The form below is suggested as a possibility for
your use. You must consult the laws in your own state for its useage.
REFUSAL OF RECOMMENDED VACCINES
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 diseases for which they are clinically fully
immunized 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% of those exposed to it.(1) I understand that there have been no
cases of wild polio in the US in the last 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° in up to 38%, sleepiness, fussiness, crying,
decreased appetite, vomiting, Guillain-Barré 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 into contact with body fluids and
wastes of the immunized person. Paralytic symptoms may follow
contraction of polio. Live virus is reportedly shed for up to 8 weeks
after the inoculation. Guillain-Barré 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
- 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 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.
- 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 proven to be highly 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: contracting HIB, localized pain, erythema and induration, fever
>100.6°, irritability, lethargy, anorexia, rhinorrhea, diarrhea,
vomiting, cough, when administered alone. Reactions occurred in up to
30% of patients. When administered in conjunction with the DPT,
reactions include local tenderness erythema and induration, fever
>100.8°, irritability, drowsiness, anorexia, diarrhea, vomiting,
persistent crying, seizures, urticaria, hives, renal failure,
Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of
- The vaccine contains yeast, thimerosal (mercury
derivative), and diphtheria toxoid when given alone.(8)
- 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 as the DaPT.
- Pertussis vaccine may cause: fevers >106,
pain swelling, diarrhea, projectile vomiting, excessive sleepiness,
high--pitched screaming, inconsolable crying bouts, seizures,
convulsions, collapse, shock, breathing problems, brain damage and SIDS.
One 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 vaccine and 37% of those died within the first
- The DaPT is recommended as a safer option for
vaccination. Side effects of the DaPT were only tracked for 72 hours and
included: tenderness, erythema, induration, fever >102.2°,
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 the DPT.
- Either form of the vaccine contains thimerosal
(mercury derivative), formaldehyde, and aluminum phosphate.(15)
I have been informed of the risk of my child developing paralysis, heart
failure, or respiratory failure associated with diphtheria. I have also
been informed 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
within the DPT or DaPT and includes the same side effects and reactions
as those listed for pertussis.
- 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 an 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: high fever, pain, recurrent abscess formation, inner ear nerve
damage, demyelinating neuropathy, anaphylactic shock and loss of
- Tetanus given in the DPT or DaPT shot include
the same side effects and reactions as those listed for pertussis.
- RUBEOLA (MEASLES):
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 (subacute sclerosing panencephalitis)
related to rubeola. 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 the
measles vaccine 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 patient to contract measles.
Other adverse reactions include: stinging or burning at the injection
site, anaphylaxis, fever up to one month following injection, rash,
cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria,
diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura,
vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis,
encephalitis and encephalopathy, ocular palsies, Guillain-Barré
Syndrome, ataxia, and subacute sclerosing panencephalitis.(24)
- Measles vaccine is most often given as a part of
the MMR which includes the following side effects: burning or stinging
at 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,
conjunctivitis, febrile convulsions, seizures, syncope, erythema
multiforme, optic neuritis, retrobulbar neuritis, papillitis, retinitis,
encephalitis and encephalopathy, ocular palsies, Guillain-Barré
Syndrome, ataxia, subacute sclerosing panencephalitis,(25) and a recent
study from Europe indicates that there may be a link between the MMR
(measles/mumps/rubella) vaccine and autism and irritable bowel
- Measles vaccine contains chick embryo cells,
neomycin, sorbitol and hydrolyzed gelatin. MMR contains all live
vaccines, chick embryo, cells from aborted babies, neomycin, sorbitol
and hydrolyzed gelatin.(27)
- 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: contraction of mumps from the live vaccine,
burning or stinging at the injection site, anaphylaxis, cough, rhinitis,
fever, diarrhea, vasculitis, parotitis, orchitis, purpura, urticaria,
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
- 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)
- RUBELLA (GERMAN MEASLES):
I have been informed of the risk of my child developing inflammation of
the brain or joints, and of 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 contract rubella in childhood, she is immune
for life, and prior to the vaccine 85% of the population was immune.(31)
I understand that if she is not immune as an adult, she can choose to
take the vaccine prior to becoming pregnant. I understand that many of
those who contract rubella have been immunized (up to 80%). (32)
- Adverse reactions from the vaccine among teenage
girls is 5-10% and 30% in adult women.(33) Adverse reactions include:
contracting rubella from the live virus in the vaccine, burning or
stinging at the 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-Barré
Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue
- Rubella is most often administered in the MMR
and may cause those side effects and adverse reactions listed under
- Rubella is cultured on the tissue of an aborted
child. This child 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)
- 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 effect and adverse reactions: induration, erythema,
swelling, fever, headache, dizziness, pain, prutitus, 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/palpitations,
bronchospasm, abnormal liver function tests, dyspepsia, migraine,
syncope, paresis neuropathy, hypothesis, paresthesis, Guillain-Barré
Syndrome, Bell's Palsy, transverse myelitis, optic neuritis, multiple
sclerosis, thrombocytopenia, eczema, purpura, herpes zoster, erythema
modosum, alopecia, conjunctivitis, keratisis, visual disturbances,
vertigo, tinnitus, earache, and dysuria.(37) The studies only followed
patients for 4 days post-vaccination.
