In 1901 a deadly smallpox epidemic tore through the Northeast, prompting the Boston and Cambridge boards of health to order the vaccination of all residents. But some refused to get the shot, claiming the vaccine order violated their personal liberties under the Constitution.
One of those holdouts, a Swedish-born pastor named Henning Jacobson, took his anti-vaccine crusade all the way to the U.S. Supreme Court. The nation's top justices issued a landmark 1905 ruling that legitimized the government’s authority to “reasonably” infringe upon personal freedoms during a public health crisis by issuing a fine to those who refused vaccination.
READ MORE: The Rise and Fall of Smallpox
A Smallpox Panic and a $5 Fine
In 1901, the city of Boston registered 1,596 confirmed cases of smallpox, a highly contagious, fever-inducing illness infamous for causing a severe rash on the face and arms that often left survivors scarred for life. In Boston alone, 270 people died from smallpox during the extended 1901 to 1903 outbreak. That’s why public health officials in Boston and neighboring Cambridge issued their compulsory vaccination orders, hoping to reach the 90 percent vaccination rate required for herd immunity.
Jacobson, who served as the pastor of a Swedish Lutheran church in Cambridge, had been vaccinated against smallpox in Sweden when he was 6 years old, an experience that he later said caused him “great and extreme suffering.” So when Dr. E. Edwin Spencer, chairman of the Cambridge Board of Health, knocked on the Jacobsons’ door on March 15, 1902, the pastor refused vaccination for himself and his son.
A few months later, Cambridge was in a full-fledged smallpox “panic” with the city ordering the closure of all schools, public libraries and churches to stem the spread of the disease. Police officers accompanied health officials like Spencer, who went door to door vaccinating as many as 100 people a day.
But while the Cambridge vaccine order was compulsory, it wasn’t a “forced” vaccination. People like Jacobson who refused to get vaccinated faced a $5 fine, the equivalent of nearly $150 today. On July 17, 1902, Dr. Spencer issued a criminal complaint against Jacobson and other anti-vaccine activists to collect that $5 fine.
READ MORE: 4 Diseases You've Probably Forgotten About Thanks to Vaccines
Jacobson Goes to Court Amid Anti-Vaccination Uproar
The broader battle over the validity of vaccination science reached a fever pitch during the smallpox outbreak. Anti-vaccination groups, citing alleged cases of death and deformity from bad reactions to smallpox vaccine, called compulsory vaccination “the greatest crime of the age,” claiming that it “slaughter[s] tens of thousands of innocent children.”
In response, newspaper editorials characterized the smallpox vaccination controversy as “a conflict between intelligence and ignorance, civilization and barbarism.” The New York Times dismissed anti-vaccine activists as “a familiar species of cranks” who were “deficient in the power to judge [science].”
It was against this heated backdrop that Jacobson fought his $5 fine, first in a state trial court and then by appeal in the Massachusetts Supreme Judicial Court. Jacobson wanted to present evidence that vaccines themselves were dangerous and ineffective, but the judges wouldn’t hear it. Instead, Jacobson’s chief argument became, “Compulsion to introduce disease into a healthy system is a violation of liberty,” specifically the personal liberty he believed was guaranteed by the U.S. and Massachusetts constitutions.
READ MORE: How an Enslaved African Man Helped Save Generations from Smallpox
Supreme Court Sets a Public Health Precedent
The highest court in Massachusetts also rejected Jacobson’s claims, siding instead with the authority of public health officials to determine the best methods for fighting an epidemic. Not ready to give up, Jacobson appealed his case to the U.S. Supreme Court in 1905, where he was accompanied by officers of the Massachusetts Anti-Compulsory Vaccination Association.
In the case known as Jacobson v. Massachusetts, Jacobson’s lawyers argued that the Cambridge vaccination order was a violation of their client’s 14th Amendment rights, which forbade the state from “depriv[ing] any person of life, liberty, or property, without due process of law.” At question, then, was whether the “right to refuse vaccination” was among those protected personal liberties.
The Supreme Court rejected Jacobson’s argument and dealt the anti-vaccination movement a stinging loss. Writing for the majority, Justice John Marshall Harlan acknowledged the fundamental importance of personal freedom, but also recognized that “the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand.”
This decision established what became known as the “reasonableness” test. The government had the authority to pass laws that restricted individual liberty, if those restrictions—including the punishment for violating them—were found by the Court to be a reasonable means for achieving a public good.
“Bottom line, there had to be some kind of real and substantial connection between the law itself and a legitimate purpose, which was the public’s health, safety and welfare,” says Anthony Sanders at the Institute for Justice.
READ MORE: Why Do 9 Justices Serve on the US Supreme Court?
Compulsory School Vaccinations and Forced Sterilizations
The Jacobson decision provided a powerful and controversial precedent for the extent of government authority in the early 20th century.
In 1922, the Supreme Court heard another vaccination case, this time concerning a Texas student named Rosalyn Zucht who was barred from attending public school because her parents refused to have her vaccinated. Zucht’s lawyers argued that the school district’s ordinance requiring proof of vaccination denied Rosalyn “equal protection of the laws” as guaranteed by the 14th Amendment.
The Supreme Court disagreed. Justice Louis Brandeis wrote in the unanimous decision: “Long before this suit was instituted, Jacobson v. Massachusetts had settled that it is within the police power of a state to provide for compulsory vaccination. These ordinances confer not arbitrary power, but only that broad discretion required for the protection of the public health.”
In a far darker chapter, the Jacobson decision also provided judicial cover for a Virginia law that authorized the involuntary sterilization of “feeble-minded” individuals in state mental institutions. In the 1920s, eugenics enjoyed wide support in scientific and medical circles, and the Supreme Court justices were not immune.
In the infamous 1927 case Buck v. Bell, the Supreme Court accepted the questionable “facts” presented in the lower court cases that a young Virginia woman named Carrie Bell hailed from a long line of “mental defectives” whose offspring were a burden on public welfare.
“The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes (Jacobson v Massachusetts, 197 US 11). Three generations of imbeciles are enough,” wrote Justice Oliver Wendell Holmes in a chilling opinion.
The Buck decision opened the floodgates and by 1930, a total of 24 states had passed involuntary sterilization laws and around 60,000 women were ultimately sterilized under these statutes.
“Buck v. Bell is the most extreme and barbaric example of the Supreme Court justifying a law in the name of public health,” says Sanders.
Supreme Court Rules on Pandemic Lockdown Orders
A lot changed since 1905, including the ways in which the Supreme Court decides if certain laws and statutes violate an individual’s constitutional rights. Starting in the second half of the 20th century, the Court began to recognize certain constitutional rights as “fundamental,” including the freedoms of speech and religion, and personal decisions about marriage, contraception and procreation.
Near the beginning of the COVID-19 pandemic, as states issued lockdown orders that closed businesses and prohibited large gatherings, several judges justified those restrictions by citing Jacobson v. Massachusetts, since it was the most recent Supreme Court ruling explicitly addressing state powers during a disease epidemic, even if it was 115 years old.
But in a reversal, the Supreme Court ruled in 2020 against broadly applying the logic of Jacobson to all COVID-19 lockdown restrictions. In Roman Catholic Diocese Of Brooklyn, New York v. Andrew M. Cuomo, the Court decided that the State of New York violated the constitutional rights of citizens wanting to safely gather in churches and synagogues during the pandemic. The reasoning was that the lockdown laws barred religious gatherings altogether while still allowing secular business to operate at limited capacity.
“Jacobson hardly supports cutting the Constitution loose during a pandemic,” wrote Justice Neil Gorsuch for the 5-4 majority. “That decision involved an entirely different mode of analysis, an entirely different right, and an entirely different kind of restriction.”
READ MORE: See full pandemics coverage here.
Who should mandate Covid vaccination?
In The Times, Ezekiel J. Emanuel, Aaron Glickman and Amaya Diana argue that health care organizations should be the first institutions to impose mandates on their employees, obligated as they are to protect patients. According to a survey conducted by the Kaiser Family Foundation and The Washington Post, 18 percent of all frontline health care workers say they do not plan to get a shot, including 24 percent of nursing home workers.
