BQ Journal Vol 48 - Q3 2022 - 17

Morbidity and Mortality Weekly Report
TABLE. (Continued) Estimated* vaccination coverage† for measles, mumps, and rubella vaccine, diphtheria, tetanus, and acellular pertussis vaccine,
and varicella vaccine, grace period or provisional enrollment,§ and any exemption¶,** among kindergartners, by immunization program -
United States,†† 2020-21 school year
% Vaccine doses
Immunization program
Marshall Islands¶¶¶¶,†††††
Northern Mariana
Islands§§§§
Palau
Puerto Rico¶¶¶¶
U.S. Virgin Islands
Kindergarten
population§§
1,016
NR
26,353
NR
%
100.0
NA
NA
NA
830 100.0
2 of
99.7
94.5
5 of
94.4
84.2
2 of
Surveyed¶¶ MMR*** DTaP††† varicella§§§
Nreq
95.3
NR NR
NR NR
NR NR
NR
NR
NR
% Grace period
or provisional
enrollment
NR
NR
NR
NR
NR
% Any
exemption
NR
0.0
NR
NR
NR
Percentage point
change in any
exemption from
2019-20 school year
NA
0.0
NA
NA
NA
% No
documentation¶¶¶
NR
NR
NR
NR
NR
% Out of
compliance****
NR
NR
NR
NR
NR
Abbreviations: DC = District of Columbia; DTaP = diphtheria, tetanus, and acellular pertussis vaccine; MMR = measles, mumps, and rubella vaccine; NA = not available; NP = no grace period
or provisional policy; NR = not reported to CDC; Nreq = not required.
* Estimates adjusted for nonresponse and weighted for sampling where appropriate.
† Estimates based on a completed vaccine series (i.e., not vaccine specific) use the " ≥ " symbol. Coverage might include history of disease or laboratory evidence of immunity.
§ A grace period is a set number of days during which a student can be enrolled and attend school without proof of complete vaccination or exemption. Provisional enrollment allows
a student without complete vaccination or exemption to attend school while completing a catch-up vaccination schedule. In states with one or both of these policies, the estimates
represent the number of kindergartners who were within a grace period, were provisionally enrolled, or were in a combination of these categories.
¶ Some programs did not report the number of children with exemptions, but instead reported the number of exemptions for each vaccine, which could count some children more
than once. Lower bounds of the percentage of children with any exemptions were estimated using the individual vaccines with the highest number of exemptions. Estimates based
on vaccine-specific exemptions use the " ≥ " symbol.
** Exemptions, grace period or provisional enrollment, and vaccine coverage status might not be mutually exclusive. Some children enrolled under a grace period or provisional
enrollment might be exempt from ≥1 vaccinations, and children with exemptions might be fully vaccinated with ≥1 required vaccines.
†† Includes five territories and three freely associated states.
§§ The kindergarten population is an approximation provided by each program.
¶¶ The number surveyed represents the number surveyed for coverage, except in Alaska. The national number does not include Alaska, which did not report coverage but surveyed
8,756 students for exemptions. In other jurisdictions, exemption estimates are based on 27,421 kindergartners for Kansas, 56,330 for South Carolina, 85,873 for Virginia, and 39,627
for Houston.
*** A majority of states require 2 doses of MMR; Alaska, New Jersey, and Oregon require 2 doses of measles, 1 dose of mumps, and 1 dose of rubella vaccines. Georgia, New York, New York
City, North Carolina, and Virginia require 2 doses of measles and mumps vaccines and 1 dose of rubella vaccine. Iowa requires 2 doses of measles vaccine and 2 doses of rubella vaccine.
††† Pertussis vaccination coverage might include some DTP vaccinations if administered in another country. A majority of states require 5 doses of DTaP for school entry or 4 doses if the
fourth dose was received on or after the fourth birthday; Maryland requires 4 doses and Nebraska requires 3 doses. The reported coverage estimates represent the percentage of
kindergartners with the state-required number of DTaP doses, except for Kentucky, which requires 5 doses of DTaP by age 5 years but reported 4-dose coverage for kindergartners.
