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Vaccination Coverage for Selected Vaccines, Exemption Rates, and Provisional Enrollment Among Children in Kindergarten--United States, 2016-17 School Year.

State and local school vaccination requirements help protect students and communities against vaccine-preventable diseases (1). CDC reports vaccination coverage and exemption data for children attending kindergarten (kindergartners) collected by federally funded immunization programs in the United States. * The typical age range for kindergartners is 4--6 years. Although vaccination requirements vary by state (the District of Columbia [DC] is counted as a state in this report.), the Advisory Committee on Immunization Practices recommends that children in this age range have received, among other vaccinations, 5 doses of diphtheria, tetanus, and acellular pertussis vaccine (DTaP), 2 doses of measles, mumps, and rubella vaccine (MMR), and 2 doses of varicella vaccine (2). This report summarizes 2016-17 school year MMR, DTaP, and varicella vaccination coverage reported by immunization programs in 49 states, exemptions in 50 states, and kindergartners provisionally enrolled or within a grace period in 27 states. Median vaccination coverage ([dagger]) was 94.5% for the state-required number of doses of DTaP; 94.0% for 2 doses of MMR; and 93.8% for 2 doses of varicella vaccine. The median percentage of kindergartners with an exemption from at least one vaccine ([section]) was 2.0%, similar to 2015-16 (1.9%). Median grace period and provisional enrollment was 2.0%. Vaccination coverage remains consistently high and exemptions low at state and national levels. Local-level vaccination coverage data provide opportunities for immunization programs to identify schools, districts, counties, or regions susceptible to vaccine-preventable diseases and for schools to address undervaccination through implementation of existing state and local vaccination policies (1) to protect communities through increased coverage.

Federally funded immunization programs partner with departments of education and school nurses and other school personnel to assess vaccination coverage and exemption status of children enrolled in public and private kindergartens. ([paragraph]) In accordance with state and local school entry requirements, parents and guardians submit their children's vaccination records or exemption forms to schools, or schools obtain kindergartners' records from their states' immunization information systems. During the 2016-17 school year, 49 states reported data on coverage for all state-required vaccines among public and private school kindergartners, 50 states reported exemption data on public school kindergartners, and 49 states reported exemption data on private school kindergartners. Seven states reported coverage and exemption data for at least some home-schooled kindergartners. ** Twenty-seven states reported data on kindergartners who, at the time of the assessment, were attending school under a grace period (a set number of days during which a student can be enrolled and attend school without proof of complete vaccination or exemption) or provisional enrollment (a provision that allows a student without complete vaccination or exemption to attend school while completing a catch-up vaccination schedule).

During the 2016-17 school year, vaccination assessments varied by immunization program because of differences in state requirements regarding required vaccinations and number of doses required, vaccines assessed, school assessment, data reported, and available resources. Among the 50 states reporting data, 35 used a census to collect kindergarten vaccination data; nine used a sample; four used a voluntary school response; and two used a mix of sampling methods. ([dagger][dagger]) States used the same methods to collect both vaccination coverage and exemption data, except in Alaska, Kansas, Virginia, and Wisconsin, where a sample was used to collect vaccination coverage data and a census to collect exemption data. Five states (Delaware, Hawaii, Nevada, New Mexico, and South Carolina) used a sample for both vaccination coverage and exemption data. Kindergartners were considered up-to-date and included in the coverage estimate for a given vaccine if they received all doses required for school entry, ([section][section]) except in seven states ([paragraph][paragraph]) that considered kindergartners up-to-date only if they had received all doses of all vaccines required for school entry in those states. Kindergartners with a history of varicella disease were reported as either vaccinated against varicella or medically exempt, varying by immunization program. Medical exemptions were issued by a health care provider; all other exemptions (i.e., religious and philosophical) were nonmedical.

