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Table of Contents


A matter of health: Immunization in the traditions of the U.S.

Immunization is vital to the health and survival of our nation. This concept has been recognized throughout American history. Health may have been one of the things Thomas Jefferson had in mind when he drafted the phrase, "life, liberty, and the pursuit of happiness" for the Declaration of Independence. Both Jefferson and Benjamin Franklin were scientists and innovators, and both were strong supporters of smallpox vaccination,(1) the only form of vaccination known to Americans at that time.

As with all of our laws, federal and state immunization laws are consistent with a basic tenet of American citizenship: The privileges of democracy, including individual freedoms, must be enjoyed in ways that do not interfere with or create risks for others. Immunization provides protection not only to the person immunized, but for many diseases, also to the people with whom the immunized person comes in contact. Immunization laws sometimes are changed as we gain new methods or understanding of disease control or new circumstances arise, but the basic truth about the responsibilities of citizenship does not change.


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Controlling epidemics through vaccination laws

American courts have addressed many times the legal issue of whether government can compel vaccination, and have repeatedly supported immunizations. States have many laws that spell out what types of vaccinations people must have in various circumstances. We also have federal laws that specify the type of information that must be given to parents before a child is immunized. Under the National Childhood Vaccine Injury Act, section 2126 of the Public Health Service Act, all health care providers in the U.S. who administer any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, or polio vaccine shall, prior to administration of each dose of the vaccine, provide a copy of the relevant vaccine informaiton materials that have been produced by the Centers for Disease Control and Prevention. Materials can be supplemented with visual presentations or oral explanations, where appropriate.(2)

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Controlling epidemics by preventing outbreaks of disease

Public health officials do not rely on vaccines alone to control epidemics. To prevent the spread of disease, it is necessary to provide sanitary water and food supplies; education on hygiene, cleanliness, and disease prevention methods; and insect or animal management, as well as prevention of exposure to infected people through quarantine. Quarantine is isolation of persons with disease that can be easily spread, so that others will not be infected.

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A matter of law: Parents must be informed

The Centers for Disease Control and Prevention believes that parents should be fully informed about the risks and benefits of vaccination by talking to a trusted health care provider. By law, parents, guardians, or patients must be given information in writing about the risks and benefits of vaccination before a vaccine is administered. In fact, a recent national survey reconfirmed that parents overwhelmingly turn to their child's health care provider to obtain information or ask questions about vaccination.(3) If your health provider is not giving you the information you need, you can obtain copies by calling the CDC National Immunization Program information hotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish), or view the information on the National Immunization Program's home page.

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Quarantine

Before vaccines, the first line of defense. Before vaccines, the first line of defense against disease was quarantine, and from its earliest days, our nation has had written laws regarding quarantine. As early as 1647, port towns in the American colonies, such as Philadelphia, Boston, Salem, New York, and Charleston, enacted laws forbidding people with smallpox to enter port.(4) Ships with outbreaks of smallpox were turned back or barred from entry into harbors, or passengers were forbidden to leave the ship until the outbreak ended and all on board were either dead or well. The penalties for sneaking into port were harsh, at times including being shot on sight.(5)

In the late 19th and early 20th century, at Ellis Island, New York; Norfolk, Virginia; and other ports of entry, millions of immigrants were processed into new lives in the United States. At the very beginning of this influx, in the late 1800s, the National Quarantine Act was passed, establishing the Division of Quarantine,(6) the agency with oversight of quarantine activities. A major activity in this period was pre-entry screenings of immigrants for contagious diseases. Depending on the nature of any diseases discovered, some were quarantined until they were well; others were immediately turned away, to be sent home on the next ship. Considering how frightening an epidemic is, it is no surprise that many of the unfortunate prejudices against immigrants originated from fear of the spread of disease. Whether the fear is justified or not, it is a natural instinct, rooted in our biologic makeup, to want to protect oneself from disease.

