EXEMPTION AND REFUSAL OF RECOMMENDED VACCINES                      11/00

Patient Name:

Birthdate:

As the parent/guardian of ___________________________, I have investigated the risks and benefits of the following vaccines and diseases.  I am aware that there are documented cases of people contracting the diseases for which they are clinically fully vaccinated and that the manufacturers of the vaccines do not guarantee 100% efficacy.  I am also aware that VAERS (Vaccine Adverse Events Reporting System) documented cases of over 54,000 adverse reactions from vaccines in a 20 month period.  The National Vaccine Injury Fund, created in 1986 to compensate those damaged by vaccines has paid out over one billion dollars in compensation to date. 

POLIO:  I have been informed of the risk of my child developing paralytic disease and meningitis associated with poliomyelitis.  I understand that even under epidemic conditions, natural polio produces no symptoms in over 90% exposed to it.  (1)  I understand that there have been no cases of wild polio in the US in the past 20 years and that those cases which have been documented have been caused by the vaccine.  (2)  I understand the following side effects for the vaccine are possible:

Killed Virus Polio: temperature of 102 degrees in up to 38%, sleepiness, fussiness, crying, decreased appetite, vomiting, Guillain-Barre Syndrome and allergic reaction in those allergic to neomycin, polymyxin B and streptomycin.  Precautions include those who have had a previous negative reaction, pregnant women, and possibly those with HIV/AIDS or otherwise compromised immune systems.

Live Virus Polio:  reactions include contraction of polio by those who have received the virus and by those who have come in contact with body fluids and wastes of the immunized person.  Paralytic symptoms may follow the contraction of polio.  Live virus is reportedly shed for up to 8 weeks after the inoculation.  Guillain-Barre Syndrome has also been noted.  Not recommended for use in households where someone has a compromised immune system, for pregnant women, or where a previous reaction has been reported.  (3)  Killed Virus Ipol® is grown on monkey kidney cells, contains formaldehyde, and triple antibiotics.  Poliovax® is grown on cells from an aborted baby, contains formaldehyde, cow serum and a triple antibiotic solution.  (4)  The monkey kidney cells used in the original killed polio vaccine contains SIV-40 and has been found in tumor cells of children whose parent’s were vaccinated against polio using the contaminated virus.  (5)  The live vaccine is grown on monkey kidney cells, antibiotics, and calf serum. 

Initial________________________________________  Date______________________________

HEMOPHILUS INFLUENZAE B:  I have been informed of the risk of my child developing meningitis (although this vaccine will not protect the child from meningitis from all other forms such as pneumococcus and meningococcus, viruses, and fungi), pneumonia, and infections of the blood, joints, bone, and soft tissue associated with Hemophilus Influenzae B.  I understand that this disease is most likely in children up to 15 months of age and is fatal in 3-6% of children who contract it.  Incidence of this disease today is low and the vaccine has not been proven to be effective in 41% of cases, according to some studies. (6)  Treatment is available.  The vaccine is often combined with the DPT which has the highest reaction rate of any vaccine available today.  Reactions include, but are not limited to:  >100.6 degree fever, irritability, lethargy, anorexia, rhinorrhea, diarrhea, vomiting cough, when administered alone.  Reactions occurred in up to 30% of recipients.  When administered in conjunction with the DPT, reactions include local tenderness erythema and induration, fever >100.8 degrees, irritability, drowsiness, anorexia, diarrhea, vomiting, persistent crying, seizures, urticaria, hives, renal failure, Guillain-Barre Syndrome and death.  Reactions occurred in up to 77% of recipients.  (7)  The vaccine contains yeast, thimerosal (mercury derivative), and diphtheria toxoid when given alone. (8)

