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Immunizations: Program Management

Effective management of immunization, or vaccination, is a fundamental component of school health services. Because of vaccines, children can now be protected from seventeen diseases, each of which can lead to suffering, long-term disabilities, or death. State governments, which are responsible for school immunization requirements, pass laws or regulations that require students to provide proof of selected immunizations for enrollment into daycare, preschools and schools (K–12). Some states also have requirements for students enrolling into colleges and universities. These requirements, often referred to as immunization mandates, allow exemptions for medical or other reasons. Schools are expected to implement immunization mandates to protect the children's and the public's health. It is therefore important for school health practitioners and program managers to be familiar with the mandates pertaining to their state, common reasons for nonadherence, policies regarding exemptions, and strategies and procedures for enforcement. It is also helpful for school health personnel to have familiarity with the vaccines and the diseases they prevent.

Immunization Mandates

Virtually every state and Washington, DC, require certain vaccines to be given to students enrolling in daycare and K–12 schools. The names of these vaccines are IPV, which prevents polio; DTaP (for children)/Tdap (for teens and adults), which prevent diphtheria, pertussis (whooping cough), and tetanus (lockjaw); MMR, which prevents measles, mumps, and rubella (German measles); hepatitis B; and varicella (chicken pox). With ongoing research and recommendations by experts, new vaccines are likely to be added to this list.

The national-level organization that makes recommendations about vaccines is the Advisory Committee on Immunization Practices (ACIP), a group of experts that reports to the Centers for Disease Control and Prevention (CDC), which is a part of the U.S. Department of Health and Human Services (DHHS). While it is the ACIP that makes recommendations, immunization mandates are state-level responsibilities.

Additional Required Vaccines

Aside from the five vaccines that are mandated in every state, there are state-by-state variations. Some states require additional vaccines based on age or grade level, prevalence of the disease, and assurance of follow-up doses. Examples include Haemophilus influenza type B (Hib), pneumococcal, hepatitis A and meningococcal vaccines. In many but not all states, children attending daycare centers are required to have Hib and pneumococcal vaccine. Some states require preschoolers and K–12 students to have hepatitis A vaccine because of the higher prevalence of hepatitis A in their states. Some states require evidence of a second dose of MMR and Tdap by middle school. Twenty states require education about or vaccination for meningococcal disease, or both. Colleges and universities in some states require hepatitis B and meningococcal vaccines.

Immunization Exemptions

The regulations that mandate immunizations permit parents or guardians to decline one or more of the mandated vaccines. To decline, parents or guardians must obtain exemptions or waivers. There are three types of exemptions: medical, religious beliefs, and philosophical. It is estimated that 1% to 3% of U.S. children have been exempted from vaccinations.

Medical Exemption

The medical exemption allows for declining a vaccine if a child had a severe or allergic reaction to a vaccine, or if the vaccine poses a significant health risk to the child due to a weakened immune system. A medical exemption, which usually applies to a specific vaccine, requires documentation signed by the child's health care provider. Medical exemptions can be permanent or temporary. Every U.S. state makes medical exemptions available.

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