Mandatory Vaccinations: Precedent and
Current Laws
Kathleen S. Swendiman
Legislative Attorney
March 10, 2011
Congressional Research Service
7-5700
www.crs.gov
RS21414
CRS Report for Congress
P
repared for Members and Committees of Congress
Mandatory Vaccinations: Precedent and Current Laws
Summary
Historically, the preservation of the public health has been the primary responsibility of state and
local governments, and the authority to enact laws relevant to the protection of the public health
derives from the state’s general police powers. With regard to communicable disease outbreaks,
these powers may include the enactment of mandatory vaccination laws. This report provides an
overview of the legal precedent for mandatory vaccination laws, and of state laws that require
certain individuals or populations, including school-aged children and health care workers, to be
vaccinated against various communicable diseases. Also discussed are state laws providing for
mandatory vaccinations during a public health emergency or outbreak of a communicable
disease.
Federal jurisdiction over public health matters derives from the Commerce Clause of the United
States Constitution, which states that Congress shall have the power “[t]o regulate Commerce
with foreign Nations, and among the several States ... ” Congress has enacted requirements
regarding vaccination of immigrants seeking entry into the United States, and military regulations
require American troops to be immunized against a number of diseases. The Secretary of Health
and Human Services has authority under the Public Health Service Act to issue regulations
necessary to prevent the introduction, transmission, or spread of communicable diseases from
foreign countries into the states or from state to state. Current federal regulations do not include
any mandatory vaccination programs; rather, when compulsory measures are needed, measures
such as quarantine and isolation are generally utilized to halt the spread of communicable
diseases.
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Mandatory Vaccinations: Precedent and Current Laws
Contents
History and Precedent ................................................................................................................. 1
State Mandatory Vaccination Laws.............................................................................................. 2
School Vaccination Requirements ......................................................................................... 2
Health Care Workers ............................................................................................................. 4
Vaccination Orders During a Public Health Emergency ......................................................... 6
Model State Emergency Health Powers Act........................................................................... 6
Role of the Federal Government.................................................................................................. 7
Contacts
Author Contact Information ........................................................................................................ 9
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Mandatory Vaccinations: Precedent and Current Laws
History and Precedent
At the end of the 20th century, the Centers for Disease Control and Prevention (CDC) published
its list of the “Ten Great Public Health Achievements” for the United States from 1900 to 1999.
Number one on the list was vaccination.1 Vaccination has resulted in the eradication of smallpox
worldwide, and in the control of many other vaccine-preventable diseases.2 Mandatory
vaccination programs, such as school immunization requirements, have played a major role in
controlling rates of vaccine-preventable diseases in the United States.3
Historically, the preservation of the public health has been the primary responsibility of state and
local governments, and the authority to enact laws relevant to the protection of the public health
derives from the state’s general police powers.4 With respect to the preservation of the public
health in cases of communicable disease outbreaks, these powers may include the institution of
measures such as quarantine and isolation5 or the enactment of mandatory vaccination laws.6
Mandatory vaccination laws were first enacted in the early 19th century, beginning with
Massachusetts’ smallpox vaccination law in 1809.7
Jacobson v. Massachusetts8 is the seminal case regarding a state’s or municipality’s authority to
institute a mandatory vaccination program as an exercise of its police powers. In Jacobson, the
Supreme Court upheld a Massachusetts law that gave municipal boards of health the authority to
require the vaccination of persons over the age of 21 against smallpox, and determined that the
vaccination program instituted in the city of Cambridge had “a real and substantial relation to the
protection of the public health and safety.”9 In upholding the law, the Court noted that “the police
power of a State must be held to embrace, at least, such reasonable regulations established
directly by legislative enactment as will protect the public health and the public safety.”10 The
Court added that such laws were within the full discretion of the state, and that federal powers
with respect to such laws extended only to ensure that the state laws did not “contravene the
Constitution of the United States or infringe any right granted or secured by that instrument.”11
1 CDC, U.S. Dep’t of Health & Human Servs., Ten Great Public Health Achievements – United States, 1900-1999, 48
MORBIDITY & MORTALITY WKLY. REP. 12, 241 (1999).
2 World Health Organization, Smallpox Fact Sheet, at http://www.who.int/mediacentre/factsheets/smallpox/en/.
3Orenstein, Walter A, The Role of Measles Elimination in Development of a National Immunization Program, Pediatr
Infect Dis Jn (2006) 25(12): 1093-1101, available at http://www.medscape.com/viewarticle/551272.
