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Vacc Mandates Chptr13
Vacc Mandates Chptr13
BACKGROUND
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VACCINATION MANDATES 263
mingled in a common pasture. At capacity, each owner still has an incentive to
add additional cattle to the common because even though the yield from each
animal decreases with the addition of more cattle, this decrease is offset for the
individual owner by the additional animal. With this incentive, individual own
ers continue to add cattle to the commons to reap their individual benefit, leading
to the inevitable failure of the common from overgrazing. The community in
terest in maximizing food production, therefore, can be achieved only by placing
controls on the interests of the individual owners in favor of those of the
community.
Analogously, a community free of an infectious disease because of a high
vaccination rate can be viewed as a common. As in Hardin’s common, the very
existence of this common leads to tension between the best interests of the
individual and those of the community. Increased immunization rates result in
significantly decreased risk for disease. Although no remaining unimmunized
individual can be said to be free of risk from the infectious disease, the herd
effect generated from high immunization rates significantly reduces the risk for
disease for those individuals. Additional benefit is conferred on the unimmuni
zed person because avoidance of the vaccine avoids the risk for any adverse
reactions associated with the vaccine. As disease rates drop, the risks associated
with the vaccine come even more to the fore, providing further incentive to
avoid immunization. Thus, when an individual in this common chooses to go
unimmunized, it only minimally increases the risk of illness for that individual,
while conferring on that person the benefit of avoiding the risk of vaccine-
induced side effects. At the same time, however, this action weakens the herd
effect protection for the entire community. As more and more individuals choose
to do what is in their “best” individual interest, the common eventually fails as
herd immunity disappears and disease outbreaks occur. To avoid this “tragedy
of the commons,” legal requirements have been imposed by communities (in
recent times, by states) to mandate particular vaccinations.
Impact of Vaccines
The introduction and widespread use of vaccines have profoundly affected the
occurrence of several infectious diseases. Smallpox was eradicated from the
world—onset of the last naturally occurring case was in 1977—and vaccination
against smallpox stopped. Poliomyelitis is on the verge of eradication (the last
indigenous case in the United States associated with wild virus occurred in 1979,
and only 20 to 30 countries were still reporting transmission as of mid-2001).
Because approximately 11,000 infants are born every day in the United States,
the need to ensure that children continue to be protected is ongoing. In addition,
a continuing threat exists of importation of disease from other countries. In the
United States, infants and young children are currently vaccinated against 11
diseases: diphtheria, Haemophilus influenzae type b, hepatitis B, measles,
mumps, pertussis, poliomyelitis, rubella, Streptococcus pneumoniae, tetanus, and
varicella.9 In states with high risk for hepatitis A, children are also vaccinated
against this disease. With the exception of tetanus, each of these diseases is
spread from person to person by direct contact or by aerosol droplet transmis
sion. Most of the diseases historically have had very high incidence in school-
aged children because of the high potential for transmission in the congregate
setting. With more children in preschool programs, outbreaks have occurred at
earlier ages. In contrast, hepatitis B has its highest incidence in young adulthood
as a result of transmission through sexual contact or needle sharing. Tetanus is
acquired by contamination of wounds and is not transmitted from person to
person. Table 13–1 shows the representative annual morbidity (typically, aver
age morbidity reported in the 3 years before introduction of the vaccine) in the
twentieth century and the number of cases reported in 2000 for diseases against
which children have been routinely vaccinated.10 Most diseases have declined
by 99% or more (pneumococcal disease and varicella are not reportable con
ditions) and are at all-time lows. Vaccination coverage in 19–35-month-old chil
dren is at an all-time high (Table 13–2).11
DTP, 3 94.1
DTP, 4 81.7
Polio, 3 89.5
Hib, 3 93.4
MMR, 1, 90.5
Hepatitis B, 3 90.3
Varicella 67.8
Combined series
4 DTP/3 polio/1 MMR 77.6
4 DTP/3 polio/1 MMR/3 Hib 76.2
4 DTP/3 polio/1 MMR/3 Hib/3 Hep B 72.8
DTP, diphtheria and tetanus toxoids and pertussis vaccine; Hib, Haemo
philus influenzae type b vaccine; MMR, measles-mumps-rubella vaccine;
Hep B, hepatitis B vaccine.
