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
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 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
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
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 patients.(7)
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 week.(13)
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
DIPHTHERIA: 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
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 syndrome.(26)
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
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 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)
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 Syndrome. (34)
Rubella is most often
administered in the MMR and may cause those side effects and adverse reactions
listed under measles.
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
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
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
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
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)
HEPATITIS A (HAV): I have been informed of the risk of my child developing
HAV which could potentially result in prolonged or relapsed hepatitis, but will
not result in chronic hepatitis disease. (41) HAV usually causes mild
"flu-like" illness, jaundice, severe stomach pains and diarrhea; and,
in rare cases may result in death. Infection confers lifelong immunity. (42) I
understand that the CDC admits that good personal hygiene (handwashing) and
proper santitation can prevent HAV. (43)
HAV infection is spread by
contaminated water or food, infected food handlers, unsanitary conditions
following natural disasters, ingestion of raw or undercooked shellfish,
institutionalized individuals, children not yet toilet trained, blood
transfusions or sharing needles with infected people. Transmission is most
likely in developing countries where sanitation is poor and infection rate of
children under 5 is 90%. Fatality rate is less than .6% overall, and 70% of
those in patients over 49 years, many of whom have underlying liver disease.
(44) Other at-risk populations include those living on American Indian
reservations and in Alaskan Native villages, homosexually active men, IV drug
users, people using clotting factor concentrates and international travelers.
Side effects and adverse
reactions from the vaccine include: injection-site soreness, headache, fever,
malaise, induration, redness, swelling, fatigue, anorexia, nausea, pruritis,
rash, utricaria, pharyngitis, upper respiratory tract infections, abdominal
pain, diarrhea, dysgeusia, vomiting, arthralgia, elevated cratine
phosphokinase, myalgia, lymphadenopathy, hypertonic episodes, insomnia,
photophobia, and vertigo. (46)
Aborted fetal tissue is an
ingredient in the Havrix® Hep A vaccine, as is formaldehyde, aluminum hydroxide
There is currently a combination
Hep A and B vaccine, Twinrix®, being tested in the UK. (48) Twinrix is grown in
human cell cultures, contains 2-phenoxyethanol, neomycin sulfate, polysorbate,
tromentamol and formaldehyde. (49)
PNEUMOCOCCAL: I have been informed of the risk of my child developing
pneumococcal disease which could result in meningitis, blood infection,
pneumonia and/or ear infections. Iunderstand studies indicate that this vaccine
may only decrease ear infections by 9%, and only result in a 20% reduction in
chronic ear infections and ear tube insertion in that group.
I understand that my child has a
7.5:5,000 chance of deveoping this disease if he or she is under age 2 and a
1:5000 chance of developing it if over age 2. Risk factors for developing this
disease are: immunoglobulin deficiency, nephrotic syndrome, Hodgkin's disease,
congenital or acquired immunodeficiency, some upper respiratory infections,
splenic dysfunctions, splenectomy or organ transplant. This vaccine (PCV) was
originally marketed for immunocompromised children. (50) This vaccine is
contraindicated to children with thrombocytopenia, coagualtion disorders, or
sensitivity to diphtheria toxoid.(51)
Possible side effects and
complications from the vaccine include: erythema, induration, tenderness,
interference of limb movement, inflamation, fever, irritability, drowsiness,
restless sleep, decreased appetite, vomiting, diarrhea, fussiness, rash, hives,
bronchitis, asthma, pneumonia, otitis media (ear infection), sepsis, seizure,
anaphylaxis and death.(52) Recipients were followed for 3 days and almost 10%
of the subjects made a visit to the emergency room in the follow-up period.
There were 8 cases of SIDS in the 17,066 subjects involved in the trial.(53)
Note: Children in the studies' control group received another experimental
vaccine, so there have been no trial studies done with children who received no
Prevnar contains .125 mg of
aluminum sulfate, protein polysaccharides from 7 strains of strep. pneumoniae
bacteria, diphtheria toxin, casamino acids, yeast extract. Studies indicate
that it may interfere with the safety and efficacy of other vaccines.(55)
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.
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. 76.
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.
16. Robert Mendelsohn, M.D., How
to Raise A Healthy Child...In Spite of your Doctor (Chicago: Contemporary
Books, 1984), p.223.
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. 34.
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. 35.
29. PDR, 1708-1709.
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. 144.
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,
39. PDR, p. 1762-1765.
41. CDC Viral Hepatitis A - Fact
Sheet, 9/29/00; www.cdc.gov/ncidod/diseases/hepatitis/a/fact.htm
42. CDC Hepatitis A Vaccine
Vaccine Information Statement; 8/25/98
43. CDC Hepatitis A Facts,
44. Mosby's GenRX®, 10th Ed.,
Hepatitis A Vaccine (003158) as posted on MDConsult website
45. CDC Hepatitis A Vaccine
Vaccine Information Statement; 8/25/98 and CDC Hepatitis A Vaccine Vaccine
Information Statement; 8/25/98
Want to know more about the
issue of vaccine choice?
Titus 2 Birthing has a 42-page packet to help
parents look at some of the issues regarding vaccine choice. This packet
includes the above form plus many other helpful documents. Topics include:
vaccine safety, disease frequency in the US, exemption information and worksheet,
religious concerns about vaccines, immunization registry information,
vaccinations and premature babies, vaccines and immune supression, the American
Association of Physicians and Surgeons policy on mandatory vaccines, additional
resources, and Jock Doubleday's challenge for immunization providers to drink a
vaccine additive cocktail.
If you are interested in getting a copy of this
packet, contact Kathy at the above email address and she will be glad give you
all of the details.
ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR
PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE
CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT
TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE. THE
DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND
SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE
DISCLAIMER: All information, data, and material contained, presented, or provided here is for general information purposes only and is not to be construed as reflecting the knowledge or opinions of the publisher, and is not to be construed or intended as providing medical or legal advice. The decision whether or not to vaccinate is an important and complex issue and should be made by you, and you alone, in consultation with your health care provider.
Copyright 2013 by Vaccination News, A Non-Profit Corporation. All Rights Reserved. This content may not be copied unless permission in writing from Sandy Gottstein has been obtained.
"A foolish faith in authority is the worst enemy of truth."
-- Albert Einstein, letter to a friend, 1901
"I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."
-- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820
"What's the point of vaccination if it doesn't protect you from the unvaccinated?"
-- Sandy Gottstein
"Who gets to decide what the greater good is and how many will be sacrificed to it?"