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Systematic Review
This CPSTF report examines laws or policies requiring vaccinations or other documentation of immunity as a condition of child care, school, and college attendance. These findings are based on studies demonstrating effectiveness of vaccination requirements for attendance in a variety of settings, for an array of recommended vaccines, and in populations ranging in age from early childhood to late adolescence.
The Task Force finding is based on evidence from 32 studies (search period January 1980 – July 2015) that examined the effectiveness of vaccination requirements on vaccination coverage rates or changes in vaccine-preventable disease or illness.
Seventeen studies with 24 study arms examined the effectiveness of state or local vaccination requirements on changes in vaccination rates. The median change was an increase of 18 percentage points (Interquartile interval [IQI]: 10 to 35 percentage points). Five additional studies examined changes in vaccination rates or series completion that could not be included in the summary effect estimate, although results were generally in the direction of increased coverage.
Ten studies examined the effectiveness of vaccination requirements on changes in vaccine-preventable disease rates or associated morbidity. Five of these studies were nationwide assessments of school entry requirements. Three U.S. studies found that the incidence of measles and mumps was lower in states with immunization requirements for school-aged children, and that low-incidence areas were more likely to enforce school entry laws by excluding non-compliant children from attendance.
One study from Italy found reductions in rates of hepatitis B disease attributable to the implementation of vaccination requirements and school and community-based vaccination programs. A study from Japan found increases in excess mortality rates among younger children due to influenza and pneumonia, after the removal of a national influenza vaccination mandate and school-based immunization program.
Five studies evaluated other vaccination requirements and found: (1) lower incidence of mumps during an outbreak in children subject to a vaccination requirement; (2) greater declines in Haemophilus influenza type b disease incidence among child care attendees subject to vaccination requirements than for New York State as a whole; (3) lower risk for measles outbreaks in colleges with pre-matriculation immunization requirements; (4) decline in hepatitis A disease incidence following implementation of a child care entry requirement in response to an outbreak, and (5) reduction in influenza-associated hospitalizations among children following a child care entry requirement.
Included studies were mostly conducted in the United States (30 studies) and examined school entry requirements (24 studies). Studies provided evidence of effectiveness for both primary school entry requirements (11 studies) and requirements for middle/high school students (13 studies). Six studies examined vaccinations for child care attendance and findings are applicable to these settings. Although only one study evaluated vaccination requirements for college (1
studies) findings are likely applicable to these settings.
The CPSTF recommends vaccination requirements for child care, school, and college attendance based on strong evidence of effectiveness in increasing vaccination rates and in decreasing rates of vaccine preventable disease (VPD) and associated morbidity and mortality.
Although intervention studies overall provide strong evidence of effectiveness, three important aspects of vaccination requirements have been identified in the broader literature as having the potential to meaningfully influence vaccinations rates and risk for vaccine-preventable disease transmission: 1) geographic clustering of under immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions.
Most included studies examined school vaccination requirements; additional evaluations of requirements for child care attendance and college residency would be useful. Additional research would be useful to clarify relationships between variations in school or child care documentation and enforcement and vaccination and exemption rates. Information on barriers to school and local enforcement and ways to overcome these barriers would also be useful. Likewise, studies examining factors that facilitate or impede the adoption and enforcement of vaccination requirements in child care and college settings would be helpful. Finally, more research is needed to assess the economic costs and benefits of vaccination requirements in each setting.