266
VACCINATION MANDATES 267
Department of Health and Human Services to coordinate and oversee all activ
ities within the U.S. government related to vaccine research and development,
vaccine-safety monitoring, and vaccination activities. In addition, the Act estab
lished the National Vaccine Injury Compensation Program (VICP) to compen
sate for injuries associated with routinely administered childhood vaccines (42
U.S.C. §§ 300aa-10–300aa-23). At least some of the decline in the number of
vaccine producers in the United States had been attributed to liability costs. The
VICP effectively removes this as a significant consideration.
Acknowledging that vaccines, as with any medication, are not without risk to
the patient, that vaccines, unlike other medications, are a medical intervention
generally given to healthy individuals, and that vaccination has benefits beyond
the individual by significantly benefitting the public health through creation of
herd immunity, the VICP was established to shift the monetary costs of vaccine
injuries away from vaccine recipients and manufacturers. Using a vaccine injury
table and a simplified administrative process through the U.S. Court of Federal
Claims, this no-fault system is designed to fairly compensate children and their
families (along with adult recipients of these vaccines) for the costs associated
with the rare injuries related to vaccination. An excise tax on each dose of
covered vaccine funds the compensation program.
Individuals alleging vaccine injury must go through the VICP before filing
any tort actions against the administering health-care provider or the vaccine
manufacturer. If the judgment of the court is accepted, further actions against
the provider and manufacturer are barred. Even if the judgment is declined, the
NCVIA significantly narrows the scope of any tort action against the manufac
turer. Since the inception of the VICP, few individuals have chosen to reject
the judgment of the court and file suit against the provider or manufacturer.
Thus, liability costs of the vaccine manufacturers have dropped dramatically
since the establishment of the VICP.
With the product liability incentive for vaccine improvement substantially
reduced by the existence of the VICP, the role of the government in monitoring
vaccine safety becomes more prominent. Beyond post-licensure surveillance re
quirements of the FDA, the NCVIA also established the Vaccine Adverse Event
Reporting System (VAERS), which requires reporting of adverse events by vac
cination providers (42 U.S.C. § 300aa-25). Providers must also record lot num
bers of vaccines administered. Furthermore, various federal agencies, including
the CDC’s National Immunization Program, have expanded vaccine-safety ac
tivities. In addition, with diminished liability costs, more pharmaceuticals have
entered the vaccine production arena with the resultant competition leading to
further vaccine improvements and development of new vaccines against other
diseases.
The NCVIA also seeks to improve the knowledge level of parents through
268 CONTROL AND PREVENTION
its requirement that the CDC produce vaccine information materials for man
datory distribution by providers to patients or parents before administration of
VICP-covered vaccines (42 U.S.C. § 300aa-26). Through these materials, called
Vaccine Information Statements, parents are informed about the schedules for
administration of the vaccines, are alerted to contraindications that dictate
against administration to particular individuals, and are informed about potential
adverse reactions to look for to encourage timely medical intervention, as
needed.
Most children in the United States receive their vaccinations in the private
sector, from pediatricians or family physicians. A significant minority receive
vaccinations in the public sector, typically from local health departments. There
is considerable variation around the country.15 At current prices, the cost for
vaccines alone (irrespective of physician fees) is approximately $600 in the
private sector (CDC, unpublished data). Most employer-based insurance plans
now cover childhood vaccinations.
Since 1962, the federal government has supported childhood vaccination pro
grams through a grant program administered by the CDC.16 These “317” grants,
named for the authorizing statute, support purchase of vaccine for free admin
istration at local health departments and support immunization delivery, sur
veillance, and communication and education. As of 2000, the CDC purchased
over half the childhood vaccine administered in the United States through two
federally overseen, state-administered programs. In addition to the 317 program,
in 1994 the Vaccines for Children (VFC) 17 program began, under which all
Medicaid-eligible children, all children who are uninsured, all American Indian
and Alaska Native children, and insured children whose coverage does not in
clude vaccinations (with limitations on the locations where this last group can
receive VFC vaccine) qualify to receive routine childhood vaccines at no cost
for the vaccine. The VFC program operates in both public health clinics and
private provider offices. The 317 grant program provides additional vaccines to
the states for administration to adults and to children who do not qualify for
VFC vaccine. Additional federal assistance for vaccination is provided by the
Children’s Health Insurance Program through expanded Medicaid eligibility for
low-income children.18 Many states use state funds to purchase additional quan
tities of vaccine.
The ACIP determines the vaccines to be administered in the VFC program
and the schedules for their use. In addition, the ACIP issues recommendations
for use of adult and pediatric vaccines in the United States and, generally in
coordination with the American Academy of Pediatrics and the American Acad
emy of Family Physicians, establishes a recommended schedule for administra
tion of routine childhood vaccines. The ACIP recommendations are often con
sidered by states as they determine which vaccinations to mandate for school
attendance.
