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School-Entry Vaccination Requirements: A Position Statement of the Society for Adolescent Medicine

      Vaccination is considered one of the greatest public health achievements in the U.S. and the world, leading to the virtual eradication of poliomyelitis in North and South America, and of smallpox worldwide [
      Centers for Disease Control and Prevention
      Impact of vaccines universally recommended for children - United States, 1900-1998.
      ]. To a large extent, the success of vaccination in this country is due to compulsory school vaccination laws, which have ensured widespread coverage and minimized vaccine-related health disparities [
      • Hinman A.R.
      • Orenstein W.A.
      • Williamson D.E.
      • Darrington D.
      Childhood immunization: Laws that work.
      ,
      A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP); Part 1: Immunization of infants, children, and adolescents.
      ,
      • Davis M.M.
      • Gaglia M.A.
      Associations of daycare and school entry vaccination requirements with varicella immunization rates.
      ]. Although these laws frequently have been challenged, U.S. courts have consistently upheld states’ authority to require vaccination [
      • Hodge J.G.
      • Gostin L.O.
      School vaccination requirements: historical, social, and legal perspectives.
      ]. At the same time, in recognition of the need to balance public health concerns with the interests of parents, all states have mechanisms for parents to seek exemption for their children from vaccine requirements [
      • Omer S.B.
      • Pan W.K.Y.
      • Halsey N.A.
      • et al.
      Nonmedical exemptions to school immunization requirements.
      ,
      • Rota J.S.
      • Salmon D.A.
      • Rodewald L.E.
      • et al.
      Processes for obtaining nonmedical exemptions to state immunization laws.
      ]. These provisions vary markedly from state to state. Some states allow only medical or religious exemptions, whereas others allow for relatively ill-defined philosophical exemptions. Similarly, although some states require parents to complete very little paperwork to exempt their children from vaccination, other states have complex procedures and require notarized letters. Research studies have demonstrated that when the grounds for exemption are liberalized, vaccine coverage drops and outbreaks of vaccine-preventable illness occur [
      • Omer S.B.
      • Pan W.K.Y.
      • Halsey N.A.
      • et al.
      Nonmedical exemptions to school immunization requirements.
      ,
      • Thompson J.W.
      • Tyson S.
      • Card-Higginson P.
      • et al.
      Impact of addition of philosophical exemptions on childhood immunization rates.
      ,
      • Feikin D.R.
      • Lezotte D.C.
      • Hamman R.F.
      • et al.
      Individual and community risks of measles and pertussis associated with personal exemptions to immunization.
      ].
      The original impetus for compulsory vaccination laws in the 19th century was to prevent the spread of smallpox among groups of children [
      • Hinman A.R.
      • Orenstein W.A.
      • Williamson D.E.
      • Darrington D.
      Childhood immunization: Laws that work.
      ]. Most, but not all, vaccines required at school entry today also are for the prevention of contagious infections that can be easily transmitted from child to child. Current exceptions to this rule include tetanus and hepatitis B virus vaccines.
      In 2006, the Association of Immunization Managers (AIM) released a position statement on school and child care immunization requirements that addressed several important issues [
      Association of Immunization Managers
      Position statement: School and child care immunization requirements.
      ]. AIM is a national organization that represents state, territorial and local immunization programs that receive direct federal grants from the Center for Disease Control and Prevention’s (CDC) National Immunization Program. The AIM statement advocates a systematic, measured approach for the consideration of adding a vaccine to existing school-entry requirements and provides a basis for this position statement from the Society for Adolescent Medicine.
      The Society for Adolescent Medicine recognizes that school entry vaccination requirements have proven to be a successful public health strategy, and supports the following positions:
      • 1
        For any vaccine required for school entry there should be an adequate supply to vaccinate all children and adolescents who are subject to the requirement and a means to ensure that those children and adolescents without adequate health insurance coverage can receive the vaccine.
      • 2
        Exemption options should not be modified on a vaccine-by-vaccine basis. That is, exemption policies, which are determined on a state-by-state basis, should not be uniquely modified for any specific vaccine, but should be applied uniformly across all required vaccines.
      • 3
        Legislation to enact additional school-entry requirements for vaccines should proceed systematically with open discussion among health experts, school administrators, and legislators. Consideration should be given to how the new vaccine requirement fits into established compulsory vaccination policy.
      • 4
        Except in emergency situations (e.g., pandemic flu), sufficient time should be given after a new vaccine becomes available before school-entry requirements are enacted in order to: a) allow medical providers and the general public an opportunity to become comfortable with the new vaccine; b) enable health insurance companies and public funding mechanisms to develop vaccine coverage policies; and c) establish the infrastructure required at a state and local level to implement both vaccine delivery and the monitoring of compliance with the school-entry requirement.
      • 5
        Vaccines chosen to be part of mandatory vaccination for school entry must be: a) approved by the CDC Advisory Committee on Immunization Practices (ACIP); b) safe and effective against an infection that has significant morbidity and mortality, and c) shown either to reduce person-to-person transmission of disease or reduce the overall burden of disease in the community or both.
      • 6
        Policy decisions regarding new school-entry vaccination requirements and the timetables for implementing such requirements should be based on careful consideration of the issues noted in this statement. These decisions should not be influenced by monetary support or other pressures exerted by private industry or any other groups with a financial stake in the promotion of, or opposition to, the vaccine.

