Our Inequitable Immigrant Vaccination Policy
Discriminatory Rules Are Not Designed for Public Health
SOURCE: AP/Donald Brown
Vaccine policy in the United States is riddled with inconsistencies that are prejudiced against those coming into the country and which undermine the system as a whole. Above, a doctor holds the human papillomavirus vaccine Gardiasil.
When the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommended in March 2007 that all females 11 to 26 should get vaccinated against the human papillomavirus, or HPV, they did not anticipate the resulting controversy over U.S. immigration policy.[1] Public response to the recommendation in fact involved a variety of debates: social conservatives argued that mandating the vaccine would encourage sexual promiscuity, and the vaccine maker, Merck, made suspicious lobbying efforts for swift passage of mandatory inoculation rules that would help its bottom line.[2] Merck obtained its license for the vaccine, Gardasil, which protects against the development of genital ulcers and cervical cancer, in June 2006. Gardasil has the potential to prevent thousands of cases of cervical cancer each year, so why were immigration advocates crying foul?
The simple answer is that vaccine policy in the United States is riddled with inconsistencies that discriminate against those coming into the country.
On September 30, 1996, Congress amended the Immigration and Nationality Act, or INA, by adding the requirement that all immigrants prove receipt of all vaccinations recommended by the Advisory Committee on Immunization Practices.[3] Thus, vaccines that are only recommended to the U.S. population automatically became mandatory for immigrants. Many of the ACIP-recommended vaccines are actually mandated for children entering public schools, but parents can home-school their children if they prefer not to vaccinate. With the exception of girls in Virginia’s public schools, Gardasil is not required for any female in the United States, public school-educated or not. This left many immigration advocates asking why immigrant girls and women should be required to have a vaccine that’s not required of most U.S. citizens.
Should the government mandate those vaccines targeted against diseases that do not pose immediate public health threats?
A 1990 amendment to the INA authorized for the exclusion of immigrants officials felt have “communicable diseases of public health significance.”[4] It is reasonable to infer that this amendment was intended to protect the U.S. population from exposure to serious infectious diseases carried by immigrants entering the country, and that the later vaccination requirements were intended for the same reason. Yet these requirements don’t apply to all who enter the country. Refugees residing in the U.S. are exempt from the vaccination requirements (unless and until they apply for adjustment of status for permanent residence), as are temporary visitors.[5] If the purpose of the law is indeed to protect the U.S. population against infectious diseases, then it would follow that all visitors entering the country must be vaccinated, since any could be a potential carrier of vaccine-preventable contagious diseases.
Another glitch in this policy, if it is designed to protect against broad threats to public health, is that not all vaccine-preventable diseases are actually contagious. The toxin produced by the bacterium Clostridium tetani causes tetanus, and the tetanus vaccine is very effective at protecting against the development of this lethal disease. It is understandable that the vaccine is recommended by the ACIP, yet by default the vaccine is mandatory for all immigrants. However, tetanus is not spread from person to person. Why is this vaccine mandated for immigrants when it doesn’t confer any protection to the population at large, but only to the individual receiving the vaccine?
While HPV is transmissible from person to person, the cervical cancer that can result from HPV infection does not usually manifest until years or even decades after. HPV does not pose an immediate significant threat to the population, unless we decide to define genital ulcers as significant threats. Pharmaceutical companies are researching other vaccines like Gardasil intended to protect against diseases that manifest years or decades after infection. This is in contrast to traditional vaccines targeted against highly contagious diseases spread via the respiratory route, which do pose immediate threats to the population. Should the government mandate those vaccines targeted against diseases that do not pose immediate public health threats?
One could argue that the immigration vaccine policy is an economic protection because the financial burden for the treatment for tetanus, cancers, and other such diseases might be significant; thus it’s better to prevent them to reduce healthcare costs. One could also argue that the vaccines should be administered to immigrants for their own, individual benefit. But again, there is an inconsistency. If these are in fact the reasons behind the vaccine requirement for immigrants, then logically, the vaccines should be mandatory for U.S citizens, too.