VACCINATION MANDATES 269
To assist parents in complying with the often complex vaccine schedules,
many states and localities, with the assistance of the CDC and professional
organizations, have established vaccination registries to send parents reminders
when vaccines are due. In a mobile era when families move often and frequently
change health-care providers, these registries also help avoid over-vaccination
and ensure catch-up vaccination when needed.19
states that strictly enforced the laws had incidence rates less than half those of
the rest of the country; and in the 1978–1979 school year, the incidence rates
were less than one tenth those of the rest of the country.27 An analysis of states
with the highest and lowest incidences of measles in 1979–1980 found that states
with the lowest incidence rates were significantly more likely to have laws cov
ering the entire school population (rather than just first entrants) and more likely
to be strictly enforcing the laws.28
By the 1980–1981 school year, all 50 states had laws covering students
first entering school. In most states, these laws affected children at all grade
levels, as well as those involved in licensed preschool settings. Some of the
laws specified the particular vaccines required (and the numbers of doses of
each); others authorized the State Health Officer (or public health board) to
designate which vaccines (and doses) were required, often after a public rule-
making process.
As of the 1998–1999 school year, all states but four (Louisiana, Michigan,
South Carolina, and West Virginia) had requirements covering all grades from
kindergarten through 12th grade. In all states, the District of Columbia, and
Puerto Rico, the requirements covered daycare centers; in 48 states (all but Iowa
and West Virginia), the requirements covered Head Start programs. Thirty states,
the District of Columbia, and Puerto Rico had some requirements for college
entrance. The requirements covered diphtheria toxoid and polio, measles, and
rubella vaccines in all 50 states; 49 states required tetanus toxoid, 46 required
mumps vaccine, 44 required pertussis vaccine, and 28 required hepatitis B
vaccine.29
Since 1981, vaccination levels in school entrants have been 95% or higher
for diphtheria and tetanus toxoids and pertussis vaccine (DTP), polio vaccine,
and measles vaccine. All states require vaccination for children attending li
censed daycare centers and as a result such children have vaccination levels
90% or higher. Nonetheless, overall levels in preschool children have not been
as high, as manifested by the resurgence of measles that occurred during 1989–
1991, primarily affecting unvaccinated preschool-aged children.30 Levels in
preschool-aged children have recently been raised to their currently high levels
as a result of major efforts (and major infusions of resources) directed at this
population.15
The Task Force on Community Preventive Services is an independent
body carrying out evidence-based reviews of the literature to assess the claims
that preventive interventions directed to populations are effective. One of
the 17 interventions reviewed for vaccine-preventable diseases was manda
tory vaccination requirements. The Task Force found that sufficient evidence
existed to demonstrate the effectiveness of these requirements in increasing
vaccine coverage, thereby reducing disease incidence, and so recommended
their use.31
VACCINATION MANDATES 271
Historical Context
Duffy’s description of smallpox vaccination in early American history highlights
both the significant positive public health impact of vaccines and the ongoing
challenges that this success presents20:
Smallpox . . . was the great scourge of the American colonies until the introduction of
inoculation or variolation, and the subsequent discovery of vaccination in 1796 relegated
it to minor importance among the great epidemic diseases. As memories of the horrifying
outbreaks of smallpox gradually faded, and a generation appeared which had had little
contact with its victims, vaccination was neglected, and the incidence of smallpox began
to rise. Beginning in the 1830s its attacks gradually intensified, and by the time of the
Civil War the disorder was once again a serious problem.
By chance, the rise of smallpox coincided with the enactment of compulsory school
attendance laws and the subsequent rapid growth in the number of public schools. Since
the bringing together of large numbers of children clearly facilitated the spread of small
pox, and since vaccination provided a relatively safe preventive, it was natural that com
pulsory school attendance laws should lead to a movement for compulsory
vaccination. . . .”