      Author Disclosures

      Gregory D. Zimet, Ph.D.: has been a speaker for Merck, a consultant and speaker for SciMed (a medical education company recipient of an unrestricted grant from Merck) and a consultant and speaker for M2Communications (a medical education company recipient of an unrestricted grant from GlaxoSmithKline). Abigail English, J.D.: The Center for Adolescent Health & the Law has received a research grant from GlaxoSmithKline and a consultant honorarium from Merck, Inc.
      low asteriskPolicy statement approved by the Society for Adolescent Medicine Board of Directors, September 2007.

      References

        • Centers for Disease Control and Prevention
        Impact of vaccines universally recommended for children - United States, 1900-1998.
        MMWR. 1999; 48: 243-248
        • Hinman A.R.
        • Orenstein W.A.
        • Williamson D.E.
        • Darrington D.
        Childhood immunization: Laws that work.
        J Law Med Ethics. 2002; 30: 122-127
      1. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP); Part 1: Immunization of infants, children, and adolescents.
        MMWR. 2005; 54: 1-23
        • Davis M.M.
        • Gaglia M.A.
        Associations of daycare and school entry vaccination requirements with varicella immunization rates.
        Vaccine. 2005; 23: 3053-3060
        • Hodge J.G.
        • Gostin L.O.
        School vaccination requirements: historical, social, and legal perspectives.
        Kentucky Law J. 2001/2002; 90: 831-890
        • Omer S.B.
        • Pan W.K.Y.
        • Halsey N.A.
        • et al.
        Nonmedical exemptions to school immunization requirements.
        JAMA. 2006; 296: 1757-1763
        • Rota J.S.
        • Salmon D.A.
        • Rodewald L.E.
        • et al.
        Processes for obtaining nonmedical exemptions to state immunization laws.
        Am J Public Health. 2001; 91: 645-648
        • Thompson J.W.
        • Tyson S.
        • Card-Higginson P.
        • et al.
        Impact of addition of philosophical exemptions on childhood immunization rates.
        Am J Prev Med. 2007; 32: 194-201
        • Feikin D.R.
        • Lezotte D.C.
        • Hamman R.F.
        • et al.
        Individual and community risks of measles and pertussis associated with personal exemptions to immunization.
        JAMA. 2000; 284: 3145-3150
        • Association of Immunization Managers
        Position statement: School and child care immunization requirements.
        (Accessed 03-20-2007)