All state immunization laws contain an exemption for individuals with medical contraindications to immunization. It is beyond the scope of this book to list all the contraindications to immunization. Every physician who cares for children or authorizes immunizations should have a current copy of the Report of the Committee on Infectious Disease published by the American Academy of Pediatrics (the “Red Book”) and a copy of Communicable Diseases Manual, published by the American Public Health Association. These books are storehouses of invaluable information about immunizations and the management of communicable diseases. They set the legal standard of care for this branch of medical practice.

The general medical concern is that persons with suppressed immune systems should not be given live vaccine preparations. These include oral polio, oral typhoid, measles, mumps, rubella, and BCG vaccines. Persons with normal immune function develop antibodies to these agents and suffer a mild or subclinical infection. Persons with suppressed immune systems may develop full symptomatic disease, including adverse sequelae. Immunosuppressed persons, or patients who live with immunosuppressed persons, should receive live vaccines only under controlled circumstances.

Physicians must be careful to ensure that patients do not receive contraindicated immunizations. As discussed in the Red Book, there are several short-term contraindications to immunization, as well as the long-term contraindication of immunosuppression. All patients must be questioned or examined to identify the existence of medical contraindications. If these are present, they should be documented in the patient’s medical record. Such patients should also be given a medical exemption form to allow them to enter school without the requisite immunizations. Unless required by state law, this exemption need not detail the patient’s personal medical condition, only that the patient is not a candidate for immunization. If the exemption is based on a short-term contraindication, this should be reviewed on a subsequent visit and the child immunized as soon as medically advisable.

Physicians should never grant medical exemptions that are not based on objective medical findings. There are parents who are unwilling to claim a religious objection for their children but do not want their children immunized. A physician who grants such a child an exemption from immunization will be legally liable if the child contracts a disease that could be prevented through immunization. Physicians who exempt a child from immunization improperly may also be a party to child neglect. This could result in a legal prosecution if the child were to suffer a permanent injury from a preventable disease.