4 See The People v. Robertson, 134 N.E. 815, 817 (1922).
5 For more information on state and federal quarantine authority, see CRS Report RL33201, Federal and State
Quarantine and Isolation Authority, by Kathleen S. Swendiman and Jennifer K. Elsea.
6 Starting with the smallpox vaccine, vaccines have been used to halt the spread of disease for over 200 years. Donald
A. Henderson & Bernard Moss, Smallpox and Vaccinia, in VACCINES 74, 75 (Stanley A. Plotkin & Walter A. Orenstein
eds., 3d ed. 1999). See also Howard Markel, M.D. Life, Liberty and the Pursuit of Vaccines, N.Y. TIMES (February 29,
2011) available at http://www.nytimes.com/2011/03/01/health/01smallpox.html?_r=1&ref=health.
7 LAWRENCE O. GOSTIN, PUBLIC HEALTH LAW: POWER, DUTY, RESTRAINT, 181 and n. 27 (2000).
8 197 U.S. 11 (1905).
9 Id. at 31. The Massachusetts statute in question reads as follows: “Boards of health, if in their opinion it is necessary
for public health or safety, shall require and enforce the vaccination and revaccination of all the inhabitants of their
towns, and shall provide them with the means of free vaccination. Whoever refuses or neglects to comply with such
requirement shall forfeit five dollars.” M.G.L.A. c. 111, § 181 (2010).
10 Id. at 25.
11 Id.
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The Court addressed constitutional concerns raised by the petitioner in Jacobson, but remained
unconvinced that his rights were “contravened” by the mandatory vaccination program. The
petitioner argued that “a compulsory vaccination law is unreasonable, arbitrary and oppressive,
and, therefore, hostile to the inherent right of every freeman to care for his own body and health
in such way as to him seems best; and that the execution of such a law against one who objects to
vaccination, no matter for what reason, is nothing short of an assault upon his person.”12 The
Court rejected the petitioner’s constitutional challenge and noted that “the liberty secured by the
Constitution of the United States to every person within its jurisdiction does not import an
absolute right in each person, to be, at all times and in all circumstances wholly free from
restraint.”13 However, the Court did acknowledge limits to the state’s power to protect the public
health and set forth a reasonableness test for public health measures:14
[I]t might be that an acknowledged power of a local community to protect itself against an
epidemic threatening the safety of all, might be exercised in particular circumstances and in
reference to particular persons in such an arbitrary, unreasonable manner, or might go so far
beyond what was reasonably required for the safety of the public, as to authorize or compel
the courts to interfere for the protection of such persons.
State Mandatory Vaccination Laws
School Vaccination Requirements
Every state and the District of Columbia has a law requiring children entering school to provide
documentation that they have met the state immunization requirements.15 In 1827, Boston was the
first city to require vaccination against smallpox for public school students.16 Other cities and
states adopted the policy, and state statutes were amended as new vaccines were introduced.17
Many modern school vaccination laws are the result of measles outbreaks in the 1960s and
1970s.18 Generally, states use the Centers for Disease Control and Prevention’s schedule of
12 Id. at 26.
13 Id. In Adams v. Milwaukee, 228 U.S. 572, 581-82 (1913), the Supreme Court reaffirmed Jacobson’s holding that
states may delegate the power to order vaccinations to local municipalities for the enforcement of public health
regulations. See also, Zucht v. King, 260 U.S. 174, 176 (1922), holding that vaccination laws do not discriminate
against schoolchildren to the exclusion of others similarly situated, i.e., children not enrolled in school. In Prince v.
Massachusetts, 321 U.S. 158 (1944), the Court held generally that the right to practice religion does not include the
liberty to jeopardize the well being of minors.
14 Id. at 28. Smallpox vaccinations are no longer administered since smallpox has been eradicated worldwide as of
1980. See World Health Organization, Smallpox Fact Sheet, at
http://www.who.int/mediacentre/factsheets/smallpox/en/. One author has suggested that while Mr. Jacobson might be
successful in his refusal to be vaccinated against smallpox today since smallpox has been eradicated, the threat of
terrorists using smallpox as a weapon might make the use of the vaccine a reasonable measure yet again. Andrew
Zoltan, JACOBSON revisited: Mandatory Polio Vaccination as an Unconstitutional Condition, 13 GEO. MASON L.
