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Vaccinations and Exemptions in Kindergarten School Year 2011-12

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Vaccinations and Exemptions in Kindergarten

School Year 2011-12  

The CDC's Morbidity and Mortality Weekly Report (MMWR) of August 24, 2012 was simply titled "Vaccination Coverage Among Children in Kindergarten – United States, 2011 – 12 School Year”.

It is not known why the authors, who were all from the CDC, chose not to mention vaccine exemptions in the title when they knew that they would be discussing them in such great detail up to and including their percentage increase or decease in kindergartens nationwide. The main report consisted of six paragraphs and was followed by a detailed Editorial Note which also consisted of six paragraphs. The Editor’s name was not revealed. 

The MMWR started with the following two paragraphs:

In 2011, CDC reported 17 outbreaks of measles and 222 measles cases, most of which were imported cases in unvaccinated persons. This was the highest number of measles cases in any year in the United States since 1996 and highlights the importance of monitoring measles vaccination coverage at the local level (1). To identify areas of undervaccination for measles and other vaccine-preventable diseases, state and local health departments monitor compliance with school immunization requirements using annual school vaccination assessment reports, supported as a CDC immunization funding objective for the 64 grantees, including the 50 states, the District of Columbia (DC), five cities, and eight other reporting areas. CDC also monitors progress toward meeting Healthy People 2020 objectives (2) for the vaccination of children entering kindergarten. This report summarizes vaccination coverage, exemption rates, and reporting methods from the 2011–12 school year kindergarten vaccination assessments submitted by 56 grantees, including 49 states, DC, one city, and five other reporting areas. Median coverage with 2 doses of measles, mumps, and rubella (MMR) vaccine was 94.8% among 47 reporting states and DC. Total exemption rates, including medical, religious, and philosophic exemptions, among 49 reporting states and DC, ranged from <0.1% to 7.0% (median: 1.5%). Although statewide levels of vaccination coverage are at or very near target levels, locally low vaccination coverage for extremely transmissible diseases such as measles remains a threat to health. Monitoring MMR vaccination coverage at the local and state level will continue to be critical as long as the risk for measles importation and outbreaks exist.

Healthy People 2020 objectives include maintaining vaccination coverage among children in kindergarten (objective IID-10) and increasing the number of states (including DC) collecting kindergarten vaccination coverage data in accordance with CDC minimum standards (objective IID-19) (2).* The coverage target is ≥95% vaccination coverage for the following vaccines: MMR; diphtheria, tetanus toxoid, and acellular pertussis (DTaP)†; poliovirus; hepatitis B (HepB); and varicella. The reporting target is 50 states and DC collecting kindergarten vaccination coverage data in accordance with CDC minimum standards.

As far as MMR vaccinations are concerned, the median coverage with two doses of the vaccine among kindergarten students this past school year averaged 94.8% among 47 reporting states and DC missing the “Healthy People2020” target of ≥95% by only 0.2%.

The median exemption rate in Kindergarten (Medical, Religious, Philosophic) during the past school year was 1.5%.

The following was clearly evident in the fifth paragraph of the report: The median coverage levels for DtaP, poliovirus, and Hepatitis B vaccines were all already above the Healthy People 2020 target of 95% and the median coverage of two doses of varicella vaccine in those states that had such school requirement was 93.2% eight years ahead of schedule.

It would be safe to say that most countries of the world would be calling a National Day of Celebration if they had such voluntary vaccination rates among children starting school. It would also be safe to say that other countries’  “vaccine authorities” would not be going around insulting and abusing the minute minority that would dare forego vaccinations for some personal reason or another.

I strongly urge everyone to carefully read the Editorial Note, particularly the fourth paragraph, where the Editor states: “… Reports might not be updated as a child obtains the required vaccines or exemption later in the school year. Vaccination and exemption status might not have been reported for every child. By grantee the proportion of children not classified as either vaccinated or exempt for each individual vaccine was estimated to range from 0% to 29.1%.”

Following is the closing paragraph of the main report:  

Overall, among the grantees in the 49 states and DC that reported exemptions for the 2011–12 school year, 10 reported <1%, and nine reported >4% total exemption rates (Figure), with a range of <0.1% in Mississippi to 7.0% in Alaska (Table 2). An estimated 89,133 exemptions were reported, for a total estimated population of 4,124,185 kindergarten children. The median total exemption level was 1.5%, a median increase of 0.2 percentage points compared with the 2009–10 school year. The largest increase in exemption levels was reported by Arkansas, with an increase of 3.4 percentage points; the largest decrease was reported by Nebraska, with a decrease of 2.3 percentage points. Where reported separately, the median medical exemption level was 0.3 %, with a range of 0.0% in New Mexico and North Dakota to 1.3% in DC. Where allowed and reported separately, the median nonmedical exemption level was 1.2 %, with a range of 0.04% in Delaware and Kentucky to 5.8% in Oregon.

