State and local school vaccination requirements exist to ensure that students are
protected from vaccine-preventable diseases (
1
). This report summarizes vaccination coverage and exemption estimates collected by
state and local immunization programs* for children in kindergarten (kindergartners)
in 49 states and the District of Columbia (DC) and kindergartners provisionally enrolled
(attending school without complete vaccination or exemption while completing a catch-up
vaccination schedule) or in a grace period (a set interval during which a student
may be enrolled and attend school without proof of complete vaccination or exemption)
for 28 states. Median vaccination coverage
†
was 95.1% for the state-required number of doses of diphtheria and tetanus toxoids,
and acellular pertussis vaccine (DTaP); 94.3% for 2 doses of measles, mumps, and rubella
vaccine (MMR); and 93.8% for 2 doses of varicella vaccine. The median percentage of
kindergartners with an exemption from at least one vaccine
§
was 2.2%, and the median percentage provisionally enrolled or attending school during
a grace period was 1.8%. Vaccination coverage among kindergartners remained high;
however, schools can improve coverage by following up with students who are provisionally
enrolled, in a grace period, or lacking complete documentation of required vaccinations.
Federally funded immunization programs collaborate with departments of education,
school nurses, and other school personnel to assess vaccination coverage and exemption
status of children enrolled in public and private kindergartens.
¶
In accordance with state and local school entry requirements, parents and guardians
submit children’s vaccination records or exemption forms to schools, or schools obtain
records from state immunization information systems. During the 2017–18 school year,
49 states and DC reported coverage for all state-required vaccines and exemption data
among public school kindergartners; 48 states and DC reported on private school kindergartners.**
Median vaccination coverage for the state-required number of doses of DTaP, 2 doses
of MMR, and 2 doses of varicella vaccine are reported. Coverage with hepatitis B and
poliovirus vaccines, which are required in most states but not included in this report,
are presented on SchoolVaxView (
2
). Twenty-eight states reported data on kindergartners who, at the time of assessment,
attended school under a grace period or provisional enrollment. Immunization programs
in U.S. territories also receive public funding for immunization and report vaccination
coverage and exemptions to CDC; however, national medians and summary measures reported
here include only the U.S. states and DC.
Vaccination coverage and exemption estimates were adjusted according to survey type
and response rates.
††
During the 2017–18 school year, vaccination coverage data were reported for approximately
3,988,127 kindergartners, exemption data for approximately 3,634,631, and grace period
and provisional enrollment data for approximately 2,825,691.
§§
Potentially achievable coverage for MMR was calculated for each state as the percentage
of students vaccinated with 2 doses of MMR plus the percentage without 2 doses of
MMR and no documented vaccination exemption. Nonexempt students included those provisionally
enrolled, in a grace period, or otherwise without documentation of vaccination.
During the 2017–18 school year, vaccination assessments varied by immunization program
because of differences in states’ required vaccines and doses, vaccines assessed,
assessment methods, and data reported. Among the 49 states and DC reporting kindergarten
vaccination data, 36 used a census; nine used a sample; three used a voluntary school
response; and two used a mix of sampling methods.
¶¶
All states used the same methods to collect both vaccination coverage and exemption
data except Alaska, Kansas, Virginia, and Wisconsin, where a sample was used for vaccination
coverage data and a census for exemption data. Kindergartners were considered up to
date and included in the coverage estimate for a given vaccine if they received all
doses required for school entry,*** except in seven states
†††
that considered kindergartners up to date only if they received all doses of all vaccines
required for school entry. Reporting of varicella vaccination status among kindergartners
with a history of varicella disease varied within and among states; some were reported
as vaccinated against varicella and others as medically exempt.
Among the 49 states and DC included in this analysis, median 2-dose MMR coverage was
94.3% (range = 81.3% [DC] to ≥99.4% [Mississippi]), 23 states reported coverage ≥95%,
and three states and DC reported coverage <90% (Table 1). Median DTaP coverage was
95.1% (range = 79.7% [DC] to ≥99.4% [Mississippi]), 25 states reported coverage ≥95%,
and three states and DC reported coverage <90%. Among the 41 states and DC that required
and reported 2 doses of varicella vaccine, median coverage was 93.8% (range = 80.5%
[DC] to ≥99.4% [Mississippi]), 17 states reported coverage ≥95%, and four states and
DC reported coverage <90%.