REV. 735, 747-752 (2005). See also CRS Report RS21288, Smallpox: Technical Background on the Disease and Its
Potential Role in Terrorism, by Frank Gottron.
15 James G. Hodge, Jr. and Lawrence O. Gostin, School Vaccination Requirements: Historical, Social, and Legal
Perspectives, 90 Ky. L. J. 831, 868-73 (2001/2002).
16 Id. at 851.
17 Id. at 867.
18 Id. at 868.
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immunizations as a guide, and require children to be vaccinated against a number of diseases on
the schedule, including diphtheria, measles, rubella, and polio.19 In addition, various state laws
also require vaccination against hepatitis B and meningococcal disease for incoming college and
university students.20
Despite the wide-spread imposition of school vaccination requirements, many states provide
exemptions for medical, religious, or philosophical reasons. These provisions vary state by state,
with medical exemptions for children who may suffer adverse effects from the vaccine being the
most common. Thus, all states allow medical exemptions for those whose immune systems are
compromised, who are allergic to vaccines, are ill at the time of vaccination, or have other
medical contraindications to vaccines.21 Generally, for a medical exemption, parents or guardians
must provide documentation from a physician.22 Nearly all states grant exemptions for persons
who oppose immunizations for religious reasons.23 Exemptions based on philosophical or moral
convictions in opposition to immunization are less common but are provided by 20 states.24 States
may specify that religious or philosophical beliefs be “sincere” or “conscientiously held.”25 The
statutes allowing religious exemptions vary, with some requiring only a statement of dissent from
the student, parent, or guardian, and others requiring a more specific statement regarding the
child’s membership in a religious denomination that opposes immunizations.26
Compulsory vaccination laws as a prerequisite for school enrollment have been the subject of
numerous court cases.27 By and large, the Supreme Court, and most lower courts, have upheld
19 See the CDC vaccination guidelines at http://www.cdc.gov/vaccines/recs/default.htm. A number of states have
considered mandating the new Human Papillomavirus vaccine as part of school vaccine requirements. See a summary
of state activity at http://www.ncsl.org/programs/health/HPVvaccine.htm. See also Rebecca E. Skov, Examining
Mandatory HPV Vaccination for All School-Aged Children, 62 Food Drug L.J. 805 (2007).
20 See the Immunization Action Coalition website state charts at http://www.immunize.org/laws/hepbcollege.asp and
http://www.immunize.org/laws/menin.asp.
21 National Conference of State Legislatures, States with Religious and Philosophical Exemptions from School
Immunization Requirements, October, 2010, at http://www.ncsl.org/Default.aspx?TabId=14376.
22 For example, in Colorado, an exemption from the vaccination requirements may be obtained by submitting to the
school a certification from a licensed physician that “the physical condition of the student is such that one or more
specified immunizations would endanger his or her life or health or is medically contradicted due to other medical
conditions.” COLO. REV. STAT. § 25-4-903(2)(a) (2010).
23 Only two states, Mississippi and West Virginia, do not provide for an exemption based on religious beliefs. The
Mississippi Supreme Court has held that religious exemptions to mandatory vaccination violate equal protection rights
under the Fourteenth Amendment because the exemptions “require the great body of school children to be vaccinated
and at the same time expose them to the hazard of associating in school with children exempted under the religious
exemption who had not been immunized as required by the statute.” Brown v. Stone, 378 So.2d 218, 223 (Sup. Ct.
Miss. 1979). See Linda E. LeFever, Religious Exemptions from School Immunization: A Sincere Belief or a Legal
Loophole?, 110 Penn St. L. Rev. 1047 (2006).
24 The 20 states that allow philosophical exemptions for persons who object to immunizations because of personal,
moral or other nonreligious beliefs are Arizona, Arkansas, California, Colorado, Idaho, Louisiana, Maine, Michigan,
Minnesota, Missouri (applies only to daycare, preschool and nursery school), New Mexico, North Dakota, Ohio,
Oklahoma, Pennsylvania, Texas, Utah, Vermont, Washington, and Wisconsin. National Conference of State
Legislatures, States with Religious and Philosophical Exemptions from School Immunization Requirements, October,
2010, at http://www.ncsl.org/Default.aspx?TabId=14376.
