Routine vaccination rates for kindergartners declined during the pandemic nationwide. Kindergarten vaccine coverage decreased during both the 2020-21 and 2021-22 school years after holding steady for a decade. The vaccination rate did not return to pre-pandemic levels during the 2022-23 school year.
All states have legislation requiring certain vaccines for school, including measles, mumps and rubella (MMR); diphtheria, tetanus and pertussis (DTaP); polio; and varicella. National kindergarten coverage for theses vaccines held steady at 95% for the 10 years before the pandemic. After two years of decline, the kindergarten vaccine coverage rate was 93% during the 2022-23 school year.
The national MMR vaccination rate for kindergartners was 93% last school year, with coverage ranging by state from 81% to 98%. The national coverage rate translates to about 250,000 kindergartners not vaccinated for MMR. The Department of Health and Human Services’ Healthy People 2030 target for MMR coverage is 95%.
School Vaccine Exemption Trends
Allowable exemptions from school vaccine requirements vary by state. All state school immunization laws grant exemptions for medical reasons. Forty-five states and Washington, D.C., grant exemptions for children of families who have religious objections to vaccinations. Fifteen states allow exemptions for families who have personal objections to vaccinations.
The vaccine exemption rate for kindergartners, including medical and nonmedical exemptions, remained steady during the pandemic. During the 2022-23 school year, exemption rates rose in 41 states, resulting in a national increase from 2.6% to 3%—the highest ever reported in the U.S. Ten states reported exemption rates over 5%. Of the kindergartners with vaccine exemptions, over 93% had a nonmedical exemption.
The High Cost of Disease Outbreaks:
- About 1 in 5 unvaccinated people who get measles are hospitalized in the U.S.
- A measles outbreak in Washington state cost an estimated $3.4 million, and New York City spent about $8.4 million responding to a measles outbreak in 2019.
Higher rates of unvaccinated people in a community are associated with a greater incidence of vaccine-preventable diseases. For example, in 2019, the largest measles outbreak in the U.S. since 1992 occurred in a New York City community with a cluster of unvaccinated children. In 2023, 18 jurisdictions reported measles cases, including a significant outbreak in Ohio.
Measles is a highly contagious virus with complications including pneumonia and swelling of the brain, or encephalitis. Since being eliminated in the U.S. two decades ago, measles has had a resurgence. Similar reoccurrences of measles have been reported in Europe, where there was a 30-fold increase in cases in 2023 compared with 2022.
Pandemic Vaccination Disruptions
Many children missed preventive health care, or well visits, during the pandemic, which disrupted their vaccinations. In 2020, the Centers for Disease Control and Prevention reported a notable drop in orders for pediatric vaccines. State immunization programs reported pandemic-related disruptions into the 2021-22 school year. Studies indicate between 26% and 41% of households had at least one child miss or delay a well visit during the pandemic.
Children’s vaccine coverage rates vary by race and ethnicity, poverty and health insurance status, and for those living in rural areas.
Black, Hispanic, American Indian and Alaskan Native children born in 2019-20 had lower vaccine coverage than white children. Reasons for racial disparities may include reduced access to health care, distrust or misconceptions of vaccination, or lack of appointment reminder systems for certain populations.
Children without health insurance experience lower rates of vaccination than children with private insurance or Medicaid. Uninsured children born in 2019-20 were 10 times more likely to have received no vaccines by age 2 than those privately insured. Ninety-six percent of children with private insurance received a primary series of vaccines versus 92% of children with Medicaid and 79% of uninsured children.
Children living below the poverty level have lower vaccine coverage than those living above the level. A KFF poll found that parents with annual household incomes less than $50,000 were more likely to be concerned about taking time off work to get their child vaccinated, paying out-of-pocket costs and traveling to a vaccination site.
Vaccination rates are lower for children living in rural areas than for those in urban areas. Rural residents face vaccine challenges such as a lack of nearby providers. Health professional shortages may contribute to access issues. Rural areas have difficulty recruiting and retaining health care professionals, with only 10% of physicians practicing in rural areas.
Vaccination disparities increased during the pandemic for children living in rural areas versus nonrural areas and for children living below the poverty level. Vaccine coverage dropped 5% since 2020 for children living in rural areas and children living in poverty.
State Actions
States play a significant role in determining child vaccination policies, and many have focused on enhancing vaccine access by:
- Expanding pharmacists’ scope of practice to administer children’s vaccines.
- Supporting vaccine access through the Vaccines for Children program.
- Exploring policies that address rural health professional shortages.
Expanding Scope of Practice
States have expanded the authority of certain health professionals to administer vaccines. Pharmacists, for example, are now authorized to administer vaccines to children under age 7 in at least 33 states. State laws may limit the types of vaccines pharmacists can administer or require pharmacists to have a prescription order or collaborative practice agreement to administer vaccines to young children.
Some states have also expanded pharmacy technicians’ scope of practice to administer vaccines. For example, Montana now permits pharmacists to delegate child vaccination to trained pharmacy technicians, given a collaborative practice agreement.
Vaccines for Children Program
The federal Vaccines for Children, or VFC, program provides vaccines recommended by the CDC’s Advisory Committee on Immunization Practices at no cost to children whose families are unable to afford them. At least two states have acted to help ensure eligible children receive vaccinations through VFC. Arkansas allows pharmacists to administer vaccines to children ages 3-6 if the pharmacist participates in VFC and informs the parent or guardian of the importance of annual well visits. Colorado reimburses pharmacists who administer vaccines to children, through the medical assistance program, conditional on the pharmacy’s enrollment in VFC.
Rural Health Professional Shortages
Rural areas are more likely to experience shortages of pediatric and family health professionals. Such shortages can affect access and prescription orders for child vaccinations. Some states are bolstering their rural health care workforces through legislation. For example, Louisiana created a program offering $30,000 in annual loan repayments for health professionals, including pediatric physicians, who complete a three-year commitment to practice in rural or underserved facilities. Georgia allows for rural physicians, including family practice and pediatric physicians, to receive a tax credit of up to $5,000 for up to five years.
NCSL’s Vaccination Resources
Shannon Kolman is a senior policy specialist in NCSL’s Health Program; Claudia Meyer was an intern in the program.
This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $250,000 with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. government.