TABLE 1
Estimated vaccination coverage* for MMR, DTaP, and varicella vaccines among children
enrolled in kindergarten, by vaccine and immunization program — United States and
territories, 2017–18 school year
Immunization program
Kindergarten population†
No. (%) surveyed
Type of survey conducted§
Local data available online¶
MMR**
DTaP††
Varicella
2 doses (%)
4 or 5 doses (%)
1 dose (%)
2 doses (%)
Median§§
94.3
95.1
96.2
93.8
Alabama¶¶
57,245
57,245 (100.0)
Census
Yes
≥92.7
≥92.7
≥92.7
NReq
Alaska***,†††
9,692
707 (7.3)
Stratified 2-stage cluster sample
No
91.6
91.1
NA
91.3
Arizona¶¶
81,710
81,710 (100.0)
Census
Yes
93.4
93.5
96.2
NReq
Arkansas§§§
39,630
38,242 (96.5)
Census (public), voluntary response (private)
No
91.9
91.3
NA
91.6
California§§§
574,702
564,121 (98.2)
Census
Yes
96.9
96.4
98.2
NReq
Colorado¶¶
65,718
65,718 (100.0)
Census
Yes
88.7
88.6
NA
87.7
Connecticut¶¶
39,174
39,174 (100.0)
Census
No
96.5
96.5
NA
96.3
Delaware
10,988
1,053 (9.6)
Stratified 2-stage cluster sample
No
96.7
96.9
NA
96.7
District of Columbia¶¶
8,205
8,205 (100.0)
Census
No
81.3
79.7
NA
80.5
Florida¶¶,***
222,397
222,397 (100.0)
Census
Yes
≥93.7
≥93.7
NA
≥93.7
Georgia¶¶
131,459
131,459 (100.0)
Census
No
≥93.4
≥93.4
NA
≥93.4
Hawaii
16,325
1,040 (6.4)
Stratified 2-stage cluster sample
No
95.6
95.4
96.2
NReq
Idaho
22,553
22,458 (99.6)
Census
Yes
89.5
89.3
NA
88.6
Illinois¶¶
144,858
144,858 (100.0)
Census
Yes
95.2
95.3
NA
94.8
Indiana
84,296
70,857 (84.1)
Voluntary response
Yes
90.4
94.3
NA
90.2
Iowa¶¶
39,632
39,632 (100.0)
Census
Yes
≥93.0
≥93.0
NA
≥93.0
Kansas***,†††,§§§
38,484
8,728 (22.7)
Stratified 2-stage cluster sample
Yes
89.1
89.5
NA
88.3
Kentucky***,§§§
55,152
50,538 (91.6)
Census
Yes
92.6
93.7
NA
91.7
Louisiana¶¶
58,277
58,277 (100.0)
Census
Yes
96.1
97.7
NA
95.6
Maine
13,255
12,527 (94.5)
Census
Yes
94.3
95.3
96.5
NReq
Maryland§§§
68,528
67,747 (98.9)
Census
No
98.6
99.0
NA
98.6
Massachusetts¶¶,§§§
63,377
63,377 (100.0)
Census
Yes
96.3
96.4
NA
96.0
Michigan¶¶
119,028
119,028 (100.0)
Census
Yes
95.0
95.3
NA
94.7
Minnesota***
69,807
67,372 (96.5)
Census
Yes
92.5
92.8
NA
92.2
Mississippi¶¶
39,284
39,284 (100.0)
Census
Yes
≥99.4
≥99.4
NA
≥99.4
Missouri¶¶
73,113
73,113 (100.0)
Census
No
95.2
95.3
NA
95.0
Montana¶¶
12,188
12,188 (100.0)
Census
No
93.2
92.6
NA
91.6
Nebraska§§§
26,313
25,796 (98.0)
Census
No
96.2
96.7
NA
95.5
Nevada
37,178
1,769 (4.8)
Stratified 2-stage cluster sample
No
93.0
92.6
NA
92.6
New Hampshire
12,165
11,939 (98.1)
Census
No
≥92.4
≥92.4
NA
