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.

There is a growing body of evidence regarding the impact of state vaccination requirements for school age children on vaccination coverage and the association of non-medical exemption rates with increased disease incidence (Wang et al, AJPH). Some recent findings include:

Use of philosophical exemptions and under immunization tend to cluster geographically, making some communities at greater risk for outbreaks (Lieu et al, PEDIATRICS; see other clustering references).
This geographic clustering of exemptions is associated with increased local risk of vaccine-preventable diseases, such as pertussis and measles (Omer et al, JAMA).

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, JAMA Viewpoint; also Gostin, JAMA; Stadlin, Bednarczyk, and Omer, JID).
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, JAMA Pediatrics; Yang and Silverman, JAMA Viewpoint).

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.

Resources

Childcare and School Vaccination Requirements, Exemptions & Web Links
This tool provides state vaccination requirements, state exemptions, and links to state web sites reporting requirements.
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