Kindergarten Vaccination Stalls at 93% as Exemptions Hit a Record 3%, 2022–23

Summary

States and localities require vaccinations for school entry and set the rules for exemptions. Each year states report to CDC how many kindergartners are vaccinated, exempt or still catching up. The 2022–23 kindergarten class became eligible for most required vaccines during the COVID-19 pandemic.

Bottom line

• National coverage stayed near 93% for all four tracked vaccines — down from 95% before the pandemic.
• Exemptions rose to 3.0% (from 2.6%), the highest ever reported in the United States.
• National MMR coverage of 93.1% means about 250,000 kindergartners are at risk of measles.

Coverage, 2022–23 (49 states and DC)

Coverage fell in most states compared with 2021–22: MMR in 29, DTaP in 31, polio in 28 and varicella in 25.

The trend: after 10 years near 95%, coverage fell about 1 point in 2020–21 and another in 2021–22, to about 93%, and stayed there. MMR has been below the Healthy People 2030 target of 95% for three years running.

Exemptions

• 3.0% of kindergartners were exempt from at least one required vaccine — 0.2% medical and 2.8% nonmedical — ranging from under 0.1% (West Virginia) to 12.1% (Idaho).
• Exemptions rose in 40 states and DC, by at least 1 point in seven states.
• Nonmedical exemptions are over 90% of all exemptions and account for about 100% of the increase.

Change in the percentage of kindergartners exempt from one or more vaccines, by state, 2021–22 to 2022–23. CDC.

Could states reach 95%?

• 2.5% of kindergartners (in 28 reporting states) attended under a grace period or provisional enrollment — attending while catching up — from 0.5% (Georgia, Hawaii) to 9.2% (Arkansas).
• Nationwide, 3.9% were not fully vaccinated against measles but not exempt — children who could still be vaccinated.
• To reach 95% MMR coverage, exemptions can't exceed 5%. In 10 states they did, so those states couldn't reach 95% even if every nonexempt child were vaccinated — up from four states in 2021–22. The number of states that could has fallen from 48 in 2020–21 to 40.

Potentially achievable MMR coverage by state: coverage plus kindergartners not up to date but not exempt, against the 95% target. CDC.

What can help

• Make sure children are fully vaccinated before school starts — for example at enrollment, often months ahead — or before provisional periods run out.
• Provisional enrollment lets children catch up, and can prevent nonmedical exemptions taken because of pandemic-era barriers such as fewer appointments.
• Proven tools: enforcing requirements, school-based clinics, reminder and recall systems and follow-up with undervaccinated students.
• It's unclear whether rising exemptions reflect real opposition to vaccines or parents choosing exemptions because of barriers or convenience. Understanding why could guide policy. Clusters of undervaccinated children can lead to outbreaks.
• CDC launched Let's RISE in 2023 to get routine vaccination back to prepandemic levels, with back-to-school campaigns and technical help.

Limitations: state requirements, documentation and data collection vary, limiting comparisons; some schools or students (such as homeschoolers) may be missed; documentation may be inaccurate; and coverage covers 49 states and DC, with some states using lower-bound estimates.

How it was done: states reported 3,832,381 kindergartners; estimates are based on 3,559,366 surveyed for coverage, 3,711,948 for exemptions and 2,683,880 for grace or provisional status.

Sources

Based on Ranee Seither et al., "Coverage with Selected Vaccines and Exemption from School Vaccine Requirements Among Children in Kindergarten — United States, 2022–23 School Year," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; published by CDC.