25 See e.g., MASS. G.L.A. c. 76, § 15 (2010); MINN. STAT. ANN. § 121A.15 (2010).
26 See e.g., LA. REV. STAT. ANN. § 17:170E (2011); KAN. STAT. ANN. § 72-5209(b)(2) (2009). In Galinsky v. Board of
Education of New York, 312 F.3d 636 (2d Cir. 2000), the circuit court upheld the district court’s finding that the
parents’ claim for a religious exemption was motivated by their personal fears for their daughters’ well being, and not
by religious beliefs.
27 Steve P. Calandrillo, Vanishing Vaccinations: Why are So Many Americans Opting Out of Vaccinating Their
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such laws, granting considerable deference to the use of the states’ police power to require
immunizations to protect the public health.28 Still, some courts have held that a state’s right to
require vaccinations is not absolute, resulting in liberal interpretations of waiver exemptions.29
Health Care Workers
A number of states have laws requiring employees of certain health care facilities, such as
hospitals and nursing homes, to be vaccinated against diseases such as measles, mumps, and
rubella. Such laws, which vary widely, generally contain opt-out provisions where a vaccine is
medically contraindicated or if the vaccine is against the individual’s religious or philosophical
beliefs.30 A few states have laws pertaining to influenza vaccination of health care workers, and
most that do provide for voluntary influenza immunization programs and staff education
measures for employees; however, a few states have mandatory requirements for influenza
vaccinations for health care workers.31
During the recent 2009 influenza A(H1N1) pandemic, despite an extensive public education
campaign, less than half of health care workers were vaccinated against pandemic influenza.32 In
August 2009, the New York State Health Department amended its regulations to require that
health care workers at hospitals, in home health care agencies, and in hospice care be immunized
against influenza viruses as a precondition to employment and on an annual basis.33 This
regulation, issued on an emergency basis, did not permit any exceptions to the influenza
vaccination mandate except for medical contraindications. Lawsuits were filed challenging the
regulation’s validity, and on October 16, 2009, a state judge issued a temporary restraining order
suspending its application to New York health care workers.34 However, on October 22, 2009,
Governor David A. Paterson announced the suspension of the flu shot mandate for health care
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Children?, 37 Mich. J.L. Reform 353, 385-388 (2004).
28 Id. at 387-388. See, e.g., cases cited at footnote 13; also, Seubold v. Fort Smith Special Sch. Dist., 237 S.W.2d 884,
887 (Ark. 1951) (mandatory school vaccination does not deprive individuals of liberty and property interests without
due process of law); McCartney v. Austin, 293 N.Y.S. 2d 188, 200 (N.Y. 1968) (New York vaccination law does not
interfere with freedom to worship since Roman Catholic faith does not proscribe vaccination).
29 See Berg v. Glen Cove City Sch. Dist., 853 F. Supp. 651, 654-55 (E.D.N.Y. 1994) (holding that a Jewish parent’s
“sincere religious belief” may support an opposition to immunizations, even though the Jewish religion does not
prohibit vaccinations); Jones ex rel. Jones v. State, Dep’t of Health, 18 P.3d 1189, 1195 (Wyo. 2001) (health
department may not require that a student provide a medical reason for seeking a waiver from immunization); In re
LePage, 18 P.3d 1177, 1180 (Wyo. 2001) (holding that a health department may not inquire into the sincerity of a
parent’s religious objection to immunizations).
30 Megan C. Lindley et al., “Assessing State Immunization Requirements for Healthcare Workers and Patients,”
American Journal of Preventative Medicine, vol. 2, no. 6 (2007), pp. 459-465.
31 The CDC maintains a continuously updated online database of state laws pertaining to vaccination requirements at
http://www2a.cdc.gov/nip/StateVaccApp/statevaccsApp/default.asp. See, generally, Abigale L. Ottenberg, Joel T. Wu,
and Gregory A. Poland, et al., “Vaccinating Health Care Workers Against Influenza: The Ethical and Legal Rationale
for a Mandate,” American Journal of Public Health, vol. 101, no. 2 (February 2011), pp. 212-216.
32 K.M. Harris et al., “Influenza Vaccine - Safe, Effective, and Mistrusted,” New England Journal of Medicine, vol. 363
(2010), pp. 2183-2185, available at http://www.nejm.org/doi/pdf/10.1056/NEJMp1012333.
33 N.Y. Comp. Codes R. & Regs. tit. 10, § 66-3.2 See also a press release issued by New York State Health
Commissioner Richard F. Daines on September 24, 2009 at http://www.health.state.ny.us/press/releases/2009/2009-09-
24_health_care_worker_vaccine_daines_oped.htm.
