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

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing appropriate vaccination.

The systematic review included 32 studies.

• 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 the summary effect estimate, although results were generally favorable.
• The 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).

Two studies provided some information about the cost and economic benefit of vaccination policies for school entry. One study considered vaccinations for Hepatitis B, the other Varicella.

• The estimated cost to implement this policy intervention included only the cost of vaccines and their administration. The economic benefits were based on healthcare costs avoided for an assumed group of children.
• Both studies found economic benefits exceeded cost based on this partial analyses.

• 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?

• Included studies were conducted as cross-sectional assessments (10 studies), time series (5 studies), before-after assessments with comparison populations (4 studies), before-after assessments without comparison population (4 studies) retrospective cohort (3 studies), posttest only (2 studies) and case control (1 study).
• 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 the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements.
• Included studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies).
• Studies examined evidence of effectiveness for children and adolescents attending child care (6 studies), primary school (11 studies), middle/high school (13 studies), or college (1 study).
• Studies examined changes in vaccination rates or disease incidence for measles-mumps-rubella (16 studies), tetanus (8 studies), pertussis (8 studies), varicella (8 studies), Haemophilus influenza type b disease (5 studies), hepatitis A (2 studies), hepatitis B (14 studies), meningococcal disease (3 studies), influenza (2 studies), and human papillomavirus (1 study).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Averhoff F, Linton L, Peddecord KM, Edwards C, Wang W, Fishbein D. A middle school immunization law rapidly and substantially increases immunization coverage among adolescents. Am J Public Health 2004;94:978-84.

Bardenheier B, Kong Y, Shefer A, Zhou F, Shih S. Managed care organizations’ performance in delivery of childhood immunizations (HEDIS, 1999-2002). Am J Manag Care 2007;13:193-200.

Baughman AL, Williams WW, Atkinson WL, Cook LG, Collins M. Impact of college prematriculation immunization requirements on risk for measles outbreaks. JAMA 1994;272:1127 32.

Bugenske E, Stokley S, Kennedy A, Dorell C. Middle school vaccination requirements and adolescent vaccination coverage. Pediatrics 2012;129(6):1056-63.

Carlson JAK, Lewis CA. Effect of the immunization program in Ontario schools. CMAJ 1985;133:215 6.

Castel AD, Reed G, Davenport MG, Harrison LH, Blythe D. College and university compliance with a required meningococcal vaccination law. J Am Coll Health 2007;56:119-27.

Chaiken BP, Williams NM, Preblud SR, Parkin W, Altman R. Effect of a school entry law on mumps activity in a school district. JAMA 1987;257:2455 8.

Centers for Disease Control and Prevention. School immunization requirements for measles United States, 1981. MMWR 1981;30:158 60.

Davis MM, Gaglia MA. Associations of daycare and school entry vaccination requirements with varicella immunization rates. Vaccine 2005; 23:3053-60.

Duggirala HJ, Hassig SE, Santana S, Rice J. Evaluation of a hepatitis A immunization program. Pediatr Infect Dis J 2005;24:974-8.

Fogarty KJ, Massoudi MS, Gallo W, Averhoff FM, Yusuf H, Fishbein D. Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1997-2000. Pub Health Rep 2004;119:163-9.

Hadler JL, Yousey-Hindes K, Kudish K, Kennedy ED, Sacco V, Cartter ML; Centers for Disease Control and Prevention (CDC). Impact of requiring influenza vaccination for children in licensed child care or preschool programs–Connecticut, 2012-13 influenza season. MMWR 2014;63(10):224.

Jacobs RJ, Meyerhoff AS. Effect of middle school entry requirements on hepatitis B vaccination coverage. J Adolesc Health 2004;34:420-3.

James DC, Chen WW. A population-based hepatitis B vaccination coverage survey among Asian and Pacific Islander American students in Alachua County, Florida. Asian Am Pac Isl J Health 2001;9:188.

Kolasa MS, Chilkatowsky AP, Stevenson JM, Lutz JP, Watson BM, Levenson R et al. Do laws bring children in child care centers up to date for immunizations? Ambul Pediatr 2003;3:154-7.

Liu H, Hynes K, Lim JM, Chung HI. Hepatitis B Catch-Up Project: analysis of 1999 data from the Chicago Public Schools. Asian Am Pac Isl J Health 2001;9:205-10.

Lopez AS, Kolasa MS, Seward JF. Status of school entry requirements for varicella vaccination and vaccination coverage 11 years after implementation of the varicella vaccination program. J Infect Dis 2008;197:S76-81.

Mele A, Stroffolini T, Zanetti AR. Hepatitis B in Italy: Where we are ten years after the introduction of mass vaccination. J Med Virol 2002; 67(3):440-3.

Morita JY, Ramirez E, Trick WE. Effect of a school-entry vaccination requirement on racial and ethnic disparities in hepatitis B immunization coverage levels among public school students. Pediatrics 2008;121:e547-52.

