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From the Centers for Disease Control and Prevention
December 6, 2006

Vaccination Coverage Among Children Entering School—United States, 2005-06 School Year

JAMA. 2006;296(21):2544-2547. doi:10.1001/jama.296.21.2544

MMWR. 2006;55:1124-1126

2 tables omitted

One of the national health objectives for 2010 is to achieve and sustain ≥95% vaccination coverage among children in kindergarten through first grade for the following vaccines: hepatitis B vaccine; diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids and acellular pertussis vaccine, or diphtheria and tetanus toxoids vaccine (DTP/DTaP/DT); poliovirus (polio) vaccine; measles, mumps, and rubella vaccines; and varicella vaccine.1 To determine vaccination coverage among children entering kindergarten, data were analyzed from reports submitted to CDC by states and the District of Columbia (DC) for the 2005-06 school year. This report summarizes the results of that analysis, which indicated that coverage for each vaccine was reported to have exceeded 95% in more than half of the states.

For the 2005-06 school year, DC and all states except two (Illinois and Wyoming) submitted reports of vaccination coverage levels for children entering kindergarten. Of these, 49 reports included coverage for polio vaccine, DTP/DTaP/DT vaccine, measles-containing vaccine, and rubella-containing vaccine; 46 reports included coverage for mumps-containing vaccine; 43 reports included coverage for hepatitis B vaccine; and 41 reports included coverage for varicella vaccine.

All states based their assessments, in part, on public schools; in addition, 47 states assessed private schools, and 17 states assessed home schools. In 2005-06, 11 states reported assessments based on 100% of children entering kindergarten in public, private, and home schools; in the 2004-05 school year, five state reports included all school types.2 Although many states conducted a census of all students in the schools they assessed, five states selected a random sample of schools, students, or both to determine coverage rates. Health departments reviewed immunization records to assess coverage in six states, relied on self-reported coverage from schools in 29 states, and used some other methodology (e.g., reports from health departments and school personnel) in 14 states.

Four of the eight U.S. territories that receive federal immunization grants also reported data for the 2005-06 school year. All four reports included coverage for polio vaccine; DTP/DTaP/DT vaccine; measles, mumps, and rubella vaccines; and hepatitis B vaccine. Two U.S. territories reported coverage for varicella vaccine. The percentage of children surveyed by the U.S. territories ranged from 10% to 100%. Both public and private schools were included in the assessments, and varying methods were used to assess coverage (e.g., self-reports, health department audits, and vaccination registries).

To determine coverage, state or territory up-to-date status was used rather than number of doses received because the number of doses required to be up-to-date varies depending on timing of vaccinations, area requirements regarding number of doses, and brand of vaccines. National and territorial estimates of coverage were calculated by weighting each state's or territory's coverage estimate according to the size of the kindergarten enrollment for 2005-06.

Coverage for the newest recommended vaccine included in the assessment, varicella, was reported as ≥95% in 29 (57%) states and DC and ≥90% in 36 (71%) states and DC. Coverage for other vaccines was higher, ranging from 31 (61%) states with ≥95% coverage for measles and hepatitis B vaccines, to 34 (67%) states with ≥95% coverage for DTP/DTaP/DT vaccine.

Varicella coverage was <95% in the two territories (Puerto Rico [89%] and the Virgin Islands [88%]) that reported varicella coverage. Vaccination coverage ≥95% was reported for hepatitis B by Mariana Islands and Puerto Rico. Coverage levels in the reporting territories for all other vaccines were <95%.

Reported by:

C Stanwyck, PhD, J Davila, MSPH, B Lyons, MPH, C Knighton, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases (proposed), CDC.

CDC Editorial Note:

More than half of reporting states indicate that they have already reached the Healthy People 2010 goal of ≥95% coverage for each of the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP); the remaining states are making progress toward this goal. However, required vaccines and methods for surveying kindergarten-aged children vary substantially from state to state; the majority of states rely on self-reports by schools, rather than audits by health departments, to determine coverage, which might lead to underestimations or overestimations. CDC provided a new online reporting system, which has been available since the 2002-03 school year, to help states and U.S.-affiliated jurisdictions collect and report data on vaccination coverage among children entering school. Anecdotal reports from states indicate that this system, which automates data-management and calculation tasks, has made reporting coverage easier. CDC also has promoted greater standardization of reporting, for example, by encouraging all states to report coverage based on ACIP recommendations rather than on state requirements.3 These improvements in survey methods and assessment procedures will help ensure that health jurisdictions are accurately reporting progress toward the ≥95% coverage goal.

State laws requiring proof of vaccination at school entry have been considered a safety net for the U.S. vaccination program because they are intended to ensure that no child is missed.4 This safety net relies on school nurses, teachers, health department staff, and others to identify children who are not up-to-date with their vaccinations. Findings of high nationwide coverage in recent years underscore the success of school entry requirements in boosting vaccination coverage, which increased substantially when entry requirements were established. Childhood vaccination coverage also is measured nationally among children aged 19-35 months.5 Higher percentages of children are up-to-date when entering kindergarten than at younger ages, suggesting that school entry laws are an important factor in maintaining high vaccination coverage and ensuring completion of the vaccine doses recommended at ages 4-6 years.5

The findings in this report are subject to at least two limitations. First, the substantial variation in assessment methods limits the comparability of these data and suggests, in some cases, that data quality could be improved (e.g., by using methods other than self-report, standardizing measurement of vaccination coverage, monitoring data for validity and reliability, and using appropriate sampling methods). Second, children attending private schools or home schools were not surveyed by all states. The difference in vaccination rates between children schooled at home and children in public or private school environments is unknown.

Additional information about assessing and reporting vaccination coverage among children entering school is available at http://www.cdc.gov/nip/coverage/schoolsurv/overview.htm. The schedule of recommended vaccinations for children is available at http://www.cdc.gov/nip/recs/child-schedule-4pg-landscp.pdf.

US Department of Health and Human Services.  Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.health.gov/healthypeople
CDC.  The school entry immunization assessment report, 2004-05. Available at http://www2.cdc.gov/nip/schoolsurv/rptgmenu05.asp
CDC.  Recommended childhood and adolescent immunization schedule—United States, 2006. Available at http://www.cdc.gov/nip/recs/child-schedule-4pg-landscp.pdf
Orenstein WA, Hinman AR. The immunization program in the United States—the role of school immunization laws.  Vaccine. 1999;17:(Suppl)  S19-S24PubMedArticle
CDC.  National, state, and urban area vaccination levels among children aged 19-35 months—United States, 2005.  MMWR. 2006;55:988-993