This report presents vaccination coverage for MMR, DTaP, and varicella vaccines. Coverage for these vaccines and hepatitis B and poliovirus vaccines that are required in most states is presented on SchoolVaxView (3). Vaccination coverage and exemption estimates were adjusted based on survey type and response rates. *** Medians and ranges of state MMR vaccination coverage and of exemption rates collected from the 2011--12 school year through the 2016-17 school year were examined over time. During the 2016-17 school year, vaccination coverage data were reported for approximately 3,973,172 kindergartners, exemption data for approximately 3,666,870, and grace period and provisional enrollment data for approximately 2,463,131. ([dagger][dagger][dagger])

Since the 2011-12 school year, median kindergarten MMR vaccination coverage has remained near 95% and median exemption rates have remained [less than or equal to] 2% (Figure). Among the 49 states included in this analysis, median MMR coverage was 94.0% (range = 85.6% [DC] to 99.4% [Mississippi]); 20 states reported coverage [greater than or equal to] 95%; and six states (Alaska, Colorado, Idaho, Indiana, Kansas, and DC) reported coverage <90% (Table 1). Among the 48 states that required and reported DTaP vaccination, median coverage was 94.5% (range = 82.2% [DC] to 99.6% [Maryland]); 23 states reported coverage [greater than or equal to] 95% and six states (Alaska, Arkansas, Colorado, Idaho, Kansas, and DC) reported coverage <90%. Among the 42 states that required and reported 2 doses of varicella vaccine, median coverage was 93.8% (range = 84.6% [DC] to 99.4% [Mississippi]); 15 states reported coverage [greater than or equal to] 95%, and seven states (Alaska, Colorado, Idaho, Indiana, Kansas, Washington, and DC) reported coverage <90%. Thirty states ([section][section][section]) published 2015-16 or 2016-17 local-level data (county parish, school district, school, or other level) online for vaccination coverage, exemptions, or both (Table 1).

The median percentage of kindergartners with an exemption from one or more required vaccines (not limited to MMR, DTaP, and varicella vaccines) among the 46 states reporting this information was 2.0% (range = 0.1% [Mississippi] to 6.8% [Alaska]), similar to the median of 1.9% reported for this group during the 2015-16 school year (Table 2). The percentage of kindergartners with any exemption was <1% in four states (Alabama, Louisiana, Mississippi, and West Virginia), and [greater than or equal to] 4% in nine states (Alaska, Arizona, Idaho, Maine, Nevada, Oregon, Utah, Washington, and Wisconsin). From the 2015-16 to the 2016-17 school year, the exemption rate decreased by >1.0 percentage points in two states (California and Vermont) and increased by >0.5 percentage points in seven states (Alaska, Georgia, Nevada, New Hampshire, New Mexico, North Carolina, and Wisconsin). Among states that reported exemptions by type, the median percentage of medical exemptions was 0.2% (range = <0.1% in two states [Delaware and New Mexico] to 1.5% [Alaska]), and the median percentage of nonmedical exemptions was 1.8% (range = 0.5% [DC] to 6.5% [Oregon]).

Twenty-seven states ([paragraph][paragraph][paragraph]) reported data on grace period or provisional enrollment for the 2016-17 school year. The median reported percentage of kindergartners attending school during a grace period or provisional enrollment was 2.0% (range = 0.2% [Georgia] to 8.1% [Pennsylvania]) (Table 2). In 12 of 27 states reporting for the 2016-17 school year, the percentage of children provisionally enrolled or within a grace period at the time of the assessment exceeded the percentage of children with exemptions from one or more vaccines.

Discussion

During the 2016-17 school year, kindergarten vaccination coverage for MMR, DTaP, and varicella vaccine each approached 95%, and the median exemption rate among children attending kindergarten was 2%; these rates have been relatively consistent since the 2011-12 school year. The median percentage of kindergartners attending school under a grace period or provisional enrollment was 2.0%. Although vaccination rates have remained high and stable, four states have reported coverage <90% for at least one vaccine for at least 6 consecutive years (3). In addition, coverage can vary within states, and clusters of undervaccinated kindergartners can exist in states with high overall rates.