§§§ A majority of states require 2 doses of varicella vaccine for school entry; Alabama, Arizona, California, Hawaii, Maine, New Jersey, Oklahoma, and Oregon require 1 dose. Reporting
of varicella vaccination status for kindergartners with a history of varicella disease varied within and among states; some kindergartners were reported as vaccinated against varicella
and others as medically exempt.
¶¶¶ Estimates represent the number of kindergartners with no documentation of any vaccinations or exemptions.
**** Students were considered out of compliance if they did not have complete documentation of having received all required vaccinations but were not eligible for provisional enrollment
and did not have documented exemptions for the missing vaccinations. This measure included those with no documentation at all.
†††† National coverage estimates and medians were calculated using data from 47 states (i.e., does not include Alaska, Illinois, or West Virginia) and DC. National grace period or provisional
enrollment estimates and median were calculated using data from the 28 states that have either a grace period or provisional enrollment policy and reported relevant data to CDC.
National exemption estimate and median were calculated from data from 48 states (i.e., did not include Illinois or West Virginia) and DC. Other jurisdictions excluded were Houston,
New York City, American Samoa, Guam, Marshall Islands, Federated States of Micronesia, Northern Mariana Islands, Palau, Puerto Rico, and the U.S. Virgin Islands. National estimate
and median were calculated using data from 30 states and DC for kindergartners with no documentation, and 17 states for kindergartners who were out of compliance. Data reported
from 3,187,569 kindergartners were assessed for coverage, 3,337,916 for exemptions, 2,467,326 for grace period or provisional enrollment, 1,799,190 for no documentation, and
1,049,075 for out of compliance. Estimates represent rates for populations of coverage (3,510,744), exemptions (3,520,205), grace period or provisional enrollment (2,608,025), no
documentation (2,190,919), and out of compliance (1,109,078).
§§§§ The proportion surveyed likely was <100% but is reported as 100% based on incomplete information about the actual current enrollment.
¶¶¶¶ Philosophical exemptions were not allowed.
***** Alaska did not report kindergarten vaccination coverage because of problems with data collection. Vaccination coverage among children aged 63-75 months in VacTrAK, Alaska's
Immunization Information System, was 70.2% for MMR, 83.0% for DTaP, and 67.1% for varicella vaccine.
††††† Religious exemptions were not allowed.
§§§§§ Counted some or all vaccine doses received regardless of Advisory Committee on Immunization Practices recommended age and time interval; vaccination coverage rates reported
might be higher than those for valid doses.
¶¶¶¶¶ Vaccination coverage data were collected from a sample of kindergartners; exemption data were collected from a census of kindergartners.
****** Did not include certain types of schools, such as kindergartens in child care facilities, online schools, correctional facilities, or those located on military bases or tribal lands.
†††††† Reported exemption data for public schools only.
school year, but not if they were enrolled in first grade for the
2021-22 school year.
The overall percentage of children with an exemption
remained low during the 2020-21 school year at 2.2%; the
percentage of children with exemptions decreased in 37 states.
Nonexempt undervaccinated students often attend school while
in a grace period or are provisionally enrolled; in many states,
these policies were expanded either formally or informally
during the 2020-21 school year. States described reluctance
to schedule and reduced access to well-child appointments,
expanded grace period or provisional enrollment, and easing
of vaccination requirements for remote learners, reduced
submission of documentation by parents, less time for school
nurses to follow-up with students missing documentation or
vaccines, fewer staff members to conduct kindergarten vaccination
coverage assessment and reporting activities, lower
response rates from schools, and both extended and compressed
kindergarten vaccination coverage data collection schedules,
all related to COVID-19 (CDC, School Vaccination Coverage
Report, unpublished data, 2021). During the 2020-21 school
US Department of Health and Human Services/Centers for Disease Control and Prevention
MMWR / April 22, 2022 / Vol. 71 / No. 16
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BQ Journal Vol 48 - Q3 2022

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