Vaccination rates (VR) are listed on Table 1 and exemptions rates (ER) can be found in Table 2

There were 89,133 exemptions among a total estimated KG population of 4,124,185.

The state of Mississippi reported the lowest ER - only 0.1%. It also reported that it had 44,912 kindergarten students, that 100% of them (44,912) were surveyed, and that its vaccination rates for required vaccines were 99.2% - 99.2% - 99.2% - 99.2% - 99.2%.

Mississippi was the only state in the Nation with such low exemption rate and the only state where all kindergarten – required vaccination rates were identical.

Mississippi and West Virginia are the only two states that do not accept or approve religious and philosophic exemptions.  WV’s ER for 2011-12 was 0.2%, the second lowest in the Nation. That rate was substantially lower than its 2009-10 ER of 1.3% and yet WV’s KG vaccination rates were all below target this last school year at 92% - 92.6% - 92.6% - 93.3% and 88.9%.

Neighboring Virginia had a higher ER of 1% and yet its vaccination rates were overall better than West Virginia’s: 93% - 98.6% - 93% - 92.7% and 95.6%.

Ohio located to the northwest of West Virginia had an even higher exemption rate of 1.5% - seven times West Virginia’s rate, and yet its vaccination rates were better at 96.1% – 95.9% - 96.2% -99.0% and 95.4%, all already better than Healthy People 2020 targets.
The state of Oregon was singled out by the authors as having the largest percentage of non-medical exemptions (5.8%) and yet its vaccination rates at 94.0% – 93.7% – 94% – 94.6% and 95% were all pretty close to the 2020 targets the Nation will be trying to reach.

Oregon happened to be listed just above Pennsylvania where total exemption rates in kindergarten in 2011-12 were only 1.8%. Pennsylvania’s vaccination rates in kindergarten during the same school year were 86.9% – 91.1% **– 95.5% – 94.4% and 85.1%, clearly all quite comparable to Oregon’s vaccination rates. There was however one difference: Pertussis vaccination was a school requirement in Oregon but not in Pennsylvania. The ** listed in the second column is explained under abbreviations as follows: “Pertussis vaccine is not required in Pennsylvania; the estimate for Pennsylvania represents DT only.”

Oregon’s neighbor, beautiful Washington State has also often been maligned for its 4.7% exemption rate, a rate that seems to be quite a bit higher than that of WV which happens to be listed alphabetically just below it. Yet a comparison of the two states’ vaccination rates clearly shows that the difference in those rates – if any – was indeed quite small.

Massachusetts is also listed just before Michigan. The Massachusetts kindergarten exemption rate for school year 2011-12 was 1.4% compared to Michigan's rate of 5.5% yet according to the MMWR of August 24, 2012, Massachusetts vaccination rates were 94.2% – 92.5% – 93.3% – 97.8% and 92.7% while Michigan's vaccination rates were somewhat better at 95.0% - 95.6% - 95.9% - 96.8% and 93.2%.

Recently, a mini-civil war almost erupted in California because of philosophic vaccine exemptions. The health department was upset with parents, parents were upset with the health department, parents were upset with other parents and everyone was upset with the legislature.

There was no such upheaval in Illinois where philosophic exemptions are not allowed.

A close review of exemptions in both states revealed the following:

  • California had 871 (0.2%)  medical exemptions compared to Illinois where 1,745 (1.1%) exemptions were filed.
  • California had no religious exemptions as they are not allowed, while Illinois recorded 7,270 (4.5%) religious exemptions.
  • California had 12,665 (2.4%) philosophic exemptions, while Illinois had none.

In all, only 2.6% of California parents with children in kindergarten filed vaccine exemptions this past school year compared to 5.5% in Illinois.


Parting Words

To the best of my knowledge, there is NO law that limits the ability of parents in the United States to make decisions concerning their children’s religious upbringing, education, diet, activities or health issues in general.   

Yet it seems that certain people get bent way out of shape when a small percentage of parents dare decide not to vaccinate their children for some reason or another. 

Lighten up people!

There are more urgent things to worry about. 


F. Edward Yazbak MD, FAAP

Falmouth, Massachusetts

August 2012