“This vaccine hesitancy can have consequences,” they write, noting that 11 percent of skilled nursing facilities nationwide have recently seen at least one staff case of Covid-19. “None of us likes being told what to do. But getting vaccinated is not just about our personal health, but the health of our communities and country.”
But others argue that vaccine mandates, if they must be imposed, should come from the state, not employers. “When a company demands that its employees should be vaccinated, this dictate expresses the private power of capital over individuals in ways we should be reluctant to accept,” Katie Attwell and Mark Navin write in The Times. “It’s different when the government requires vaccinations, since mandates are typically introduced, removed or modified by democratically elected legislatures, lending legitimacy to public efforts to govern people’s immunization choices.”
The U.S. Equal Employment Opportunity Commission released its first guidance on workplace coronavirus vaccination requirements Dec. 16.
Hood Report TV took to Instagram to share the news. "Employers Can Reportedly Require Workers to Get COVID-19 Vaccine," its post read.
Western Journal also wrote about the guidelines on its website. "Employers Can Now Legally Fire You for Refusing COVID Vaccine," the headline reads.
Hood Report TV and Western Journal have not responded to requests from USA TODAY for comment.
February 27, 2015 by Laura Beltz
How did the government first deal with the legal issue of requiring vaccines that promote immunity against diseases? The legal debate goes back more than a century and gives most of that power to the states.
The resurfacing of controversy over vaccines due to the recent measles outbreak has brought more attention to the constitutional authority of the government to require vaccinations.
In the 1905 case Jacobson v. Massachusetts, the Supreme Court upheld the authority of the states to enforce mandatory vaccination laws under the police power of the states. In the opinion, Justice John Marshall Harlan explained that personal liberties might be suspended in cases where the interest of the &ldquocommon good&rdquo of the community are of paramount importance.
The Court in Jacobson did, however, recognize that for some individuals a vaccine requirement could be harmful, creating room for medical exemptions where vaccines would be unduly harmful to the individual.
In a 1922, the Court further clarified in Zucht v. King that a school system could refuse admission to a student who did not meet vaccination requirements, and that this would not be in violation of the 14 th Amendment&rsquos Equal Protection Clause for singling out a particular class of individuals.
Then in 1944, in Prince v. Massachusetts, the Court held that states may require vaccination regardless of a parent&rsquos religious objection, stating that, &ldquothe 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.&rdquo This case made it clear that religious exemptions offered by states are elective, rather than mandated by the First Amendment&rsquos right to free exercise of religion.
While the Supreme Court authorized the states to pass these laws mandating vaccinations, it was in no way required for the states to do so. Federal authority on vaccines only applies to situations of national concern, such as the quarantine of foreign disease and regulation between states.
As a result, states have varying rules to regulate vaccines. All 50 states require students to be vaccinated before starting school, and every state has an exemption for cases of medical conditions that would make vaccines risky, like an immune disorder or cancer. Most states have the option for parents to opt out for religious reasons, and about half of states broaden that exemption to personal or philosophical reasons.
Some states have stringent requirements attached to their exemptions, such as approval of a doctor. Others however, particularly with religious and personal exemptions, are as simple as a checkbox on a student enrollment form.
There has been one recent case at the federal level that confirmed a state&rsquos right to implement vaccine policy as it sees fit.
In January 2015, the Second Circuit Court of Appeals, based in New York, upheld a New York statute in Phillips v. City of New York that allows students with &ldquogenuine and sincere&rdquo religious beliefs against vaccination to go to school, but reserves the right of school authorities to send them home if believe there is an outbreak of disease.
Laura Beltz is a pro bono intern at the National Constitution Center. She is also a student at the University of Pennsylvania Law School.
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Supreme Court correspondents Jess Bravin and Marcia Coyle join host Jeffrey Rosen to recap recent key decisions from the 2020-21 term.
Some workers don’t want a COVID-19 vaccine. Can their bosses make them get it anyway?
Most of the faculty at a southern Minnesota high school can’t wait to get the shots that will protect them against COVID-19. But an instructor who teaches business classes said he’s not ready to take it, and he fears that his refusal to get vaccinated will prevent him from returning to his classroom.
“My kids are everything to me, my classroom is everything, but I’m not going to take the vaccine,” said the teacher, who asked not to be identified by name because he didn’t want to antagonize administrators at his school.
He’s not an “anti-vaxxer.” He’s had all the usual childhood vaccinations, and he gets a flu shot each year. But the COVID-19 vaccines feel different to him. He worries they were rushed out too fast and might have long-term side effects that won’t emerge for years.
“I’m not saying never, ever, ever,” he said. “But I am saying I don’t feel like I’m informed enough to make a smart decision.”’
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He’s hardly alone. A recent survey by the Kaiser Family Foundation found that 27% of Americans are “vaccine hesitant,” saying they probably or definitely would not get a COVID-19 vaccine even if it were available for free and deemed safe by scientists. Among healthcare workers who are first in line to get vaccinated, that number is even higher: 29%.
Can they be fired if they refuse to get vaccinated? Should they lose their jobs if they won’t do their part to achieve herd immunity?
Questions like these will be asked with increasing frequency as more doses of COVID-19 vaccine become available in the weeks and months to come. And there are no easy answers.
“It’s not cut and dry,” said Ubaka Ogbogu, professor of law and bioethics at the University of Alberta in Canada. “Not all vaccines are created equal and not all diseases are created equal. It’s a very complex thing.”
Health experts hope to nudge people of color to the front of the COVID-19 vaccine line without explicitly saying race, ethnicity influence priority.
The legal issues alone are complicated. An employer can establish a mandatory vaccination policy if the need for it is job-related or if remaining unvaccinated would pose a direct threat to other employees, customers or themselves, according to guidance released last month by the U.S. Equal Employment Opportunity Commission.
For instance, a dentist could make a case that an unvaccinated hygienist would be a danger to others, or a retailer could say a cashier is at risk because of daily exposure to customers.
But there are two main exceptions, said Michelle Strowhiro, employment law partner at McDermott Will & Emery. Employees can object to the vaccine if they think it will exacerbate an established disability or medical condition. They can also turn it down if it goes against their sincerely held religious belief.
In either case, the employer and employee work together to find a reasonable way to accommodate the worker, such as allowing them to work from home instead of going into an office, Strowhiro said. If they work on-site, they can be moved to an area where they’re less exposed to other employees.
If the exemption is based on a religious belief, an employer may deny a potential accommodation that would be more than a small cost or burden, Strowhiro said. For disability-related objections, the bar is higher.
Ultimately, though, employers have the final say on how far they’re willing to go to accommodate an employee, she said. If they can’t find a reasonable accommodation, an unvaccinated worker can be fired — though such drastic action could prompt a lawsuit, she said.
Pro & Con Quotes: Should Any Vaccines Be Required for Children?
Pew Research Center, in an article by Monica Anderson, MA, Research Analyst at Pew Research Center, in a Feb. 2, 2015 article “Young Adults More Likely to Say Vaccinating Kids Should Be Parental Choice,” available at pewresearch.org, stated:
Overall, 68% of U.S. adults say childhood vaccinations should be required, while 30% say parents should be able to decide. Among all age groups, young adults are more likely to say vaccinating children should be a parental choice. Some 41% of 18- to 29-year-olds say parents should be able to decide whether or not their child gets vaccinated only 20% of adults 65 or older echo this opinion.Feb. 2, 2015 - Pew Research Center
Saad Omer, MPH, PhD, William H. Foege Professor of Global Health at Emory Vaccine Center, in a Mar. 5, 2019 written testimony, “Hearing Title: ‘Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks’ – March 05, 2019,” available at help.senate.gov, stated:
“A national outbreak, or an outright national-level measles resurgence, would not be out of the ordinary for a Western country. In recent years, there have been several large sustained outbreaks in Europe… It’s not just luck that the United States hasn’t seen a similar resurgence. There are many things the United States does right in vaccine policy, compared to Europe. For example, the United States has a tapestry of school-entry vaccine requirements that work. These requirements, based in state laws, have contributed to maintaining high immunization rates and keeping rates of vaccine noncompliance low… Mandates have played a key role in keeping disease rates low.”