34 The temporary restraining order issued by state Supreme Court Judge Thomas J. McNamara, may be accessed at
http://op.bna.com/hl.nsf/r?Open=sfak-7wvsxh.
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employees due to the current shortage of both the seasonal flu vaccine and the influenza A(H1N1)
vaccine.35
In the private sector, employers can require health care workers to be vaccinated against
communicable diseases as a condition of employment, unless a state law applies which permits
employees to opt out.36 A number of professional organizations, including the Infectious Diseases
Society of America and the American College of Physicians, endorse the proposition that health
care workers have a professional and ethical responsibility to help prevent the spread of infectious
pathogens among patients and themselves, and that health care workers should receive annual
influenza vaccinations as a condition of employment and professional privileges.37 Virginia
Mason Hospital in Seattle, WA, became the first hospital in the nation, in 2004, to make
vaccination a condition of employment for all of its employees. Within three years, the hospital
reported 98% staff coverage, except for 2% of the staff who refused for medical or religious
reasons.38 Staff who refuse the vaccine are required to wear surgical masks when in the hospital.39
Other hospitals in the private sector have instituted similar mandatory flu vaccination policies,40
and some policies have been the subject of lawsuits.41
In 2008, the Department of Defense (DOD) issued a policy directive requiring “all civilian health
care personnel who provide direct patient care in DOD military treatment facilities to be
35 See press release at http://www.ny.gov/governor/press/press_1022094.html. In September, 2010, Sen. Tom Duane of
the New York state legislature suggested the issue be reconsidered. See http://vaccinenewsdaily.com/news/215731-ny-
pushing-for-mandatory-health-care-worker-flu-vaccinations. Some groups, such as the American Academy of
Pediatrics, have recommended mandatory influenza vaccination of health care workers. See
http://www.msnbc.msn.com/id/39066862/.
36 The Joint Commission, a private accreditation body, requires accredited organizations such as hospitals and skilled
nursing facilities to offer influenza vaccinations to licensed independent practitioners and staff as a condition of
accreditation. See Occupational Safety and Health Administration (OSHA) Fact Sheet at http://www.osha.gov/
Publications/seasonal-flu-factsheet.pdf.
37 A list of organizations and links to their policy statements may be found at http://www.immunize.org/honor-roll/.
The American College of Physicians policy declares that “health care workers that cannot receive flu vaccines due to
medical or religious contraindications should either be reassigned to non-patient care areas during influenza season or
wear a mask at all times during influenza season in the context of patient care.” S.A. Fryhofer, “Immunization 2011:
Expanding Coverage, Enhancing Protection,” Annuals of Internal Medicine, vol. 154, no. 3 (2011), pp. 204-206.
38 Anita Manning, “Hospitals Shoot for Employees to Get Flu Vaccine,” USAToday, September 16, 2007 at
http://www.usatoday.com/news/health/2007-09-16-flu-doctors_N.htm. See, also, paper presented at: 42nd NIC National
Immunization Conference—Mandatory Influenza Vaccination: The Virginia Mason Story, March 18, 2008; Atlanta,
Georgia. http://cdc.confex.com/recording/cdc/nic2008/ppt/free/4db77adf5df9fff0d3caf5cafe28f496/paper15824_5.ppt.
39 The Washington State Nurses Association filed suit in 2007 alleging that implementing the mandatory flu
vaccination policy without first negotiating with the nurses’ union violated the Labor Management Relations Act. The
9th Circuit Court of Appeals upheld the arbitrator’s decision prohibiting Virginia Mason Hospital from unilaterally
implementing the vaccination policy without bargaining with the nurses’ union. The court’s decision is available at
http://healthcareemploymentcounsel.com/examining-room/
WashingtonStateNursesAssociationVersusVirginiaMasonHospital.pdf.
40 See, e.g., H.M. Babcock et al., “Mandatory Vaccination of Healthcare Workers: Translating Policy to Practice,”
Clinical Infectious Diseases, vol. 50, no. 4 (2010), pp. 459-464., available at http://cid.oxfordjournals.org/content/50/4/
459.full, and “Mandatory Flu Vaccination Policies Spreading,” at http://www.massnurses.org/health-and-safety/
articles/infectious-diseases/p/openItem/3207.