The mission of the U.S. Division of Quarantine is to prevent introduction, transmission, or spread of communicable diseases from foreign countries into the U.S.(7) Today the Division is housed in the CDC National Center for Infectious Diseases. It operates eight quarantine stations (New York, Atlanta, Miami, Chicago, Los Angeles, San Francisco, Seattle, and Honolulu) and two overseas posts (Frankfurt and Bangkok)..(8)


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School immunization laws

Each state has immunization requirements, sometimes called "school laws," that must be met before a child may enter school. These may include vaccination against diphtheria, pertussis (whooping cough), tetanus (lockjaw), Haemophilus influenzae type b, measles, mumps, rubella, polio, and hepatitis B. Some states have added varicella (chicken pox) vaccination to the list of required vaccines. Smallpox vaccination was once required, but the disease has been so successfully eradicated that this vaccination is no longer needed.

In most states, a parent must bring written proof of a child's immunizations from the health provider or clinic at the time of school registration. If a required vaccination has not been obtained, and there is no health condition or religious objection preventing immunization, the child must receive the vaccinations before school entry. You can find out what the requirements are in your state through a link provided at the end of this section.

These required vaccinations don't just protect the children in a classroom. They protect the teachers, parent volunteers, visiting grandparents, and everyone else who enters the classroom or provides services to the school. The blanket of protection provided by rubella ("German measles") vaccination is especially important for women who are pregnant. Rubella can cause serious effects on the developing fetus, including deafness, blindness, heart disease, brain damage, or other serious problems, including miscarriage.(9) Today's middle-aged adults may remember how common this disease was before the rubella vaccine became available. Rubella was feared for its effects, including ear infection, pneumonia, diarrhea, seizures, brain damage, and death.(10)


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Adult immunization laws

There are no legally mandated vaccinations for adults, except for persons entering military service. The National Immunization Program does recommend certain immunizations for adults, depending on age, occupation, and other circumstances, but these immunizations are not required by law. For example, adults may seek immunization for protection against seasonal illnesses, such as influenza and pneumococcal diseases; specific diseases that may be related to work exposure or personal interests (handlers of animals may be concerned about rabies); or upon potential exposure to a specific disease (such as rabies after an animal bite, or tetanus after sustaining a wound).

Some employers require certain immunizations for those employees who work with people who are sick or vulnerable to disease, or those who handle or are exposed to dangerous substances, such as certain bacteria or viruses. Hospitals, for example, may require some staff to have influenza or hepatitis B vaccine. The CDC National Immunization Program home page offers an Adult Immunization Schedule that gives more complete information on adult vaccinations, including those associated with occupational risk.


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Travel immunization laws

TravelImmunizations were once required for persons traveling overseas. None are required at this time, but some vaccinations are recommended. Such immunizations may include tetanus, diphtheria, polio, rabies, typhoid, hepatitis A and B, meningococcal disease, yellow fever, Japanese encephalitis, and influenza.(11) A vaccine is available for cholera, but it is not very satisfactory. Again, smallpox vaccination was once a "must" but thanks to worldwide cooperative efforts, the disease has been eradicated and vaccination against it is no longer needed in this country or elsewhere. There are many serious disease that occur, particularly in developing countries, for which no vaccines exist, or existing vaccines are only marginally helpful. Research and development of vaccines to prevent malaria, and improved vaccines against tuberculosis and cholera, is ongoing and is a priority of the National Vaccine Program.

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Globalization and international law

It's often been said that our world is growing smaller. As the notion of a global economy becomes a reality, many people are now traveling extensively, as part of their work or to pursue personal interests. The possibility of small, local outbreaks of disease--such as ebola--spreading to the international arena is a serious and immediate concern. The survival of the human race may someday depend on rapid and smooth cooperation between nations to develop and distribute vaccines and to take other public health measures to contain diseases. Workers in public health and in law recognize the growing need for an international code of law.

*The CDC provides online information on travel immunizations, including updates on outbreaks of specific diseases at travel destinations and a hotline number.
*An in-depth discussion of globalization and international law is available in the CDC National Center for Infectious Diseases online journal, Emerging Infectious Diseases.


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Immigration immunization laws

Under new immigration laws passed in 1996 and in effect as of July 1, 1997, all individuals seeking permanent entry into the U.S. must prove that they have been inoculated against all vaccine-preventable diseases. This includes infants and children being brought into the country for international adoption.(12)

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Immunization recommendations

In special circumstances, health officials may issue recommendations for immunizations. For example, although influenza can be deadly if complications (such as pneumonia) develop, annual flu vaccinations are not required; they are recommended, especially for the elderly and others who may be at high risk for serious illness from the flu. In locations where natural disasters such as hurricanes have created conditions ripe for disease, immunizations such as tetanus and typhoid may be recommended and offered to individuals who wish to have them.

