Immunization Mandates Vaccination Coverage and Exemption Rates in the United States.

Monday, 6th of August 2018 Print

Open Forum Infect Dis. 2018 Jun 2;5(6):ofy130. doi: 10.1093/ofid/ofy130. eCollection 2018 Jun.

Immunization Mandates Vaccination Coverage and Exemption Rates in the United States.

Shaw J1 Mader EM2 Bennett BE2 Vernyi-Kellogg OK3 Yang YT4 Morley CP25.

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Vaccination coverage among children entering kindergarten in the United States is high but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both measles mumps and rubella (MMR) and diphtheria tetanus and pertussis (DTaP) vaccination coverage and exemptions to school immunization requirements.


We conducted a retrospective longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose MMR and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (ie medical religious philosophical) to school immunization requirements.


We found that state policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department-led parental education was associated with 5.1% and 4.5% increases in vaccination rates. Permission of religious and philosophical exemptions was associated with 2.3% and 1.9% decreases in MMR and DTaP coverage respectively and a 1.5% increase in both total exemptions and nonmedical exemptions respectively.


We found higher vaccination coverage and lower nonmedical exemption rates for MMR and DTaP vaccines in states adopting Advisory Committee on Immunization Practices guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.


children; coverage; exemptions; immunization; law

PMID: 29977973 PMCID: PMC6016709 DOI: 10.1093/ofid/ofy130


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