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August 17, 2020

Outcome of Coronavirus Disease 2019 on School Vaccination Policies for 2020-2021

Author Affiliations
  • 1Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson
  • 2Center for Public Health Law and Policy, Sandra Day O’Connor College of Law, Arizona State University, Tempe
JAMA Health Forum. 2020;1(8):e201018. doi:10.1001/jamahealthforum.2020.1018

In 2019, the US experienced a record number of measles cases, the most since 1992.1 Most cases were seen in individuals who had not received vaccinations.1 Vaccinations, especially those targeted to childhood infectious diseases, have been one of the most successful public health interventions of all time. The amount of morbidity and mortality prevented and the large economic benefits from universal vaccination have been well documented.2 There is concern and evidence that the coronavirus disease 2019 (COVID-19) pandemic is causing a decline in vaccination rates for recommended vaccines among US children.3 This article examines changes in vaccination policies for the 2020-2021 school year, along with proactive options communities can take to ensure children remain up to date on vaccinations.

Potential Effects on Childhood Vaccination Rates

One of the most effective ways to achieve high rates of child vaccination is to require a defined set of immunizations before entry into childcare and school. All 50 states and Washington, DC have established vaccination requirements for school entry. These requirements vary by vaccine type and exemptions, if permitted. The most common and noncontroversial exemptions are medical (eg, allergy to a vaccine component or contraindication because of a medical condition). Most states allow nonmedical exemptions based on religious grounds, and some allow a personal belief or philosophical exemption. States with the most lenient nonmedical exemption options have higher rates of vaccine-preventable infections.4 Vaccine refusal is also associated with a large proportion of measles and pertussis cases in some communities.4

A potential decline in childhood vaccination as a result of the COVID-19 pandemic is likely because of hesitancy to visit medical facilities out of exposure concerns. If states grant grace periods for vaccine requirements, a large number of children may present to school in the fall without the required vaccinations. This is especially concerning in states with more lenient nonmedical exemption provisions, where only a signature or a waiver form is required. In those states, it is easier not to be vaccinated than it is to be vaccinated, allowing for what we refer to as a nonmedical exemption of convenience.

How states address the issue of mandated vaccines for school entry during the COVID-19 pandemic will very likely affect the risk of vaccine-preventable outbreaks, especially of measles. Twenty-two measles outbreaks occurred in the US in 2019, which almost resulted in the US losing its measles elimination status (which was obtained in 2000).1 Almost 90% of reported measles cases occurred in individuals who were unvaccinated for the disease.1 There are various negative actions states may take during a pandemic, including not enforcing school entry requirements or allowing attendance for students with incomplete vaccinations for a limited time. These actions will result in community risk for vaccine-preventable outbreaks.

State and Local Vaccine Policy Changes

Selected jurisdictions have shown diverging approaches to potentially declining vaccination rates or access, with some jurisdictions permitting delays to vaccine requirements, others maintaining existing vaccination requirements, and others scheduling drive-through clinics to increase access for childhood vaccinations.5 Nevada has granted immunization extensions for the 2020-2021 school year, and a school principal in Tennessee noted that their school would permit immunization schedule delays if the parents demonstrate attempts to catch children up on their required vaccines.5 Ohio and Kentucky schools have announced vaccine requirements will be maintained, and vaccination records must be up to date for fall.5 These varying approaches could have profound associations with vaccination rates in the upcoming school year, especially in jurisdictions permitting vaccination status delays.

Proactive Options to Assure School Vaccination Coverage

During this pandemic, state and local health departments, health care entities, school districts, and others are creating proactive ways to offer vaccinations, including offering vaccinations on-site at schools or through drive-through clinics. On-site vaccination programs can be offered in collaboration with local health departments and staffed by school nurses, health department personnel, or volunteers. Drive-through clinics reduce interaction with others by ensuring points of contact are limited to the vaccine administration in the person’s own vehicle. Several locales currently offer this model to promote timely vaccination before completed immunization records are required for school enrollment.5 Schools in Cleveland county, North Carolina, are partnering with the county’s public health department to provide drive-through vaccination clinics.5 Public health officials in Sweetwater county, Wyoming, have offered drive-through clinics specifically for students in the seventh grade who needed vaccines for tetanus, diphtheria, and pertussis and meningococcal vaccine.5 Both on-site and drive-through clinics can be efficient and effective for meeting vaccine requirements.

States can also change vaccination laws to add requirements before a nonmedical exemption is permitted. Colorado passed legislation in June 2020 requiring parents to complete an online education module or obtain an exemption form signed by a health care professional before being granted a nonmedical exemption for their child.6 State laws requiring signatures from health care professionals provide an opportunity for the clinician to discuss the benefits of vaccine and potential harms of refusing vaccines. States can also consider banning nonmedical exemptions altogether. New York legislatively removed all nonmedical exemptions in 2019.7 The legislation also required students attending public school to prove they have all necessary vaccinations within 14 days of their first day of school. While the change is not a direct response to COVID-19, this requirement affects the 2020-2021 school year enrollment amid the pandemic to ensure children return to schools fully vaccinated.


Amidst a pandemic unlike any this country has faced in more than 100 years, the association of COVID-19 with vaccination rates in children cannot be overlooked. Initial evidence has already shown a decrease in vaccination rates in 2020. Select local and state jurisdictions have made decisions permitting delays or reinforcing current vaccination requirements. These differing approaches can either ensure classrooms of children with complete vaccinations or result in classrooms of children who are only partially vaccinated or unvaccinated, an environment ripe for another outbreak. Methods to increase vaccination rates should be considered, including on-site vaccination or drive-through clinics. The outcome of changing vaccination laws, such as removing nonmedical exemptions, could also increase the likelihood of achieving high vaccination rates.

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Article Information

Corresponding Author: Leila Barraza, JD, MPH, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin, PO Box 245210, Tucson, AZ 85724 (lbarraza@arizona.edu).

Correction: This article was corrected on December 17, 2020, to fix an inaccurate mention of Sweetwater county as being in New York. This county is in Wyoming. The article has been corrected.

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Conflict of Interest Disclosures: None reported.

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Hodge  JG  Jr. COVID-19 emergency legal preparedness primer, as of June 26, 2020. Published June 26, 2020. Accessed August 10, 2020. https://www.networkforphl.org/wp-content/uploads/2020/06/Western-Region-Primer-COVID-6-26-2020.pdf
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