41 See class action lawsuit filed September 2010 by a health care worker against AnMed Health, a network of hospitals
and health care facilities in South Carolina, challenging its Influenza Immunization Protocol that provides “unless an
approved exemption is made,” the flu vaccination will be “a condition of initial and continued employment of all
AnMed employees…” The lawsuit alleges that the mandatory flu vaccination requirements constitute an unreasonable
invasion of privacy under South Carolina’s state constitution. The complaint is available at
http://healthcareemploymentcounsel.com/examining-room/HunterVersusAnmedHealth.pdf.
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immunized against seasonal influenza infection each year as a condition of employment, unless
there is a documented medical or religious reason not to be immunized.”42 The Department of
Veterans Affairs has an influenza vaccination program for patients and employees of the Veterans
Health Administration that encourages, but does not mandate, yearly influenza vaccinations.43
Vaccination Orders During a Public Health Emergency
Many states also have laws providing for mandatory vaccinations during a public health
emergency or outbreak of a communicable disease. Generally, the power to order such actions
rests with the governor of the state or with a state health officer. For example, a governor may
have the power to supplement the state’s existing compulsory vaccination programs and institute
additional programs in the event of a civil defense emergency period.44 Or, a state health officer
may, upon declaration of a public health emergency, order an individual to be vaccinated “for
communicable diseases that have significant morbidity or mortality and present a severe danger
to public health.”45 In addition, exemptions may be provided for medical reasons or where
objections are based on religion or conscience.46 However, if a person refuses to be vaccinated, he
or she may be quarantined during the public health emergency giving rise to the vaccination
order. State statutes may also provide additional authority to permit specified groups of persons to
be trained to administer vaccines during an emergency in the event insufficient health care
professionals are available for vaccine administration.47
Model State Emergency Health Powers Act
In addition to the current laws, many states have considered the provisions set forth in the Model
State Emergency Health Powers Act (Model Act). The Model Act was drafted by The Center for
Law and the Public’s Health at Georgetown and Johns Hopkins Universities.48 It seeks to “grant
public health powers to state and local public health authorities to ensure strong, effective, and
timely planning, prevention, and response mechanisms to public health emergencies (including
42 Department of Defense/Joint Forces, HA Policy: 08-005, Policy for Mandatory Seasonal Influenza Immunization for
Civilian Health Care Personnel Who Provide Direct Patient Care in Department of Defense Military Treatment
Facilities, April 4, 2008, available at http://mhs.osd.mil/Content/docs/pdfs/policies/2008/08-005.pdf. See, infra, section
on Role of the Federal Government, for a discussion of the authority of the military to require immunizations of its
personnel.
43 See “2010/2011 VA Influenza Manual” at http://www.publichealth.va.gov/docs/flu/vaflumanual_2010.pdf#page=36.
44 HAW. REV. STAT. § 128-8 (2010). In Arizona, the Governor, during a state of emergency or state of war emergency in
which there is an occurrence or the imminent threat of smallpox or other highly contagious and highly fatal disease,
may “issue orders that mandate treatment or vaccination of persons who are diagnosed with illness resulting from
exposure or who are reasonably believed to have been exposed or who may reasonably be expected to be exposed.”
ARIZ. REV. STAT. § 36-787 (2011).
45 FLA. STAT. § 381.00315 (2010).
46 See, e g., CONN. GEN. STAT. § 19a-222 (2010) (exemption for physician’s determination of sickness); VA. CODE ANN.
§ 32.1-48 (2010) (vaccination waived if detrimental to person’s health, as certified by a physician); WIS. STAT. §
252.041 (2010) (vaccination may be refused for reasons of religion or conscience). See, generally, W.E. Parmet,
“Pandemic Vaccines - The Legal Landscape,” New England Journal of Medicine, vol. 362, no. 21 (2010), pp. 1949-
1952.
47 See article, “State Takes Extra Steps to Battle Flu in the Fall,” at http://www.boston.com/news/health/articles/2009/
08/13/state_asks_volunteers_to_aid_flu_vaccinations/.
48 The text of the Center’s Model State Emergency Health Powers Act from 2001 is available at
http://www.publichealthlaw.net/ModelLaws/MSEHPA.php.
