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Research Letter
January 11, 2021

A Survey of Camp Leadership to Assess Immunization Requirements, Policies, and Practices in a National Cohort of Summer Camps

Author Affiliations
  • 1University of Michigan, Ann Arbor
  • 2Clemson University, Clemson, South Carolina
  • 3University of Michigan Medical School, Ann Arbor
  • 4Association of Camp Nursing, Fisherville, Kentucky
  • 5DocNetwork, Ann Arbor, Michigan
JAMA Pediatr. 2021;175(4):421-423. doi:10.1001/jamapediatrics.2020.5342

More than 14 million children attend summer camps yearly.1 While all states require immunizations for children attending public schools,2 most do not mandate immunizations for campers. Multiple vaccine-preventable outbreaks have been reported at camps.3,4 A 2019 American Academy of Pediatrics (AAP) camp health policy strongly recommended age-appropriate vaccinations for all campers and staff with elimination of nonmedical exemptions.5 We assessed the state of camps’ immunization requirements, policies, and practices by surveying a national cohort of camp leadership.


We partnered with CampDoc.com, an online camp electronic health records system, and the Association of Camp Nursing to conduct an online survey of camp leadership (eMethods in the Supplement). One response was chosen from each camp by predetermined criteria. Data analyses were performed, including multivariate logistic regression models that examined associations between camps’ written immunization policy presence and leadership responses. The University of Michigan institutional review board deemed our study exempt, and thus informed consent was not required.


A total of 710 of 881 respondents, representing 378 camps (Figure), answered the survey completely for a response rate of 38% (1000 available camps). Respondents were directors (44%; n = 164), nurses (26%; n = 98), office staff (16%; n = 60), physicians (3%; n = 13), owners (2%; n = 8), medical technicians (1%; n = 3), and other (8%; n = 32). Most leadership (80%; n = 276) agreed that campers should be fully immunized prior to attending camp. However, only 50% of camps (n = 174) reported having an immunization policy for campers and 39% for staff (n = 133). Fifty-four percent (n = 181) allowed unvaccinated children with nonmedical exemptions to attend camp. Three percent of camps (n = 10) experienced a vaccine-preventable outbreak and 14% (n = 47) were warned of potential county exposures within the past 2 years; 20% (n = 68) responded that camps might lose significant numbers of campers by requiring immunizations. The Table illustrates the percentage of camps that required specific immunizations. Stepwise logistic regression analysis indicated camps were more likely to report having a policy requiring immunization for campers if leadership agreed that all campers should be immunized prior to attending camp (adjusted odds ratio [aOR], 3.1; 95% CI, 1.5-6.2; P < .05) or if camps were located in states requiring immunization documentation (aOR, 4.86; 95% CI, 2.9-8.0; P < .05), but were less likely to have a policy when accepting nonmedical exemptions (aOR, 0.27; 95% CI, 0.1-0.4; P < .05). Analysis was adjusted for survey respondent role, recent county reports of disease, camp outbreaks, special needs children, and belief that risk of preventable disease was higher now than 1 year ago.

Figure.  Geographic Distribution of Survey Respondents
Geographic Distribution of Survey Respondents
Table.  Percentage of Camps Requiring Various Immunizations
Percentage of Camps Requiring Various Immunizations


Children in camps are an overlooked cohort when considering communicable disease spread. Despite a widely disseminated AAP policy,5 our survey is, to our knowledge, the first to report that 50% of camp leadership reported not having a written immunization policy and more than half of camps allow unvaccinated campers with nonmedical exemptions. With the rise in vaccine-preventable outbreaks, future efforts should address these findings. While 100% vaccination rates in camps may not be possible, an improvement in vaccine policies may lead to enough of an increase in immunization rates to achieve herd immunity.6 Reasons for lack of policies among camps are multifactorial and highlight challenges camp leadership face, including lack of legislative requirements for vaccine documentation, difficulty obtaining accurate immunization records, and concern for losing participants and thus business. Limitations of this study include lack of representation of camps that did not respond or were not within the network, and survey responses that may not be reflective of actual camps’ policies. In conclusion, primary care clinicians should partner with camp leadership to create immunization policies that are fully aligned with AAP guidelines, and public health stakeholders should continue to advocate for state policies that require documentation of campers’ immunization status to ensure the optimal well-being of all children in camps.

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Article Information

Corresponding Author: Carissa Bunke MD, University of Michigan, 1540 E Hospital Dr, Ann Arbor, MI 48109 (carisssa@med.umich.edu).

Accepted for Publication: June 29, 2020.

Published Online: January 11, 2021. doi:10.1001/jamapediatrics.2020.5342

Author Contributions: Drs Bunke and Hashikawa had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ambrose, Hashikawa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Bunke, Schellpfeffer, Ambrose, Hashikawa.

Critical revision of the manuscript for important intellectual content: Schellpfeffer, Garst, Bradin, Gaslin, Ambrose, Hashikawa.

Statistical analysis: Bunke, Ambrose, Hashikawa.

Administrative, technical, or material support: Schellpfeffer, Garst, Bradin, Gaslin, Ambrose.

Supervision: Bradin, Ambrose, Hashikawa.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: An abstract for this article was accepted for poster presentation at Pediatric Academic Society 2020; however, this meeting was canceled due to the coronavirus disease 2019 pandemic.

Additional Contributions: We thank Alexsandra Dubin, BA, MS, Clemson University, for help with discussion and editing assistance with the final manuscript. She did not receive compensation for her work, and we obtained written permission to include her name in the acknowledgments section of this manuscript.

American Camp Association. ACA facts and trends. Published 2016. Accessed December 1, 2020. https://www.acacamps.org/press-room/aca-facts-trends.
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