Vaccination policy

Individual and herd immunity Vaccination policies aim to produce immunity to preventable diseases. Besides individual protection from getting ill, some vaccination policies also aim to provide the community as a whole with herd immunity. Herd immunity refers to the idea that the pathogen will have trouble spreading when a significant part of the population has immunity against it, reducing the effect an infectious disease has on society. This protects those unable to get the vaccine due to medical conditions, such as immune disorders. However, for herd immunity to be effective in a population, a majority of those who are vaccine-eligible must be vaccinated. Vaccine-preventable diseases remain a common cause of childhood mortality with an estimated three million deaths each year. Every year, vaccination prevents between two and three million deaths worldwide, across all age groups, from diphtheria, tetanus, pertussis and measles. Eradication of diseases With some vaccines, a goal of vaccination policies is to eradicate the diseasedisappear it from Earth altogether. The World Health Organization (WHO) coordinated the effort to eradicate smallpox globally through vaccination, the last naturally occurring case of smallpox was in Somalia in 1977. Endemic measles, mumps and rubella have been eliminated through vaccination in Finland. On 14 October 2010, the UN Food and Agriculture Organization declared that rinderpest had been eradicated. The WHO is currently working to eradicate polio, which was eliminated in Africa in August 2020 and remained only in Pakistan and Afghanistan at the time. Individual versus group goals The likely behavior of individuals when offered vaccines can be modeled economically using ideas from game theory. According to such models, individuals will attempt to minimize the risk of illness, and may seek vaccination for themselves or their children if they perceive a high threat of disease and a low risk to vaccination. However, if a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease enough so that an individual's optimal strategy is to encourage everyone but their family to be vaccinated, or (more generally) to refuse vaccination once vaccination rates reach a certain level, even if this level is below that optimal for the community. For example, a 2003 study predicted that a bioterrorist attack using smallpox would result in conditions where voluntary vaccination would be unlikely to reach the optimum level for the U.S. as a whole, and a 2007 study predicted that severe influenza epidemics cannot be prevented by voluntary vaccination without offering certain incentives. Governments often allow exemptions to mandatory vaccinations for religious or philosophical reasons, but decreased rates of vaccination may cause loss of herd immunity, substantially increasing risks even to vaccinated individuals. However, mandatory vaccination policies raise ethical issues regarding parental rights and informed consent. Fractional dose vaccination is a strategy that trades societal benefit for individual vaccine efficacy, has proven to be effective in randomized trials in poverty diseases, and in epidemiologic models was thought to hold a significant potential for shortening the COVID-19 pandemic when vaccine supply is limited. ==Compulsory vaccination==

At various times, governments and other institutions have established policies requiring vaccination with the aim of reducing the risk of disease. An 1853 law required universal vaccination against smallpox in England and Wales, with fines levied against people who did not comply. In the United States, the Supreme Court ruled in Jacobson v. Massachusetts (1905) that states have the authority to require vaccination against smallpox during a smallpox epidemic. All fifty U.S. states require that children be vaccinated to attend public school, although 47 states provide exemptions based on religious or philosophical beliefs. In the European Union, the 2021 case of Vavřička and Others v. the Czech Republic, decided by the European Court of Human Rights (ECtHR), held that the nation of the Czech Republic did not violate the European Convention on Human Rights by imposing a vaccination mandate on children in that country. Forced vaccination (as opposed to fines or refusal of services) is uncommon, and typically happens only as an emergency measure during an outbreak. This has been reported in parts of China. Compulsory vaccinations greatly reduce infection rates for the diseases they protect against. Common objections included the argument that governments should not infringe on individuals' freedom to make medical decisions for themselves or their children, or claims that proposed vaccinations were dangerous. In 1904, in the city of Rio de Janeiro, Brazil, following an urban renewal program that displaced many poor, a government program of mandatory smallpox vaccination triggered the Vaccine Revolt, several days of rioting with considerable property damage and a number of deaths. Compulsory vaccination is a difficult policy issue, requiring authorities to balance public health with individual liberty: An ethical dilemma may emerge when health care providers attempt to persuade vaccine-hesitant families towards receiving vaccinations as this persuasion may lead to violating their autonomy. There is also evidence that mandatory vaccination policies for healthcare workers, for instance for influenza shots, increase uptake. One argument among public health