Kindergarten vaccination coverage is near the recommended 95%, but nonexempt holdouts, which could be addressed, can still lead to outbreaks.
Each year, state immunization programs assess kindergarten vaccination to monitor school-entry vaccination coverage with state-required vaccines. The US Centers for Disease Control and Prevention (CDC) released a summary of these findings in its Morbidity and Mortality Weekly Report (MMWR) indicating that although the exemption rate increased to 2.5%, most states could reach the 95% recommended measles, mumps, and rubella (MMR) vaccine coverage if undervaccinated children outside the exemption group were completely vaccinated.
For the 2018-19 school year, kindergarten vaccination coverage was 94.7% for 2 doses of MMR and 94.9% for the state-required doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. Coverage was 94.8% for varicella vaccine. Although 2.5% of kindergartners had an exemption from at least 1 vaccine, 2.8% of kindergartners were not up to date for MMR and did not have an exemption.
Vaccination information for children enrolled in public and private kindergarten was gathered by federally funded immunization programs in collaboration with education departments and school staff and was aggregated by school type, to the CDC through a web-based questionnaire. Investigators with the CDC then used those counts to estimate state and national level vaccination coverage.
According to the article, 49 states reported coverage for all state-required vaccines for public school kindergartners and 48 states reported on private school kindergarteners. All 50 states reported their exemption data among public school kindergartners and 49 reported on private school kindergartners. Estimates for the 2018-19 school year are based on 3,634,896 kindergartners surveyed for vaccination coverage, 3,643,598 surveyed for exemptions, and 2,813,482 for grace period or provisional enrollment among the 4,001,404 children reported as in kindergarten by the 50 state immunization programs.
Nationally, DTaP coverage was 94.9% with a range of 88.8% in Idaho to >99.2% in Mississippi. Coverage of >95% was reported by 21 states and coverage of <90% by one.
Two-dose MMR coverage was 94.7% with a range from 87.4% in Colorado to >99.2^ in Mississippi. Coverage of >95% was reported by 20 states and coverage of <90% was reported by 2 states.
Varicella vaccine coverage was 94.8% with a range of 86.5% in Colorado to >99.2% in Mississippi, with 20 states reporting coverage >95% and 4 reporting <90% coverage.
The percentage of kindergartners with an exemption from any vaccine was 2.5%, including vaccines beyond DTaP, MMR, and varicella. The fewest exemptions were found in Mississippi at 0.1%, and the most were reported in Idaho and Oregon at 7.7%. This represents a slight increase in exemptions compared to 2.3% in 2017-18 and 2.1% in 2016-17. Nationally, 2.2% of kindergartners had a nonmedical exemption compared to 0.3% with a medical exemption.
Most nonexempt unvaccinated kindergartners attending school are enrolled provisionally or in a grace period, according to the report. Investigators pointed out that the burden of following up with parents of such students to verify vaccination schedules are completed tends to fall on school nurses or other school staff members.
Most American parents have their children vaccinated in line with the required schedules, as the report indicates, but holdouts may exist beyond traditional barriers to coverage. The anti-vaccine movement has gained attention as a possible cause for concern among health care professionals.
The MMWR article noted that while national vaccination coverage remained at the recommended 95%, there are still cases of vaccine-preventable diseases in areas with high coverage. For example, during 2018-19 New York experienced several outbreaks of measles while maintaining high overall MMR coverage.
The article also emphasized the importance of assessing vaccination coverage at the local level and working to reduce barriers to vaccination in communities with disproportionately unvaccinated students.
In a Contagion® Insights series on overcoming vaccine hesitancy, Glenn Fennelly, MD, MPH, spoke about experiences at his practice at the New Jersey Medical School in Newark, emphasizing the need to build trust with the community and patiently explain how minimal vaccine side effects are. Fennelly also pointed out that the statistics around vaccine hesitancy have shifted since the measles outbreak of 1989 to 1991, where “most outbreaks were in urban areas,” so that now “it’s in suburban areas where there is a lot of vaccine hesitancy.”
Christina Tan, MD, MPH highlighted the need for an empathetic approach when dealing with parents who have vaccine hesitancy, recommending clinicians “be available to offer any sort of answers…because this is their child whom they’re trusting to you.”
In another segment of the Insights, Tan said that many parents may not have enough knowledge about vaccines themselves, making “understanding vaccines” the “crux of trying to help parents understand the importance of vaccinating and to [dispelling] any sort of myths related to vaccine-safety concerns.”