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bioterrorism) while also respecting individual rights.”49 It is important to note that this is intended
to be a model for states to use in evaluating their emergency response plans; passage of the Model
Act in its entirety is not required, so state legislatures may select the entire act, parts of it, or none
at all. Many states have used sections of the Model Act while tailoring their statutes and
regulations to respond to unique situations that may arise in their jurisdiction.50
The Model State Emergency Health Powers Act addresses a number of issues likely to arise
during a public health emergency and offers guidelines for states with respect to what powers
may be necessary during such an emergency. With respect to vaccinations, the Model Act
includes provisions similar to the current laws discussed above. Under the Model Act, during a
public health emergency, the appropriate public health authority would be authorized to
“vaccinate persons as protection against infectious disease and to prevent the spread of
contagious or possibly contagious disease.”51 The Model Act requires that the vaccine be
administered by a qualified person authorized by the public health authority, and that the vaccine
“not be such as is reasonably likely to lead to serious harm to the affected individual.”52 The
Model Act recognizes that individuals may be unable or unwilling to undergo vaccination “for
reasons of health, religion, or conscience,” and provides that such individuals may be subject to
quarantine to prevent the spread of a contagious or possibly contagious disease.53
Role of the Federal Government
Federal jurisdiction over public health matters derives from the Commerce Clause, which states
that Congress shall have the power “[t]o regulate Commerce with foreign Nations, and among the
several States ... ”54 Thus, under the Public Health Service Act, the Secretary of the Department of
Health and Human Services has authority to make and enforce regulations necessary “to prevent
the introduction, transmission, or spread of communicable diseases from foreign countries into
the States or possessions, or from one State or possession into any other State or possession.”55
With regard to interstate commerce, the Public Health Service Act deals primarily with the use of
quarantine and isolation measures to halt the spread of certain communicable diseases.56 No
mandatory vaccination programs are specifically authorized, nor do there appear to be any
regulations regarding the implementation of a mandatory vaccination program at the federal level
during a public health emergency.57
49 Id.
50 The Center for Law and the Public’s Health tracked state legislative activity relating to the Model Act through 2006
at http://www.publichealthlaw.net/Resources/Modellaws.htm#MSEHPA.
51 Model State Emergency Health Powers Act, Article VI, Sec. 603.
52 Id.
53 Id. See Section 604 of the Model Act for provisions relating to quarantine.
54 U.S. CONST. Art. I, § 8. Recognizing that vaccines occasionally cause adverse events, and to assure a supply of
vaccines while still providing a financial remedy to those injured, Congress passed the National Vaccine Injury
Compensation Act, which created the National Vaccine Injury Program. That program provides a no-fault
compensation plan, with capped damages for pain and suffering. 42 U.S.C. §§ 300aa-1–300aa-34.
55 42 U.S.C. § 264(a). Originally, the statute conferred this authority on the Surgeon General; however, pursuant to
Reorganization Plan No. 3 of 1966, all statutory powers and functions of the Surgeon General were transferred to the
Secretary.
56 See 42 C.F.R. Parts 70 (interstate matters) and 71 (foreign arrivals).
57 It may be noted that Congress established a vaccine injury compensation program in the 1980’s which provides a no-
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With regard to foreign countries, the Secretary has the power to restrict the entry of groups of
aliens for public health reasons.58 This power includes the authority to issue vaccination
requirements for immigrants seeking entry into the United States. Currently, certain vaccines
specified in statute, and other vaccines recommended by the CDC Advisory Committee on
Immunization Practices for the general U.S. population, are required for immigrants who seek
permanent residence in the United States, and people currently living in the United States who
seek to adjust their status to become permanent residents.59 CDC has determined that two diseases
for which vaccines are recommended for routine use by the ACIP—for human papillomavirus
(HPV) and zoster (shingles)—do not have the potential to cause outbreaks, and are therefore not
required for admission.60 Vaccination requirements may be waived when the foreign national
receives the vaccination, if the civil surgeon or panel physician certifies that the vaccination
would not be medically appropriate, or if the vaccination would be contrary to the foreign
national’s religious or moral beliefs.61
The military has broad authority in dealing with its personnel, both military and civilian,
including the protection of their health.62 Military regulations require American troops to be
immunized against a number of diseases, including tetanus, diphtheria, influenza, hepatitis A,
measles, mumps, rubella, polio, and yellow fever.63 Inoculations begin upon entry into military
service, and later vaccines depend upon troop specialties or assignments to different geographic
areas of the world. Courts have upheld the legality of military mandatory vaccination orders. For
example, in United States v. Chadwell,64 two U.S. Marines refused to be vaccinated against
smallpox, typhoid, paratyphoid, and influenza because of their religious beliefs.65 In upholding
the convictions, the Navy Board of Review court (now the Navy-Marine Corps Court of Criminal
Appeals) stated that religious beliefs were not above military orders and that “to permit this
(...continued)
fault mechanism to resolve vaccine injury claims and provides partial immunity for vaccine manufacturers. For more
information on this program, see the Department of Health and Human Services website at http://www.hrsa.gov/
vaccinecompensation/, and CRS Report RL33927, Selected Federal Compensation Programs for Physical Injury or
Death, coordinated by Sarah A. Lister and C. Stephen Redhead.