Mar. 5, 2019 - Saad B. Omer, MPH, PhD
Jonathan A. McCullers, MD, Chair of the Department of Pediatrics at the University of Tennessee Health Science Center, in Mar. 5, 2019 written testimony, “United States Senate Committee on Health, Education, Labor, and Pensions ‘Vaccines Save Lives: What is Driving Preventable Disease Outbreaks?,'” available at help.senate.gov, stated:
“The rate of parents claiming non-medical exemptions to vaccines is 2.5 times higher in states that allow both religious and philosophical exemptions compared to religious exemptions alone – evidence that allowing multiple pathways to exemption worsens this problem… Vaccine refusal is one of the growing public health threats of our time. If we continue to allow non-medical exemptions to vaccination, rates of vaccination will continue to fall and more outbreaks will undoubtedly follow.”Mar. 5, 2019 - Jonathan A. McCullers, MD
Sarah Davis, JD, Texas State Representative (R), in a Jan. 17, 2017 article, “Davis: Why the Debate? Vaccines Do Work,” available at the Houston Chronicle website, stated:
“The state [Texas] mandates childhood vaccines for enrollment in our schools because all children should have the opportunity to be educated in a safe and healthy environment. A twisted concept of parental personal liberty should not risk the health and safety of millions of schoolchildren… Cancers that are preventable should be prevented. Viruses that are preventable should be eradicated. And the safety and efficacy of vaccines are no longer subject to serious debate. They work, and Texas must make sure more of our citizens are immunized against preventable diseases.”Jan. 17, 2017 - Sarah M. Davis, JD
Ben Carson, MD, Professor Emeritus of Neurosurgery at Johns Hopkins University, in a Feb. 2, 2015 article, “Ben Carson Backs Vaccinations as ‘Safe,'” available at thehill.com, stated:
“Although I strongly believe in individual rights and the rights of parents to raise their children as they see fit, I also recognize that public health and public safety are extremely important in our society… Certain communicable diseases have been largely eradicated by immunization policies in this country and we should not allow those diseases to return by foregoing safe immunization programs, for philosophical, religious or other reasons when we have the means to eradicate them.”
Feb. 2, 2015 - Ben Carson, Sr., MD
Robert Pearl, MD, Executive Director and CEO of the Permanente Medical Group, in a Feb. 5, 2015 article, “A Doctor’s Take: Why Measles Vaccination Must Be Mandatory,” available at forbes.com, stated:
“As a society, we don’t condone behavior that puts others at risk for injury or death. There are no exemptions for laws that prohibit drunk-driving, for example.
Refusing vaccination for reasons other than a serious medical condition is unfair and dangerous to those who can’t protect themselves. Those who remain unvaccinated pose a great risk to many, including: all children under 1 year old who are too young to be vaccination, older adults who don’t know their immunity has lapsed and others with impaired immune systems…
Eliminating personal belief exemptions will prevent suffering and save lives. It is the right thing to do.”Feb. 5, 2015 - Robert Pearl, MD
Kristen A. Feemster, MPH, MSHPR, MD, Attending Physician and Research Director at the Vaccine Education Center at Children’s Hospital of Philadelphia, and Assistant Professor of Pediatrics at the Perelmen School of Medicine at the University of Pennsylvania, in her Mar. 23, 2014 article, “Eliminate Vaccine Exemptions,” available at nytimes.com, stated:
“Vaccines work by protecting individuals, but their strength really lies in the ability to protect one’s neighbors. When there are not enough people within a community who are immunized, we are all at risk.
Personal and religious belief exemptions should be curtailed because some people, whether because of age or compromised immune systems, cannot receive vaccines. They depend on those around them to be protected. Vaccines aren’t the only situation in which we are asked to care about our neighbors. Following traffic laws, drug tests at work, paying taxes — these may go against our beliefs and make us bristle, but we ascribe to them because without this shared responsibility, civil society doesn’t work.
Public health is no different.”Mar. 23, 2014 - Kristen A. Feemster, MPH, MSHPR, MD
Marco Rubio, JD, US Senator (R-FL), in a Feb. 3, 2015 NBCNews article, “Rubio and Jindal Latest to Weigh in on Vaccine Debate,” available at nbcnews.com, stated:
“Absolutely, all children in America should be vaccinated. Unless their immune (system is) suppressed, obviously, for medical exemptions, but I believe that all children, as is the law in most states in this country, before they can attend school, have to be vaccinated for a certain panel.”Feb. 3, 2015 - Marco Rubio, JD
Barbara Boxer, US Senator (D-CA), and Dianne Feinstein, US Senator (D-CA), in a Feb. 4, 2015 joint open letter to Diana Dooley, JD, Secretary of California Health and Human Services, available at Boxer’s Senate website, stated:
“We write today to ask that you and other appropriate state officials reconsider California’s policy on vaccine exemptions…
While a small number of children cannot be vaccinated due to an underlying medical condition, we believe there should be no such thing as a philosophical or personal belief exemption, since everyone uses public spaces. As we have learned in the past month, parents who refuse to vaccinate their children not only put their own family at risk, but they also endanger other families who choose to vaccinate.
California’s current law allows two options for parents to opt out of vaccine requirements for school and daycare: they must either make this decision with the aid of a health professional, or they can simply check a box claiming that they have religious objections to medical care. We think both options are flawed, and oppose even the notion of a medical professional assisting to waive a vaccine requirement unless there is a medical reason, such as an immune deficiency.
Furthermore, recent reports have shown that the problem is not limited to parents opting out of all vaccinations. There is also a growing trend of parents failing to follow full vaccine schedules and schools and daycare centers failing to track those families that have pledged to get the required vaccines after the year begins. We think that under your leadership, California can change this practice and reassure families that all children are safe at schools, daycare centers, and in other public places.”Feb. 4, 2015 - Barbara Boxer
Manny Alvarez, MD, Senior Managing Editor for FOX News Channel’s Health News, in a Jan. 30, 2015 article, “Dr. Manny: Should Obama Make Vaccines Mandatory for All Children?,” available at foxnews.com, stated:
“I am calling on the federal government to mandate vaccinations for all children, and to eliminate all of the silly loopholes that are creating chaos in so many communities throughout America. Vaccinations are not only about the individual, but they are also meant to protect the lives of others.
As we have seen over the past several weeks, measles, and other communicable diseases that were all but eradicated decades ago, are popping up across the country, and putting people’s lives in danger.
Basic childhood vaccines should be the legal requirement of every citizen in this country, except in the case of medical contraindications. However, those exclusions should only be granted by a physician or health care provider. It is not for the parent, or consumer advocate to offer an opinion that prevents a child from receiving a vaccination. All these opinions serve to do is confuse the caregiver and possibly even misinform them, which could have fatal implications for the child.”
Jan. 30, 2015 - Manny Alvarez, MD
Phil Plait, PhD, astronomer and author of Slate’s “Bad Astronomy” blog, in a Sep. 24, 2014 blog post, “Should Public School Students Get Mandatory Vaccines?,” available at slate.com, stated:
“In some areas, public school authorities have mandated that students be vaccinated for various diseases, and that of course can run afoul of parents’ beliefs. I’ve wrestled with this problem for a while, and I eventually came to the conclusion that a parent does not have the right to have their child in a public school if that child is unvaccinated, and for the same reason health care workers should not be unvaccinated. It all comes down to a very simple reality: It puts other children at risk.
If you want to rely on the public trust then you have an obligation to the public trust as well, and part of that obligation is not sending your child to a place with other children if they aren’t immunized against preventable, communicable diseases.
