State Vaccination Policies: Requirements and Exemptions for Entering School  

By Erik Skinner  | Vol . 25, No. 48 / December 2017


Did you know?

  • According to the World Health Organization, immunization prevents between 2 million to 3 million deaths every year across the world.
  • When immunization rates are high, herd immunity develops and limits the spread of the disease, which helps protect those who cannot be vaccinated.
  • Vaccination rates for measles, mumps and rubella vary across the United States, ranging from 85.6 percent in Washington, D.C., to 99.4 percent in Mississippi.

The Centers for Disease Control and Prevention (CDC) ranks vaccination among the most significant public health achievements of the 20th century. The CDC also reported that, over the last two decades, immunizations prevented more than 21 million hospitalizations and 732,000 child deaths in the United States. This translates to nearly $295 billion in savings on direct health care costs.

Immunizations protect individuals and the larger population. When immunization rates are high, herd immunity develops and can help protect not only healthy people, but those with immune system disorders who cannot receive vaccines. On the contrary, when immunization rates are low, disease outbreaks may occur, creating a health and economic toll. Recently, communities in Minnesota and Washington experienced outbreaks of measles and mumps, respectively, due to low vaccination rates among certain populations.

Vaccines go through rigorous testing prior to licensure. However, like any medication, they can cause side effects. The most common side effects are mild and typically resolved within 24 to 48 hours.

Rarely, more serious side effects, such as allergic reactions, can occur. Licensed health care providers administer vaccines, ensure that patients are informed about vaccine safety, and are screened based on the federal prescribing guidelines for each vaccine. Regarding concerns about vaccines and autism, the peer-reviewed literature does not recognize a link between vaccines and autism spectrum disorder.

State Action

States play a significant role in determining, implementing and enforcing vaccination policies. All 50 states currently have school entry requirements for vaccinations. All state policies feature medical exemptions. For many vaccines, the CDC recommends that parents of children with certain diseases affecting the immune system consult with their pediatrician to receive, wait for or skip certain vaccines. Forty-seven states permit vaccine exemptions on religious grounds, and 18 states allow exemptions for personal or philosophical reasons.

The most recent state laws focus on promoting increased coverage rates by eliminating personal belief exemptions for school entry, adding or strengthening vaccination requirements, and promoting better education about vaccines. California and Vermont passed bills removing exemptions in 2015. The California legislation removed exemptions based on personal beliefs, which are defined as also including religious objections. Vermont’s law repealed the personal belief exemption.

Some states require interagency collaboration between the departments of education and health to ensure that parents receive medically accurate information about vaccines. Georgia enacted a bill in 2017 that requires a school system that provides information on immunizations to also include recommendations from the Advisory Committee on Immunization Practices (ACIP), a description of covered diseases and other information. The law requires the Department of Education to work with the Department of Public Health to develop these resources.

States also work with education and child care stakeholders to enforce immunization requirements. Minnesota passed a law that applied its public-school immunization and exemption criteria to its voluntary prekindergarten program, in which district and charter schools contract with Head Start programs, family child care programs, community-based organizations and other groups. Eligible children must provide documentation of the required immunizations to participate in those programs.

Many states operate online education modules for parents who choose to go through the exemption process to learn about vaccines and their effectiveness. These policies can accompany other vaccine-related requirements. At least seven states (Arizona, Arkansas, Michigan, Oregon, Utah, Vermont and Washington) require education during the exemption process about the benefits of vaccination or the risks of opting out. Some states view this as a consumer protection issue. For example, Maine’s law, enacted in 2015, established the Vaccine Consumer Protection Program to disseminate information on vaccine-related adverse events to medical professionals and the public.

A Utah law, enacted in 2017, created an online education module regarding certain preventable diseases. It also amended the grounds for exemptions from required vaccines and requires parents to renew a student’s vaccination exemption annually under certain conditions. The law allows for the vaccination exemption form to be completed online.

While further from the purview of the legislature, vaccine requirements for higher education are also part of the state’s role. Colleges and universities generally form their own policies and submit them to the state. Thirty-three states require the meningococcal vaccine in middle school or as a requirement for attending higher education institutions. For example, Virginia enacted legislation in 2017 that requires students entering college to receive an immunization against meningitis and hepatitis B. Students can obtain an exemption if they review information about the risks of meningitis and hepatitis B and sign a waiver. Eleven states require education about the disease and six states do not have a specific meningitis policy.

Federal Action

The Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts, was convened by the CDC to develop recommendations for using vaccines in the U.S. The CDC director, under the Department of Health and Human Services, reviews and approves the recommendations, and the CDC publishes the final official recommendations. The Prevention and Public Health Fund supports immunization infrastructure in the states, allocating more than $324 million in 2016 to coordinate with states in conducting vaccination surveys for different population groups and managing vaccination efforts.

The federal government also sponsors the National Vaccine Injury Compensation Program (VICP), a system that provides financial compensation to individuals who file a petition and are found to have been injured by a VICP-covered vaccine. The Vaccines for Children Program makes vaccines available at no cost for eligible children (Medicaid-eligible, uninsured, underinsured, American Indian or Alaska Native) under age 19.