≥92.4
New Jersey¶¶
107,630
107,630 (100.0)
Census
Yes
≥96.1
≥96.1
≥96.1
NReq
New Mexico
26,896
1,256 (4.7)
Stratified 2-stage cluster sample
No
94.8
94.9
NA
94.5
New York (including New York City)¶¶
226,456
226,456 (100.0)
Census
Yes
97.2
96.9
NA
96.9
New York City¶¶
100,466
100,466 (100.0)
Census
No
97.8
97.3
NA
97.4
North Carolina***,§§§
127,197
120,827 (95.0)
Census
No
97.0
96.8
NA
96.8
North Dakota
10,365
10,293 (99.3)
Census
Yes
94.2
94.1
NA
93.9
Ohio
138,753
132,763 (95.7)
Census
No
92.1
92.1
NA
91.5
Oklahoma***
53,898
48,481 (89.9)
Census (public), voluntary response (private)
No
92.6
93.9
96.8
NReq
Oregon¶¶,§§§
45,818
45,818 (100.0)
Census
Yes
93.2
92.4
94.4
NReq
Pennsylvania
141,571
123,377 (87.1)
Voluntary response
Yes
96.7
97.0
NA
97.0
Rhode Island¶¶,***,§§§
11,025
11,025 (100.0)
Census
Yes
96.4
96.2
NA
96.0
South Carolina
58,458
16,174 (27.7)
Stratified 1-stage cluster sample
No
96.3
96.6
NA
96.1
South Dakota
12,125
12,112 (99.9)
Census
Yes
96.6
95.9
NA
95.8
Tennessee¶¶,***
78,743
78,743 (100.0)
Census
Yes
96.9
96.7
NA
96.8
Texas (including Houston)***,§§§
387,981
378,008 (97.4)
Census
Yes
96.9
96.8
NA
96.4
Houston***,§§§
43,340
38,343 (88.5)
Voluntary response (public), Census (private)
No
95.1
95.2
NA
94.7
Utah¶¶
48,827
48,827 (100.0)
Census
Yes
93.4
93.2
NA
93.7
Vermont¶¶
6,255
6,255 (100.0)
Census
Yes
94.1
94.0
NA
93.2
Virginia†††
100,581
4,224 (4.2)
Stratified 2-stage cluster sample
Yes
95.5
98.2
NA
93.3
Washington***
85,118
79,977 (94.0)
Census
Yes
90.6
90.7
NA
89.4
West Virginia****
19,519
15,120 (77.5)
Voluntary response
Yes
98.4
98.0
NA
98.1
Wisconsin***,†††,§§§
66,178
1,223 (1.8)
Stratified 2-stage cluster sample
No
91.8
96.5
NA
91.2
Wyoming
NA
NA
Not conducted
No
NA
NA
NA
NA
Territories and associated states
American Samoa¶¶,****
758
758 (100.0)
Census
No
90.9
81.8
NReq
NReq
Federated States of Micronesia¶¶
1,886
1,886 (100.0)
Census
No
94.0
75.8
NReq
NReq
Guam
2,625
700 (26.7)
Stratified 2-stage cluster sample
No
85.0
92.0
NReq
NReq
Marshall Islands¶¶
1,086
1,086 (100.0)
Census
No
96.6
67.7
NReq
NReq
Northern Mariana Islands¶¶
876
876 (100.0)
Census
No
92.8
75.6
NA
92.6
Palau¶¶,¶¶¶
313
313 (100.0)
Census
No
100.0
100.0
NReq
NReq
Puerto Rico††††
NA
NA
Not conducted
No
NA
NA
NA
NA
U.S. Virgin Islands††††
NA
NA
Not conducted
No
NA
NA
NA
NA
Abbreviations: DTaP/DT = diphtheria and tetanus toxoids (DT) and acellular pertussis
vaccine; MMR = measles, mumps, and rubella vaccine; NA = not available; NReq = not
required for school entry.