Many other childhood diseases for which vaccines were developed also fre
quently occurred in school-based outbreaks; consequently, when polio and mea
sles vaccines were introduced in 1955 and 1963, respectively, adding them to
the list of requirements for school entry was a logical consideration. The 1963
survey of state laws found that, of 20 states with requirements, 18 included
smallpox, 11 included diphtheria, 10 included polio, 7 included tetanus, and 5
included pertussis. Measles requirements were soon added. By 1970, 20 states
required measles vaccination, and by 1983 all 50 states did.32
Police Power
The first state law mandating vaccination was enacted in Massachusetts in 1809;
in 1855, Massachusetts became the first state to enact a school vaccination re
quirement. The constitutional basis of vaccination requirements rests in the po
lice power of the state. Nearly 100 years ago, the U.S. Supreme Court issued
its landmark ruling in Jacobson v. Massachusetts,33 upholding the right of states
to compel vaccination. The Court held that a health regulation requiring small
pox vaccination was a reasonable exercise of the state’s police power that did
not violate the liberty rights of individuals under the Fourteenth Amendment to
the U.S. Constitution. The police power is the authority reserved to the states
by the Constitution and embraces “such reasonable regulations established di
rectly by legislative enactment as will protect the public health and the public
safety”a (197 U.S. at 25, 25 S.Ct. at 361).
272 CONTROL AND PREVENTION
Neither rights of religion nor rights of parenthood are beyond limitation. Acting to guard
the general interest in youth’s well being, the state as parens patriae may restrict the
parent’s control by requiring school attendance, regulating or prohibiting the child’s
labor, and in many other ways. Its authority is not nullified merely because the parent
grounds his claim to control the child’s course of conduct on religion or conscience.
Thus, he cannot claim freedom from compulsory vaccination for the child more than for
himself on religious grounds. The right to practice religion freely does not include liberty
to expose the community or the child to communicable disease or the latter to ill health
or death.d (321 U.S. at 166–7, 64 S.Ct. at 442)
Whether a vaccination law that does not provide for religious exemptions
would meet the compelling state interest test is essentially moot now because
of a U.S. Supreme Court ruling that significantly lowers the bar for states to
prevail. In its 1990 decision in Employment Div., Dept. of Human Resources of
Oregon v. Smith,46 the Supreme Court rejected the compelling interest test and
established a new standard that holds that “the right of free exercise does not
relieve an individual of the obligation to comply with a ‘valid and neutral law
of general applicability on the ground that the law proscribes (or prescribes)
conduct that his religion prescribes (or proscribes)’ ” (494 U.S. at 879, 110 S.Ct.
at 1600 [quoting United States v. Lee, 455 U.S. 252, 263, n. 3, 102 S.Ct. 1051,
1058, n. 3 (1982)]).
Congress attempted to legislatively override the ruling in Smith by enacting
the Religious Freedom Restoration Act of 1993 (RFRA), which reestablished
the compelling interest test as the standard for considering the constitutionality
of free exercise claims.47 However, the U.S. Supreme Court in City of Boerne
v. Flores48 struck down RFRA, holding that Congress had exceeded its consti
tutional authority in implementing the statute (521 U.S. at 510–37, 117 S.Ct. at
2160–72). Thus, the Smith standard is the current law. Whether judged under
the neutral law of general applicability test of Smith or the compelling interest
test of Sherbert, it is reasonable to conclude that there is no First Amendment
free exercise right to an exemption from mandatory vaccination requirements.
Strength of convictions aside, defining “religious” belief can be difficult, and un
derstanding its implications for philosophic exemptions that a state may or may
not wish to voluntarily confer is a challenge. As the Supreme Court noted in
Yoder: “to have the protection of the Religion Clauses, the claims must be rooted
in religious belief” (406 U.S. at 215, 92 S.Ct. at 1533). Decisions by the U.S.
Supreme Court in two conscientious objector cases indicate that a bright line
may not always exist between the religious and the philosophic and that at least
some amount of philosophic opposition to vaccination may rise to the level of
being religious and therefore incorporated into a voluntarily conferred religious
exemption, regardless of whether the state explicitly provides for a philosophic
exemption.k In United States v. Seeger52 and Welsh v. United States,53 the Court
interpreted “religious,” as it appeared in a federal statutory religious-based con
scientious objector exemption from military conscription, very expansively to
extend beyond traditional religious beliefs. Seeger defined the test as “[a] sincere
and meaningful belief which occupies in the life of its possessor a place parallel
to that filled by the God of those admittedly qualifying for the exemption” (380
U.S. at 176, 85 S.Ct. at 859). The Court elaborated in Welsh: “to be ‘religious’
. . . this opposition . . . [must] stem from . . . moral, ethical, or religious beliefs
about what is right and wrong and that these beliefs be held with the strength of
traditional religious convictions” (398 U.S. at 340, 90 S.Ct. at 1796).