Initial __________________________________  Date____________________

PERTUSSIS:  I have been informed of the risk of my child developing whooping cough, pneumonia, convulsions, inflammation of the brain, and death associated with pertussis.  I understand the disease is rarely fatal, with a 99.8% recovery rate.  It is most serious and life-threatening in children under 6 months old, but there are adequate methods of treatment available. (9)  The vaccine is most often given in conjunction with diphtheria and tetanus as the DPT or DaPT.  Pertussis vaccine reactions can include, but are not limited to: fevers >106 degrees, pain, swelling, diarrhea, projectile vomiting, excessive sleepiness, high pitched screaming, inconsolable crying bouts, seizures, convulsions, collapse, shock, breathing problems, brain damage and SIDS.  1 in 600 suffer a severe reaction in one study (10) and 1 in 875 suffered shock collapse and convulsions. (11)  Those in the 2nd study were only tracked for the first 48 hours following immunization.  A more recent study indicates that 1 in 100 react with convulsions, collapse or high pitched screaming and 1 in 3 of those cases sustained permanent brain damage.  (12)  In a study of 103 children who died of SIDS, 70% died within 3 weeks of the DPT shot and 37% of those died within the first week. (13)  The DaPT is recommended as a safer option for vaccination.  Side effects for the DaPT were only tracked for 72 hours and included: tenderness, erythema, induration, fever >102.2 degrees, drowsiness, fretfulness, vomiting, upper respiratory infection, diarrhea, rash, febrile seizures, persistent or unusual crying, lethargy, hypronic-hyporesponsive episode, urticaria, anaphylactic shock, convulsions, encephalopathy, mono– and polyneuropathies, and death. (14)  Not recommended for children under 15 months or for those who have not had 3 injections of DPT.  Either form of the vaccine contains thimerosal (mercury derivative), formaldehyde, and aluminum phosphate. (15)

Initial ___________________________________  Date ______________________

DIPTHERIA:  I have been informed of the risk of my child developing paralysis, heart failure, or respiratory failure with diphtheria.  I have also been in formed that there have only been 5 cases reported annually since 1980. (16)  I am also aware that diphtheria is rarely fatal and treated with antibiotics and bed rest.  (17)  The diphtheria component is most often given with the DPT or DaPT and include the same side effects and reactions as those listed with pertussis.

Initial ___________________________________  Date _______________________

TETANUS:  I have been informed of the risk of my child developing fatal neuromuscular disease related to tetanus.  I understand that the incidence of tetanus is low, and there is antitoxin, should we decline the immunization.  I understand that contracting tetanus does not provide life-long immunity, and neither does the vaccine.  I understand that to prevent more severe reactions from the vaccine, the tetanus component has been so significantly “diluted” that it is clinically ineffective. (18)  I understand that the death rate for properly treated cases of tetanus may be as high as 20%. (19)  Side effects of the tetanus vaccine alone include, but are not limited to: high fever, pain, recurrent abscess formation, inner ear nerve damage, demyelinating neuropathy, anaphylactic    

shock,  and loss of consciousness. (20) Tetanus given in the DPT or DaPT shot include the same side effects and reactions listed for pertussis.

Initial _________________________________  Date _______________________

RUBEOLA (MEASELS):  I have been informed of the risk of my child developing pneumonia, encephalitis (inflammation of the brain), degenerative disease of the nervous system with convulsions (sub acute sclerosing panencephalitis) related to rubella.  I understand  the death rate for measles is .03 in 100,000. (21)  I understand that since 1984, over 55% of documented, confirmed cases of measles have been in fully immunized persons. (22) I understand that the greatest risk of measles vaccines may be to push the incidence of this disease into the late teens and adulthood where it is more likely to be fatal or cause more adverse and long-term effects. (23)  The measles vaccine is a live vaccine, and carries the risk that it will cause the recipient to contract measles.  Other adverse reactions include, but are not limited to:  stinging or burning at the injection site, anaphylaxsis, fever up to 1 month following the injection, rash, cough, rhinitis, erythema multiforms, lymphadenopathy, urticaria, diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura, vasculitis, optic neuritis, papillitis, retinitis, encephalitis, and encephalopathy, ocular palsies, Guillain-Barre Syndrome, ataxia, and sub acute sclerosing panencephalitis. (24)  Measles vaccine is most often given as part of the MMR shot, which includes the following side effects: burning or stinging at the injection site, malaise, sore throat, cough, rhinitis, headache, dizziness, fever, rash, nausea, vomiting, diarrhea, erythema, induration, tenderness, lymphadenopathy, parotitius, orchitis, nerve deafness, thrombocytopenia, purpura, allergic reactions, urticaria, polyneuritis, arthralgia, arthritis, anaphylaxis, vasculitis, otitis media (ear infection), conjunctivitis (ear infection), febrile convulsions, seizures, syncope, erythema multiforme, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barre Syndrome, ataxia, sub acute sclerosing panencephalitis, (25) and a recent study from Europe indicates a link between MMR vaccine and autism and irritable bowel syndrome. (26) Measles vaccine contains chick embryo cells, neomycin, sorbitol, and hydrolyzed gelatin. (27)