Ultimately, the different rules for immigrants are a question of justice. The policy places a burden on immigrants that is not demanded of U.S. citizens. Vaccines are expensive. Gardasil, administered in three doses, costs about $360 for the series.[6] The high cost is a disadvantage to poorer immigrants. A physician may waive the vaccine requirements if there are medical contraindications, such as an allergy to the vaccine. An immigrant may also opt out of vaccines on the basis of religious or moral objections, but he or she must be opposed to vaccinations in all forms.[7] Immigrants are often desperate to enter the United States, and if there is any perception that opposition to vaccination could be used to deny them entry, it is unlikely they will protest such preconditions.
Unlike immigrants, U.S. citizens are allowed to cherry pick what vaccines, if any, they receive. While there is a set of mandatory vaccinations for children entering public school, parents can simply choose home schooling. Many adult vaccines, such as herpes zoster vaccines, are completely optional. If a young U.S. woman opposes the vaccine Gardasil on the grounds that she is not sexually active, she can do so without having to forgo other vaccines. Immigrant females do not have this choice. They must either take all or no vaccinations. This lack of choice leaves them in a precarious and vulnerable situation—in terms of health and cultural discrimination. Immigrants are already vulnerable to stigma due to language barriers, differences in appearance, and cultural practices. Mandatory vaccination of immigrants can compound negative views towards them by implying that they are sexually promiscuous, disease-ridden, and pose significant health risks to Americans.
The immigration vaccine policy should be rooted in sound scientific and public health rationales. As it stands, it is discriminatory and it can compound a sometimes-hostile environment toward immigrants. Moreover, the current inconsistencies of the immigration-related policy could undermine all vaccine-related policies and guidelines. A growing group of U.S. parents are opting out of vaccinating their children because of a lack of trust in the decision-making behind the vaccination guidelines. Misinformation in the media about an unsubstantiated link between vaccines and autism has fueled the anti-vaccine movement, though recent findings and a court ruling last month underscore the fact the opposition rests on little to no evidence.[8] Inconsistencies in vaccine policy for immigrants undermine the entire system. Moreover, continued opposition to vaccination could lead to a resurgence of very serious and immediately threatening diseases that have been largely absent in recent U.S. history, as exemplified by a recent Haemophilus influenzae type B (Hib) meningitis outbreak in Minnesota among five children, three of whose parents had opted not to have them vaccinated.[9] Further discussion of immigrant vaccination policy must involve what constitutes a significant public health threat, what is equitable, and what is reasonable given economic and political constraints. At the very least, however, the policy needs to be fair, effective, and re-evaluated.
Aysha Akhtar, MD, MPH a neurologist and public health specialist and a fellow of the Oxford Centre for Animal Ethics. She can be reached at: aysha.akhtar@oxfordanimalethics.com.
Notes
[1] Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER, Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices (ACIP), “Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP),” MMWR Recomm Rep. 2007, 56(RR-2):1-24.
[2] “Merck lobbies for vaccine policy to become law,” Associated Press, January 30, 2007, available at: http://www.foxnews.com/story/0,2933,248781,00.html (last accessed February 22, 2009).
[3] Mautino KS, “Vaccination requirements for immigrants to the United States,” Journal of Immigrant Health, 1999 (1): 61-63.
[4] Ibid.
[5] Ibid; CDC, “Adjustment of status for U.S permanent residence requirements: technical instructions for vaccination 2008,” available at: http://www.cdc.gov/Ncidod/dq/civil.htm (last accessed January 12, 2009).
[6] Mary Engle, “Immigrant advocates decry cervical cancer vaccine order,” Los Angeles Times, October 22, 2008, available at: http://articles.latimes.com/2008/oct/22/science/sci-gardasil22 (last accessed January 20, 2009).
[7] U.S. Department of Justice Immigration and Naturalization Service, “Medical examinations, vaccination requirements, waivers of medical grounds of inadmissibility, and Designation of civil surgeons and revocation of such designation” (AD 01-03), October 17, 2002, available at: http://www.immigrationequality.org/uploadedfiles/2002%20HIV%20Immigration%20policy%20memo.pdf (last accessed January 20, 2009).
[8] WebMD, “Vaccine court rejects autism claim,” February 12, 2009, available at: http://www.webmd.com/brain/autism/news/20090212/vaccine-court-rejects-autism-claims (last accessed February 22, 2009).
[9] WebMD, “Hib outbreak kills unvaccinated child,” available at: http://children.webmd.com/vaccines/news/20090123/hib-outbreak-kills-unvaccinated-child (last accessed February 6, 2009).
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