professionals is that compulsory vaccination is necessary in severe circumstances, but that it should be approached carefully in order to avoid polarizing the population and decreasing trust in the long term. Many countries (Canada, Germany, Japan, and the United States) have specific requirements for reporting vaccine-related adverse effects; others (Australia, France, and the United Kingdom) include vaccines under their general requirements for reporting injuries associated with medical treatments. A number of countries have both compulsory vaccination and national programs for the compensation of injuries alleged to have been caused by a vaccination. In November 2021, during a COVID-19 outbreak, Austria banned unvaccinated individuals from leaving their home apart from going to work, buying essential supplies, or exercise, in an effort to reduce the spread of disease. During the fourth wave of the COVID-19 pandemic, with a low vaccination rate compared to the rest of Western Europe (79%), the Austrian government made vaccination mandatory. However, government entities, such as Child Protective Services, can intervene only when the parents directly harm their child via abuse or neglect, considering a child does not have the ability to give or take away consent. Although withholding medical care meets the criteria of abuse or neglect, refusing vaccinations does not, as the child is not being harmed directly. To prevent the spread of disease by unvaccinated individuals, some schools and doctors' surgeries have prohibited unvaccinated children from being enrolled, even where not required by law. Doctors who refuse to treat unvaccinated children harm both the child and public health, and may be considered unethical when parents are unable to find another provider. Opinion on this is divided, with the largest professional association, the American Academy of Pediatrics, saying that exclusion of unvaccinated children may be an option under narrowly defined circumstances. One historical example is the 1990–91 Philadelphia measles outbreak, which led to the deaths of nine children in an anti-vaccination faith healing community. Court orders were obtained to have infected children given life-saving medical treatment, against the wishes of their parents, and also for healthy children to be vaccinated without parental consent. In schools and daycare Vaccination requirements for access to daycare and schools increase vaccine uptake in the United States and there is evidence that these requirements may decrease disease. However, the majority of studies of mandatory vaccination took place in the US and the cultural climate in United States is quite different from other industrialized nations. Canada has a similar vaccination to the US despite 11 of its provinces and territories having no vaccine mandates, which may in part be due to vaccination programs taking place in school in Canada. Globally, systematic reviews indicate that nudge-based interventions can modestly improve COVID-19 vaccination uptake. These behavioral strategies are often discussed alongside debates about compulsory vaccination and exemptions. Scholars such as Mark Navin argue that while mandates remain common, policies should balance public health goals with respect for parental autonomy. Navin suggests that nonmedical exemptions should remain available but be made more burdensome to discourage casual refusal, rather than eliminated entirely. == Immunity acquired through deliberate infection ==

In the United Kingdom, children are not vaccinated against chickenpox despite the availability of a vaccine since the 1990s. Modelling predicted that vaccinating children would increase the number of cases amongst adults due to the absence of natural boosting from exposure to chickenpox in day-to-day life. The Joint Committee on Vaccination and Immunisation were concerned that more pregnant women would become infected because immunity in the general population would decrease . == Planning vaccination policy ==

Vaccination committees Vaccination policy is typically proposed by national or supranational advisory committees on immunization, and in many cases, is regulated by the government. Vaccination strategy models Predictive vaccination strategy models play an important role in predicting effectiveness of vaccination strategies at population level. The may, e.g., compare the sequence of age groups to be vaccinated and study the outcome in terms of caseload, deaths, length of a pandemic, healthcare system load, and economic impact. ==Evaluating vaccination policy==

Vaccines as a positive externality The promotion of high levels of vaccination produces the protective effect of herd immunity as well as positive externalities in society. Large scale vaccination is a public good, in that the benefits obtained by an individual from large scale vaccination are both non-rivalrous and non-excludable, and given these traits, individuals may avoid the costs of vaccination by "free-riding" The costs and benefits to individuals and society have been studied and critiqued in stable and changing population designs. Other surveys have indicated that free-riding incentives exist in individual decisions, and in a separate study that looked at parental vaccination choice, the study found that parents were less likely to vaccinate their children if their children's friends had already been vaccinated. Trust in vaccination Trust in vaccines and in the health system is an important element of public health