The US has the highest child immunization rates in its history, which is a result of many factors. One such factor that has contributed to this rise is the enforcement of indoor vaccine mandates. However, as we will discuss below, enforcement varies between states and localities due to different levels of commitment on behalf of public health officials and differences in state-level policies.
This inconsistency can lead to incomplete coverage, increased risk for outbreaks and missed opportunities for children who need vaccines but are not receiving them because they live in areas where enforcement is more lax. In some areas, stand-alone vaccine regulations may be enforced, but in others they are not. Some of these regulations apply only to childcare centers and schools, while others require all children to receive vaccines regardless of where they live or work.
Noncompliance is a common problem with laws and policies that require vaccinations for school entry and attendance. Up to 40% of parents in the U.S. do not vaccinate their children on time, resulting in millions of unvaccinated school-age kids each year 1.
Many states require that students be up-to-date on vaccines before attending public and sometimes private schools, but this doesn’t necessarily ensure full compliance. According to the CDC, some parents are against vaccines for religious reasons or because they want to delay certain vaccinations. Other common reasons include fears that vaccinations cause autism despite studies debunking this myth, safety concerns and the inability to miss work or school to take children for follow-up appointments 2.
Laws on vaccine exemption vary between states. While all 50 states have medical exemptions, 48 states also allow religious exemptions and 18 states provide a philosophical or personal belief exemption for those who do not want to get their children vaccinated 1. The state-level requirements are further complicated by the varying requirements of local school boards. A student may be able to attend public school while under an exemption in one school district, but may need all vaccines in order to attend school in another district 1.
This inconsistency has led to outbreaks of vaccine-preventable disease such as measles and pertussis in states with less stringent enforcement. Outbreaks sometimes occur among the vaccinated population when vaccine coverage rates are high enough that herd immunity is not achieved 3. However, these outbreaks also occur in areas with high vaccine compliance, which suggests that they are not solely due to unvaccinated children. This is likely because less strict policies regarding non-medical exemptions do not necessarily indicate lower rates of vaccination see below 4.
Many states allow parents to use personal or philosophical beliefs as an exemption from vaccination, and some go as far as to allow religious and philosophical exemptions . However, it is important to remember that these exemptions do not necessarily mean that a child will be denied an education; they simply make the requirement for full vaccine compliance stricter. For example, in Colorado (one of the 48 states with a religious or personal exemption parents are required to complete an online education module before obtaining a vaccine exemption. The certificate of completion must be reported by schools annually, but exemptions are still allowed for those who do not wish to receive them 1.
These requirements vary widely between localities within states as well. For example, in Boulder County the compliance rate is 95%; students are required to have all of the vaccinations defined by the CDC unless they have a medical or religious exemption. However, in nearby Adams County, where more lenient requirements are enforced, exemptions account for 15-20% of incoming kindergartners 1.