Four states (California, New York, North Dakota, and Tennessee) reported increases in coverage of >1.5 percentage points for all reported vaccines (3); these increases might have resulted from programmatic measures to address undervaccination and incomplete documentation of vaccination during the 2016-17 school year. California eliminated new nonmedical exemptions for kindergartners attending public or private school (4,5) and continued to educate school staff members on criteria for provisional enrollment, thus reducing provisional enrollment from 4.4% to 1.9% (6). New York conducted webinars to train school staff members on vaccination requirements, exemptions, and exclusion policies; coverage increased by >1.5 percentage points for all reported vaccines in 2016-17 (Assessment Branch, Immunization Services Division, CDC, unpublished data, 2017). In North Dakota, school superintendents were educated about the importance of immunizations and their mandated role in enforcement of requirements (7), which prompted most school districts in the state to begin strict enforcement of school vaccination requirements, leading to increases in coverage of >3 percentage points for MMR, DTaP, and varicella vaccine in 2016-17. In Tennessee, the immunization program worked to increase the proportion of public school kindergartners who were completely up to date in the state's immunization information systems and to improve schools' capacity to correctly assess student vaccination status; MMR, DTaP, and varicella vaccination coverage increased >3 percentage points in Tennessee in 2016-17 (Assessment Branch, Immunization Services Division, CDC, unpublished data, 2017).

In 12 of 27 states reporting for the 2016-17 school year, the percentage of children provisionally enrolled or within a grace period at the time of the assessment exceeded the percentage of children with exemptions for one or more vaccines, indicating that children who do not have exemptions are not receiving their childhood immunizations in a timely fashion. The median percentage of children provisionally enrolled or within a grace period for the 2016-17 school year was 2.0%, which is the same as for the 2015-16 school year. Pennsylvania's estimated grace period and provisional enrollment prevalence increased from 5.1% to 8.1%, probably because the assessment date changed from March 31 in the 2015-16 school year to December 31 in the 2016-17 school year, giving students enrolled under the grace period less time to complete required vaccination and documentation (Assessment Branch, Immunization Services Division, CDC, unpublished data, 2017). CDC encourages programs to collect and use these data to identify areas with high rates of provisional or grace period enrollment, where increasing coverage through a targeted intervention might be possible.

The number of states sharing local-level school vaccination coverage increased from 25 to 30 (8). The online sharing of local-level data with the public contributes to transparency in public health by placing information about the risk for vaccine preventable diseases in the hands of parents and communities. The type of data published (exemptions, vaccine-specific coverage, complete vaccination, compliance with documentation requirements, and other information) varies across states, as does the geographic level of detail (school, school district, county, region of the state, or other geographic or administrative area), and the method of displaying the data (table, chart, map, or other format).

The findings in this report are subject to at least four limitations, which have been reported previously (8). First, comparability is limited because of variations in states' requirements, data collection methods, and definitions of grace period and provisional enrollment. Second, representativeness might be negatively affected because of data collection methodologies that miss some schools or students or assess vaccination status at different times. Collecting vaccination and exemption data from a validated census of schools and students can improve comparability and representativeness of the data, and therefore, census data are the most programmatically useful. The majority of immunization programs do use a census to collect vaccination and exemption data. Third, actual vaccination coverage, exemption estimates, or both might be under- or overestimated because of improper or absent documentation. Finally, median coverage estimates include only 48 of 50 states and DC, median exemptions estimates include only 45 of 50 states and DC, and the median grace period or provisional enrollment estimate includes only 27 states for the 2016-17 school year.

Kindergarten vaccination requirements provide an opportunity for children to be fully vaccinated with recommended age-appropriate vaccines and to catch up on any missed early childhood vaccinations. CDC works with immunization programs to monitor kindergarten vaccination coverage, improve data quality, and promote data use for effective program planning. Based on state-level kindergarten vaccination data reported to CDC, median vaccination coverage was consistently high and median exemption rates were consistently low. However, clusters of low vaccination coverage continue to serve as opportunities for outbreaks of vaccine-preventable diseases (9). Because vaccination coverage and exemption levels are clustered locally, availability of local-level vaccination data can help immunization programs identify schools that might be vulnerable in an outbreak. CDC is working with programs to improve collection and use of grace period and provisional enrollment data to understand contributing factors for reported undervaccination and identify programmatic actions that might increase vaccination coverage among kindergartners.

Summary

What is already known about this topic?

Immunization programs conduct annual kindergarten vaccination assessments to monitor school-entry vaccination coverage for all state-required vaccines.

