Vaccination policy in the United 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.[18] 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.[19] 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, 20 states had school vaccination laws.[19]

These vaccination laws resulted in political debates throughout the United States as those opposed to vaccination sought to repeal local policies and state laws.[20] An example of this political controversy occurred in 1893 in Chicago, where less than 10 percent of the children were vaccinated despite the twelve year old state law.[19] 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 90% 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.[21]

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.[21] In 1987, a measles epidemic occurred in Maricopa County, Arizona and another court case, Maricopa County Health Department vs. Harmon, examined the arguments of an individual's right to education over the states 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.[21]

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 that 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.[22] 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.[6] Research studies have found a correlation between the rise of vaccine-preventable diseases and non-medical exemptions from school vaccination requirements.[23][24]

Mandatory vaccinations for attending public schools have received criticism. Parents say that vaccine mandates in order to attend public schools prevent one's right to choose, especially if the vaccinations could be harmful.[25] Some people believe that being forced to get a vaccination could cause trauma, and may lead to not seeking out medical care/attention ever again.[26] 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.[27] 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. [27] However, all such lawsuits ultimately failed.[28]

Most states have some kind of requirement in place that at least some kinds of health care workers receive certain vaccinations intended to protect their patients from having communicable diseases passed to them through the health care workers. The vaccines at issue often include those for influenza, measles, hepatitis B for healthcare workers likely to be exposed to human blood, and rubella for healthcare workers likely to be in contact with pregnant women.

Judge's cartoon of Rudyard Kipling's famous poem "The White Man's Burden" published in 1899. The poem's philosophy quickly was utilized to explain/justify the United States response to annexation of the Philippines. The United States used the "white man's burden" as an argument for imperial control of the Philippines and Puerto Rico on the basis of moral necessity to ensure the spread of civility and modernity.

Immunizations are often compulsory for military enlistment in the U.S.[29] The United States has a very complex history with compulsory vaccination, particularly in enforcing compulsory vaccinations both domestically and abroad to protect American soldiers during times of war. There are hundreds of thousands of examples of soldier deaths that were not the result of combat wounds, but were instead from disease.[30] During the American Revolutionary War, General George Washington required American soldiers to undergo variolation for smallpox out of concern that the British, who had long engaged in that practice in their own military, would be able to use smallpox as a weapon against the Continental Army. Among wars with high death tolls from disease is the Civil War where an estimated 620,000 soldiers died from disease. American soldiers in other countries have spread diseases that ultimately disrupted entire societies and healthcare systems with famine and poverty.[31]

The Spanish–American War began in April 1898 and ended in August 1898. During this time the United States gained control of Cuba, Puerto Rico, and the Philippines from Spain. As a military police power and as colonizers the United States took a very hands-on approach in administering healthcare particularly vaccinations to natives during the invasion and conquest of these countries.[30] Although the Spanish–American War occurred during the era of "bacteriological revolution" where knowledge of disease was bolstered by germ theory, more than half of the soldier casualties in this war were from disease.[30] Unknowingly, American soldiers acted as agents of disease transmission, fostering bacteria in their haphazardly made camps. These soldiers invaded Cuba, Puerto Rico, and the Philippines and connected parts of these countries that had never before been connected due to the countries sparse nature thereby beginning epidemics.[30] The mobility of American soldiers around these countries encouraged a newfound mobility of disease that quickly infected natives.

Military personnel used Rudyard's Kipling's poem "The White Man's Burden" to explain their imperialistic actions in Cuba, the Philippines, and Puerto Rico and the need for the United States to help the "dark-skinned Barbarians"[30] reach modern sanitary standards. American actions abroad before, during, and after the war emphasized a need for proper sanitation habits especially on behalf of the natives. Natives who refuse to oblige with American health standards and procedures risked fines or imprisonment.[30] One penalty in Puerto Rico included a $10 fine for a failure to vaccinate and an additional $5 fine for any day you continue to be unvaccinated, refusal to pay resulted in ten or more days of imprisonment. If entire villages refused the army's current sanitation policy at any given time they risked being burnt to the ground in order to preserve the health and safety of soldiers from endemic smallpox and yellow fever.[30] Vaccines were forcibly administered to the Puerto Ricans, Cubans, and Filipinos. Military personnel in Puerto Rico provided Public Health services that culminated in military orders that mandated vaccinations for children before they were six months old, as well as a general vaccination order.[30] By the end of 1899 in Puerto Rico alone the U.S. military and other hired native vaccinators called practicantes, vaccinated an estimated 860,000 natives in a five-month period. This period began the United States' movement toward an expansion of medical practices that included "tropical medicine" in an attempt to protect the lives of soldiers abroad.[30]