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


What the CPSTF Found

About The Systematic Review

This CPSTF finding is based on evidence from 32 studies (search period January 1980 – July 2015). The finding updates and replaces the 2009 finding for Vaccination Requirements for Child Care, School, and College Attendance pdf icon [PDF - 542 KB].

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.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 547 KB].

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).

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 547 KB].

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.


The CPSTF considers the evidence to be applicable to the range of vaccinations recommended for children and adolescents attending child care, primary school, middle school, high school, or college.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • 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?

Study Characteristics

  • 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).