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Vaccination requirements for school and child care: What parents need to know

Sept. 6, 2019
Vaccination requirements for school and child care: What parents need to know

If your child attends school or day care, you probably know vaccines are required for attendance. But you might not realize some rules have recently changed in certain areas. For example, this year New York state stopped allowing families to take a religious exemption to vaccines required for school. California vaccine law also stopped allowing religious exemptions in 2015.

Vaccine laws vary by state, so you might need to brush up on what’s mandatory in your area, given your child’s age and/or grade in school. Here’s what you should know about the vaccines required for school, vaccine laws, vaccine opposition and vaccine exemptions.

‘Herd immunity’ and why schools require vaccines

Simply put, vaccines prevent communicable diseases from spreading. While different states have different vaccine requirements, some commonly mandated ones include DTaP (diphtheria, tetanus, pertussis), hepatitis B, IPV (Polio), MMR (measles, mumps, rubella) and varicella (chicken pox).

These diseases killed kids by the thousands in their heyday, and widespread vaccination has lowered and even eliminated cases of them in the U.S., says Johan Bester, Ph.D., assistant professor of family medicine and director of Bioethics for the University of Nevada Las Vegas. Bester explains that mandating vaccines in schools prevents outbreaks in a community by creating “herd immunity,” a phenomenon in which a community is protected from an outbreak because a high percentage of the population has been vaccinated.

“To do this, we all have to do our bit and get vaccinated,” says Bester. “And it presents a good legal and moral argument that it shouldn’t just be an individual decision but a decision that should be mandated for the whole of society.” 

Schools in particular are places where diseases can spread, Bester says, and because school attendance is monitored, vaccine compliance can be monitored through schools, as well.

The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) recommend the same immunization schedule. It’s available on the AAP and CDC websites.

How to find vaccine laws by state

To find out which vaccines are required for your child to attend school or day care, go to your state’s health department website. You may also contact your child’s school’s health office or day care director.

The CDC website has a handy chart that shows which states allow vaccination exemptions and for what reasons. The chart gives you a sense of what’s needed to file for an exemption. For example, some requirements include documentation from a health provider or a written affidavit from the parent. If you’re interested in getting an exemption, contact your state health department for more detailed information.

Why some states are cracking down

“Unfortunately, some families have not adhered to the recommended vaccine schedule, and it puts all children at risk,” says Dr. Danelle Fisher, FAAP, pediatrician and vice chair of Pediatrics at Providence Saint John’s Health Center in Santa Monica, California. “We [doctors] see [patients with these diseases], and they still cause morbidity and mortality.”

For example, California moved to eliminate exemptions based on religious or personal beliefs following a measles outbreak that spread at Disneyland in 2014. New York’s more recent crackdown on religious exemptions followed a measles outbreak that, in 2018 and 2019, affected more than 654 people.

Opting out of vaccines not only puts your own child at risk but also your community, including people who can’t get vaccinated for medical reasons and those who haven’t yet received all their vaccine doses, says Fisher. California and New York became susceptible to outbreaks because some communities fell below the rate necessary for herd immunity.

People who ask for exemptions based on religion but who don’t really practice a religion that forbids vaccines is just one factor contributing to the falling rate of immunization, says Fisher.

“Studies show that the more broad you make the exemption, the more exemptions you get,” says Bester. “So states are starting to tighten up wording or make it more of a challenge to get an exemption. For example, you may have to show that you came in and sat through an educational session and that, despite knowing all these facts about vaccines, you still don’t agree.”

Medical and religious exemption for vaccines

Medical exemptions may be afforded for people who:

  • Have a medical condition in which their immune system is compromised.

  • Are taking a medication that compromises their immune system.

  • Are allergic to one of the components of the vaccine.

But true allergies to vaccines are rare, says Fisher. 

“You would not know if you were allergic until you’ve had the vaccine and had a reaction that is not a typical reaction,” she says. “I’ve been doing this for 18 years and literally have had only two patients in that time that have required a medical exemption because they did actually have an allergic reaction to the vaccine.” 

One of those patients, whose reaction was hives, was later able to work with an immunologist to get vaccines safely after his allergic reaction, she says. 

What constitutes a religious exemption and/or philosophical exemption varies from state to state. If you’d like to file for any kind of exemption, there are some steps you should take:

  • Check with your county and/or state health office. Be sure you know exactly what documentation is necessary. For example, in Michigan, parents now need to have waivers certified by their local health office. Several states require notarized documentation or a written affidavit, and others require parents undergo educational sessions, as Bester mentions. Melanie M., a mom of three in Belgrade, Montana, who uses a religious exemption for her kids, says she simply has to turn in a signed, notarized form to her school district each year.

  • Know any specific rules regarding the exemption. In some states, kids who have exemptions may not be allowed to attend day care or school while there is a local outbreak of a disease they’re not vaccinated for, according to the CDC. Schools will enforce these rules. 

If you can’t get an exemption and your child isn’t vaccinated, they may not be able to attend public school, day care or even private or parochial school at all. Getting a nanny and/or home-schooling may be your only option, depending on your state. 

The opposition to vaccine mandates

Some parents are opposed to vaccination laws, and there are several reasons for this. 

“Some people discuss vaccines on social media, and myths are propagated that way,” says Bester. “Or they Google and find false information that looks like it is reliable and sound.” 