However, the Welsh Court clarified that “moral, ethical, or religious princi
ples” do not incorporate “considerations of policy, pragmatism, or expediency”
(398 U.S. at 342–3, 90 S.Ct. at 1798). Yoder provides further illumination: “A
way of life, however virtuous and admirable, may not be interposed as a barrier
to reasonable state regulation of education if it is based on purely secular con
siderations. . . . [T]he very concept of ordered liberty precludes allowing every
person to make his own standards on matters of conduct in which the society
as a whole has important interests. Thus, if the Amish asserted their claims
because of their subjective evaluation and rejection of the contemporary secular
values accepted by the majority, much as Thoreau rejected the social values of
his time and isolated himself at Walden Pond, their claims would not rest on a
religious basis. Thoreau’s choice was philosophical and personal rather than
religious, and such belief does not rise to the demands of the Religion Clauses”
(406 U.S. at 215–6, 92 S.Ct. at 1533). Thus, the court in Mason v. General
Brown Central School District54 rejected fear of the possible side effects from
vaccination, although based on strong convictions, as rising to the level of re
ligious beliefs because of evidence that the plaintiff’s beliefs were “simply an
embodiment of secular chiropractic ethics” (851 F.2d at 51–2). Mason, and
similar decisions, indicate that the expansive religious interpretation of Seeger
and Welsh should not be read too broadly.
VACCINATION MANDATES 279
Impact of Evolving Privacy Rights
Finally, the general concept of a liberty interest in bodily integrity was first
articulated by then-Judge, later Justice, Cardozo in Schloendorff v. Society of
New York Hospital: “Every human being of adult years and sound mind has a
right to determine what shall be done with his own body” regarding medical
needs.55 Recognition by the courts in recent years of a liberty right, or right to
privacy, in medical decision making emanating from the due process clause of
the Fourteenth Amendment and noted most prominently by the U.S. Supreme
Court in its 1973 decision Roe v. Wade56 might be used as the basis of a claimed
privacy right by a college student subject to mandatory vaccination. However,
the Court in Roe, referencing Jacobson, noted that the medical privacy right is
not unlimited and must be balanced against important state interests in regulation
(410 U.S. at 154, 193 S.Ct. at 727). More recently, in dicta in the 1990 “right
to die” case of Cruzan v. Director, Missouri Dept. of Health,57 the U.S. Supreme
Court again acknowledged the viability of the Jacobson holding, leading to the
conclusion that, as long as the public health need for widespread vaccination
exists, the courts will not recognize a privacy right to refuse state-mandated
vaccination and will uphold the police power of states to mandate vaccination.
has led to congressional hearings and challenges to requirements for this vac
cine.59 Persons opposed to vaccination have extensively used the Internet to
communicate their beliefs.
Of course, the appearance of new adverse events caused by vaccines further
feeds the controversy. The occurrence of intestinal intussusception after admin
istration of the recently licensed rotavirus vaccine led to withdrawal of the vac
cine and lent some support to the arguments of those opposed to vaccination.60
CONCLUSION
School vaccination requirements have been a key factor in the prevention and
control of vaccine-preventable diseases in the United States. Their constitutional
basis rests in the police power of the state as well as in the parens patriae
doctrine. No constitutional right exists to either a religious or philosophic ex
emption to these requirements, although most states allow religious exemptions
and several allow philosophic exemptions. The courts have generally upheld
these exemptions. Most litigation regarding exemptions has focused on the scope
of the exemption, with courts holding that religious exemptions may not be
limited to members of organized religions but rather must allow all who have
sincerely held religious beliefs in opposition to vaccination to qualify. “Reli
gious” may be defined broadly enough to incorporate some amount of philo
sophic opposition but should not be interpreted to bring purely secular-based
“philosophic” opposition to vaccination within the meaning of religion.
With the increasing numbers of vaccines being introduced and the generally
low level of visible threat from disease, continued challenges to school vacci
nation requirements are expected. School vaccination laws continue to play a
central role in avoiding “the tragedy of the commons” by preventing disease
through high vaccination coverage. These laws can be expected to be upheld by
the courts as long as the balance of protecting the public health is achieved by
mandating such requirements.
Notes
a
Compulsory vaccination is not beyond the police power without arbitrariness or ex
treme injustice under particular facts. (See note b regarding medical-based exemption).
