Vaccination Programs: Requirements for Child Care, School, and College Attendance

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends vaccination requirements for child care, school, and college attendance to increase vaccination rates and decrease rates of vaccine-preventable disease.

The full CPSTF Finding and Rationale Statement and supporting documents for Vaccination Programs: Requirements for Child Care, School, and College Attendance are available in The Community Guide Collection on CDC Stacks.

Intervention

Vaccination requirements are laws or policies requiring anyone attending child care, school, or college to be vaccinated or provide other documentation of immunity. State legislatures may enact statutes specifying required vaccinations or health or education departments may adopt administrative rules.

Institutions such as colleges and private schools may establish additional vaccination policies. Vaccination requirements vary across jurisdictions by comprehensiveness, acceptable documentation of immunity, access to exemptions (especially nonmedical exemptions), and type and consistency of enforcement.

About The Systematic Review

The CPSTF finding is based on evidence from 32 studies (search period January 1980-July 2015). The finding updates and replaces the 2009 finding for Vaccination Requirements for Child Care, School, and College Attendance.

Study Characteristics

  • Studies conducted as cross-sectional assessments (10), time series (5), before-after assessments (8), retrospective cohort (3), posttest only (2), and case control (1)
  • Common limitations affecting this body of evidence were differences in measurement of change in outcomes and confounding by secular trends or community characteristics
  • Ten studies examined effectiveness on vaccine-preventable disease rates or associated morbidity; five were nationwide assessments
  • Mostly conducted in United States (30 studies) and examined school entry requirements (24 studies)
  • Examined evidence for children and adolescents attending child care (6), primary school (11), middle/high school (13), or college (1)
  • Examined changes for measles-mumps-rubella (16), tetanus (8), pertussis (8), varicella (8), Haemophilus influenza type b (5), hepatitis A (2), hepatitis B (14), meningococcal disease (3), influenza (2), and human papillomavirus (1)

Summary of Results

Thirty-two studies were included.

  • Overall vaccination rates increased by a median of 18 percentage points (17 studies with 24 study arms)
  • Five additional studies examined vaccination outcomes that could not be included in summary estimate; results generally favorable
  • Incidence of measles and mumps was lower in U.S. states with immunization requirements for school-aged children, and low-incidence areas were more likely to enforce school entry laws and prevent non-compliant children from attending (3 studies)

Summary of Economic Evidence

Two studies provided information about cost and economic benefit. One considered Hepatitis B, the other Varicella.

  • Estimated cost included only vaccines and administration; economic benefits based on healthcare costs avoided
  • Both studies found economic benefits exceeded costs based on partial analyses

Applicability

Evidence applicable to range of vaccinations recommended for children and adolescents attending child care, primary school, middle school, high school, or college.

Evidence Gaps

  • How effective are requirements for child care attendance and college residency?
  • Are estimates of risk for vaccine-preventable disease similar when individual vaccination and exemption records are used to determine vaccination coverage in the school or community?
  • What are the relationships between variations in school or child care documentation, enforcement, and vaccination and exemption rates?
  • What are barriers to school and local enforcement, and how can they be overcome?
  • What factors facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings?
  • How do changes in vaccination requirements effect rates of vaccination, exemption, and enrollment?
  • What are the economic costs and benefits of vaccination requirements in different settings?

Implementation Considerations and Resources

State vaccination requirements allow medical exemptions and may allow nonmedical exemptions for religious reasons or philosophic beliefs.

Updated information on vaccination requirements for each state and setting are available from the Immunization Action Coalition.

Three important aspects have potential to meaningfully influence vaccination rates and risk for vaccine-preventable disease:

  • Geographic clustering of under-immunization
  • Inconsistent enforcement of requirements
  • Relative ease of obtaining nonmedical exemptions

Practices to reduce nonmedical exemptions: strengthen rigor of exemption application process, increase submission frequency, implement clear and consistent enforcement and monitoring.

Requirements should complement ongoing provider outreach and public education to increase demand and access to services.

Findings from two studies suggest requirements may reduce health disparities by improving rates among racial and ethnic minorities and children in low-income communities.

No harms were associated with vaccination requirements.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.