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Under immigration laws, a foreign national will be inadmissible to the United States unless he or she has received all vaccinations against vaccine-preventable diseases explicitly listed in Section 212(a)(1)(A)(ii) of the Immigration and Nationality Act (INA) as well as all vaccinations recommended by the Advisory Committee for Immunization Practices.  The diseases listed in Section 212(a)(1)(A)(ii) of the INA  --  mumps, measles, rubella, polio, tetanus and diphtheria toxoids, pertussis (whooping cough), influenza Type B, and hepatitis B -- are standard vaccinations for the U.S. domestic population. However, immigration laws also make mandatory vaccinations that have been recommended by the Advisory Committee for Immunization Practices (ACIP), and thus may be less commonly utilized among the general population. ACIP is an advisory body to the Centers for Disease Control and Prevention (CDC), the agency charged which administering the federal regulations governing immigrant medical exams, and is responsible for recommending immunizations for the U.S. domestic population. Up until recently, the CDC’s practice was to require that all vaccines recommended by ACIP be administered to foreign nationals as part of the adjustment of status medical examination. Thus, any vaccination recommended by ACIP was added, without further examination, to the list of required vaccinations in the Technical Instruction for the Medical Examination of Aliens in the United States, the guides issued by the CDC which establish the requirements for the immigrant medical examination and are binding on all civil surgeons. Under this practice, the CDC incorporated several additional vaccinations into the Technical Instructions as a result of ACIP recommendations. As we go to press, a total of 15 vaccinations are currently required for immigration purposes.

Objecting to the Vaccination Requirement

What happens if a foreign national objects to receiving any and all vaccinations, or just one in particular?  Immigration laws permit individuals who object to all vaccinations to receive a waiver from the vaccination requirement, so long as they can prove that (1) they are opposed to vaccinations in any form, (2) their objection is based on religious beliefs or moral convictions, and (3) these religious beliefs or moral convictions are sincere. The adjustment applicant must file this waiver on either Form I-602, Application by Refugee for Waiver of Grounds of Excludability, or Form I-601, Application for Waiver of Grounds of Inadmissibility, along with the adjustment application.

However, there currently is no remedy where an individual objects to receiving a specific vaccine out of concern with the vaccination’s efficacy or side effects. In this situation, the foreign national must choose to either receive the unwanted vaccination or forego the medical examination -- and thereby, their application for adjustment -- entirely.

This posed a problem recently when the Advisory Committee for Immunization Practices recommended that Gardasil, a vaccine designed to treat the Human Papillomavirus (HPV), be administered to girls and women aged 11-26. HPV is the most prevalent sexually transmitted infection and is responsible for most cases of cervical cancer in women. In July 2008, the CDC, in keeping with its policy of automatically requiring all ACIP-recommended vaccines for immigration purposes, issued a revised version of the Technical Instructions that added Gardasil to the list of required vaccinations for all immigration medical examinations of female applicants aged 11-26 starting August 1, 2008.

As soon as it was promulgated, the Gardasil vaccination requirement met with criticism both by foreign nationals forced to undergo it as well as reproductive justice, women’s health, immigrants rights and public health advocacy groups. For one, Gardasil’s long term effectiveness against HPV was questionable, and the vaccine was associated with adverse side effects that made its potential risks outweigh any beneficial effects in the mind of many immigrants. Some argued that immigrant women were being used as test subjects for the drug’s efficacy. Moreover, paying for the series of three shots was prohibitively expensive for many immigrant families, with Gardacil averaging $120 per dose in most areas.  Furthermore, many foreign nationals objected to their young daughters being vaccinated for a sexually transmitted disease that could be easily avoided through abstinence or safe sex practices.

Some foreign nationals refused to receive the Gardasil vaccination during their medical exams; others delayed filing for adjustment until they obtained the necessary funds or reached age 27, when Gardasil was no longer required.  Although many individuals applied for a waiver of the Gardasil requirement, these waiver applications were denied on the basis that the applicants did not object to vaccination in all forms.

New Criteria for Immigration Vaccinations

The controversy over Gardasil led the CDC to reconsider its policy of automatically adding all ACIP-recommended vaccinations to the list of required vaccines for immigrants. CDC has now changed its immigration vaccination policy so that, effective December 14, 2009, the CDC will only require for immigration purposes those ACIP-recommended vaccinations that meet the following criteria:

• The vaccine must be an age-appropriate vaccine as recommended by the ACIP for the general U.S. population; and
• At least one of the following:
  • The vaccine must protect against a disease that has the potential to cause an outbreak, or
  • The vaccine must protect against a disease eliminated in the United States, or is in the process of being eliminated in the United States.

According to the CDC, these criteria will help carry out the original intent of the immigration vaccination requirement, which is to reduce importation of those diseases for which a single case has the potential to spread widely, or which may threaten reintroduction of an eliminated or soon-to-be eliminated disease. The CDC has also announced that, because HPV does not meet these new criteria, the Gardasil vaccination will no longer be required for immigration purposes.

The new U.S. Citizenship and Immigration Services guidance issued last week explains that foreign nationals who objected to the HPV vaccine at the time of their medical examination need not worry if their Form I-693 indicates that they refused to receive the Gardasil vaccination. It recognizes that the HPV vaccine is no longer required for immigration purposes as of December 14, 2009: “USCIS will not return your Form I-693, not will it deny your application because you did not receive the vaccine.”

Advocates have warmly welcomed the new CDC policy on immigrant vaccination requirements and the end of the Gardasil requirement. I hope that that the new immigration vaccination policy will provide the CDC with the flexibility it needs in selecting which recommended vaccinations should become mandatory on the immigrant population, and results in a wiser immigration vaccination policy.