programs that aim to deliver life-saving vaccines. Trust in vaccination and health care is an important indicator of government work and the effectiveness of the social policy. The success in overcoming diseases and in vaccination depends on the level of trust in vaccines and health care. The lack of trust in vaccines and immunization programs can lead to vaccine refusal, risking disease outbreaks, and challenging immunization goals in high- and low-income settings. Today, the medical and scientific communities obviously face a big challenge where vaccines are concerned, namely enhancing the trust with which the general public regards the entire endeavor. Indeed, earning the public's trust in public health is a big challenge. Accurately, studying the trust in vaccines, and understanding the factors that affect the reduction of trust, allows authorities to build an effective vaccine campaign and communication strategies to fight the disease. Trust is a key parameter to work with before and while undertaking any vaccine campaigns. The state is responsible for providing smart communication, and to inform a population about diseases, vaccines, and the risks of both. The WHO recommends that states work long-term, to build population resilience against vaccine myths and scares, to develop a strong campaign that is well prepared to respond to any event that may erode trust, and respond immediately to any event which may erode trust in health authorities. A review of 34 studies into communication strategies to tackle untruths about vaccines has also suggested strategies that are helpful, such as communicating scientific consensus and using humour to dispel myths, and unhelpful, such as scare tactics. Cost-benefit: United States The first economic analysis of routine childhood immunizations in the United States took place in 2001, and reported cost savings over the lifetime of children born that year. Other analyses of the economic costs and potential benefits to individuals and society have since been evaluated. In 2014, the American Academy of Pediatrics published a decision analysis that evaluated direct costs, such as program costs, vaccine cost, administrative burden, negative vaccine-linked reactions, and transportation time lost to parents. there is an economic incentive and "global value" to invest in preventive vaccination programs, especially in children as a means to prevent early infant and childhood deaths. Socioeconomic disparities have been found to hinder reasonable access to vaccinations in the U.S., and it has also been found that even if such status is not a factor, "racial ethnic minority adults are less likely than whites to receive preventive care including vaccination". Cost-benefit for older adults There is an economic incentive to establish vaccination programs for older adults as the general population is aging due to increasing life expectancy and decreasing birth rates. Vaccinations can reduce the issues linked with both polypharmacy and antibiotic-resistant bacteria in the older demographic with comorbidities by preventing infectious diseases and decreasing the necessity of polypharmacy and antibiotics. One 2016 study done in Western Europe found that the estimated cost of vaccinating one person over a lifetime against 10–17 potentially debilitating pathogens would be €443–3,395 (equivalent to €– in ). Another study found that if 75% of adults over 65 were vaccinated against seasonal influenza, 3.2–3.8 million cases and 35,000–52,000 influenza-related deaths could be avoided, and €438–558million saved annually, solely on the European continent. ==International Organizations==

In 2006, the World Health Organization and UNICEF created the Global Immunization Vision and Strategy (GIVS). This organization created a ten-year strategy with four main goals: • to immunize more people against more diseases • to introduce a range of newly available vaccines and technologies • to integrate other critical health interventions with immunization • to manage vaccination programmes within the context of global interdependence The Global Vaccination Action Plan was created by the World Health Organization and endorsed by the World Health Assembly in 2012. The plan, which is set from 2011 to 2020, is intended to "strengthen routine immunization to meet vaccination coverage targets; accelerate control of vaccine-preventable diseases with polio eradication as the first milestone; introduce new and improved vaccines and spur research and development for the next generation of vaccines and technologies." ==By country==

Table Argentina In December 2018, Argentina enacted a new vaccine policy requiring all persons who are medically able, both adults and children, to be vaccinated against specified diseases. Proof of vaccination is required to attend any level of school, file for a marriage license, and request any kind of government ID, including a passport or driver's license. The law requires the government to pay for all aspects of vaccinations and deems vaccination to be a national emergency; vaccines are exempt from internal and customs taxes. The policy is supported by a majority of Australian parents as well as the Australian Medical Association (AMA) and Early Childhood Australia. In 2014, about 97 percent of children under seven were vaccinated, although the number of conscientious objectors to vaccination had increased by 24,000 to 39,000 in the previous decade. The government began the Immunise Australia Program to increase