* Estimates are adjusted for nonresponse and weighted for sampling where appropriate.
Estimates based on a completed vaccine series (i.e., not vaccine-specific) use the
“≥” symbol. Coverage might include history of disease or laboratory evidence of immunity.
† The kindergarten population is an approximation provided by each program.
§ Sample designs varied by state or area: census = program attempted to include all
schools (public and private) and all children within schools in the assessment and
had a student response rate of ≥90%; 1-stage or 2-stage cluster sample = schools were
randomly selected, and all children in the selected schools were assessed (1-stage),
or a random sample of children within the schools was selected (2-stage); voluntary
response = a census with a student response rate of <90% (does not imply that participation
was optional).
¶ Some programs publish kindergarten vaccination data online that are more detailed
than the state-level estimates in this table. Examples of more detailed data include
county, parish, school district, and school-level estimates.
** Most states require 2 doses of MMR; Alaska, New Jersey, and Oregon require 2 doses
of measles, 1 dose of mumps, and 1 dose of rubella vaccines. Georgia, New York, New
York City, North Carolina, and Virginia require 2 doses of measles and mumps and 1
dose of rubella vaccines. Iowa requires 2 doses of measles and 2 doses of rubella
vaccines.
†† Pertussis vaccination coverage might include some diphtheria, tetanus toxoids,
and pertussis vaccine (DTP) vaccinations if administered in another country or by
a vaccination provider who continued to use DTP after 2000. Most states require 5
doses of DTaP for school entry, or 4 doses if the fourth dose was received on or after
the fourth birthday; Illinois, Maryland, Virginia, and Wisconsin require 4 doses;
Nebraska requires 3 doses. The reported coverage estimates represent the percentage
of kindergartners with the state-required number of DTaP doses, except for Kentucky,
which requires ≥5 but reports ≥4 doses of DTaP.
§§ Medians calculated from data from 49 states and the District of Columbia (i.e.,
does not include Wyoming, Houston, New York City, American Samoa, Federated States
of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico,
or U.S. Virgin Islands). Coverage data were reported for 3,988,127 kindergartners.
¶¶ The percentage surveyed likely was <100%, but is reported as 100% based on incomplete
information about the actual current enrollment.
*** Did not include some types of schools, such as online schools or those located
on military bases or in correctional facilities.
††† Kindergarten vaccination coverage data were collected from a sample, and exemption
data were collected from a census of kindergartners.
§§§ Counted some or all vaccine doses received regardless of Advisory Committee on
Immunization Practices recommended age and time interval; vaccination coverage rates
reported might be higher than those for valid doses.
¶¶¶ For Palau, estimates represent coverage among children in first grade.
**** Reported public school data only.
†††† Puerto Rico and U.S. Virgin Islands did not report data for the 2017–18 school
year because of widespread logistical issues caused by Hurricane Maria.
The median percentage of kindergartners with an exemption from one or more required
vaccines (not limited to MMR, DTaP, and varicella vaccines) was 2.2% (range = 0.1%
[Mississippi] to 7.6% [Oregon]), compared with 2.0% during the 2016–17 school year
(Table 2). The median percentage of medical exemptions was 0.2% (range = <0.1% [Hawaii]
to 0.8% [Alaska]); the median percentage of nonmedical exemptions was 2.0% (range = <0.1%
[California] to 7.5% [Oregon]). Among the 29 states and DC with an increase in exemptions
in 2017–18, vaccination coverage was ≥95% in 15 states for MMR, 16 states for DTaP,
and 11 states for 2 doses of varicella.
TABLE 2
Estimated number and percentage* of children enrolled in kindergarten with reported
type of exemption from vaccination, and grace period/provisional enrollment, by immunization
program
†
— United States and territories, 2017–18 school year
Immunization program
Medical exemptions, no. (%)
Nonmedical exemptions
Any exemption
Grace period or provisional enrollment§ no. (%)
Religious no.
Philosophical
no.
Total
no. (%)
2017–18, no.