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Religious and philosophical exemptions

In every state, parents with religious objections to immunization may apply for an exemption for their child or children from the state's immunization requirements for school entry. All states offer medical exemptions (individuals who are immunocompromised, have allergic reactions to vaccine constituents, have moderate or severe illness, etc.). Religious exemptions are allowed in 48 states (West Virginia and Mississippi do not), and 15 states offer philosophical exemptions.(13) The requirements for documentation of medical, religious, or philosophical exemptions vary.

In some states, parents with philosophical exemptions may apply for an exemption for their child or children from the state's immunization requirements for school entry.

Parents should be aware that withholding vaccinations leaves their child vulnerable to vaccine-preventable diseases in the event of an outbreak. As a matter of personal health, children without immunizations should remain home during outbreaks of the diseases for which they have not received vaccination. Also, as a matter of responsibility to the community, unvaccinated children should be kept at home if there is an outbreak of a vaccine-preventable disease within the family. Such illnesses should be reported to the pediatrician or family physician.

If you are considering a philosophical or religious exemption for your child, you should be aware that outbreaks tend to occur in waves: One group becomes ill; a second group becomes ill within a week or two, and so on. This means that the time an unvaccinated child must miss school can run into months.

For clarification of the laws in your state, contact your state health department. Some states have posted their school entry immunization requirements on line. You can check your state's home page by going to the Centers for Disease Control and Prevention home page.

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footnoteFootnotes
1. Duffy J. Epidemics in Colonial America. Baton Rouge: Louisiana State University Press, 1953.

2. Centers for Disease Control and Prevention. Information on immunizations that must be given to parents, guardians, or patients [fact sheet]. Atlanta, GA: Office of Communications, CDC: 1997.

3.Centers for Disease Control and Prevention. What you may have heard about vaccines... and what you should know [fact sheet]. Atlanta, GA: CDC, 1997. A copy of this fact sheet may be viewed online at http://www.cdc.gov/nip/vacsafe or obtained from the CDChotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish).

4.Hoehling, Adolph A. The Great Epidemic. Boston: Little, Brown, & Co., 1961.

5. Hoehling, Adolph A. The Great Epidemic. Boston: Little, Brown, & Co., 1961.

6. National Center for Infectious Diseases, Centers for Disease Control and Prevention. DQ illustrates intra agency cooperation. DQ history available online at http://www.cdc.gov/ncidod/dq/history.htm.

7. National Center for Infectious Diseases, Centers for Disease Control and Prevention. DQ illustrates intra agency cooperation. DQ mission available online at http://www.cdc.gov/ncidod/dq/mission.htm.

8. National Center for Infectious Diseases, Centers for Disease Control and Prevention. DQ illustrates intra agency cooperation. List of quarantine stations available online at http://www.cdc.gov/ncidod/dq/quarantine_stations.htm.

9. National Immunization Program, Centers for Disease Control and Prevention. Measles, mumps, and rubella vaccine [fact sheet]. Atlanta: CDC, 1994.

10. National Immunization Program, Centers for Disease Control and Prevention. Measles, mumps, and rubella vaccine [fact sheet]. Atlanta: CDC, 1994.

11. CDC. CDC Travel Information [online database: http://www.cdc.gov/travel/travel.html]. Atlanta: CDC, 1997.

12. Cimons M. Critics finding holes in overseas vaccination law. Los Angeles Times [online]. 5 June 1997.

13. National Vaccine Advisory Committee. Report of the NVAC working group on philosophical exemptions. Atlanta, GA: National Vaccine Program Office, Centers for Disease Control and Prevention, January, 1998. All States offer medical exemptions (individuals who are immunocompromised, have allergic reactions to vaccine constituents, have moderate or severe illness, etc.), 48 States offer religious exemptions (W. Virginia and Miss. do not) and 15 States offer philosophical exemptions.


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