national immunization rates. They fund a number of different vaccinations for certain groups of people. The intent is to encourage the most at-risk populations to get vaccinated. The government maintains an immunization schedule. In most states and territories, children can consent to vaccinations if they are judged Gillick competent; normally, this applies to children aged 15 or older. In South Australia, the Consent to Medical Treatment and Palliative Care Act 1995 allows children 16 and older to consent to medical treatment. Additionally, children under this age can be immunized if judged capable of informed consent. It is also lawful for workplaces in Australia to mandate vaccines. The legality of this was upheld in the Fair Work Commission case Kimber v Sapphire Coast Community Aged Care Ltd in 2021. Austria Austrian vaccine recommendations are developed by the National Vaccination Board (), which is part of the Federal Ministry of Social Affairs, Health, Care and Consumer Protection. Children aged 14 and older can be vaccinated without parental consent. Brazil Vaccinating children has been mandatory in Brazil since 1975, when the federal government instituted the National Immunization Program. The compulsory character was written into law in 1990, in the Statute of Children and Adolescents (Art. 14, Para. 1). Parents in Brazil who don't take their children to be vaccinated run the risk of being fined or charged with negligence. Canada Vaccination in Canada is voluntary. Under the mature minor doctrine, minors capable of granting informed consent can be vaccinated without parental approval. Alberta British Columbia New Brunswick Ontario Quebec China China has passed the World Health Organization's (WHO) regulatory vaccine assessments, demonstrating that they adhere to international standards. The Chinese government's Expanded Program on Immunization (EPI) was created in 1978 and provides certain obligatory vaccines, named Category1 vaccines, for free to all children up to 14 years of age. Initially, the vaccines consisted of Bacillus Calmette-Guérin (BCG) vaccine, oral polio vaccine (OPV), measles vaccine (MV) and diphtheria, tetanus and pertussis (DPT vaccine). By 2007, the vaccine list was expanded to include hepatitis A, hepatitis B, Japanese encephalitis, A + C meningococcal polysaccharide, mumps, Rubella, hemorrhagic fever, anthrax, and leptospirosis. Category2 vaccines, such as the rabies vaccine, are private-sector, non-obligatory vaccines that are not included in neither EPI nor the government health insurance. Due to the privatized nature of Category2 vaccines, these vaccinations are associated with low coverage rates. Both the Changsheng Bio-Technology Co Ltd and the Wuhan Institute of Biological Products have been fined for selling ineffective vaccines. In December 2018, China enacted new laws imposing strict controls over the production and inspection of aspects of vaccine production from research, development, and testing through production and distribution. Costa Rica In November 2021, Costa Rica added COVID-19 to the list of infectious diseases required to be vaccinated against. The vaccine is mandatory for children between the ages of 5 and 18. Finland France In France, the High Council of Public Health is in charge of proposing vaccine recommendations to the Minister of Health. Each year, immunization recommendations for both the general population and specific groups are published by the Institute of Epidemiology and Surveillance. Since some hospitals are granted additional freedoms, there are two key people responsible for vaccine policy within hospitals: the Operational physician (OP), and the Head of the hospital infection and prevention committee (HIPC). In 2012, the French government and the Institut de veille sanitaire launched a 5-year national program to improve vaccination policy. The program simplified guidelines, facilitated access to vaccination, and invested in vaccine research. In 2014, fueled by rare health-related scandals, mistrust of vaccines became a common topic in the French public debate on health. According to a French radio station, as of 2014, three to five percent of kids in France were not given the mandatory vaccines. Therefore, criminal trials based on vaccine refusals may be referred to the Cour de Cassation, which will then certify whether the case meets certain criteria. French Health Minister, Marisol Touraine, finds vaccinations "absolutely fundamental to avoid disease," and has pushed to have trained pharmacists and doctors administer vaccinations. Vaccinations within the immunization schedule are given for free at immunization services within the public sector. When given in private medical practices they are reimbursed at 65%. Germany In Germany, the Standing Committee on Vaccination (STIKO) is the federal commission responsible for recommending an immunization schedule. The Robert Koch Institute in Berlin (RKI) compiles data of immunization status upon the entry of children at school, and measures vaccine coverage of Germany at a national level. Founded in 1972, the STIKO is composed of 12–18 volunteers, appointed members by the Federal Ministry for Health for 3-year terms. Members include experts from many scientific disciplines and public health fields and professionals with extensive experience on vaccination. Although the STIKO makes recommendations, immunization in Germany is voluntary and there are no official government recommendations. German Federal States typically