I imagine the anti-vaccination movement will be up in arms about this, but here’s the thing: They’re wrong. They’ve been trying to tie vaccines to autism for years, andthey’re wrong. They’ve been saying vaccines have dangerous levels of toxins in them, but they’re wrong. They say vaccines overtax a baby’s immune system, but they’re wrong. They say these diseases aren’t that bad, but they’re very wrong. They say lots of things, but the one thing you can count on is that they’re wrong.”Sep. 24, 2014 - Phil Plait, PhD
Paul Offit, MD, Chief of the Division of Infectious Diseases at the Children’s Hospital of Philadelphia, in a Jan. 20, 2007 Wall Street Journal article, “Fatal Exemption: Relationship Between Vaccine Exemptions and Rates of Disease,” stated:
“[A]s anti-vaccine activists continue to push more states to allow for easy philosophical exemptions one thing is clear, more and more children will suffer and occasionally die from vaccine preventable diseases…
When it comes to issues of public health and safety we invariably have laws. Many of these laws are strictly enforced and immutable. For example, we don’t allow philosophical exemptions to restraining young children in car seats or smoking in restaurants or stopping at stop signs. And the notion of requiring vaccines for school entry, while it seems to tear at the very heart of a country founded on the basis of individual rights and freedoms, saves lives.”Jan. 20, 2007 - Paul Offit, MD
Rand Paul, MD, former ophthalmologist and US Senator (R-KY), in a Mar. 5, 2019 Senate hearing, “Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks?,” available at help.senate.gov, stated:
“[M]any governments have taken to mandating a whole host of vaccines, including vaccines for non-lethal diseases. Sometimes these vaccine mandates have run amok as when the government mandated a rotavirus vaccine that was later recalled because it was causing intestinal blockage in children. I’m not a fan of government coercion, yet, given the choice, I do believe the benefits of most vaccines vastly outweigh the risks… Each year, before that year’s flu strain is known, the scientists put their best guess into that year’s vaccine. Some years it’s completely wrong. We vaccinate for the wrong strand, the wrong strain of flu vaccine. Yet five states already mandate flu vaccines. Is it really appropriate to mandate a vaccine that more often than not vaccinates for the wrong flu strain? As we contemplate forcing parents to choose this or that vaccine, I think it’s important to remember that force is not consistent with the American story, nor is force consistent with the liberty our forefathers sought when they came to America. I don’t think you have to have one or the other, though. I’m not here to say don’t vaccinate your kids. If this hearing is for persuasion I’m all for the persuasion. I vaccinated myself and I vaccinated my kids. For myself and my children I believe that the benefits of vaccines greatly outweigh the risks, but I still don’t favor giving up on liberty for a false sense of security.”Mar. 5, 2019 - Rand Paul, MD
The Association of American Physicians and Surgeons (AAPS), in a Feb. 26, 2019 letter written by Jane M. Orient, MD, Executive Director of AAPS, “Statement on Federal Vaccine Mandates,” available at aapsonline.org, stated:
“The Association of American Physicians and Surgeons (AAPS) strongly opposes federal interference in medical decisions, including mandated vaccines. After being fully informed of the risks and benefits of a medical procedure, patients have the right to reject or accept that procedure… Measles is a vexing problem, and more complete, forced vaccination will likely not solve it. Better public health measures—earlier detection, contact tracing, and isolation a more effective, safer vaccine or an effective treatment are all needed. Meanwhile, those who choose not to vaccinate now might do so in an outbreak, or they can be isolated. Immunosuppressed patients might choose isolation in any event because vaccinated people can also possibly transmit measles even if not sick themselves.
AAPS believes that liberty rights are unalienable. Patients and parents have the right to refuse vaccination, although potentially contagious persons can be restricted in their movements (e.g. as with Ebola), as needed to protect others against a clear and present danger. Unvaccinated persons with no exposure to a disease and no evidence of a disease are not a clear or present danger.”
Feb. 26, 2019 - Association of American Physicians and Surgeons, Inc. (AAPS)
Mississippi Parents for Vaccine Rights (MPVR) in an undated article accessed on Jan. 19, 2017, “A Note to Legislators,” available at the MPVR website, stated:
“Vaccination is a one-size-fits-all GOVERNMENT PROGRAM that has grown out of control. Our children receive 49 doses of 15 vaccines before kindergarten! Children received just 10-12 vaccines during a lifetime in the 1980s. The current vaccine schedule has never once been tested as it is administered to our children… Bureaucrats at the Health Department do no know our children, have never seen our children, yet have tyrannical power over their care regarding vaccines… We are not asking the state to decide if shots are good or bad or safe or unsafe. We are asking those of you who represent the people of Mississippi to restore our fundamental parental right to make medical decisions for our own children.”Jan. 19, 2017 - Mississippi Parents for Vaccine Rights (MPVR)
Jack Wolfson, DO, cardiologist at Wolfson Integrative Cardiology, in a Jan. 29, 2015 CNN interview, “Watch Doctors Have Heated Debate over Vaccination,” available at cnn.com, stated:
“Our children have the right to get infections. We have immune systems for that purpose… These are typically benign childhood conditions. We cannot sterilize the body [with vaccines]. We cannot sterilize our society. We need to be affected by these viruses… and we can treat it all naturally.”Jan. 29, 2015 - Jack Wolfson, DO
The World Chiropractic Alliance stated the following in its article “Vaccinations and Freedom of Choice in Health Care,” available at the World Chiropractic Alliance website (accessed Aug. 21, 2014):
“Medical and scientific research, as well as overwhelming clinical reports, have clearly demonstrated the potential for risk posed by many commonly administered vaccines. These same reports have indicated that the effectiveness of many of these vaccines has not been adequately proven. Based on such evidence, doctors of chiropractic have been joined by progressive medical doctors and public health administrators in questioning public policy regarding mandatory vaccines…
It is the position of The World Chiropractic Alliance that… No person should be forced by government regulation or societal pressure to receive any medication or treatment, including vaccines, against his or her will. This includes mandated vaccines as a requirement for public school admission or for employment eligibility.”Aug. 21, 2014 - World Chiropractic Alliance
Bob Sears, MD, pediatrician, in an Aug. 30, 2013 article “Dr. Bob Sears Offers Advice in March 21st New York Times Health Section on Vaccine Choices Parents Make,” available at askdrsears.com, stated:
“So the question is, are unvaccinated parents putting the rest of our children at risk? Maybe a little. But in my opinion parents SHOULD have the right to make health care choices for their children. They should not be forced into vaccinating if they feel strongly against it.”Aug. 30, 2013 - Bob Sears, MD
Mandatory vaccinations: The Canadian picture
As might be expected in Canada, vaccination policies are as diverse as the geogra-high immunization rates by educating their populations about the benefits of vaccines. Just three have legislated vaccination policies, applying strictly to children about to enrol in school. Ontario and New Brunswick require immunization for diphtheria, tetanus, polio, measles, mumps, and rubella immunization, while Manitoba requires a measles vaccination.
In each case, though, the legislation includes an exemption clause. Essentially, each of the three provinces allows parents to request that their child be exempted from the vaccination requirement on medical or religious grounds, or simply out of conscience. In such instances, in the event of a disease outbreak, unvaccinated children can be excluded from entering a school.
“The exclusion of nonimmunized individuals from entry during an outbreak situation is to protect the public and to contain the outbreak as quickly as possible,” Andrew Morrison, spokesperson for the Ontario Ministry of Health and Long-Term Care, writes in an email.
New Brunswick takes a similar approach and it’s “unlikely” that the province would ever 𠇎nforce mandatory vaccination for the population in general,” Danielle Phillips, spokesperson for the province’s Department of Health, writes in an email. “That being said, during something like a pandemic event, people who are not immunized might have to be excluded from certain social/ work environments where causing risk to others would be unacceptable.”
Phillips adds that if actions ever had to be taken against individuals, they would probably be in the form of isolation, quarantine or directly observed treatment.
For the most part, vaccination compliance rates appear high in most provinces.
In Ontario, Manitoba and New Brunswick, unvaccinated children can be excluded from entering a school in the event of a disease outbreak.
In New Brunswick, for example, 93.6% of children entered kindergarten in the 2008 school year with the required vaccinations, Phillips writes.
In Ontario, “the vast majority of school pupils comply with the requirement to report their immunization status to attend school in the province,” Morrison writes. In the 2009 school year, 84%% of students aged 7 to 17 had been vaccinated. “That means 8%% of school-aged children either did not report to local health units the appropriate number of required immunizations or have exemption on file,” he adds.
Theoretically, noncompliance can result in hefty penalties. In Ontario, failure to vaccinate children can result in a fine of up to $1000 (www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90i01_e.htm).