2017–18
%
2016–17
%
Percentage point difference (2016–17 to 2017–18)
Median¶
(0.2)
—
—
(2.0)
—
2.2
2.0
0.2
(1.8)
Alabama
59 (0.1)
460
—**
460 (0.8)
519
0.9
0.7
0.2
None
Alaska
75 (0.8)
549
—**
549 (6.1)
624
7.0
6.8
0.2
NR
Arizona
400 (0.5)
—††
4,336
4,336 (5.3)
4,736
5.8
5.1
0.7
NR
Arkansas
14 (0.1)
213
428
641 (1.6)
655
1.7
1.4
0.3
3,379 (8.5)
California
4,190 (0.7)
—§§
—§§
5 (<0.1)
4,195
0.7
1.1
-0.4
10,568 (1.8)
Colorado
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
NR
Connecticut
126 (0.3)
764
—**
764 (2.0)
890
2.3
2.1
0.2
None
Delaware
3 (0.1)
148
—**
148 (1.3)
151
1.4
1.2
0.2
NR
District of Columbia
58 (0.7)
352
—**
352 (4.3)
410
5.0
1.1
3.9
NR
Florida
1,051 (0.5)
5,394
—**
5,394 (2.4)
6,445
2.9
2.5
0.4
7,349 (3.3)
Georgia
102 (0.1)
3,480
—**
3,480 (2.6)
3,582
2.7
2.8
-0.1
287 (0.2)
Hawaii
4 (<0.1)
514
—**
514 (3.1)
518
3.1
2.8
0.3
37 (0.2)
Idaho
93 (0.4)
—§§
—§§
1,504 (6.7)
1,597
7.1
6.5
0.6
408 (1.8)
Illinois
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
NR
Indiana
156 (0.2)
579
—**
579 (0.7)
735
0.9
1.0
-0.1
NR
Iowa
93 (0.2)
694
—**
694 (1.8)
787
2.0
1.8
0.2
1,356 (3.4)
Kansas
125 (0.3)
544
—**
544 (1.4)
669
1.7
1.8
-0.1
NR
Kentucky
174 (0.3)
623
—**
623 (1.1)
797
1.4
1.1
0.3
NR
Louisiana
61 (0.1)
49
552
601 (1.0)
662
1.1
0.8
0.3
NA
Maine
34 (0.3)
58
608
666 (5.0)
700
5.3
5.0
0.3
186 (1.4)
Maryland
390 (0.6)
614
—**
614 (0.9)
1,005
1.5
1.4
0.1
NR
Massachusetts
166 (0.3)
687
—**
687 (1.1)
853
1.3
1.3
0.0
None
Michigan
251 (0.2)
1,095
3,658
4,753 (4.0)
5,004
4.2
3.7
0.5
719 (0.6)
Minnesota
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
NR
Mississippi
38 (0.1)
—††
**
—**,††
38
0.1
0.1
0.0
165 (0.4)
Missouri
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
—¶¶
NR
Montana
48 (0.4)
478
—**
478 (3.9)
526
4.3
3.7
0.6
211 (1.7)
Nebraska
192 (0.7)
394
—**
394 (1.5)
586
2.2
2.0
0.2
463 (1.8)
Nevada
26 (0.1)
1,170
—**
1,170 (3.1)
1,196
3.2
4.4
-1.2
600 (1.6)
New Hampshire
22 (0.2)
334
—**
334 (2.7)
357
2.9
3.2
-0.3
573 (4.7)
New Jersey
171 (0.2)
2,148
—**
2,148 (2.0)
2,319
2.2
1.9
0.3
991 (0.9)
New Mexico
51 (0.2)
394
—**
394 (1.5)
445
1.7
2.3
-0.6
679 (2.5)
New York (incl. New York City)
349 (0.2)
2,199
—**
2,199 (1.0)
2,548
1.1
1.0
0.1
4,170 (1.8)
New York City
85 (0.1)
581
—**
581 (0.6)
666
0.7
0.6
0.1
1,173 (1.2)
North Carolina
284 (0.2)
2,323
—**
2,323 (1.8)
2,607
2.0
1.8
0.2
2,248 (1.8)
North Dakota
31 (0.3)
74
244
318 (3.1)
350
3.4
3.4
0.0
NR
Ohio
336 (0.2)
—§§
—§§
3,207 (2.3)
3,543
2.6
2.4
0.2
7,367 (5.3)
Oklahoma
