Schools and Requirements | The Children's Hospital of Philadelphia

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Schools and Vaccine Requirements

Schools and vaccines
Requirements versus recommendations
Vaccine recommendations and package inserts
Immunization registries

Schools and vaccines

School entry requirements

Are you unsure about which vaccines are required for your child to enter school? Are you going to be moving to a new state and need to check on vaccine requirements? The Immunization Action Coalition (IAC) has gathered all of this information into one place for you.

Exemptions and herd immunity

Some parents are confused about whether their children need vaccines. They may have heard that vaccines cause autism or other chronic conditions or that the vaccines were made using aborted-fetal tissue, or they may feel that vaccines are not necessary because they haven't seen anyone they know getting the diseases that vaccines prevent.

In most states, vaccines are required for entry into school or child care centers. However, there are cases in which a child may be able to go to school without having a particular vaccine. In these cases, the parent must exercise an "exemption," which is a legal option to forego a vaccine.

Different states have different laws regarding exemptions (see "School Entry Requirements" above). There are three kinds of exemptions:

Medical exemptions

These are allowed when a child has a medical condition or allergy that may make receiving the vaccine dangerous. All 50 states allow medical exemptions. For school entry purposes, these exemptions require a physician's note supporting the medical necessity of the exemption.

Religious exemptions

These are allowed when immunizations are not in agreement with the parents' religious beliefs. Forty-eight of the 50 states allow these exemptions.

Philosophical exemptions

These are allowed when non-religious, but strongly held beliefs, prevent a parent from allowing their child to be immunized. Twenty states allow these exemptions.

In certain situations an exemption can be challenged by the state. These situations include those that would put the child at a higher risk of disease than is reasonable (medical neglect) or those that would put society at risk (e.g., epidemic situations). Also, in some states, if an unvaccinated child is found to transmit a vaccine-preventable disease to someone else, the parents may be liable in a civil suit.

Because vaccines are considered medically necessary (except in the medical cases mentioned above), they are considered to be "best-care" practices. Therefore, if parents choose not to immunize their children, doctors will often have them sign a statement that they have discussed the risks and benefits of the vaccines and they understand that they are taking a risk in refusing vaccines for their children.

Risking disease

Many people incorrectly assume that a choice not to get a vaccine is a risk-free choice. But it isn't. The choice not to get a vaccine is a choice to risk the disease that the vaccine prevents. Studies have shown that unimmunized children are more likely to get vaccine-preventable diseases if there is an outbreak than those who have been immunized. Unimmunized children will be barred from school during an outbreak to protect them from the disease.

Here are some things to consider before making a decision not to immunize a child:

Harm to others

There are four ways that others in the community may be harmed by a parent's decision not to immunize their child:

Those who choose not to immunize their child may be considered to be "free riders" by those who have immunized their children. For example, a mother whose son recently experienced a severe bout with pertussis was angry that other children in the classroom were not immunized. In discussing vaccine safety as the reason that many parents give for not wanting to immunize, she wondered why their children should be protected by herd immunity when her child and all of the other immunized children bore the small risk of side effects. In addition, she wondered why she wasn't made aware that so many of the children in the school weren't immunized due to personal beliefs. She concluded by saying, "Had I known . . .I would never have enrolled him in that school."


Requirements versus recommendations

Are requirements and recommendations the same thing?

No. Recommendations made by the CDC are based on health and safety considerations. Requirements, on the other hand, are laws made by each state government determining which vaccines a child must have before entering school. To use an example, consider smoking. Experts tell us that smoking is bad for our health, but it is still our choice whether we smoke or not; that is like a recommendation. In contrast, no-smoking laws prohibit people from smoking in certain places and vary from state to state; this is similar to a requirement.

It is important to remember that even if a vaccine is not required, it may be the best health choice. Talk to your doctor about vaccines that are available and whether they are important for you or a loved one to receive.


Vaccine recommendations and package inserts

I understand that the information included with a vaccine sometimes differs from more commonly available information. Can you explain why?

While a package insert provides information about the vaccine, it is important to realize that it is being provided by the company and, therefore, has legal requirements that must be followed in its preparation. During the development of a vaccine, safety studies are completed by comparing a group of people who received the vaccine to a group of people who did not, called the placebo group. If a side effect occurs more times in the vaccine group, it may be a result of the vaccine. However, the company, according to the Food and Drug Administration (FDA), must report any side effects that occurred in the vaccine group, even if the number of occurrences was similar to those in the placebo group. All of these side effects are then listed in the package insert.

Groups that make recommendations about vaccines to healthcare professionals, such as the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP), don't use the same criteria as the FDA to determine whether a side effect is caused by vaccines. When these groups make recommendations, they review the data in the context of whether a particular side effect occurs significantly more often in the vaccine group than the placebo group. If it does, these side effects are listed in educational materials to physicians. For this reason, the number of side effects listed in the package insert is much greater than that listed by the CDC and AAP.


Immunization registries

What is an immunization registry?

An immunization registry is a confidential computerized information system that tracks which vaccines have been given to a child. One of the goals of the Healthy People 2010 initiative is to have at least 95% of children in the United States under 6 years old participating in a registry. By 2004, about 48% of children were included in a registry.

How will participation in a registry benefit my child?

Registries allow healthcare professionals to provide better care for your family because all of your child's immunization information is stored in one place. If you visit more than one doctor, change health insurance providers, no longer have access to records from a previous doctor, or are physically displaced, such as occurred to families after Hurricane Katrina, your records will remain up-to-date and intact. In the aftermath of Katrina, many children were relocated to different states where they attended schools that required proof of immunization. Most families did not have their medical records with them and family doctors could not be reached to forward the records. Because registries were in place in some of the affected areas, those families had less difficulty getting their children back to school. Another benefit of registries is that they ensure timely immunizations through reminders to parents and healthcare professionals. In addition, registries prevent unnecessary (duplicative) immunizations because there is a complete, official copy of a child's immunization history when needed by other healthcare professionals or to provide to schools, day cares, and camps.

What are the concerns about registries and how are they being addressed?

Concerns about registries focus on maintaining confidentiality and preventing misuse of information by outside agencies. However, parents can be reassured for several reasons. First, privacy and confidentiality have come to the forefront in medical institutions as they comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and move toward electronic medical records for their patients. Second, any information reported about immunizations is only reportable from a population standpoint, so at no time can an individual's immunization status be shared with outside sources. Further, systems are being established that assure parental knowledge and consent for participation in a registry. This affords parents the opportunity to learn about the specific registry in their area. Finally, parents who are still hesitant about registries may opt not to participate in them.


Updated: January 2013

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