Other provinces, such as Alberta, which do not have any form of legislation governing vaccinations, nevertheless retain the authority to preclude students from attending school in the event of a disease outbreak. “Immunization in Alberta is voluntary therefore no student is denied entrance into a school facility based on their immunization status. However, if there is a case or outbreak of measles in school setting, a child would be excluded from school until two weeks after the last case occurred if he/she is not immunized against measles,” the Alberta Ministry of Health writes in an email.
The ministry added that 𠇊lberta has not considered making school immunization mandatory since the immunization rates achieved to date are over 90% by the time a student leaves grade one.”
Vaccination skeptics say there’s no need for provinces to move with stricter policies.
In the case of outbreaks, parents should be allowed to determine whether they 𠇊re willing to take the risk that their children get that disease, get through it and develop long-term, lifelong immunity,” says Edda West, coordinator coordinator of Vaccination Risk Awareness Network (Canada), a not-for-profit educational group. “The parents of the vaccinated children believe their children are totally protected from that disease, so what is the problem? Who is being protected?”
West adds that if vaccination advocates lieve the vaccine works and they’re really effective, then the unvaccinated child should pose no problems to anybody.”
Advocates counter that the extent to which a vaccine is effective within a population is based on both coverage (the number of people vaccinated), and efficacy of the vaccine within those individuals, which varies.
Vaccine effectiveness, in terms of percentage, ranges from the low seventies and eighties for influenza or pertussis, to the nineties for measles and up to 100% for human papilloma virus and hepatitis B, says Dr. Ian Gemmill, former chair of the Canadian Coalition of Immunization Awareness and Promotion.
Vaccination policies for health care workers appear equally languorous across the nation. Most provinces do not have legislation in the area, although, in Alberta, all health care workers who deal with infants, prenatal women or in postpartum settings must be protected against rubella. As well, “some private long term care facilities in Alberta have instituted mandatory influenza immunization in the event of an influenza outbreak in that facility,” the Ministry of Health and Wellness writes in an email.
Ontario has no plans to proceed with legislation, although the Ontario Ministry of Health and Long-Term Care “is strongly supportive of statements by the National Advisory Committee on Immunization (NACI) which highly recommends that health care workers be immunized,” Morrison writes. “In many instances, individual work place policies require health care workers to be immunized against specific diseases as a condition of employment at the facility or institution.”
The federal government doesn’t appear inclined to step into the fray, noting that vaccination policies, and enforcement therein, fall within provincial jurisdiction.
“The Public Health Agency of Canada supports immunization as an effective means to protect Canadians from infectious diseases, and encourages all Canadians to keep their immunizations up-to-date,” Charlene Wiles, media relations advisor for the agency, writes in an email.
Editor’s note: First of a three-part series on mandatory vaccination
February 20, 2021 by Nicholas Mosvick
In the face of future public health emergencies like the Coronavirus, a precedential Supreme Court decision about the government&rsquos power to protect citizens by quarantine and forced vaccinations could receive new interest.
On February 20, 1905, the Supreme Court, by a 7-2 majority, said in Jacobson v. Massachusetts that the city of Cambridge, Massachusetts could fine residents who refused to receive smallpox injections. In 1901, a smallpox epidemic swept through the Northeast and Cambridge, and Massachusetts reacted by requiring all adults receive smallpox inoculations subject to a $5 fine. In 1902, Pastor Henning Jacobson, suggesting that he and his son both were injured by previous vaccines, refused to be vaccinated and to pay the fine. In state court, Jacobson argued the vaccine law violated the Massachusetts and federal constitutions. The state courts, including the Massachusetts Supreme Judicial Court, rejected his claims. Before the Supreme Court, Jacobson argued that, &ldquocompulsion to introduce disease into a healthy system is a violation of liberty.&rdquo
On February 20, 1905, the Supreme Court rejected Jacobson&rsquos arguments. Justice John Marshall Harlan wrote about the police power of states to regulate for the protection of public health: &ldquoThe good and welfare of the Commonwealth, of which the legislature is primarily the judge, is the basis on which the police power rests in Massachusetts,&rdquo Harlan said &ldquoupon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.&rdquo
Jacobson had argued that the Massachusetts law requiring mandatory vaccination was a violation of due process under the 14th Amendment, particularly the right &ldquoto live and work where he will&rdquo under the precedent of Allgeyer v. Louisiana (1897), a case that found that a state law preventing certain out-of-state insurance corporations from conducting business in the state was unconstitutional restriction of freedom of contract under the 14th Amendment. Harlan answered that while the Court had protected such liberty, a citizen:
[M]ay be compelled, by force if need be, against his will and without regard to his personal wishes or his pecuniary interests, or even his religious or political convictions, to take his place in the ranks of the army of his country and risk the chance of being shot down in its defense. It is not, therefore, true that the power of the public to guard itself against imminent danger depends in every case involving the control of one's body upon his willingness to submit to reasonable regulations established by the constituted authorities, under the sanction of the State, for the purpose of protecting the public collectively against such danger.&rdquo
The Court did not extend the rule beyond the facts of the case before it. Harlan ended his opinion by stating the limitations of the ruling: &ldquoWe are not inclined to hold that the statute establishes the absolute rule that an adult must be vaccinated if it be apparent or can be shown with reasonable certainty that he is not at the time a fit subject of vaccination or that vaccination, by reason of his then condition, would seriously impair his health or probably cause his death.&rdquo
In the years following the case, the anti-vaccine movement mobilized and the Anti-Vaccination League of America was founded three years later in Philadelphia under the principle that &ldquohealth is nature&rsquos greatest safeguard against disease and that therefore no State has the right to demand of anyone the impairment of his or her health,&rdquo and aimed &ldquoto abolish oppressive medical laws and counteract the growing tendency to enlarge the scope of state medicine at the expense of the freedom of the individual.&rdquo The League warned about what it believed to be the dangers of vaccination and allowing the intrusion of government and science into private life,
When a separate question of vaccinations&mdashstate laws requiring children to be vaccinated before attending public school&mdashcame up in 1922 in Zucht v. King, Justice Louis Brandeis and a unanimous court held that Jacobson &ldquosettled that it is within the police power of a state to provide for compulsory vaccination&rdquo and the case and others &ldquoalso settled that a state may, consistently with the federal Constitution, delegate to a municipality authority to determine under what conditions health regulations shall become operative.&rdquo More recently, in 2002, a federal district court declined to find a exemption to mandatory vaccinations laws for &ldquosincerely held religious beliefs&rdquo or a fundamental right of parents to make decisions concerning medical procedures of their children.
The application of Jacobson to the modern age of vaccinations is a source of scholarly debate, with some arguing that the case no longer applies in an era in which vaccines like HPV are not medically necessary to prevent the spread of disease. But others maintain Jacobson&rsquos importance today in providing ample power to protect the public health, especially with the threat of pandemics.
Nicholas Mosvick is a Senior Fellow for Constitutional Content at the National Constitution Center.
Immunity and herd immunity Edit
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. 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. 
State and local vaccination requirements for daycare and school entry are important tools for maintaining high vaccination coverage rates, and in turn, lower rates of vaccine-preventable diseases (VPDs). 
Vaccine-preventable diseases remain a common cause of childhood mortality with an estimated three million deaths each year.  Each year, vaccination prevents between two and three million deaths worldwide, across all age groups, from diphtheria, tetanus, pertussis and measles. 
Eradication of diseases Edit
With some vaccines, a goal of vaccination policies is to eradicate the disease – disappear 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 eradicated in Africa in August 2020 and remained only in Pakistan and Afghanistan at the time. 
Individual versus group goals Edit
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 found 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 found 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. 
At various times governments and other institutions have established policies requiring vaccination, with the aim of reducing the risk of disease. For example, an 1853 law required universal vaccination against smallpox in England and Wales, with fines levied on 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.  Forced vaccination (as opposed to fines or refusal of services) is rare and typically happens only as an emergency measure during an outbreak. A few other countries [ which? ] also follow this practice. Compulsory vaccination greatly reduces infection rates for the diseases the vaccines protect against.  These policies stirred resistance from a variety of groups, collectively called anti-vaccinationists, who objected on ethical, political, medical safety, religious, and other grounds.  Other reasons including that socioeconomic disparities and being an ethnic minority can prevent reasonable access to vaccinations.  