91 (0.2)
333
657
991 (1.8)
1,182
2.2
1.9
0.3
NR
Oregon
62 (0.1)
—§§
—§§
3,427 (7.5)
3,489
7.6
6.7
0.9
NR
Pennsylvania
638 (0.5)
1,600
1,779
3,379 (2.4)
4,017
2.8
2.3
0.5
3,124 (2.2)
Rhode Island
10 (0.1)
110
—**
110 (1.0)
120
1.1
1.2
-0.1
NR
South Carolina
119 (0.2)
1,028
—**
1,028 (1.8)
1,147
2.0
2.0
0.0
328 (0.6)
South Dakota
23 (0.2)
238
—**
238 (2.0)
261
2.2
2.0
0.2
NR
Tennessee
114 (0.1)
1,085
—**
1,085 (1.4)
1,199
1.5
1.3
0.2
1,124 (1.4)
Texas (incl. Houston)
780 (0.2)
—§§
—§§
7,044 (1.8)
7,825
2.0
1.8
0.2
6,811 (1.8)
Houston
66 (0.2)
—§§
—§§
459 (1.1)
525
1.2
1.0
0.2
NR
Utah
80 (0.2)
19
2,507
2,526 (5.2)
2,606
5.3
5.1
0.2
1,039 (2.1)
Vermont
13 (0.2)
227
—**
227 (3.6)
240
3.8
3.9
-0.1
321 (5.1)
Virginia
384 (0.4)
1,125
—**
1,125 (1.1)
1,508
1.5
1.2
0.3
NR
Washington
621 (0.7)
202
3,142
3,344 (3.9)
3,966
4.7
4.8
-0.1
1,396 (1.6)
West Virginia***
32 (0.2)
—††
—**
—**,††
32
0.2
0.3
-0.1
809 (4.1)
Wisconsin
164 (0.2)
291
3,122
3,413 (5.2)
3,577
5.4
5.5
-0.1
1,907 (2.9)
Wyoming
NA
NA
NA
NA
NA
NA
NA
NA
NA
Territories and associated states
American Samoa
0 (0.0)
0
—**
0 (0.0)
0
0
0
0
None
Federated States of Micronesia
0 (0.0)
0
0
0 (0.0)
0
0
0
0.0
NR
Guam
0 (<0.1)
10
—**
10 (0.4)
10
0.4
0.2
0.2
NR
Marshall Islands
0 (0.0)
—††
—**
0 (0.0)
0
0
0
0.0
NR
Northern Mariana Islands
0 (0.0)
0
0
0 (0.0)
0
0
0
0.0
NR
Palau†††
0 (0.0)
—§§
—§§
0 (0.0)
0
0
0
0.0
NR
Puerto Rico§§§
NA
NA
NA
NA
NA
NA
NA
NA
NA
U.S. Virgin Islands§§§
NA
NA
NA
NA
NA
NA
NA
NA
NA
Abbreviations: NA = not available (i.e., not collected); None = state does not allow
grace period or provisional enrollment; NR = not reported to CDC.
* Estimates are adjusted for nonresponse and weighted for sampling where appropriate.
† Medical exemptions, nonmedical exemptions, and grace period or provisional enrollment
status might not be mutually exclusive. Some children might have both medical and
nonmedical exemptions, and some enrolled under a grace period or provisional enrollment
might be exempt from one or more vaccinations.
§ A grace period is a set number of days during which a student can be enrolled and
attend school without proof of complete vaccination or exemption. Provisional enrollment
allows a student without complete vaccination or exemption to attend school while
completing a catch-up vaccination schedule. In states with one or both of these policies,
the estimates represent the number of kindergartners within a grace period, provisionally
enrolled, or some combination of these categories.