What is added by this report?

Median vaccination coverage was 94.0% for 2 doses of measles, mumps, and rubella vaccine; 94.5% for the state-required number of doses of diphtheria, tetanus, and acellular pertussis vaccine; and 93.8% for 2 doses of varicella vaccine. The median exemption level remained low (2.0%) but exemption rates varied by state. The median proportion of kindergartners under a grace period or provisional enrollment was 2.0%, the same as in 2015-16.

What are the implications for public health practice? Vaccination coverage might vary at the local level. School assessment allows immunization programs to focus on schools with lower vaccination coverage and higher exemption levels, allowing schools to follow up with undervaccinated students to help ensure kindergartners are protected from vaccine preventable diseases.

Conflict of Interest

No conflicts of interest were reported.

Corresponding author: Ranee Seither, rseither@cdc.gov, 404-639-8693.

References

(1.) Hinman AR, Orenstein WA, Williamson DE, Darrington D. Childhood immunization: laws that work. J Law Med Ethics 2002;30(Suppl):122-7.

(2.) Robinson CL, Romero JR, Kempe A, Pellegrini C; Advisory Committee on Immunization Practices Child/Adolescent Immunization Work Group. Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger--United States, 2017. MMWR Morb Mortal Wkly Rep 2017;66:134-5. https://doi.org/10.15585/mmwr.mm6605e1

(3.) CDC. SchoolVaxView interactive! Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/vaccines/vaxview/ index.html

(4.) California Department of Public Health. Exemptions: new law (SB 277) effective in 2016. Sacramento, CA: California Department of Public Health; 2015. http://www.shotsforschool.org/laws/exemptions

(5.) Delamater PL, Leslie TF, Yang YT. Change in medical exemptions from immunization in California after elimination of personal belief exemptions. JAMA 2017;318:863-4. https://doi.org/10.1001/jama.2017.9242

(6.) California Department of Public Health. 2015-2016 conditional entrant intervention project. Sacramento, CA: California Department of Public Health; 2016.

(7.) Hall K, Pinnick D, Fix N, Jansen R, Gold A, Carson P. Immunization and exemption policies and practices in North Dakota: a comprehensive review and recommendations for improvement. Fargo, ND: North Dakota State University Center for Immunization Research and Education; 2016. https://www.ndsu.edu/centers/immunize/news/detail/25076/

(8.) Seither R, Calhoun K, Mellerson J, et al. Vaccination coverage among children in kindergarten--United States, 2015-16 school year. MMWR Morb Mortal Wkly Rep 2016;65:1057-64. https://doi.org/10.15585/ mmwr.mm6539a3

(9.) Lieu TA, Ray GT, Klein NP, Chung C, Kulldorff M. Geographic clusters in underimmunization and vaccine refusal. Pediatrics 2015;135:280-9. https://doi.org/10.1542/peds.2014-2715

Ranee Seither, MPH [1]; Kayla Calhoun, MS [1]; Erica J. Street, MPH [2]; Jenelle Mellerson, MPH [1]; Cynthia L. Knighton [1]; Ashley Tippins, MPH [1]; J. Michael Underwood, PhD [1]

* Federally funded immunization programs are located in the 50 states and District of Columbia (DC) ("states"), five cities, and eight U.S territories and freely associated states ("territories"). Two cities reported data to CDC, which were included in their state data to calculate medians. Immunization programs in U.S. territories reported vaccination coverage and exemptions to CDC; however, these data were not included in median calculations.

([dagger]) Median vaccination coverage was determined using estimates for 49 states; Oklahoma and Wyoming did not report data because of widespread problems with the quality of data reported by schools. Data from cities and territories were not included in median calculation.

([section]) Median exemption rate was determined using estimates for 46 states; Wyoming did not report data because of widespread problems with the quality of data reported by schools, and Colorado, Illinois, Minnesota, and Missouri were excluded because they could not report the number of kindergartners with an exemption because of the way they collect the data. Data from local areas and territories were not included in median calculation.

([paragraph]) Assessment date varied by state/area.