Initial __________________________________  Date  _________________________

MUMPS:  I have been informed of the risk of my child developing inflammation of the testicles, joints, kidneys, and/or thyroid, and hearing impairment related to mumps.  I understand that mumps is rarely harmful in childhood, and that most of the above risks occur when mumps is contracted in adolescence or adulthood. (28)  I understand that there is a mumps vaccine which poses the following risks, but are not limited to: contraction of mumps from the live vaccine, burning or stinging at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, vasculitis, parotitis, orchitis, purpura, uticaria, erythema multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, febrile seizures, and nerve deafness. (29)  Mumps is usually given in the MMR and may cause those side effects and adverse reactions as noted  in the measles section above.  Mumps vaccine is live and should not be given to pregnant women.  It is cultured in chick embryos and contains sorbitol and hydrolyzed gelatin. (30)

Initial ___________________________________  Date ___________________________

RUBELLA (GERMAN MEASLES):  I have been informed of the risk of my child developing inflammation of the brain or joints, and the risk of birth defects (including eye defects, heart defects, deafness, mental retardation, growth failure, jaundice, and disorders of blood clotting) in infants born to mothers who contract rubella during pregnancy, related to rubella.  Therefore, I understand that the greatest risk to my child may be if she never contracts rubella as a child, but when she is pregnant and it damages her unborn child.  If she contracts rubella in childhood, she is immune for life, and prior to the vaccine 85% of the population was immune. (31)  I understand that is she is not immune as an adult, she can chose to take the vaccine prior to pregnancy.  I understand that many of those who’ve contracted rubella have been immunized (up to 80%). (32)  Adverse reactions from the vaccine among teenage girls is 5-10% and 30% in adult women.  Adverse reactions include, but are not limited to:  contracting rubella from the live virus vaccine, burning or stinging at the injection site, lymphadenopathy, urticaria, rash, malaise, sore throat, fever, headache, dizziness, nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, Guillain-Barre Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue Syndrome. (34)  Rubella is most often administered in the MMR and may cause the side effects and adverse reactions listed under measles.  Rubella is cultured on the tissue of an aborted baby.  This baby was the 27th child aborted and tested by researchers due to exposure to rubella in a pregnant woman.  It contains neomycin, sorbitol, and hydrolyzed gelatin. (35)

Initial ___________________________________  Date ____________________________

HEPATITIS B:  I have been informed of the risk of my child developing Hepatitis B viral infection which can cause chronic inflammation of the liver leading to cirrhosis, liver cancer, and possibly death.  I understand that my child’s risk of developing Hepatitis B is low if I am not a carrier or infected, if my child does not engage in promiscuous sex or use drugs.  I understand that there is antibiotic treatment for HepB and that most of those who contract it recover. (36)  I understand that the HepB vaccine only contains strains of HepB and is not effective against HepA, C, D, E, F, or G.  I understand that the HepB vaccine has the following side effects and adverse reactions:  induration, erythema, swelling, fever, headache, dizziness, pain, prutitis, ecchymosis, sweating, malaise, chills, weakness, flushing, tingling, hypotension, flu-like symptoms, upper respiratory illness, nausea, anorexia, abdominal pain and cramping, vomiting, constipation, diarrhea, lymphadenopathy, pain or stiffness in muscles and joints, arthralgia, myalgia, back pain, rash, urticaria, petechiae, sleepiness, insomnia, irritability, agitation, anaphylaxis, angioedema, arthritis, tachycardia/palpatations, bronchospasms, abnormal liver function, dyspepsia, migraine, syncope, paresis neuropathy, hypothesis, parethesis, Guillain-Barre Syndrome, Bell’s Palsy, transverse mylitis, optic neuritis, multiple sclerosis, thrombocytopenia, eczema, purpura, herpes zoster, erythema modosum, alopecia (loss of hair), conjunctivitis (eye infection), keratisis, visual disturbances, vertigo, tinnitus, earaches, and dysuria. (37)  The studies only followed recipients for 4 days post-vaccination.  The most commonly used HepB vaccine contains thimerosal, although a relatively new release does not contain this mercury derivative.  The vaccine also contains aluminum hydroxide, yeast protein, and phosphate buffers. (38)

