MMWR: Vaccination Coverage Among Children in Kindergarten — United States, 2012–13 School Year

CDC/MMWR Watch [to 3 August 2013]
MMWR August 2, 2013 / Vol. 62 / No. 30
Vaccination Coverage Among Children in Kindergarten — United States, 2012–13 School Year
August 2, 2013 / 62(30);607-612
Excerpt – Editor’s Text Bolding
State and local school vaccination requirements are implemented to maintain high vaccination coverage and minimize the risk from vaccine preventable diseases (1). To assess school vaccination coverage and exemptions, CDC annually analyzes school vaccination coverage data from federally funded immunization programs. These awardees include 50 states and the District of Columbia (DC), five cities, and eight U.S.-affiliated jurisdictions.* This report summarizes vaccination coverage from 48 states and DC and exemption rates from 49 states and DC for children entering kindergarten for the 2012–13 school year. Forty-eight states and DC reported vaccination coverage, with medians of 94.5% for 2 doses of measles, mumps, and rubella (MMR) vaccine; 95.1% for local requirements for diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccination; and 93.8% for 2 doses of varicella vaccine among awardees with a 2-dose requirement. Forty-nine states and DC reported exemption rates, with the median total of 1.8%. Although school entry coverage for most awardees was at or near national Healthy People 2020 targets of maintaining 95% vaccination coverage levels for 2 doses of MMR vaccine, 4 doses of DTaP† vaccine, and 2 doses of varicella vaccine (2), low vaccination and high exemption levels can cluster within communities, increasing the risk for disease. Reports to CDC are aggregated at the state level; however, local reporting of school vaccination coverage might be accessible by awardees. These local-level data can be used to create evidence-based health communication strategies to help parents understand the risks for vaccine-preventable diseases and the benefits of vaccinations to the health of their children and other kindergarteners.

Vaccination coverage among children entering kindergarten is assessed annually by awardees. Each school year, the health department, school nurse, or other school personnel assess the vaccination and exemption status of a census or sample of kindergarteners enrolled in public and private schools to determine vaccination coverage, as defined by state and local school requirements established to protect children from vaccine-preventable diseases. Among the 50 states and DC, 43 awardees used an immunization information system (IIS) as at least one source of data for some of their school assessment. To collect data, 33 awardees used a census of kindergarteners; 11 a sample of schools, kindergarteners, or both; two a voluntary response of schools; and five a mix of methods. Results of the school-level assessments are reported to the health department. Aggregated data are reported to CDC for public and private schools. Data for homeschooled students were not reported to CDC. All estimates of coverage and exemption were weighted based on each awardee’s response rates and sampling methodology, unless otherwise noted. Of the 50 states and DC, 12 awardees met CDC standards for school assessment methods in 2012–13.

Kindergarteners were considered up-to-date for each vaccination if they had received all of the doses required for school entry in their jurisdiction. School entry requirements varied by awardee: all reporting awardees required 2 doses of MMR vaccine; for DTaP vaccine, two awardees required 3 doses, 35 required 4 doses, and 20 required 5 doses; and for varicella vaccine, 13 required 1 dose, 41 required 2 doses, and three did not require varicella vaccination.

   The types of exemptions allowed varied by awardee. All reporting awardees allowed medical exemptions, 46 allowed religious exemptions, 18 allowed philosophic exemptions, and two (Mississippi and West Virginia) did not allow exemptions for religious or philosophic reasons. Medical, religious, and philosophic exemptions were reported as the percentage of kindergarteners with each type of exemption. Total exemptions were reported as the percentage of kindergarteners with any exemption.

Overall, among the 48 states and DC that reported 2012–13 school vaccination coverage, median 2-dose MMR vaccination coverage was 94.5% (range: 85.7% in Colorado to ≥99.9% in Mississippi); 20 reported coverage ≥95% (Table 1). Median DTaP vaccination coverage was 95.1% (range: 82.9% in Colorado and Arkansas to ≥99.9% in Mississippi); 25 reported coverage ≥95%. Median 2-dose varicella vaccination coverage among the 36 states and DC requiring and reporting 2 doses was 93.8% (range: 84.6% in Colorado to ≥99.9% in Mississippi); 14 reported coverage ≥95%.

    An estimated 91,453 exemptions were reported among a total estimated population of 4,242,558 kindergarteners. Overall, among the 49 states and DC that reported 2012–13 school vaccination exemptions, the percentage of kindergarteners with an exemption was <1% for nine awardees and >4% for 11 awardees (range: <0.1% in Mississippi to 6.5% in Oregon), with a median of 1.8% (Figure; Table 2). The largest increases in total exemptions between 2011–12 and 2012–13 were reported by Georgia and West Virginia, each with an increase of 1.0 percentage point; four states reported decreases of >1.0 percentage points (range: -1.3 in Colorado to -1.6 in New Mexico). Where reported separately, the median medical exemption level was 0.3% (range: <0.1% in five states [Arkansas, Minnesota, Mississippi, North Dakota, and Virginia] to 1.6% in Alaska). Where allowed and reported separately, the median nonmedical exemption level was 1.5% (range: 0.2% in New Mexico to 6.4% in Oregon).

Reported by

Ranee Seither, MPH, Lauren Shaw, MS, Cynthia L. Knighton, Stacie M. Greby, DVM, Shannon Stokley, MPH, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Ranee Seither,, 404-639-8693.