BQ Journal Vol 48 - Q3 2022 - 15

Morbidity and Mortality Weekly Report
coverage regardless of population size. During the 2020-21
school year, 3,520,205 children in 48 states and DC were
reported by immunization programs as enrolled in kindergarten.¶¶
Reported estimates are based on 3,187,569 of these
kindergartners who were surveyed for vaccination coverage;
3,337,916 for exemptions; 2,467,326 for grace period and
provisional enrollment; 1,799,190 for documentation; and
1,049,075 for compliance. Kindergarten enrollment reported
by the 48 states and DC was approximately 10% lower than
that reported for the 2019-20 school year by 48 states.
Potentially achievable coverage with MMR, defined as the
sum of the percentage of children who were up to date with
2 doses of MMR and those with no documented vaccination
exemption but not up to date, was calculated for each state.
Nonexempt students include those who were provisionally
enrolled in kindergarten, in a grace period, or otherwise without
documentation of complete vaccination. SAS software
(version 9.4; SAS Institute) was used for all analyses.
Vaccination assessments varied by state because of differences
in required vaccines and doses, vaccines assessed, methods of
data collection, and data reported (Supplementary Table 1,
https://stacks.cdc.gov/view/cdc/116354). Kindergartners were
considered up to date for a given vaccine if they received all
doses of that vaccine required for school entry,*** except in
nine states††† that reported kindergartners as up to date for
any given vaccine only if they received all doses of all vaccines
required for school entry. States were asked to report
any COVID-19-related impact on kindergarten vaccination
measurement and coverage.
Nationally, 2-dose MMR coverage was 93.9%
(median = 93.7%; range = 78.9% [DC] to ≥98.9%
[Mississippi]). Coverage ≥95% was reported by 16 states and
<90% by 7 states and DC (Table). DTaP coverage was 93.6%
(range = 78.5% [DC] to ≥98.9% [Mississippi]). Coverage
¶¶ These totals are the summations of the kindergartners surveyed among
programs reporting data for coverage, exemptions, grace periods, and
provisional enrollment. Data from cities and territories were not included in
these totals.
*** All states required 2 doses of a measles-containing vaccine. Six states (Georgia,
New Jersey, New York, North Carolina, Oregon, and Virginia) require only
1 dose of rubella vaccine. New Jersey and Oregon require only 1 dose of
mumps vaccine, and mumps vaccine is not required in Iowa. Local DTaP
requirements varied. Nebraska required 3 doses of DTaP, two states (Maryland
and Wisconsin) required 4 doses, and all other states required 5 doses, unless
dose 4 was administered on or after the fourth birthday. The reported coverage
estimates represent the percentage of kindergartners with the state-required
number of DTaP doses, except for Kentucky, which required 5 doses of
DTaP by age 5 years but reported 4-dose coverage for kindergartners. Two
states (Maryland and Nebraska) require only 3 doses of polio vaccine, all
other states require 4 doses unless the last dose was given on or after the
fourth birthday. Six states required 1 dose of varicella vaccine; 44 states and
DC required 2 doses.
††† Alabama, Florida, Georgia, Iowa, Mississippi, New Hampshire, New Jersey,
Wisconsin, and Wyoming considered kindergartners up to date only if they
had received all doses of all vaccines required for school entry.
≥95% was reported by 16 states, and coverage <90% by eight
states and DC. Varicella vaccine coverage nationally was 93.6%
(range = 78.0% [DC] to ≥98.9% [Mississippi]), with 17 states
reporting coverage ≥95% and nine states and DC reporting
<90% coverage.
The percentage of kindergartners with an exemption for ≥1
required vaccines (not limited to MMR, DTaP, and varicella
vaccines) was 2.2% in 2020-21 (range = 0.1% [Mississippi
and New York] to 8.2% [Idaho]), similar to the 2.5% reported
during the 2019-20 school year (Table). Nationally, 0.2%
of kindergartners had a medical exemption and 1.9% had
a nonmedical exemption (Supplementary Table 2, https://
stacks.cdc.gov/view/cdc/116355). The percentage of kindergartners
provisionally enrolled in kindergarten or within
a grace period among the 28 states reporting these data was
2.0% (range = 0.1% [Hawaii] to 10.0% [Arkansas]) (Table).
Among states that reported data for both 2019-20 and
2020-21, MMR coverage and exemptions for ≥1 vaccines
decreased in approximately 75% of states; grace period or provisional
enrollment increased in 18 of the 28 states reporting
this measure (Figure 1). The proportion of students who were
not fully vaccinated and not exempt increased in a majority
of states. Among states reporting these measures in 2020-21,
the proportion of kindergartners attending school with no
documentation of required vaccinations or exemptions ranged
from 0.1% (Pennsylvania and Virginia) to 8.3% (Maryland);
the proportion out of compliance with school requirements
ranged from 0.2% (Florida) to 16.6% (Indiana) (Table).
Among the 33 states and DC with MMR coverage <95%, all
but two could potentially achieve ≥95% MMR coverage if all
nonexempt kindergartners who were within a grace period,
provisionally enrolled, or out of compliance received vaccination
(Figure 2).
Discussion
During the 2020-21 school year, vaccination coverage
among kindergartners nationwide was lower than during the
2019-20 school year at approximately 94% (2,3) for MMR,
DTaP, and varicella vaccines, a level just under the target of
95%; coverage for all three vaccines decreased in a majority
of states. National MMR coverage among kindergartners fell
below the Healthy People 2030 target of 95% (4). Reported
enrollment and response rates also decreased nationally and in
a majority of states (3). Some of the decreases in enrollment
could be because of schools not reporting these data to state
immunization programs, or parents might have decided to have
the child delay or skip the kindergarten year. The kindergarten
assessment for the 2021-22 school year will include these
students if they are enrolled in kindergarten for the 2021-22
US Department of Health and Human Services/Centers for Disease Control and Prevention
MMWR / April 22, 2022 / Vol. 71 / No. 16
563
Diagnostics I Pharmaceuticals I DxRx Solutions I Continuing Education I News
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A Henry Schein Publication
https://stacks.cdc.gov/view/cdc/116355 https://stacks.cdc.gov/view/cdc/116355 https://stacks.cdc.gov/view/cdc/116354
BQ Journal Vol 48 - Q3 2022

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