Initial ____________________________________  Date _____________________________

VARICELLA (CHICKEN POX):  I have been informed of the risk of my child developing chicken pox which could potentially result in pneumonia, secondary skin or generalized infections, or, if caught during pregnancy, birth defects in baby.  I understand that chicken pox is generally benign in children, but results in significant lost hours at work for parents.  Chicken pox in adults often manifests as shingles, a chronic and painful condition.  I also understand that contracting chicken pox later in life may increase the risk for herpes simplex and infertility.  Side effects and adverse reactions for the chicken pox vaccine include, but are not limited to:  contracting chicken pox from the live vaccine (27%), pain and redness at the injection site, swelling, erythema, rash, prutitis, hematoma, induration, stiffness, upper and lower respiratory illness, cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis media (ear infection), diaper/contact rash, nausea, eye complaints, chills, lymphadenopathy, myalgia,  headaache, teething, malaise, abdominal pain, other rash, allergic reactions including: hives, stiff neck, heat rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile seizures, and cold/canker sore. (39)  Varicella vaccine is cultured on cells from aborted babies, and guinea pig cell cultures.  It contains live virus, monosodium

Glutamate (MSG), sucrose, phosphate, processed gelatin, neomycin, and fetal calf serum. (40)

Initial _______________________________  Date ______________________

REFERENCE LIST:

M. Burnet and D. White,  The Natural History of Infectious Disease (Cambridge, 1972), p.16.

Strebel, et al, “Epiddemology in the US One Decade After the Last Reported Case of Indigenous Wild Virus Associated Disease,” Clinical Infectious Diseases, (Center for Disease Control, Feb 1992), pp.568-79.

Physician’s Desk Reference (PDR), 50th edition; Medical Economics, 1996, p. 1388-1390.

Ibid, P.885-886 and 891-892

J. Butel, et al; “Molecular Evidence of Simian Virus 40 Infections in Children”, The Journal of Infectious Diseases; Sept 1999; 180:884-887

PDR, 50th edition, p. 872-875

Ibid.

Ibid.

Richard Moskowitz, M.D., “Immunizations: The Other Side,” Mothering (Spring 1984), p. 34.

Immunization: Survey of Recent Research, (US Dept of Health and Human Services, April 1983), p. 76

“Nature and the rates of Adverse Reactions Associated with DPT and DT Immunizations…,” Pediatrics, Volume 68, No. 5 (Nov. 1981)

Walene, James, “Immunization: the Reality Behind the Myth” (South Hadley, MA: Bergin and Garvey 1988) p. 14

W.C. Torch, “Tetanus-pertussis-tetanus (DPT) immunization: A potential cause of sudden infant death syndrome (SIDS),” (American Academy of Neurology, 34th Annual Meeting, Apr 25– May 1, 1982), Neurology 32(4), pt. 2.

PDR, p. 875-879 and 892-895

Ibid.

Robert Mendelsohn, M.D., “How to Raise a Healthy Child In Spite of Your Doctor,” (Chicago Contemp. Books, 1984), p. 223

Ibid. 244-246

Isaac Golden, Ph.D., “Vaccination? A Review of Risks and Alternatives,” (Geelong, Victoria, Australia: Arum Healing Centre, 1991), p. 31

See reference #9

See Reference # 18 p. 71

See Ref. #16 p. 217

John Frank Jr., M.D., et al.  “Measles Elimination—Final Impediments,” 20th Immunization Conference Proceedings, May 6-9, 1985, p. 21.

Infectious Diseases (Jan 1982), p. 21.

PDR, p. 1610-1611

PDR, p. 1687-1689.

Sara Solovitch, “Do Vaccines Spur Autism in Kids?” San Jose Mercury News, 5/25/99

PDR, p. 1687-89, 1610-1611.

See Ref #9 p. 35

PDR, 1708-1709.

Ibid.

See Ref #16 p. 218

Dr. Beverly Allan, Australian Nurses Journal, May 1978

Hannah Allen, “Don’t Get Stuck: The Case Against Vaccinations,” Oldsmar, FL: Natural Hygiene Press, 1985), p. 144

PDR, P. 1697-1699

Ibid and Attenuation of RA 27/3 Rubella Virus in WI-38 Human Diploid Cells, Amer J Dis Child vol 118 Aug 1969 and Studies of Immunization With Living Rubella Virus; Arch J Dis Child vol 110 Oct 1965.

John Hanchette, “Safety of Controversial Hepatitis B Vaccine at Center of Debate,” Gannett News Service, 5/18/99.

PDR, p. 1744-1747, 2482-2484.

Ibid.

PDR, p. 1762-1765.

Ibid.