Nelson DB, Layde MM, Chatton TB. Rubella susceptibility in inner-city adolescents: the effect of a school immunization law. Am J Public Health 1982;72:710 3.

Olshen E, Mahon BE, Wang S, Woods ER. The impact of state policies on vaccine coverage by age 13 in an insured population. J Adolesc Health 2007;40:405-11.

Potter RC; DeVita SF; Vranesich PA; Boulton ML. Adolescent immunization coverage and implementation of new school requirements in Michigan, 2010. Am J Public Health 2014;104(8):1526-33.

Rickert D, Deladisma A, Yusuf H, Averhoff F, Brink E, Shih S. Adolescent immunizations. Are we ready for a new wave? Am J Prev Med 2004;26:22-8.

Robbins KB, Brandling-Bennett AD, Hinman AR. Low measles incidence: association with enforcement of school immunization laws. Am J Public Health 1981;71:270 4.

Scheiber M, Halfon N. Immunizing California’s children: Effects of current policies on immunization levels. West J Med 1990;153:400 5.

Schulte EE, Birkhead GS, Kondracki SF, Morse DL. Patterns of Haemophilus influenzae type b invasive disease in New York state, 1987 to 1991: the role of vaccination requirements for day-care attendance. Pediatrics 1994;94:1014 6.

Simpson JE, Hills RA, Allwes D, Rasmussen L. Uptake of meningococcal vaccine in Arizona schoolchildren after implementation of school-entry immunization requirements. Public Health Rep 2013;128(1):37-45.

Stanwyck CA, Kolasa MS, Shaw KM. Immunization requirements for childcare programs. Are they enough? Am J Prev Med 2004;27:161-3.

Sugaya N, Takeuchi Y. Mass vaccination of schoolchildren against influenza and its impact on the influenza-associated mortality rate among children in Japan. Clin Infect Dis 2005;41:939-47.

van Loon FPL, Holmes SJ, Sirotkin BI, et al. Mumps surveillance United States, 1988 1993. MMWR Surveillance Summaries 1995;44(SS-3):1 14.

Weiss T, Zhang D, Borse NN, Walter EB. Initiation & completion rates of hepatitis A vaccination among US pediatric populations born between 2005 and 2009. Vaccine 2015;33(48):6871-7.

Wilson TR, Fishbein DB, Ellis PA, Edlavitch SA. The impact of a school entry law on adolescent immunization rates. J Adolesc Health 2005;37:511-16.

Economic Review

Abrevaya J, Mulligan K. Effectiveness of state-level vaccination mandates: evidence from the varicella vaccine. J Health Econ 2011;30(5):966-76. http://dx.doi.org/10.1016/j.jhealeco.2011.06.003.

Jacobs RJ, Meyerhoff AS. Effect of middle school entry requirements on hepatitis B vaccination coverage. J Adolesc Health 2004;34(5):420-3. http://dx.doi.org/10.1016/S1054-139X(03)00343-4.

Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Diekema DS. Personal belief exemptions from school vaccination requirements. Annual Review of Public Health 2014;35:275 92.

Seither R, Calhoun K, Knighton CL, et al. Vaccination coverage among children in kindergarten United States, 2014 15 school year. MMWR 2015;64(33);897-904.

• State vaccination requirements allow medical exemptions for students with medical contraindications and may allow nonmedical exemptions for religious reasons or philosophic beliefs (Seither et al., 2015).
• Updated information on vaccination requirements for each state and setting are available from the Immunization Action Coalition.
• A compilation of state school and child care vaccination laws, including both statutes and regulations, is available from CDC.
• Three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease:
  • Geographic clustering of under-immunization — the presence of meaningful differences in vaccination coverage or nonmedical exemption rates within or across communities
  • Inconsistent enforcement of requirements
  • Relative ease of obtaining nonmedical exemptions
• Practices suggested in the broader literature to reduce nonmedical exemptions:
  • Strengthen the rigor of the nonmedical exemption application process and increase how often they must be submitted (Diekema, 2014)
  • Implement clear and consistent enforcement and monitoring (CDC, 2016)
• Requirements should complement ongoing provider outreach and public education to increase demand for vaccinations and access to services, as part of an overall strategy to achieve and maintain high vaccination rates.
• Findings from two included studies suggest that vaccination requirements may reduce health disparities by improving vaccination rates among racial and ethnic minorities and children in low-income communities.
• Although not directly evaluated by studies in this review, vaccination requirements may increase contact between youth (especially adolescents) and their primary care providers, increasing opportunities for the provision of other preventive health services.
• Vaccination requirements were not associated with any harms in the identified studies.
• Vaccination and documentation requirements may lead to higher rates of nonmedical exemptions (where permitted) when perceived by the public as more convenient than obtaining a vaccination or documentation, or as inconsistently enforced.

Healthy People 2030

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

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03