follow the Standing Vaccination Committee's recommendations minimally, although each state can make recommendations for their geographic jurisdiction that extends beyond the recommended list. If a vaccination is recommended because of occupational risks, it must adhere to the Occupational Safety and Health Act involving Biological Agents. Criteria for the recommendation include disease burden, efficacy and effectiveness, safety, feasibility of program implementation, cost-effectiveness evaluation, clinical trial results, and equity in access to the vaccine. Beginning in March 2020, Germany made the measles vaccine compulsory for all children attending school or day care, as well persons employed at schools, day cares, and medical or community facilities. Ghana As of January 2022, COVID-19-vaccination is mandatory for staff and students of secondary and tertiary education, employees in all arms of government, health workers, security personnel, and commercial drivers. Italy As aging populations in Italy bring a rising burden of age-related disease, the Italian vaccination system remains complex. The fact that services and decisions are delivered by 21 separate regional authorities creates many variations in Italian vaccine policy. Regions may add more scheduled vaccinations, but cannot exempt citizens from nationally mandated or recommended ones. However, vaccination levels continued to pass the Italian government's goal of 95% outreach. HPV vaccine coverage increased well, and pneumococcal vaccine and meningococcal C vaccines faced positive public reception. However, both infant vaccine coverage rates and influenza immunization in the elderly have been decreasing. Partially in response to the statistic that less than 86% of Italian children receive the measles shot, the National Vaccination Plan for 2016–18 (PNPV) increased vaccination requirements. By November 2018, the government had changed its stance because of the "measles emergency" and decided to uphold the obligation for children up to the age of 16, teachers and health professionals to be vaccinated. A midwife working at a hospital in central Italy was terminated for refusing vaccination. Japan In Japan, there are three types of vaccination practices: Routine (scheduled); Temporary (ad-hoc); and Non-legal. Infections of the first two types are defined by () and its related (). As of January 2020, sixteen infections in total are on the legal listsfourteen are CategoryA diseases (vaccination is not mandatory but recommended to prevent pandemic), and two are CategoryB (not even recommended and only for a personal care purpose). For instance, Japan is the only developed country that does not list mumps on the vaccine schedule. The lawsuit risks, particularly the 1992 Tokyo High Court's ruling on the MMR vaccine class action, impacted on law amendment. In addition to legal and social risk concerns, an issue of the decision-making process underlies the vaccine gap. Unlike the Advisory Committee on Immunization Practices (ACIP) in the United States, a centralized permanent advisory committee for vaccination policy was not organized in Japan until 2009, when a deadly flu outbreak struck the nation. Since the committee kick-off, however, the vaccine gap has been gradually improved. Latvia According to a 2011 publication in CMAJ: The notion of "mandatory" in Latvia differs from that of other nations. Latvia appears unique in that it compels health care providers to obtain the signatures of those who decline vaccination. Individuals have the right to refuse a vaccination, but if they do so, health providers have a duty to explain the health consequences. Vaccines that are not mandatory are not publicly funded, so the cost for those must be borne by parents or employers, she adds. Funded vaccinations include tuberculosis, diphtheria, measles, hepatitis B, human papillomavirus for 12-year-old girls, and tick-borne encephalitis until age 18 in endemic areas and for orphans. Beginning at age 14, minors can consent to vaccination in Latvia without parental permission. Malawi COVID-19 vaccination is mandatory for health workers, journalists, and other frontline staff starting 20 December 2021. Mexico Mexico has a multi-year program for immunisation of children. The immunisation of children is fully covered by the government. Vaccine doses administered in Mexico are usually valid in the United States. Nigeria In Nigeria, the Expanded Programme on Immunization (EPI), was introduced in 1978 to provide free immunization against polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever to Nigerian children less than two years old. This free immunization can be obtained at any primary healthcare provider in the country. The vaccines are usually administered by a government health care worker. They also conduct routine vaccination visits in schools where all the children in a given school are vaccinated. Panama COVID-19 vaccination may become mandatory for government employees. Unvaccinated employees may be forced to take unpaid leave. Having completed the vaccine schedule for schoolchildren up to the child's age, is required for access to the government's main scholarship program. Russia As of 2019, immunization is voluntary in Russia. In May 2021, Russian President Vladimir Putin said that mandating COVID-19 vaccines would be "impractical and impossible." Samoa In the wake of a declared measles epidemic, Samoan authorities made vaccination against measles compulsory in November 2019. Slovenia