters approach influential stakeholders who may provide crucial partnerships but bring an array of conflicting vaccination views?

Because our initial qualitative interviews demonstrated a variety of views, we perceived the need to develop a community-centered approach that connects with the clergy and attends to their vaccine questions and those of their communities. Thus, in Colorado, we recently embarked on 1 such undertaking: Coloradans Understanding Religion and Immunization through Sustained Partnership. This community-academic partnership seeks to promote a colearning and empowering process that attends to Coloradan clergy and citizens’ religious questions about vaccines. Partnering with the Colorado Council of Churches, a social justice organization with >800 member churches and numerous interfaith connections, we will host listening circles with religious leaders and congregants from various faith traditions in their own houses of worship, create a community advisory board, and collaborate to refine vaccine questions of interest to religious Coloradans. Through this iterative process, we hope to avoid transactional interactions that pursue research agendas in favor of building trust so that physicians, the clergy, and congregants feel safe to discuss religion and vaccination together. Although it may not provide a quick end to nonmedical vaccine exemption laws, this work will allow crucial stakeholders to hold equal seats at the policy-making table as important discussions ensue.

In a particularly insightful interview, a seasoned pastor reminded us that “clergy are people, too.” Thus, although all major religious traditions support vaccination in principle, individual religious leaders who are responsible for the practice and propagation of their faith traditions can hold the same range of vaccine views as the general public. Their mission, however, aligns with public health goals: creating flourishing communities, protecting vulnerable populations, and promoting holistic congregational health.4  Therefore, as the AAP creates a toolkit and aids chapters working toward the elimination of nonmedical exemptions, engaging clergy and building trust are crucial first steps into the intersection of religion and vaccination. Such efforts will minimize concerns that scientists are infringing on religious liberty and avoid putting many religious leaders who support vaccines in awkward positions. After all, the clergy, parents, and pediatricians who meet at these intersections care deeply for the children of their communities.

The authors acknowledge the Colorado Council of Churches and its executive director, Adrian Miller, JD, for their warm partnership as we study vaccines together.

Dr Williams conceptualized and designed the study, drafted the manuscript, and reviewed and revised the manuscript; Drs Nussbaum and O’Leary critically reviewed the manuscript, provided important intellectual additions, and assisted with revisions; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: The Coloradans Understanding Religion and Immunization through Sustained Partnership is supported in part by the National Institutes of Health National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award (grant UL1TR002535). Funded by the National Institutes of Health (NIH).

     
  • AAP

    American Academy of Pediatrics

1
National Conference of State Legislatures
.
States with Religious and Philosophical Exemptions from School Immunization Requirements.
2019
. Available at: www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx. Accessed August 20, 2019.
2
Sundaram
ME
,
Guterman
LB
,
Omer
SB
.
The true cost of measles outbreaks during the postelimination era [published online ahead of print March 7, 2019]
.
JAMA
.
doi:10.1001/jama.2019.1506
3
AAP
News
.
Elimination of non-medical vaccine exemptions ranked top priority at Annual Leadership Forum.
2019
. Available at: www.aappublications.org/news/2019/03/16/alfresolutions031619. Accessed March 19, 2019
4
Grabenstein
JD
.
What the world’s religions teach, applied to vaccines and immune globulins
.
Vaccine
.
2013
;
31
(
16
):
2011
2023
5
Williams
JTB
,
Nussbaum
AM
.
Minister to their Instruction: revisiting the minister-vaccinator Rowland Hill
.
Pediatrics
.
2018
;
142
(
6
):
e20181021
6
Williams
JTB
,
O’Leary
ST
.
Denver religious leaders’ vaccine attitudes, practices, and congregational experiences
.
J Relig Heal
.
2019
;
58
(
4
):
1356
1367
7
Oladejo
O
,
Allen
K
,
Amin
A
, et al
.
Comparative analysis of the Parent Attitudes about Childhood Vaccines (PACV) short scale and the five categories of vaccine acceptance identified by Gust et al
.
Vaccine
.
2016
;
34
(
41
):
4964
4968

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.