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.