According to a 2011 publication in CMAJ: For TBE, the vaccination rate in 2007 was estimated to be 12.4% of the general population in 2007. For comparison, in neighboring Austria, 87% of the population is vaccinated against TBE. South Africa In South Africa vaccination is voluntary. The South African Vaccination and Immunisation Centre (SAVIC) began in 2003 as an alliance between the South African Department of Health, vaccine industry, academic institutions, and other stakeholders. SAVIC works with the WHO and the South African National Department of Health to educate, research, provide technical support, and advocate for country-wide vaccinations. Spain Spain's 19 autonomous communities, consisting of 17 Regions and two cities, follow health policies established by the Inter-Territorial Health Council that was formed by the National and Regional Ministries of Health. This Inter-Territorial Council is composed of representatives from each region and meets to discuss health related issues spanning across Spain. The Institute of Health CarlosIII (ISCIIII) is a public research institute that manages biomedical research for the advancement of health sciences and disease preventions. The ISCIII may suggest the introduction of new vaccines into Spain's Recommended Health Schedule and is under direct control of the Ministry of Health. Although the Ministry of Health is responsible for the oversight of health care services, the policy of devolution divides responsibilities among local agencies, including health planning and programing, fiscal duties, and direct management of health services. This decentralization proposes difficulties in collecting information at the national level. The Inter-Territorial Council's Commission on Public Health works to establish health care policies according to recommendations by technical working groups via letters, meetings, and conferences. The Technical Working Group on Vaccines review data on vaccine preventable diseases and proposes recommendations for policies. In 1921, vaccination became mandatory for smallpox, and in 1944 the Bases Health Act mandated compulsory vaccination for diphtheria and smallpox, but was suspended in 1979 after the elimination of the threat of an epidemic. Due to vaccination coverage in each Community, there is little anti-vaccine activity or opposition to the current schedule, and no organized groups against vaccines. The autonomous regions collect data, from either electronic registries or written physician charts, to calculate immunization coverage. Minors aged 12 and older may consent to immunization with the Pfizer–BioNTech COVID-19 vaccine without parental approval. Tanzania According to the World Health Organization vaccination coverage in Tanzania was more than 90% in 2012. An Electronic Immunisation Register has been established, which permits online access to the medical records of mothers and infants, enabling vaccination teams in remote areas to operate more effectively, especially with nomadic people. It also helps to coordinate stock levels and order new supplies. United Kingdom In the United Kingdom, the purchase and distribution of vaccines is managed centrally, and recommended vaccines are provided for free by the NHS. In the UK, no laws require vaccination of schoolchildren. Under the Gillick test, children under 16 can consent to vaccination over parental objections if they demonstrate a mature understanding of the ramifications of the procedure. United States In the United States, the Advisory Committee on Immunization Practices makes scientific recommendations regarding vaccines and vaccination schedules that the federal government, state governments, and private health insurance companies generally follow. See Vaccination schedule for the schedule recommended in the United States. As of 2025, all states in the U.S. except for Idaho mandate immunizations for children to enroll in public school, but various exemptions are available depending on the state. All states have exemptions for people who have medical contraindications to vaccines, all states except for California, Maine, Mississippi, New York, and West Virginia (as directed by its Board of Education) allow religious exemptions, and sixteen states allow parents to cite personal, conscientious, philosophical, or other objections. An increasing number of parents are using religious and philosophical exemptions: researchers have cited this increased use of exemptions as contributing to loss of herd immunity within these communities, and hence an increasing number of disease outbreaks. Of the 49 states with existing immunization requirements for public school, all of them require DTaP (diphtheria-tetanus-pertussis), MMR (measles-mumps-rubella), Polio, Tdap (tetanus-diphtheria-pertussis; secondary school only) and Varicella (chickenpox) vaccines for school attendance. Additionally, 46 states require the Hepatitis B vaccine, 34 states require the Meningococcal vaccine, and 18 require the Hepatitis A vaccine; Rhode Island, Virginia, and Hawaii also require the HPV vaccine (human papillomavirus; secondary school only). The American Academy of Pediatrics (AAP) advises physicians to respect the refusal of parents to vaccinate their child after adequate discussion, unless the child is put at significant risk of harm (e.g., during an epidemic, or after a deep and contaminated puncture wound). Under such circumstances, the AAP states that parental refusal of immunization constitutes a form of medical neglect