Common reasons for opposing vaccines are:

Potential side effects

Side effects vary from vaccine to vaccine. The most common side effects from vaccines include pain at the site of the shot, low fever, chills, tiredness, headaches and muscle and joint aches. Fisher says those minor side effects are an immune response, and are, in fact, a sign of the vaccine working, not a sign of an allergy to the vaccine.

More serious side effects are rare, but some people have experienced some pretty scary sounding problems after getting vaccines, including seizures, coma and brain damage, according to the U.S. Department of Health and Human Services (HHS).

“When you list it out like that it, it seems so horrible,” Bester says. “But when you compare it to the risks of the measles disease and the risks you take with not being vaccinated, these are really insignificant risks. If you eat chicken nuggets, I think your risk for getting gastroenteritis, if you’re a child, is seven or eight times higher [than having a serious side effect from a vaccine], which is not insignificant. And you can die from gastroenteritis, but nobody thinks about that when they’re eating chicken nuggets.”

Also, Bester says, the few patients who had brain problems reported them after having vaccines, and they haven’t been undoubtedly proven to have been caused by vaccines. 

“In people who get the measles disease, brain infections are much more common, and they usually cause permanent damage,” he says.

You can see the potential side effects of each vaccine on the CDC website.

Autism worries

You may have heard vaccines and autism mentioned in the same vein, specifically the MMR vaccine. That concern was brought up in a small 1998 case study, which later was proven to be fraudulent. Since then, more than 45 scientific studies have disproven a link between the MMR vaccine and autism.

Vaccine ingredients

But what about mercury? Bester says mercury is no longer used in any vaccine except the flu shot, which does sometimes contain a form of it, called thimerosal. This is included in the shot to help prevent contamination. Thimerosal has been proven to be safe by several studies.

Is it too much?

“A common fear is that if you give too many vaccines, it will overwhelm the immune system,” says Bester. “That really has shown not to be any concern.” 

Think about it this way: Children’s immune systems fight 2,000 to 6,000 antigens on a typical day, and the recommended vaccine schedule doesn’t include any more than 150 antigens in any one day’s shots, according to the AAP. The recommended schedule has been tested and approved by the CDC, AAP and American Academy of Family Physicians, but alternative schedules haven’t, and they could leave children vulnerable to disease for longer.

Personal and religious freedoms

Many people feel states have no right to mandate vaccinations. 

“As parents, we should always have the right to make informed decisions based on our children's health,” says Emily F., a mom in Newnan, Georgia, who gets religious exemptions for her kids. 

However, without the mandates, the vaccination rate has gone down in recent years, while the rates of measles and pertussis (whooping cough) have gone up.

On the other hand, some parents are happy with the mandate. 

“I am a vaccinating mother of two, and I think this mandate is important,” says Tomika B., in King of Prussia, Pennsylvania. “Children are being afflicted with illnesses that could have been preventable if a vaccine were given. I believe in your right to decide, except when it affects the public.”

The diseases are rare or minor

We don’t regularly hear about people getting diphtheria. And we’ve all heard people in older generations talk about getting the measles as kids and lived to tell the tale. So some people wonder if kids really need to be protected from them. But keep in mind that in the 1950s, before the MMR vaccine became available, measles used to hospitalize 48,000 people and kill 400 to 500 people per year in the U.S., according to the CDC. Herd immunity needs to be maintained to prevent outbreaks. Many of these diseases still exist in other countries and could be spread by infected travelers.

“Some people argue that vaccines are a victim of their own success because they’ve been so successful at removing these diseases that people no longer fear these diseases,” says Bester. “A hundred years ago, if you told people you had a reliable way to protect against measles, people would line up outside the door.” 

The same goes for polio, diphtheria and the like.

Distrust in doctors or the government

Some people believe the government and/or doctors recommend and mandate vaccinations for ulterior motives — to control people and/or to receive kickbacks. 

“We [pediatricians] do what we do because we love children,” says Fisher. “There’s absolutely no financial gain in this for us. It’s only an immune system gain, and that’s what I wish everyone understood.”

Understanding vaccines better

Still skeptical or unsure if you want to vaccinate? Speak to your pediatrician, family doctor or another medical professional you trust. They can talk you through all the information you need to know to make your decision.

“I love to have a calm and respectful conversation about vaccines, their side effects, the reason we’re giving them and really break it down one by one,” says Fisher. “I am dedicated to doing that with each and every patient who comes into our office and has questions.”

Be careful to get your vaccine information from a trusted source, as there’s plenty of false and misleading information online. Bester recommends going to the websites of the American Academy of Pediatrics’ HealthyChildren.org (run by the AAP) and the World Health Organization for trustworthy information about vaccine side effects and safety. The CDC and Mayo Clinic also have good info. You may also look to your local hospital or county or state health department.

How to catch up if your child isn’t vaccinated

Ready to send your child to school but they haven’t been on the recommended vaccine schedule? Don’t panic. It’s safe to get your child caught up, says Bester. Your pediatrician can work with you to create an immunization plan that can get them back on track.

“If your child is not vaccinated or undervaccinated, we are happy to catch them up, and we can write letters to the school explaining,” says Fisher. “They should not be excluded from school.”

If your child is not insured or is underinsured, contact your county health department, which likely offers free and low-cost vaccines.

“You want your child to be safe at school,” says Fisher. In order to ensure that, “Every parent should be doing the responsible thing to protect their child, which protects other children. And that’s getting them their vaccines.”

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