As the needle pricks his left arm, Gustavo is not about to flinch--not with his brother and several friends watching. The casual smile never leaves his face, and afterward he jokes with the others about the "mosquito bite."
The brothers are among several Latinos gathered at Don Jose's Tienda in Carrboro to receive free rubella immunizations from Orange County medical personnel. With the help of a student translator, two registered nurses spend the afternoon administering shots to roughly a dozen of the small grocery store's Latino patrons.
Some customers at Don Jose's are skeptical about the shots, but to Gustavo, their importance is clear.
"I'm a construction worker," he explains. "If I'm sick, I can't work. And if [the vaccination] is free, I'm going to take advantage of it."
In counties across North Carolina, public health officials are offering free immunizations against rubella, also called German measles, in an effort to combat one of the largest occurrences of the disease the state has seen since a vaccine was developed more than 30 years ago. So far this year, health workers have confirmed 80 rubella cases--more than in any other state--and by year's end the number of confirmed cases is likely to eclipse North Carolina's vaccine-era record of 87 cases in 1996.
Today, nearly every child born in this country receives vaccinations against rubella (as well as measles and mumps) at 1 year old and again at 2. But this year's rash of outbreaks in North Carolina has hit particularly hard among members of the state's Hispanic community, many of whom immigrated from countries that don't require vaccinations. Reaching out to this growing population is creating some unique challenges for state and county health officials.
Brian LeTourneau, Durham County's health director, says a major problem is that "there's no easy way to identify who needs [the vaccination] and who doesn't need it." He points out that many immigrants who need the shot are living in the United States illegally and won't come forward for fear of deportation. Such concerns may discourage many Latinos from participating in any sort of official, highly publicized vaccination drive.
Instead, health workers in counties across the state are going out into the community, visiting churches, soccer fields, markets and other venues where Latinos might gather.
"You name it, we've been there," LeTourneau says.
Some of these community vaccinations have met with considerable success. Orange County medical personnel vaccinated more than 50 people after a recent Sunday service at St. Thomas More Catholic Church in Chapel Hill. At other locations, however, workers may vaccinate only one or two people. Officials say it's difficult to know where they'll get the best results, so they continue to set up immunization tables at a variety of sites.
Among the largest of these venues will be this summer's La Fiesta del Pueblo in Chapel Hill. The annual two-day festival, which celebrates Latino arts and culture, is expected to draw nearly 40,000 people from throughout the Triangle. Orange County's health department is working with La Fiesta's organizers to ensure that medical workers are on hand to take advantage of the opportunity.
One of the obstacles to vaccinating at this type of event, however, is that people are generally there to relax with friends and family. Most will not be thinking about rubella, or looking to have needles stuck in their arms. Recognizing this, officials plan to focus on educating as well as immunizing festival participants. By letting Latinos know about the dangers of rubella, health workers hope they can overcome some of the stigma associated with receiving a shot.
LeTourneau says that, among most adults, rubella actually is a "relatively innocuous disease, not like HIV or syphilis." It is almost flu-like in its symptoms, he explains, which usually last no more than a week. These symptoms may include a slight fever, a sore throat or a rash, which generally appears first on the face and spreads quickly to the chest, arms, legs and stomach. In addition, an attack of rubella usually confers lifelong immunity.
The bigger concern, however, is the threat the disease poses to unborn children. When contracted by women in the first three months of pregnancy, rubella can have severe consequences: The newborn child may be afflicted with heart defects, mental retardation, deafness, cataracts or other congenital abnormalities. In fact, according to the U.S. Centers for Disease Control and Prevention, up to 90 percent of infants born to mothers infected in the first trimester develop some sort of defects. So far this year, two of North Carolina's confirmed rubella cases have been pregnant women, both in Henderson County in Western North Carolina.
Jeff Rivenbark, who works in the immunization branch of the state's Division of Public Health, says his office's main priority is trying to reach women who are pregnant or of childbearing age. But because the disease is communicable, health officials say even women who are not pregnant and men need the vaccination--not only to protect their own health but to ensure that they don't pass the disease to an expectant mother, and in turn to her unborn child.
Despite ongoing vaccination and outreach efforts in several North Carolina counties, some leaders in the Triangle's Hispanic community believe it's the state's response to the rubella outbreak that needs a shot in the arm.
"Basically, they have not made this a priority," says John Herrera, head of the new Latino Community Credit Union and a leading advocate for Latinos in Durham and Orange counties. Herrera says a statewide vaccination strategy is needed, but he accuses state health officials of dragging their heels on the issue.
"What we need is not just a Band-Aid," he says. "I'm afraid that this will result in more pregnant women getting rubella."
Mauricio Castro, president of El Centro Latino in Carrboro, also questions the state's commitment to addressing the problem. At a June 30 rubella strategy meeting organized by the Division of Public Health--the third such meeting this year--Castro said health officials need to make more of an effort to work with Hispanic leaders in the community to get the word out about rubella and vaccinations. He called for more effective communication between the state and the various affected counties.
"I'm very concerned about the fact that we have not responded as quickly as we should," he said. "I don't feel that we have really stepped on the gas."
Dennis McBride, the state health director, defends ongoing community outreach and vaccination efforts, insisting that the issue is a top priority and that progress is being made.
"I think we're doing a good job, but it really does bother us that we still have this situation," McBride says, encouraging cooperation and "a positive dialogue about the issue."
Still, Castro remains concerned about the state's commitment to fighting rubella. Leaving the June 30 strategy meeting, he said many of his questions remained unanswered, and that there are "issues still floating, with no clear idea who's going to do what and what should be done."
Rivenbark in the Public Health Division also defends the state's response to the outbreaks. Even though the number of cases this year is high, he says, the U.S. Centers for Disease Control and Prevention are using North Carolina's response as a "poster child" for how to handle outbreaks. He points out that the Division of Public Health is offering free vaccinations statewide, even though it has to stretch its resources to do this. Since March, the office has shipped out almost $1 million worth of MMR (measles, mumps and rubella) vaccine, equaling roughly 63,000 doses.
The state also recently hired a rubella outreach coordinator to spearhead statewide vaccination and outreach efforts. Adlih Moreno-Coll will begin work July 18, and the temporary position will last through the end of this year. Moreno-Coll was unavailable for comment.
Other state initiatives include outreach packets for churches with Hispanic congregations, explaining the disease and where to get vaccinated, as well as monthly updates about rubella sent to Latino media outlets.
Rogelio Valencia, with the state Department of Health and Human Services, says the goal of all of these efforts is more than just educating Latinos about the problem.
"We need to gain the trust of the Hispanic community," he says.
In the meantime, Miguel Angel Villegas, an employee at Don Jose's Tienda, says the market will continue opening its doors for medical personnel to administer the immunizations. They're important, Villegas says, for the health of the community.
Gustavo and his brother agree. After all, a "mosquito bite" is a small price to pay for staying healthy and on the job.