** California included data for independent study students in public school data and data for homeschools with six or more students in private school data. Massachusetts included two virtual schools in the public school data. North Dakota reported some homeschool data separately. Oregon reported some homeschool data separately; children enrolled in public online homeschools were included in the public school data. Pennsylvania included all homeschooled students in their public school data. Utah included some homeschooled students in public and private school data. Vermont included homeschooled students in their public and private school data if the students were enrolled in one or more classes at a school; homeschooled children who were exclusively homeschooled were not subject to vaccination requirements and were not included in these estimates.

([dagger][dagger]) States using a census attempted to collect data from all kindergartners at all schools and succeeded in collecting data for >90% of students. The type of sample employed by the nine states using a sample to collect coverage data varied and included a stratified two-stage cluster sample (eight states) and a stratified one-stage cluster sample (one state). A voluntary response of schools was defined as a census survey with a response rate <90% of the known population of kindergartners. A mix of methods included two or more described sampling methods, usually a census for one school type and voluntary response for the other.

([section][section]) All 50 states and DC required 2 doses of a measles-containing vaccine; MMR is the only measles-containing vaccine available in the United States. Local DTaP requirements varied. Nebraska required 3 doses, four states (Illinois, Maryland, Virginia, and Wisconsin) required 4 doses, Pennsylvania did not require pertussis vaccination, and all other states required 5 doses, unless the fourth dose was administered on or after the fourth birthday. The reported coverage estimates represent the percentage of kindergartners with the state-required number of DTaP doses, except for Kentucky, which required 5 doses of DTaP by age 5 years, but reported 4-dose coverage for kindergartners. Eight states required 1 dose of varicella vaccine and 42 states and DC required 2 doses.

([paragraph][paragraph]) Alabama, Florida, Georgia, Iowa, Mississippi, New Hampshire, and New Jersey considered kindergartners up-to-date only if they had received all doses of all vaccines required for school entry.

*** Most immunization programs that used census or voluntary response provided CDC with data aggregated at the state or local (city or territory) level. Coverage and exemption data based on a census or voluntary response were adjusted for nonresponse using the inverse of the response rate, stratified by school type (public, private, and home school, where available). Programs that used complex sample surveys provided CDC with deidentified data aggregated at the school or county level for weighted analysis. Weights were calculated to account for sample design and adjusted for nonresponse for data collected through complex sample design wherever possible.

([dagger][dagger][dagger]) The kindergarten population is an approximation provided by each immunization program. The totals reported here are the summations of the kindergarten population among programs reporting data for coverage, exemptions, and grace period or provisional enrollment. Data from cities and territories were not included in these totals.

([section][section][section]) https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/datareports/ index.html.

Caption: FIGURE. Median and range * of measles, mumps, and rubella vaccine (MMR) coverage and exemptions from any required vaccination ([dagger]) among kindergartners--United States, 2011-12 to 2016-17 school years

([paragraph][paragraph][paragraph]) Twenty-seven states (Arkansas, California, Florida, Georgia, Hawaii, Idaho, Iowa, Maine, Michigan, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Utah, Vermont, Washington, West Virginia, and Wisconsin) reported data on kindergartners attending school under a grace period or provisional enrollment.

[1] Immunization Services Division, National Center for Immunization and Respiratory Disease, CDC; 2Association of Schools and Programs of Public Health Fellowship, Immunization Services Division, National Center for Immunization and Respiratory Disease, CDC.
TABLE 1. Estimated vaccination coverage * for MMR, DTaP, and varicella
vaccines among children enrolled in kindergarten, by vaccine and
immunization program--United States and territories, 2016-2017 school
year
%                                     %

                                 Kindergarten
                                  population
Immunization program              ([dagger])    No. (%) surveyed

