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Background
People conducting immunization programs may encounter individuals who hesitate, question, or decline some or all vaccines or immune globulins based on religious beliefs or related cultural reasons. Such matters are intensely personal and may be disconcerting for health professionals not comfortable discussing religious issues or who usually make immunization decisions based on matters more closely aligned to quantitative sciences.
The word religion derives from the Latin religio or religionem, describing respect for the sacred or reverence for God or gods [1,2] . Multiple definitions of religion have been proposed, but religions are fundamentally sets of beliefs about God or spirituality held by groups of people. Like all groups, religious groups develop their own systems of culture. And yet, as we will see, behaviors of like-minded individuals are not necessarily related to the theological basis of their religions. "Religious" differs from "theological," in part, as social differs from scholarly.
Religious concerns about immunization have a long history, reaching back to those who rejected Edward Jenner's 1796 mode of smallpox vaccination as contrary to God's will [3] . In the United Kingdom, the Anti-Vaccination League formed in 1853 in London to oppose compulsory vaccination acts [3-6] . Similar events occurred in the Netherlands and elsewhere [6] . In the United States, several Boston clergymen and devout physicians formed the Anti-vaccination Society in 1879 [3,4,6-8] . In contemporary cases, such objections involve blood products, porcine or bovine pharmaceutical excipients, or the remote fetal origins of cell-culture media and rubella strain RA 27/3. In contrast, it is also worth remembering that some of the earliest descriptions of variolation to prevent smallpox involved the proponency of Buddhist religious women [9] .
Individual rights are deeply embedded in many cultures. With contagious diseases, though, vaccine and immune globulin decisions may affect more than an individual's health. This occurs if a parent chooses to withhold immunization from a child or where vaccine-exempting people increase the infectious risk of their neighbors.
Numerous examples of vaccine-preventable outbreaks among religious schools, congregations, and communities illustrate how clusters of vulnerable people can enable epidemics, even spreading beyond those foci to neighboring, well-immunized communities [12-15] . Published examples include diphtheria [16,17] , Haemophilus influenzae type b [18,19] , hepatitis A [20,21] , measles [22-51],...