In Jacobson, the Court—in addition to holding that providing for compulsory vacci
nation is within the police power of a state—also held that such authority may be
delegated to a local body (197 U.S. at 25, 25 S.Ct. at 361).
b
In dicta, the Court in Jacobson indicated, however, that there would be a liberty right
to an exemption based on known medical contraindication “to protect the health and
life of the individual concerned” (197 U.S. at 39, 25 S.Ct. at 366). (Dicta is discussion
in a court decision that addresses an issue outside the direct facts presented by the
case and therefore outside the court’s holding and thus is of no precedential value in
directing future court decisions.)
VACCINATION MANDATES 281
c
See also Brown v. Stone (378 So. 2d 218, 222–3) (Miss. 1979), cert. denied 449
U.S. 887 (1980) for discussion regarding the logical nexus between mandatory vac
cination and school attendance: “overriding and compelling public interest . . . [in] ex
clusion of a child until such immunization has been effected, not only as a protection
of that child but as a protection of the large number of other children comprising the
school community and with whom he will be daily in close contact in the school
room.”
d
See also In re: Christine M., 157 Misc.2d 4, 595 N.Y.S.2d 606 (N.Y. Fam. Ct. 1992)
in which the court, citing Prince, held that a father’s knowing failure to have his child
vaccinated against measles in the midst of a measles outbreak, and not qualifying for
a statutory religious exemption, caused the child to be a “neglected child” under state
law. However, the court declined to order vaccination because the measles outbreak
had ended by then and the child was not yet old enough to be subject to the school
attendance law.
e
But see discussion regarding holding in Sherr striking down state religious exemption
requirement that an individual be a “bona fide member of a recognized religious
organization.”
f
The First Amendment to the U.S. Constitution states in pertinent part, “Congress shall
make no law respecting an establishment of religion, or prohibiting the free exercise
thereof. . . .” The Free Exercise and Establishment Clauses have been held applicable
to the States through the Due Process Clause of the Fourteenth Amendment.40
g
See also Cude v. State, 237 Ark. 927, 377 S.W.2d 816 (Ark. 1964) (upholding ruling
of neglect and appointment of temporary guardian to consent to vaccination of children
despite parents’ good faith religious beliefs in opposition).
h
See note f, above.
i
See also Davis v. State, 294 Md. 379, 451 A.2d 107 (Md. 1982), which held that
limiting religious exemption to children whose parents were “members” (as statute
provided) or “adherents” (as health department regulation further attempted to narrow
the qualification) of a “recognized church or religious denomination” opposing vac
cination violated the Establishment Clause. On the basis of rules of statutory construc
tion in Maryland, the court severed the offending religious exemption from the statute
and upheld the conviction of Davis under the remaining statute that compelled vac
cination (294 Md. at 382–5, 451 A.2d at 114–5). Rules of statutory construction vary
so that in the Sherr case the court struck down the limiting “bona fide members of a
recognized religious organization” language but otherwise upheld the religious ex
emption. In addition, the court enjoined enforcement of the “bona fide” language as
to one of the two sets of plaintiffs, who otherwise qualified, and further enjoined the
state from enforcing the offending language in the future (672 F.Supp. at 97–9).
j
The court in Sherr, having noted the constitutional infirmity of the “bona fide” limi
tation under the other two prongs of Lemon, did not resolve whether the “bona fide”
portion of the religious exemption possessed a secular purpose as required under the
first prong. However, in dicta, the court noted that the legislature may have had a
number of secular purposes for adopting such language, including “as a guard against
claims of exemption on the basis of personal moral scruples or unsupported fear of
vaccinations, as a means of allowing certain exemptions without risking lessened ef
fectiveness of the state’s inoculation program due to the granting of a large number
of exemptions, or perhaps because of the difficulties inherent in devising a legally
workable definition of religion” (672 F.Supp. at 89).
k
Fifteen states provide a separate philosophic exemption to school attendance vacci
282 CONTROL AND PREVENTION
29
nation laws, in addition to religious exemptions (RH Snyder, NIP, CDC, personal
communication).
References
55. Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 129, 105 N.E. 92, 93
(N.Y. 1914).
56. Roe v. Wade, 410 U.S. 113, 193 S.Ct. 705 (1973).
57. Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 278, 110 S.Ct. 2841,
2851 (1990).
58. Hinman AR. The pertussis vaccine controversy. Public Health Rep 1984;99:255–9.
59. Institute of Medicine. Measles-Mumps-Rubella Vaccine and Autism. Report by the
Immunization Safety Review Committee, Institute of Medicine. Washington, DC: Na
tional Academy Press, 2001.
60. CDC. Withdrawal of rotavirus vaccine recommendation. MMWR 1999;48:1007.