Common objections included the argument that governments should not infringe on an individual's freedom to make medical decisions for themselves or their children, or claims that proposed vaccinations were dangerous.  Many modern vaccination policies allow exemptions for people with compromised immune systems, allergies to vaccination components, or strongly held objections.  It has also been argued that for vaccination to effectively prevent disease, there must be not only available vaccines and a population willing to immunize, but also sufficient ability to decline vaccination on grounds of personal belief. 
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:
Vaccination is unique among de facto mandatory requirements in the modern era, requiring individuals to accept the injection of a medicine or medicinal agent into their bodies, and it has provoked a spirited opposition. This opposition began with the first vaccinations, has not ceased, and probably never will. From this realisation arises a difficult issue: how should the mainstream medical authorities approach the anti-vaccination movement? A passive reaction could be construed as endangering the health of society, whereas a heavy-handed approach can threaten the values of individual liberty and freedom of expression that we cherish. 
An ethical dilemma emerges when health care providers attempt to persuade vaccine-hesitant families towards receiving vaccinations as this persuasion may lead to violating their autonomy.  Investigation of different types of vaccination policy finds strong evidence that standing orders and allowing healthcare workers without prescription authority (such as nurses) to administer vaccines in defined circumstances increases vaccination rates, and sufficient evidence that requiring vaccinations before attending child care and school also does so.  However, there is insufficient evidence to assess effectiveness of requiring vaccinations as a condition for hospital and other healthcare jobs. 
Many countries, including Canada, Germany, Japan, and the United States have specific requirements for reporting vaccine-related adverse effects, while other countries including 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. 
Parents versus children's rights Edit
Medical ethicist Arthur Caplan argues that children have a right to the best available medical care, including vaccines, regardless of parental opinions toward vaccines, saying "Arguments about medical freedom and choice are at odds with the human and constitutional rights of children. When parents won't protect them, governments must."   However, government entities such as child protective services can intervene only when the parents directly harm their child via abuse or neglect. Although withholding medical care meets the criteria of abuse or neglect, refusing vaccinations does not as the child is not being harmed directly. [ according to whom? ] 
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 occurred in an anti-vaccination faith healing community, causing nine children to die. 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.  
Vaccines as a positive externality Edit
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"  off the benefits of others being vaccinated.    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 Edit
Trust in vaccines and in the health system is an important element of public health programs that aim to deliver lifesaving vaccines. Trust in vaccination and health care is an important indicator of government work and the effectiveness of social policy. The success in overcoming diseases and in vaccination depend on the level of trust in vaccine 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, understanding the factors that effect on the reduction of trust, allows authorities to build an effective vaccine campaign and communication strategies to fight the disease. Trust is key parameter to work with before and while undertaking any vaccine campaigns. The state is responsible to provide a smart communication and inform a population about disease, vaccine and risks. The WHO recommends that states should: work long-term to build population resilience against vaccine rumours and scares, build a strong programme 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. 
Cost-benefit – United States Edit
Since the first economic analysis of routine childhood immunizations in the United States in 2001 that reported cost savings over the lifetime of children born in 2001,  other analyses of the economic costs and potential benefits to individuals and society have since been studied, evaluated, and calculated.   In 2014, the American Academy of Pediatrics published a decision analysis that evaluated direct costs (program costs such as vaccine cost, administrative burden, negative vaccine-linked reactions, and transportation time lost to parents to seek health providers for vaccination).  The study focused on diphtheria, tetanus, pertussis, Haemophilus influenza type b conjugate, poliovirus, measles/mumps/rubella (MMR), hepatitis B, varicella, 7-valent pneumococcal conjugate, hepatitis A, and rotavirus vaccines, but excluded influenza. Estimated costs and benefits were adjusted to 2009 dollars and projected over time at three percent interest.  Of the theoretical group of 4,261,494 babies beginning in 2009 who had regular immunizations through childhood in accordance with the Advisory Committee on Immunization Practices guidelines "will prevent ∼42 000 early deaths and 20 million cases of disease, with net savings of $13.5 billion in direct costs and $68.8 billion in total societal costs, respectively".  In the United States, and in other nations,    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. 
Cost-benefit for older adults Edit
Furthermore, 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 be used to 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 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 between €443 to €3,395 (assuming 100% compliance).  Another European 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 €438–558 million saved annually solely in the European continent. 
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". 
- ^ abTuberculosis
- ^ abDTP (Diphtheria, Tetanus and Pertussis (whooping cough))
- ^ abInfluenza (flu)
- ^ abHepatitis A
- ^ abHepatitis B
- ^ abHaemophilus Influenza B
- ^ abHuman papillomavirus
- ^ abMeningo
- ^ abMR (Measles and Rubella) is usually provided as MMR vaccine.
- ^ abMumps vaccine is usually provided as MMR vaccine (Measles, Mumps and Rubella).
- ^ abPneumo
- ^ abPoliomyelitis
- ^ abRabies
- ^ abRotavirus
- ^ abTick-borne encephalitis
- ^ abChickenpox (varicella)
- ^ abShingles (herpes zoster)
- ^ abYellow Fever
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, from infancy through adulthood, or obtain a marriage license, or any kind of government ID, including a passport or driver's license. Furthermore, the law requires the government to pay for all aspects of all vaccinations. The law deems vaccination to be a national emergency, and therefore exempts vaccines from internal and customs taxes.  
- Recommended ages for everyone.
- # Recommended ages for certain other high-risk groups.
- Recommended ages for catch-up immunization.
- § Recommended range of additional vaccinations for Aboriginals and Torres Strait Islanders.
In an effort to boost vaccination rates in Australia, the Australian government has decided that starting on 1 January 2016, certain benefits (such as the universal "Family Allowance" welfare payments for parents of children) will no longer be available for conscientious objectors of vaccination those with medical grounds for not vaccinating will continue to receive such benefits.  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, though the number of conscientious objectors to vaccination has increased by 24,000 to 39,000 over the past decade. 
The government began the Immunise Australia Program to increase national immunisation 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.  In New South Wales, children can consent to medical treatment at the age of 14. 
When several COVID-19 vaccines were nearing completion in November 2020, Australian Prime Minister Scott Morrison announced that all international travellers who fly to Australia without proof of a COVID-19 vaccination would be required to quarantine at their own expense. 
Vaccinating children is 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. 
Vaccination in Canada is voluntary.  While vaccination is generally required to attend school in Ontario and New Brunswick there are exemptions given to those who are opposed. 
British Columbia Edit
New Brunswick Edit
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 Category 1 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.  Category 2 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 Category 2 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.  
- ^ For specific at risk-groups only (to be given at the earliest age
- ^ Thereafter Td booster every 10 years with or without vaccination against poliomyelitis (IPV) in case of travel to endemic areas and when previous IPV dose was given more than 5 years before
- ^ Recommended but not free of charge for those over 65 years.
- ^ Vaccination can be given from 6 months of age in case of travel abroad. If vaccination starts before 12 months of age, 2 doses are recommended (14–18 months and 6 years) The temporary recommendation of giving measles at 12 months of age was made a permanent recommendation ie. now MMR should be given from 12–18 months except if travelling abroad to measles infected countries when it can be given from 6 months on. In case MMR is given at 6–11 months, the child needs a second and third dose to complete the series.
- ^ Varicella vaccination implemented from 1 September 2017. Catch-up to all those born on 1 January 2006 or after and with no history of varicella.
- ^ One or two doses administered depending on previous influenza vaccination history. Annual vaccination. IIV tri-or quadrivalent used as follows: IIV3 for all those 6–35 months. IIV4 with nonpreferential alternative to all those 24–35 months. IIV3 also recommended to medical risk group children from 36 months up.