- The most commonly used HepB vaccine contains
thimerosal, although a relatively new release does not contain
thimerosal. The vaccine also contains: aluminum hydroxide, yeast
protein, and phosphate buffers.(38)
- VARICELLA (CHICKENPOX):
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
the baby. I understand 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
my risk for herpes simplex.
- Side effects and adverse reactions for the
chicken pox vaccine include: contracting chicken pox from the live
vaccine (27%), pain and redness at site, swelling, erythema, rash,
pruritus, hematoma, induration, stiffness, upper respiratory illness,
cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea,
loss of appetite, vomiting, otitis, diaper rash/contact rash, nausea,
eye complaints, chills, lymphadenopathy, myalgia, lower respiratory
illness, headache, teething, malaise, abdominal pain, other rash,
allergic reactions including rash and 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,
monisodium glutamate (msg), sucrose, phosphate, processed gelatin,
neomycin and fetal calf serum. (40)
- Reference List
- 1. M. Burnet and D. White, The Natural History
of Infectious Disease (Cambridge, 1972), p. 16.
- 2. Strebel, et al, "Epidemology in the U.S.
One Decade After the Last Reported Case of Indigenous Wild Virus
Associated Disease," Clinical Infectious Diseases, (Center for
Disease Control, February 1992), pp. 568-79.
- 3. Physician's Desk Reference (PDR), 50th
Edition; Medical Economics, 1996, p. 1388-1390.
- 4. Ibid, p. 885-886 and 891-892.
- 5. J. Butel, et al; "Molecular Evidence of
Simian Virus 40 Infections in Children", The Journal of Infectious
Diseases ; September 1999;180:884-887.
- 6. PDR, 50th Edition, p. 872-875.
- 7. Ibid.
- 8. Ibid.
- 9. Richard Moskowitz, M.D., "Immunizations:
The Other Side," Mothering, (Spring1984),p. 34.
- 10. Immunization: Survey of Recent Research,
(United States Department of Health and Human Services, April 1983), p.
- 11. "Nature and Rates of Adverse Reactions
Associated with DPT and DT Immunizations...," Pediatrics, Volume
68, No. 5 (November 1981).
- 12. Walene James, Immunization the Reality
Behind the Myth, (South Hadley, Massachusetts: Bergin & Garvey,
1988), p. 14.
- 13. W.C. Torch, "Diptheria-pertussis-tetanus
(DPT) immunization: A potential cause of sudden infant death syndrome
(SIDS)," (Amer. Academy of Neurology, 34th Annual Meeting, Apr 25 -
May 1, 1982), Neurology 32(4), pt. 2.
- 14. PDR, p. 875-879 and 892-895.
- 15. Ibid.
- 16. Robert Mendelsohn, M.D., How to Raise A
Healthy Child...In Spite of your Doctor (Chicago: Contemporary Books,
- 17. Ibid. 244-246
- 18. Isaac Golden, Ph.D., Vaccination? A Review
of Risks and Alternatives, (Geelong, Victoria, Australia: Arum Healing
Centre, 1991), p. 31
- 19. Richard Moskowitz, M.D.,
"Immunizations: The Other Side," Mothering, (Spring1984),p.
- 20. Isaac Golden, Ph.D., Vaccination? A Review
of Risks and Alternatives; p. 71
- 21. R. Mendoholson; How to Raise a Healthy
Child; p. 217.
- 22. John Frank Jr., M.D., et al. "Measles
Elimination - Final Impediments," 20th Immunization Conference
Proceedings, May 6-9, 1985, p. 21.
- 23. Infectious Diseases (January 1982), p. 21.
- 24. PDR, p. 1610-1611.
- 25. DR, p. 1687-1689.
- 26. Sara Solovitch, "Do vaccines spur
autism in kids?", San Jose Mercury News, 5/25/99.
- 27. PDR, p. 1687-89, 1610-1611.
- 28. Richard Moskowitz, M.D.,
"Immunizations: The Other Side," Mothering, (Spring1984),p.
- 29. PDR, 1708-1709.
- 30. Ibid.
- 31. R. Mendoholson; How to Raise a Healthy
Child; p. 218.
- 32. Dr. Beverley Allan, Australian Nurses
Journal, (May 1978).
- 33. Hannah Allen, Don't Get Stuck: The Case
Against Vaccinations..., (Oldsmar, FL: Natural Hygiene Press, 1985), p.
- 34. DR, p. 1697-1699.
- 35. 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.
- 36. John Hanchette, "Safety of
controversial hepatitis B vaccine at center of debate" Gannett News
- 37. PDR, p. 1744-1747, 2482-2484.
- 38. Ibid.
- 39. PDR, p. 1762-1765.
- 40. Ibid.
- Complied by Kathryn E. Rateliff, CCD, CCCE, SM
- October, 1999
Questions and comments can be addressed to her at: Titus2@flash.ne
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