58 See 8 U.S.C. § 1182.
59 See the CDC Division of Global Migration and Quarantine website for information on vaccination requirements for
immigrants at http://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html. For further information
about health-related grounds for exclusion of immigrants see CRS Report R40570, Immigration Policies and Issues on
Health-Related Grounds for Exclusion, by Ruth Ellen Wasem.
60 See CDC, “Criteria for Vaccination Requirements for U.S. Immigration Purposes,” 74 Federal Register 58634-
58638, November 13, 2009.
61 8 U.S.C. § 1182(g)(2).
62 Congress’ war powers include the power to “raise and support Armies,” to “provide and maintain a Navy,” and to
“make Rules for the Government and Regulation of the land and naval Forces.” U.S. CONST. Art. 1, § 8, cls. 12-14. The
Supreme Court has called these powers “broad and sweeping,” United States v. O’Brian, 391 U.S. 367 (1967), and the
Court gives its highest level of deference to legislation made under Congress’ authority to raise and support armies and
make rules and regulations for their governance. See Rostker v. Goldberg, 453 U.S. 47 (1981).
63 See Department of Defense (DOD) Directive Number 6200.04, “Force Health Protection,” (2004) and DOD
Directive Number 6205.02E, “Policy and Programs for Immunizations to Protect the Health of Service Members and
Military Beneficiaries,” (2006) at http://www.dtic.mil/whs/directives/corres/dir.html. See also Army Regulation 40-
562, Immunizations and Chemoprophylaxis, September 29, 2006, available at http://www.vaccines.mil/documents/
969r40_562.pdf.
64 36 C.M.R. 741 (1965).
65 Id. at 748.
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Mandatory Vaccinations: Precedent and Current Laws
would be to make the professed doctrines of religious belief superior to military orders, and in
effect to permit every soldier to become a law unto himself.”66
As noted above, state and local governments have primary responsibility for protecting the public
health, and this has been reflected in the enactment of various state laws requiring that school
children be vaccinated against certain diseases before enrolling in school and that health care
workers be vaccinated as a condition of employment, as well as laws providing for mandatory
vaccination procedures during a public health emergency. Any federal mandatory vaccination
program applicable to the general public would likely be limited to areas of existing federal
jurisdiction, i.e., interstate and foreign commerce, similar to the federal quarantine authority.67
This limitation on federal jurisdiction acknowledges that states have the primary responsibility for
protecting the public health, but that under certain circumstances, federal intervention may be
necessary.
Author Contact Information
Kathleen S. Swendiman
Legislative Attorney
kswendiman@crs.loc.gov, 7-9105
66 Id. Current Army regulations, supra, footnote 63, at Chapter 2, Para 2-6, permit two types of exemptions from
immunization, medical and administrative, under certain circumstances. A mandatory anthrax vaccination program for
certain military personnel, begun in 1998, has been the subject of various lawsuits brought by members of the military
who argued the vaccine was unproven and that studies describing its safety were unsound. In one case, Rempfer v. Von
Eschenbach, 535 F. Supp. 2d 99 (D. D.C. 2008), the court held that the FDA had applied its expertise and found that
the anthrax vaccine in question was effective for immunization against anthrax. The court refused to substitute its own
judgment for that of the FDA. The court of appeals affirmed the district court ruling in Rempfer v. Sharfstein, 583 F. 3d
860 (D.C. Cir. 2009). See, also, DOD’s Anthrax Vaccine Immunization Program website questions and answers at
http://www.vaccines.mil/default.aspx?cnt=resource/qaAll&dID=21&cID=350.
67 It has been suggested that in the case of a serious outbreak of a communicable disease, the federal government might
enact policies to encourage vaccinations or place restrictions on those who refuse. Bureau of Justice Assistance, U.S.
Department of Justice, The Role of Law Enforcement in Public Health Emergencies (September, 2006) at 19.
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