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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
Immunizations 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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Footnotes |
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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