Vaccine Mandates: Legal Requirements And Implications

The topic of whether or not a vaccine can be required by law has been widely discussed, especially in the context of the COVID-19 pandemic and immigration laws. In the United States, the Immigration and Nationality Act (INA) mandates that immigrants and those seeking permanent residency must provide proof of vaccination against vaccine-preventable diseases. The CDC, in conjunction with the Advisory Committee on Immunization Practices (ACIP), determines which vaccines are required for immigration purposes. This includes the seasonal flu vaccine. Similarly, several states in the US have implemented laws requiring students and staff in schools and childcare facilities to be vaccinated against diseases like measles, mumps, and rubella (MMR). While there is no federal law mandating COVID-19 vaccination, some states have introduced efforts to enforce or limit COVID-19 vaccine mandates. Outside of the US, the opposition in Brazil criticized President Bolsonaro for stating that COVID-19 vaccinations would not be mandatory. Historically, the US Supreme Court ruled in 1905 that mandatory vaccination laws are constitutional, as seen in the case of Jacobson v. Massachusetts, which involved smallpox vaccination.

Mandatory vaccination laws

Immigration and Nationality Laws

Under the immigration laws of certain countries, individuals applying for immigrant visas or seeking permanent resident status may be required to receive specific vaccinations. For example, the United States mandates that immigrants and those adjusting their status to permanent residents must provide proof of vaccination against vaccine-preventable diseases as outlined by the Advisory Committee for Immunization Practices (ACIP). Failure to provide such proof may result in ineligibility for admission or status adjustment. Similarly, the CDC in the US has established vaccination criteria for immigrants, requiring them to receive certain vaccines during their medical examination if they cannot provide proof of prior vaccination.

Educational Institutions

Educational institutions, particularly schools and universities, have considered or implemented mandatory COVID-19 vaccination policies for students. However, this has sparked debates about parental authority, religious freedom, disability accommodations, and equal protection under the law. In response, some governments have taken steps to end COVID-19 vaccine mandates in schools, arguing that such requirements infringe on personal freedom and usurp parental authority.

Employment Laws

Employers can also enforce mandatory vaccination policies in the workplace. In the United States, employers can demand that workers get vaccinated under the US Code, which states that individuals should not pose a direct threat to the health or safety of others. Additionally, the Equal Employment Opportunity Commission (EEOC) has indicated that mandatory vaccination programs are not forbidden under federal law, provided they consider specific legal obligations. Employers must accommodate employees' disabilities, medical conditions, or sincerely held religious beliefs when enforcing vaccination mandates.

Human Rights and Ethical Considerations

The compatibility of mandatory vaccination laws with human rights has been a subject of discussion. While philosophers and jurists agree that restrictions on liberty can be justified to prevent harm to others, the implementation of such laws must consider economic and social rights to health, work, and education. The World Health Organization (WHO) has reinforced the view that immunization is a core component of the human right to health. The LAC19 Principles provide guidelines for mandatory vaccination schemes, recommending that they be prescribed by clear and consultative laws and regulated by statute rather than executive rules.

Immigration and vaccination

In the United States, immigration laws require that an individual applying for an immigrant visa abroad or seeking to adjust their status to that of a lawful permanent resident must be vaccinated against certain diseases. The specific vaccines mandated are outlined in the Immigration and Nationality Act (INA) section 212(a)(1)(A)(ii) and include mumps, measles, rubella, polio, tetanus, and diphtheria toxoids, pertussis, Haemophilus influenza type B, and hepatitis B.

The Advisory Committee for Immunization Practices (ACIP), an advisory body to the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), recommends immunizations for the general U.S. population. Since December 14, 2009, the CDC has regularly assessed whether new vaccines recommended by the ACIP for the general population should be mandated for immigration purposes, based on specific criteria. These criteria include whether the vaccine protects against a disease that has the potential to cause an outbreak and whether the disease is in the process of being eliminated in the United States. The ACIP also considers age-appropriate recommendations for the general immigrant population.

All immigrant applicants are required to undergo a medical examination, during which they must provide proof of receiving the necessary vaccines. If an applicant does not have the required proof, the necessary vaccines will be administered at the time of the medical exam, unless there is a medical exemption. Applicants for adjustment of status must submit Form I-693, Report of Immigration Medical Examination and Vaccination Record, signed by a civil surgeon, along with their application. This form also applies to pregnant individuals, who may delay their immigration medical examination until they can safely receive the required vaccines.

It is important to note that the specific vaccines required for U.S. immigration may change over time, and applicants should refer to the most up-to-date information provided by official sources.

Religious exemptions

The Equal Protection Clause has been invoked in arguments surrounding religious exemptions, with some asserting that it should protect all people claiming religious objections to vaccination, regardless of their specific religious affiliation. This argument challenges the requirement in certain states for individuals to belong to a religious group with bona fide objections to vaccination to receive an exemption. Courts have generally upheld the right of states to mandate vaccination despite parents' religious beliefs, but they have also found that requiring individuals to belong to specific religious groups to qualify for exemptions violates the Constitution's Equal Protection Clause.