¶ Medians calculated from data from 45 states and District of Columbia; states excluded
were Colorado, Illinois, Minnesota, Missouri, and Wyoming. Houston, New York City,
American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana
Islands, Palau, Puerto Rico, and U.S. Virgin Islands also were excluded. Exemption
data were reported for 3,634,631 kindergartners. Grace period or provisional enrollment
median was calculated from data from 28 states; data were reported for 2,825,691 kindergartners.
** Philosophical exemptions were not allowed.
†† Religious exemptions were not allowed.
§§ Religious and philosophical exemptions were not reported separately.
¶¶ Program did not report the number of children with exemptions, but instead reported
the number of exemptions for each vaccine, which could count some children more than
once. Lower bounds of the percentage of children with any exemptions estimated using
the individual vaccines with the highest number of exemptions are for Colorado, 0.2%
with medical exemptions, 0.3% with religious exemptions, 4.2% with philosophical exemptions,
and 4.7% with any exemptions; for Illinois, 0.2% with medical exemptions, 1.4% with
religious exemptions, and 1.6% with any exemptions; for Minnesota, 0.2% with medical
exemptions, 3.4% with nonmedical exemptions, and 3.5% with any exemptions; and for
Missouri, 0.2% with medical exemptions, 2.1% with religious exemptions, and 2.3% with
any exemptions.
*** Reported public school data only.
††† For Palau, estimates represent exemptions among children in first grade.
§§§ Puerto Rico and U.S. Virgin Islands did not report data for the 2017–18 school
year because of widespread logistical issues caused by Hurricane Maria.
The median reported percentage of kindergartners attending school during a grace period
or provisionally enrolled was 1.8% (range = 0.2% [Georgia and Hawaii] to 8.5% [Arkansas])
(Table 2). In 11 of 28 states reporting for the 2017–18 school year, the percentage
of children provisionally enrolled or within a grace period at the time of the assessment
exceeded the percentage of children with exemptions from ≥1 vaccines. Among the 26
states and DC with MMR coverage <95%, 20 could potentially achieve ≥95% coverage if
all nonexempt students who were provisionally enrolled, in a grace period, or otherwise
without evidence of complete vaccination were vaccinated (Figure).
FIGURE
Estimated percentage of kindergartners with documented up-to-date vaccination for
measles, mumps, and rubella vaccine (MMR)*; exempt from one or more vaccines
†
,
§
; and not up to date with MMR and not exempt
¶
— selected states and District of Columbia,** 2017–18 school year
* Estimates are based on completed vaccine series and are not MMR-specific for Alabama,
Florida, Georgia, Iowa, and New Hampshire. Up-to-date coverage reported here is the
lower bound of possible MMR coverage.
† Most states report the number of kindergartners with an exemption from one or more
vaccines. Estimates reported here might include exemptions from vaccines other than
MMR, except in Colorado and Minnesota, where MMR-specific exemptions are reported.
§ Coverage estimates are based on a sample of kindergartners, and exemption estimates
are based on a census for Alaska, Kansas, and Wisconsin.
¶ Includes nonexempt students provisionally enrolled, in a grace period, or otherwise
without documentation of complete MMR vaccination.
** Figure includes all states with reported MMR coverage for the 2017–18 school year
of <95%, the Healthy People 2020 target for MMR vaccination coverage among kindergartners.
https://www.healthypeople.gov/.
The figure shows the estimated percentage of kindergartners with documented up-to-date
vaccination for measles, mumps, and rubella vaccine (MMR); exempt from one or more
vaccines; and not up to date with MMR and not exempt in selected states and District
of Columbia during the 2017–18 school year.
Discussion
During the 2017–18 school year, median kindergarten vaccination coverage was close
to 95% for MMR, DTaP, and varicella vaccine. The number of states with coverage ≥95%
increased from 20 to 23 (MMR), 23 to 25 (DTaP), and 15 to 17 (2 varicella vaccine
doses) since the 2016–17 school year (
2
,
3
). Coverage increases in selected states might result from modifications to state
programs. For example, Pennsylvania reduced its provisional enrollment period from
240 days to 5 days with a medical certificate indicating the scheduling of missing
vaccine doses. The Indiana State Department of Health initiated report cards for schools
displaying kindergarten vaccination coverage rates and built a bidirectional interface
that increased the amount of data in their immunization information system. Kentucky
removed the provider signature requirement when printing a certificate of immunization
status, allowing school nurses to use the immunization information system certificate
to document vaccination history. In Virginia, the number of local health departments
participating in back-to-school immunization clinics for children entering school
increased, with most local health departments following up with parents about missing
vaccinations before the clinics (J Mellerson, CDC, unpublished data, 2018).