- ^ TBE vaccination for to those living permanently on the island of Åland
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. [france 1] Since some hospitals are granted additional freedoms, there two key people responsible for vaccine policy within hospitals: the Operational physician (OP), and the Head of the hospital infection and prevention committee (HIPC). [france 1] Mandatory immunization policies on BCG, diphtheria, tetanus, and poliomyelitis began in the 1950s and policies on Hepatitis B began in 1991. Recommended but not mandatory suggestions on influenza, pertussis, varicella, and measles began in 2000, 2004, 2004, and 2005, respectively. [france 1] According to the 2013 INPES Peretti-Watel health barometer, between 2005 and 2010, the percentage of French people between 18–75 years old in favor of vaccination dropped from 90% to 60%. [ citation needed ]
Since 2009, France has recommended meningococcus C vaccination for infants 1–2 years old, with a catch up dosage up to 25 years later. French insurance companies have reimbursed this vaccine since January 2010, at which point coverage levels were 32.3% for children 1–2 years and 21.3% for teenagers 14–16 years old.  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.  Some families may avoid requirements by finding a doctor willing to forge a vaccination certificate, a solution which numerous French forums confirm. However, the French State considers "vaccine refusal" a form of child abuse.  In some instances, parental vaccine refusals may result in criminal trials. France's 2010 creation of the Question Prioritaire Constitutionelle (QPC) allows lower courts to refer constitutional questions to the highest court in the relevant hierarchy. [france 2] 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. [france 2]
In May 2015, France updated its vaccination policies on diphtheria, tetanus, acellular pertussis, polio, Haemophilus influenzae b infections, and hepatitis B for premature infants. As of 2015, while failure to vaccinate is not necessarily illegal, a parent's right to refuse to vaccinate his or her child is technically a constitutional matter. Additionally, children in France cannot enter schools without proof of vaccination against diphtheria, tetanus, and polio.  French Health Minister, Marisol Touraine, finds vaccinations "absolutely fundamental to avoid disease", and has pushed to have trained pharmacists and doctors administer vaccinations.  Most recently, the Prime Minister's 2015–2017 roadmap for the "multi-annual social inclusion and anti-poverty plan" includes free vaccinations in certain public facilities.  Vaccinations within the immunization schedule are given for free at immunization services within the public sector. When given in private medical practices, vaccinations are 65% reimbursed.
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.  The independent advisory group meets biannually to address issues pertaining to preventable infectious diseases.  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.  In addition to the proposed immunization schedule for children and adults, the STIKO recommends vaccinations for occupational groups, police, travelers, and other at risk groups. 
Vaccinations recommendations that are issued must be in accordance with the Protection Against Infection Act (Infektionsschutzgesetz), which regulates the prevention of infectious diseases in humans.  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.  In the event of vaccination related injuries, federal states are responsible for monetary compensation.  Germany's central government does not finance childhood immunizations, so 90% of vaccines are administered in a private physician's office and paid for through insurance. The other 10% of vaccines are provided by the states in public health clinics, schools, or day care centers by local immunization programs.  Physician responsibilities concerning immunization include beginning infancy vaccination, administering booster vaccinations, maintaining medical and vaccination history, and giving information and recommendations concerning vaccines. 
Children aged 15 and over can legally consent to being vaccinated, even if their parents expressly object, provided the child gives the impression of being mature, informed, and capable of understanding the risks and benefits of their decision.  
In the Republic of Ireland, childhood vaccination (up to age 16) requires the consent of the parents. The Department of Health strongly recommend vaccinations. 
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.  There is a National committee on immunizations that updates the national recommended immunization schedule, with input from the ministry of health representatives, regional health authorities, national institute of health, and other scientific societies.  Regions may add more scheduled vaccinations, but cannot exempt citizens from nationally mandated or recommended ones.  For instance, a nationwide plan for eliminating measles and rubella began in 2001.  Certain vaccinations in Italy are based on findings from the National Centre for Epidemiology, Surveillance and Health Promotion are also used to determine miscellaneous vaccination mandates.
Childhood vaccinations included in national schedules are guaranteed free of charge for all Italian children and foreign children who live in the country.  Estimated insurance coverage for the required three doses of HBV-Hib-IPV vaccines is at least 95% when the child is two years old. Later, Influenza is the only nationally necessary vaccine for adults, and is administered by general practitioners.  To mitigate some public concerns, Italy currently has a national vaccine injury compensation program. Essentially, those who are ill or damaged by mandatory and recommended vaccinations may receive funding from the government as compensation. One evaluation of vaccine coverage in 2010, which covered the 2008 birth cohort, showed a slight decline in immunization insurance coverage rates of diphtheria, hepatitis B, polio, and tetanus after those specific vaccinations had been made mandatory.  However, vaccination levels continued to pass the Italian government's goal of 95% outreach. 
Aiming to integrate immunization strategies across the country and equitize access to disease prevention, the Italian Ministry of Health issued the National Immunization Prevention Plan (Piano Nazionale Prevenzione Vaccinale) in 2012. This plan for 2012–2014 introduced an institutional "lifecourse" approach to vaccination to complement the Italian health policy agenda.  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.  A 2015 government plan in Italy aimed to boost vaccination rates and introduce a series of new vaccines, triggering protests among public health professionals.  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.  For instance, nationwide varicella shots would be required for newborns.  Under this plan, government spending on vaccines would double to €620 million annually, and children could be barred from attending school without proving vaccination.  Although these implementations would make Italy a European frontrunner in vaccination, some experts questioned the need for several of the vaccines, and some physicians worried about the potential punishment they may face if they do not comply with the proposed regulations. 
There were 5,000 cases of measles in 2017, up from 870 in 2016, 29% of all those in the European Union. The law compelling children to have ten vaccinations to enroll at state schools came into effect in March 2018 but in August 2018 the Five Star Movement pushed legislation through the Italian Senate abolishing it. It did not pass the Chamber of Deputies but parents did not have to provide schools with a doctor's note to show their children have been vaccinated.  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 sacked for refusing vaccination. 
- ^ ab Vaccines for measles and rubella (MR vaccine) can be received anytime from 5 y/o before 7 y/o, AND the time should be also between one year and one day before the first day of schooling (quote: "五歳以上七歳未満の者であって、小学校就学の始期に達する日の一年前の日から当該始期に達する日の前日までの間にあるもの".
- ^ ab HPV for female students only. Vaccination can be started from the first day of school year within she turns 12, and until the last day of school year within she turns 16 (quote: "十二歳となる日の属する年度の初日から十六歳となる日の属する年度の末日までの間にある女子").
- ^ Age 60-64 with certain diseases: heart, kidney or respitory failures, or with an immune-related disorder due to HIV infection.
Only in the legal term in Japan, citizens get old one day before their birthdays. If a person was born on January 1, 2020 and Immunization Act specifies vaccine against measles could be received from age 12 months to 24 months, vaccination shall be practiced between December 31, 2020 and December 31, 2021 (not between January 2021 and January 2022.)   Some vaccinations are scheduled in line with the school year system, which starts from April 1 in Japan.  As explained, those who born on April 1 and on April 2 get old legally on March 31 and April 1, respectively. Thus, these two people are in different school years and thereby they may take vaccines in different calendar years.
- ^ ab Vaccines for measles and rubella (MR vaccine) can be received anytime from 5 y/o before 7 y/o, AND the time should be also between one year and one day before the first day of schooling (quote: "五歳以上七歳未満の者であって、小学校就学の始期に達する日の一年前の日から当該始期に達する日の前日までの間にあるもの".
- ^ ab HPV for female students only. Vaccination can be started from the first day of school year within she turns 12, and until the last day of school year within she turns 16 (quote: "十二歳となる日の属する年度の初日から十六歳となる日の属する年度の末日までの間にある女子").
- ^ abc Starts elementary schooling from April 1, 2026
- ^ ab 2020 is a leap year. Person B socially turns 2 months old on March 1, 2004. In the legal term, however, Person B's 2-month birthday is the day before March 1, 2004. Thus, It shall be February 29, 2004. There are no February 30 or 31 in 2020. As a result Person A and Person B have the same 2-month birthday.
- ^ Starts elementary schooling from April 1, 2027
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 Immunization Act [ja] (Japanese: 予防接種法 ) and its related cabinet order [ja] (Japanese: 予防接種法施行令 ). As of January 2020, sixteen infections in total are on the legal lists – fourteen are Category A diseases (vaccination is not mandatory but recommended to prevent pandemic), and two are Category B (not even recommended and only for a personal care purpose).  