The volume of religious exemption requests has increased, yet no major religions have explicitly objected to the COVID-19 vaccine. This has led to speculation that these exemptions are "no longer serving their original purpose." Professor Mello from the University of Colorado noted that many individuals filing for religious exemptions have no history of refusing vaccines and that the nature of their objection is more closely aligned with a personal belief exemption. Mello suggested that while these objections need not be supported by church attendance or donations to a recognized denomination, they must articulate an argument rooted in religion rather than personal opinion.

The Equal Employment Opportunity Commission (EEOC) states that employers have the right to deny a religious exemption for "undue hardship." This adds another layer of complexity to the issue. Additionally, the Civil Rights Act of 1964 is considered a pivotal piece of legislation that brought religious exemptions into the conversation surrounding mandatory vaccinations.

To request a religious exemption from one or more required vaccinations for school entry in Mississippi, for instance, the parent or guardian must complete the MSDH Religious Exemption Request (Form 139-R) and submit it to the County Health Department. The process involves watching an educational video, discussing the benefits and risks of immunizations with a nurse, and obtaining a Certificate of Medical/Religious Exemption (Form 122).

School and childcare immunisation

Immunisation is a critical component of public health, particularly in schools and childcare settings, where diseases can spread quickly. In this context, immunisation refers to both receiving a vaccine and becoming immune to a particular disease. Vaccines are essential in preventing the spread of infection and reducing the risk of outbreaks.

In the United Kingdom, the School Age Immunisation Services (SAIS) providers play a crucial role in delivering school-based immunisation programmes. These programmes are designed to ensure that children and young people are up to date with their vaccinations, which directly impacts their health, wellbeing, and the overall health of their communities. The success of these programmes relies on a collaborative effort between schools, school nurses, and SAIS providers. Schools support the immunisation process by providing space and time, reminding students and staff about immunisation sessions, sharing information with parents, and facilitating consent.

By law, some young people may be considered 'Gillick competent', meaning they are mature enough to provide their own consent for medical treatments, including vaccinations. A health professional will assess whether a child under 16 can understand the benefits and risks of a particular treatment. This assessment is crucial in respecting the autonomy and decision-making capacity of young people while also ensuring their health and safety.

In the United States, immigration laws mandate that individuals applying for immigrant visas or seeking permanent resident status must provide proof of vaccination against vaccine-preventable diseases. The Advisory Committee for Immunization Practices (ACIP) recommends immunisations for the general US population, and the Centers for Disease Control and Prevention (CDC) determines which of these vaccines are required for immigration purposes. This process ensures that immigrants are protected against vaccine-preventable diseases and contributes to overall public health.

Documenting vaccination

Importance of Documentation

Maintaining proper vaccination records is essential for several reasons. Firstly, it allows individuals to provide proof of vaccination when required, such as for school, work, or travel purposes. Additionally, in certain situations, documentation can help prevent unnecessary revaccination. For example, if an individual has no record of vaccination but is suspected to have been vaccinated, serologic testing for immunity can be performed as an alternative to revaccination for certain antigens like measles or rubella.

Recommended Practices for Individuals

It is recommended that individuals keep their vaccination records up to date and securely stored with other important documents. Individuals can obtain immunization record forms from their doctors, pharmacists, or other vaccine providers. Bringing these forms to health visits and having them signed and dated by the vaccine provider ensures that the immunization information is current and accurate. Individuals can also request to have their vaccinations documented in immunization registries, where applicable.

Guidelines for Healthcare Providers

Vaccination providers should only accept written, dated records as valid evidence of vaccination. Self-reported doses without written documentation are generally not recommended, except in specific cases such as the influenza and pneumococcal polysaccharide vaccines. When administering a vaccine, providers should document the following information on the patient's paper or electronic medical record or a permanent office log:

• The Vaccine Information Statement (VIS) edition date, located on the back of the VIS
• When administering combination vaccines, record all applicable VISs and their individual edition dates
• The date the VIS is given to the patient, parent, or guardian
• Any federally required information, ensuring it is both permanent and accessible

It is important to note that federal law does not require a parent, patient, or guardian to sign a consent form to receive a vaccination. Providing the appropriate VIS(s), IIS, or Emergency Use Authorization (EUA) Fact Sheet and addressing any questions or concerns are typically sufficient.

Special Considerations

There may be situations where individuals do not have adequate documentation of their vaccinations. In such cases, attempts should be made to locate missing records by contacting previous healthcare providers, checking state or local immunization information systems, or searching for personally held records. If records cannot be located, individuals should be considered susceptible and started on an age-appropriate vaccination schedule.

Immigration Requirements

The United States has specific vaccination requirements for immigrants. All immigrant applicants must undergo a medical examination and provide proof of receiving certain vaccines. If proof of vaccination is not available, the required vaccines must be administered during the medical exam. The CDC, in collaboration with the Advisory Committee on Immunization Practices (ACIP), determines which vaccines are required for immigration purposes. These criteria are regularly assessed and updated as needed.

Frequently asked questions