Although the overall percentage of children with an exemption was low, this was the
third consecutive school year that a slight increase was observed (
2
). Reasons for the increase cannot be determined from the data reported to CDC but
could include the ease of the procedure for obtaining exemptions (
4
) or parental vaccine hesitancy (
5
). Reported exemptions do not distinguish between exemptions for one vaccine versus
all vaccines. Previous studies indicate that most children with exemptions have received
at least some vaccines (
6
–
8
).
Recent data from the National Immunization Survey indicate the percentage of children
reaching age 2 years without having received any vaccinations has increased gradually,
from 0.9% for children born in 2011 to 1.3% for children born in 2015 (
9
). Two of the 10 states with <90% coverage for ≥1 dose of MMR among children aged
19–35 months in the 2014 National Immunization Survey (
10
) (the approximate cohort of children entering kindergarten in the 2017–18 school
year) also had <90% coverage for ≥2 doses of MMR among kindergartners in 2017–18;
in eight states, coverage with ≥2 doses of MMR was <95%, indicating that some children
who were undervaccinated in early childhood do not catch up before kindergarten entry.
This highlights the importance of school entry vaccination requirements to ensure
catch-up vaccination of unvaccinated and undervaccinated children.
In 11 of the 28 states reporting 2017–18 grace period or provisional enrollment data,
the percentage of kindergartners in these groups at the time of assessment exceeded
the percentage with an exemption from one or more vaccines, representing a group of
children who could be fully vaccinated with appropriate follow-up. CDC encourages
programs to collect and use these data to identify populations of undervaccinated
students. Almost all states could achieve ≥95% vaccination coverage if undervaccinated
nonexempt children were vaccinated in accordance with local and state vaccination
policies.
The findings in this report are subject to at least five limitations. First, comparability
is limited because of variation in states’ requirements, data collection methods,
and definitions of grace period and provisional enrollment. Second, representativeness
might be negatively affected because of data collection methodologies that miss some
schools or students or assess vaccination status at different times. Third, actual
vaccination coverage, exemption rates, or both might be underestimated or overestimated
because of inaccurate or absent documentation. Fourth, median coverage estimates include
only 49 of 50 states and DC, median exemption estimates include only 45 states and
DC, and the median grace period or provisional enrollment estimate includes only 28
states for the 2017–18 school year. Finally, because most states do not report vaccine-specific
exemptions, estimates of potentially achievable MMR coverage are approximations. However,
if reported exemptions were for a vaccine or vaccines other than MMR, estimates of
potentially achievable MMR coverage would be higher than those presented.
Kindergarten vaccination requirements help ensure that students are fully vaccinated
with age-appropriate vaccines upon school entry. Although overall vaccination coverage
is high, coverage could be improved in many states. CDC works with immunization programs
to collect and report data on school vaccination coverage, exemption rates, and grace
period and provisional enrollment each year. Immunization programs can use these data
to understand and address undervaccination among kindergartners and to identify schools
and communities where focused interventions could improve coverage with required vaccines.
Summary
What is already known about this topic?
Immunization programs conduct annual kindergarten vaccination assessments to monitor
school-entry vaccination coverage for all state-required vaccines.
What is added by this report?
Median vaccination coverage was 94.3% for 2 doses of measles, mumps, and rubella vaccine;
95.1% for the state-required number of doses of diphtheria and tetanus toxoids and
acellular pertussis vaccine; and 93.8% for 2 doses of varicella vaccine. Although
the median exemption rate gradually increased for the third year in a row to 2.2%,
most undervaccinated children did not have exemptions.
What are the implications for public health practice?
School assessment allows immunization programs to target interventions to schools
with undervaccinated kindergartners to increase compliance with state and local vaccination
requirements.