Compared to the global standard, Japanese vaccination policy is sometimes described by medical experts as the "Vaccine Gap".   For instance, Japan is the only developed country that does not list mumps on the vaccine schedule.  Another fact is that the government approval for new combination vaccines usually takes longer time than the United States does. 
One reason behind the vaccine gap is that the government was sued several times for negligence of duty of care and for malpractice liabilities throughout the vaccination history.    The lawsuit risks, particularly the 1992 Tokyo High Court's ruling on the MMR vaccine class action, impacted on law amendment.  Vaccination is no longer mandatory as of 1994.   As a result, vaccination rate declined in Japan. The rate of flu vaccination, for example, was 67.9% among schoolchildren in 1979 but dropped down to approximately 20% in 1998-1999. With the rapidly aging society issue, the decline among schoolchildren hit the elderly generation. In 1998–1999 season, deadly flu outbreak spread widely in nursing homes for the elderly as well as inpatients wards. The outbreak was followed by the 2001 amendment of Immunization Act to add flu vaccination for the elderly.  As of February 2020, flu vaccination under the Act is in Category B (for a personal care purpose) only for the elderly.  However, historical data sets suggest that flu vaccination for schoolchildren is also the key to take care of the elderly. 
In addition to legal and social risk concerns, an issue of 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, the time when a deadly flu outbreak struck Japan. Since the committee kick-off, however, the vaccine gap has been gradually improved.  
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 papilloma virus for 12-year-old girls, and tick-borne encephalitis until age 18 in endemic areas and for orphans.
In Malaysia, mass vaccination is practised in public schools. The vaccines may be administered by a school nurse or a team of other medical staff from outside the school. All the children in a given school year are vaccinated as a cohort. For example, children may receive the oral polio vaccine in Year One of primary school (about six or seven years of age), the BCG in Year Six, and the MMR in Form Three of secondary school. Therefore, most people have received their core vaccines by the time they finish secondary school. 
New Zealand Edit
- ^ Only if the person has not previously received the varicella vaccine or had a varicella infection
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 health centre 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. 
Facing numerous minor polio epidemics, the Pakistani government has now ruled that the polio vaccination as mandatory and indisputable. In a statement from Pakistani Police Commissioner Riaz Khan Mehsud "There is no mercy, we have decided to deal with the refusal cases with iron hands. Anyone who refuses [the vaccine] will be sent to jail." [ citation needed ]
Immunization is voluntary in Russia as of 2019 [update] .  In May 2021, Russian President Vladimir Putin said that mandating coronavirus vaccinations would be "impractical and impossible". 
In the wake of a declared measles epidemic, Samoan authorities made vaccination against measles compulsory in November 2019. 
According to a 2011 publication in CMAJ:  Slovenia has one of the world's most aggressive and comprehensive vaccination programs. Its program is mandatory for nine designated diseases. Within the first three months of life, infants must be vaccinated for tuberculosis, tetanus, polio, pertussis, and Haemophilus influenza type B. Within 18 months, vaccines are required for measles, mumps and rubella, and finally, before a child starts school, the child must be vaccinated for hepatitis B. While a medical exemption request can be submitted to a committee, such an application for reasons of religion or conscience would not be acceptable. Failure to comply results in a fine and compliance rates top 95%, Kraigher says, adding that for nonmandatory vaccines, such as the one for human papilloma virus, coverage is below 50%.
Mandatory vaccination against measles was introduced in 1968 and since 1978, all children receive two doses of vaccine with a compliance rate of more than 95%.  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 Edit
In South Africa vaccination is voluntary. 
The South African Vaccination and Immunisation Centre began in 2003 as an alliance between the South African Department of Health, vaccine industry, academic institutions and other stakeholders.  SAIVC works with the WHO and the South African National Department of Health to educate, do research, provide technical support, and advocate. They work to increase rates of vaccination to improve the nation's health. [ citation needed ]
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 Carlos III (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.  No additional groups outside the government propose recommendations. Recommendations must be approved by the Commission of Public Health and then by the Inter-Territorial Council, at which point they are incorporated into the National Immunization Schedule. 
The Spanish Association of Pediatrics, in conjunction with the Spanish Medicines Agency, outlines specifications for vaccination schedules and policies and provides a history of vaccination policies implemented in the past, as well as legislature pertaining to the public currently. Spain's Constitution does not mandate vaccination, so it is voluntary unless authorities require compulsory vaccination in the case of epidemics.  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.  The first systematic immunization schedule for the provinces of Spain was established in 1975 and has continuously been updated by each autonomous community in regard to doses at certain ages and recommendation of additional vaccine not proposed in the schedule. 
The 2015 schedule proposed the newest change with the inclusion of pneumococcal vaccine for children under 12 months. For 2016, the schedule plans to propose a vaccine against varicella in children at 12–15 months and 3–4 years. Furthermore, the General Health Law of 1986 echoes Article 40.2 from the Constitution guaranteeing the right to the protection of health, and states employers must provide vaccines to workers if they are at risk of exposure.  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 universal public health care provides coverage for all residents, while central and regional support programs extend coverage to immigrant populations. However, no national funds are granted to the Communities for vaccine purchases. Vaccines are financed from taxes, and paid in full by the Community government.  Law 21 in Article 2.6 establishes the need for proper clinical documentation and informed consent by the patient, although written informed consent is not mandated in the verbal request of a vaccine for a minor.  The autonomous regions collect data, from either electronic registries or written physician charts, to calculate immunization coverage. 
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 Edit
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. 
Children aged 16 and 17 can consent to immunizations without parental consent.  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 Edit
- Range of recommended ages for everyone. See references for more details.
- # Range of recommended ages for certain high-risk groups. See references for more details.
- Range of recommended ages for catch-up immunization or for people who lack evidence of immunity (e.g., lack documentation of vaccination or have no evidence of prior infection). [a]
- § Recommended vaccination based on sharedclinical decision-making.
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.
All fifty states in the U.S. 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, and all states except for California, Maine, Mississippi, New York, and West Virginia allow religious exemptions,  while 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.   
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.  
All vaccines recommended by the U.S. government for its citizens are required for green card applicants.  This requirement stirred controversy when it was applied to the HPV vaccine in July 2008 due to the cost of the vaccine. In addition, the other thirteen 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.  
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 Commonwealth of Massachusetts 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 Western US. By 1963, twenty states had school vaccination laws. 
These vaccination laws resulted in political debates throughout the United States as those opposed to vaccination sought to repeal local policies and state 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.  Resistance was seen at the local level of the school district as some local school boards and superintendents opposed the state vaccination laws, leading the state board health inspectors to examine vaccination policies in schools. Resistance proceeded during the mid-1900s and in 1977 a nationwide Childhood Immunization Initiative was developed with the goal of increasing vaccination rates among children to ninety percent by 1979. During the two-year period of observation, the initiative reviewed the immunization records of more than 28 million children and vaccinated children who had not received the recommended vaccines. 
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.  In 1987, there was a measles epidemic in Maricopa County, Arizona, and Maricopa County Health Department vs. Harmon examined the arguments of an individual's right to education over the state's need to protect against the spread of disease. The court decided that it is prudent to take action to combat the spread of disease by denying un-vaccinated children a place in school until the risk for the spread of measles had passed. 
Schools in the United States require an updated immunization record for all incoming and returning students. While all states require an immunization record, this does not mean all students must get vaccinated. Exemptions are determined at a state level. In the United States, exemptions take one of three forms: medical, in which a vaccine is contraindicated due to a component ingredient allergy or existing medical condition religious and personal philosophical opposition. As of 2019, 45 states allow religious exemptions, with some states requiring proof of religious membership. Until 2019, only Mississippi, West Virginia and California did not permit religious exemptions.  However, the 2019 measles outbreak led to the repeal of religious exemptions in the state of New York and for the MMR vaccination in the state of Washington. Prior to 2019, 18 states allowed personal or philosophical opposition to vaccination, but the measles outbreak also led to the repeal of these exemptions in a number of states.  Research studies have found a correlation between the rise of vaccine-preventable diseases and non-medical exemptions from school vaccination requirements.  
Mandatory vaccinations 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 out 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.  However, all such lawsuits ultimately failed.