and should be reported to state child protective services agencies. Several states allow minors to legally consent to vaccination over parental objections under the mature minor doctrine. Immunizations are compulsory for military enlistment in the U.S. However, exceptions exist, but may be determined by an uneven process. The suppression of religious exemptions to the military COVID-19 vaccination mandate was successfully proven by members of the Air Force and overturned in the Sixth Circuit federal court of appeals in September 2022, when evidence was presented that more than 99% of requests for religious exceptions were systematically denied approval, though other kinds of exemption requests were more often granted. The judge had previously awarded class action status to the case, extending the suit to cover an estimated more than 12,000 joint plaintiffs. All vaccines recommended by the U.S. government for its citizens are required for green card applicants. This requirement stirred controversy over related costs when, in July 2008, it was applied to the HPV vaccine. In addition, the 13 other required vaccines prevent highly contagious diseases communicable through the respiratory route, while HPV is spread only through sexual contact. In November 2009, this requirement was canceled. Though the federal guidelines do not require written consent to receive a vaccination, they do require doctors give the recipients or legal representatives a Vaccine Information Statement (VIS). Specific informed consent laws are made by the states. Schools The United States has a long history of school vaccination requirements. The first school vaccination requirement was enacted in the 1850s in Massachusetts to prevent the spread of smallpox. The school vaccination requirement was put in place after the compulsory school attendance law caused a rapid increase in the number of children in public schools, increasing the risk of smallpox outbreaks. The early movement towards school vaccination laws began at the local level including counties, cities, and boards of education. By 1827, Boston had become the first city to mandate that all children entering public schools show proof of vaccination. In addition, in 1855 the Massachusetts General Court had established its own statewide vaccination requirements for all students entering school, this influenced other states to implement similar statewide vaccination laws in schools as seen in New York in 1862, Connecticut in 1872, Pennsylvania in 1895, and later the Midwest, South, and the Western United States. By 1963, 20 states had school vaccination laws. An example of this political controversy occurred in 1893, in Chicago, where less than ten percent of the children were vaccinated, despite the twelve-year-old state law. In 1922, the constitutionality of childhood vaccination was examined in the Supreme Court case Zucht v. King. The court decided that a school could deny admission to children who failed to provide a certification of vaccination for the protection of the public health. However, this changed after California removed personal and religious exemptions with the passage of California Senate Bill 277. This is the first time an immunization exemption was removed by a state legislature. The bill was prompted by the 2014 Disneyland measles outbreak and low levels of vaccination in pockets of California, with some schools having vaccination rates below 60%. Despite the bill receiving support by the California Medical Association, as well as by the American Academy of Pediatrics' California affiliate, opposition to the bill had been characterized as "possibly the most strident outpouring of political dissent in recent memory." After the 2019 measles outbreak, the state legislatures of New York (2019), Maine (2019, upheld by voters in a 2020 referendum), and Connecticut (2021) removed their religious exemptions. and in January 2025, West Virginia governor Patrick Morrisey issued an executive order allowing religious exemptions in the state, though the order has not been enforced by the state's Board of Education. however, mandatory vaccination requirements for attending public schools have received criticism. Parents say that vaccine mandates to attend public schools prevent one's right to choose, especially if the vaccinations could be harmful. Some people believe being forced to get a vaccination could cause trauma, and may lead to not seeking medical care/attention ever again. In the constitutional law, some states have the liberty to withdraw to public health regulations, which includes mandatory vaccination laws that threaten fines. Certain laws are being looked at for immunization requirements, and are trying to be changed, but cannot succeed due to legal challenges. After California removed non-medical exemptions for school entrance, lawsuits were filed arguing for the right for children to attend school regardless of their vaccination history, and to suspend the bill's implementation altogether. As of 2022, 300 American colleges and universities mandate that their students receive a COVID-19 booster. A study in the Journal of Medical Ethics concludes that the cost of these mandates likely outweigh the benefits. For example, to prevent one COVID hospitalization over a 6-month period, 31,000 to 42,000 adults in that age group would have to get a third mRNA booster; and those boosters will result in at least 18 "serious adverse events" (SAEs) for that single prevented hospitalization. ==See also==