Key points
Review state vaccination requirements, laws, and other federal requirements.
State vaccination requirements
State and local vaccination requirements for daycare and school entry are important tools for maintaining high vaccination coverage rates, and in turn, lower rates of vaccine-preventable diseases (VPDs).
State laws establish vaccination requirements for school children. These laws often apply not only to children attending public schools but also to those attending private schools and day care facilities. All states provide medical exemptions, and some state laws also offer exemptions for religious and/or philosophical reasons. State laws also establish mechanisms for enforcement of school vaccination requirements and exemptions.
Studies have shown that vaccine exemptions tend to cluster geographically, making some communities at greater risk for outbreaks (Wang et al; Lieu et al; other clustering references).
Practices suggested in the literature to reduce non-medical exemptions include:
- States can consider strengthening the rigor of the application process, frequency of submission, and enforcement as strategies to improve vaccination rates (Yang and Silverman; also, Gostin; Stadlin et al.).
- In addition to state vaccination requirements, stronger health care practices such as more in-depth discussions with hesitant parents and establishing vaccination as the default are strategies to improve vaccination coverage rates (Opel and Omer; Yang and Silverman).
In summary, vaccination requirements that reach more children through a broad range of facilities, that have more requirements for receiving an exemption, that require parental documentation of exemption requests, and that are implemented with strong enforcement and monitoring may help promote higher rates of vaccination coverage, and in turn, lower rates of VPDs. Ongoing provider outreach and public education about vaccines and the diseases they prevent may also lead to such an increase.
CDC's Public Health Law Program (PHLP) has compiled state statutes and regulations regarding school vaccinations. For more information, please visit the State School and Childcare Vaccination Laws.
See selected references.
State vaccination requirements selected references
General epidemiology of exemptions
- Wang E, Clymer J, Davis-Hayes C, Buttenheim A. Nonmedical exemptions from school immunization requirements: a systematic review. AJPH. Nov 2014;104:e62-e84.
Impact of state laws on preventing disease and achieving high coverage
- Kevin M. Malone & Alan R. Hinman, Vaccination Mandates: The Public Health Imperative and Individual Rights, in LAW IN PUBLIC HEALTH PRACTICE (Richard A. Goodman et al. eds.). New York: Oxford University Press. 2003: 262-284.
- Orenstein W, Hinman A. The immunization system in the United States: the role of school immunization laws. Vaccine 1999;17(Suppl 3):S19–24.
Clustering
- Lieu T et al. Geographic clusters in underimmunization and vaccine refusal. PEDIATRICS 2015;135:280-289.
- Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley S, Salmon DA. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008;168:1389-96.
- May T, Silverman RD. "Clustering of exemption" as a collective action threat to herd immunity. Vaccine. 2003;21:1048-51.
- Wang E, Clymer J, Davis-Hayes C, Buttenheim A. Nonmedical Exemptions from school immunization requirements: A systematic review. AJPH. Nov 2014;104:e62-e84.
Association of levels of exemptions and disease
- Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA. 2000;284:3145-50.
- Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley S, Salmon DA. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008;168:1389-96.
- Omer SB et al. Nonmedical exemptions to school immunization requirements: Secular trends and association of state policies with pertussis incidence. JAMA 2006;296:1757-1763.
Ease of obtaining a medical exemption and higher medical exemption rates
- Stadlin S, Bednarczyk RA, Omer SB. Medical exemptions to school immunization requirements in the United States — association of state policies with medical exemption rates (2014-2011). JID 2012;206:989-992.
Changing the ease of exemption requirements to decrease VPDs
- Yang YT, Silverman RD. Legislative prescriptions for controlling nonmedical vaccine exemptions. JAMA Viewpoint. 2015;313:247-248.
- Gostin LO. Law, ethics, and public health in the vaccination debates. Politics of the measles outbreak. JAMA 2015;313:1099-1100.
- Stadlin S, Bednarczyk RA, Omer SB. Medical exemptions to school immunization requirements in the United States – association of state policies with medical exemption rates (2014-2011). JID 2012;206:989-992.
Other
- Opel DJ, Omer SB. Measles, mandates, and making vaccination the default option. JAMA Pediatrics. 2015;16(4):303-4.
Resources
- Public Health Law Program Vaccination Laws This page includes a series of menus developed by CDC's Public Health Law Program that summarize state vaccination laws for healthcare workers and patients in different types of healthcare facilities.
- Improving Vaccination Coverage Fact Sheet There is some evidence suggesting vaccination requirements that have broad reach, limited exemption criteria, and strong enforcement may help promote higher rates of vaccination coverage along with complementary actions such as monitoring VPD cases, vaccination coverage, and exemption rates; and also reporting on recent VPD outbreaks.
- State Immunization Laws for Healthcare Workers and Patients This database tool displays results from a 50-state legislative review of laws requiring assessment of vaccination status and vaccine administration for healthcare workers and patients/residents. Data on laws for various healthcare facilities (hospitals, ambulatory care facilities, individual providers' practices, correctional facilities, and facilities for the developmentally disabled) were compiled in 2005 and most recently updated in November 2014.
- Immunization requirements, by disease Lists vaccine-preventable diseases, and then shows state mandates (prenatal, daycare, childcare, kindergarten, elementary, secondary, K-12, colleges and universities, long-term care facilities) on immunization requirements Immunization Action Coalition (IAC)
- Also see SchoolVaxView School Vaccination Requirements and Exemptions