Median ([section][section])
Alabama ([paragraph]                58,394       58,394 (100.0)
  [paragraph])
Alaska ***, ([dagger][dagger]        9,815          747 (7.6)
  [dagger])
Arizona ([paragraph]                83,627       83,627 (100.0)
  [paragraph])
Arkansas ([section][section]        39,666       30,091 (75.9)
  [section])
California ([section][section]     575,305      562,924 (97.8)
  [section])
Colorado ([paragraph]               64,440       64,440 (100.0)
  [paragraph])
Connecticut ([paragraph]            39,002       39,002 (100.0)
  [paragraph])
Delaware                            11,490        1,066 (9.3)
District of Columbia                 8,522        8,522 (100.0)
  ([paragraph][paragraph])
Florida ([paragraph]               224,463      224,463 (100.0)
  [paragraph]), ***
Georgia ([paragraph]               136,165      136,165 (100.0)
  [paragraph])
Hawaii                              16,325        1,093 (6.7)
Idaho ([paragraph][paragraph])      22,589       22,589 (100.0)
Illinois                           151,309      147,857 (97.7)
Indiana                             83,263       66,885 (80.3)
Iowa ([paragraph][paragraph])       39,587       39,587 (100.0)
Kansas ***, ([dagger][dagger]       38,298        8,789 (22.9)
  [dagger], [section]
  [section][section])
Kentucky ***, ([section]            51,487       47,814 (92.9)
  [section][section])
Louisiana ([paragraph]              55,257       55,257 (100.0)
  [paragraph])
Maine                               13,834       12,462 (90.1)
Maryland ([section][section]        71,467       70,106 (98.1)
  [section])
Massachusetts ([paragraph]          70,109       70,109 (100.0)
  [paragraph], [section]
  [section][section])
Michigan ([paragraph]              118,777      118,777 (100.0)
  [paragraph])
Minnesota ***                       69,140       66,861 (96.7)
Mississippi ([paragraph]            40,509       40,509 (100.0)
  [paragraph])
Missouri ([paragraph]               73,355       73,355 (100.0)
  [paragraph])
Montana ([paragraph]                11,956       11,956 (100.0)
  [paragraph])
Nebraska ([paragraph]               27,117       27,117 (100.0)
  [paragraph], [section]
  [section][section],
  [paragraph][paragraph]
  [paragraph])
Nevada                              36,885        1,348 (3.7)
New Hampshire ([paragraph]          12,145       12,145 (100.0)
  [paragraph])
New Jersey ([paragraph]            109,577      109,577 (100.0)
  [paragraph])
New Mexico                          27,119        1,214 (4.5)
New York (including                227,050      227,035 (100.0)
New York City) ([paragraph]
  [paragraph])
New York City ([paragraph]         102,374      102,374 (100.0)
  [paragraph])
North Carolina ***, ([section]     126,454      111,544 (88.2)
  [section][section])
North Dakota                         9,799        9,675 (98.7)
Ohio                               137,542      131,385 (95.5)
Oklahoma ([section][section]        52,184       48,453 (92.9)
  [section]), ****
Oregon ([paragraph]                 45,705       45,705 (100.0)
  [paragraph], [section]
  [section][section])
Pennsylvania                       143,888      121,405 (84.4)
Rhode Island ***, [section]         11,100       10,920 (98.4)
  [section][section]
South Carolina                      59,177        5,277 (8.9)
South Dakota                        12,106       12,081 (99.8)
Tennessee ([paragraph]              78,169       78,169 (100.0)
  [paragraph]), ***
Texas (including Houston) ***,     389,999      386,149 (99.0)
  ([section][section]
  [section])
Houston ***, ([section]             42,086       40,802 (96.9)
  [section][section])
Utah ([paragraph][paragraph])       49,073       49,073 (100.0)
Vermont ([paragraph]                 6,344        6,344 (100.0)
  [paragraph])
Virginia ([dagger][dagger]         102,357        4,051 (4.0)
  [dagger])
Washington ***                      87,142       85,601 (98.2)
West Virginia ***                   28,666       19,074 (66.5)
Wisconsin ***, ([dagger]            67,607        1,472 (2.2)
  [dagger][dagger],
  [section][section]
  [section])
Wyoming                                 NA           NA
Guam                                 2,703          703 (26.0)
Marshall Islands                     1,248        1,248 (100.0)
Federated States of                    194          194 (100.0)
Micronesia (Kosrae)
Federated States of                    400          400 (100.0)
Micronesia (Yap)
N. Mariana Islands                     865          865 (100.0)
  ([paragraph][paragraph])
Palau ([paragraph][paragraph],         333          333 (100.0)
  [paragraph][paragraph]
  [paragraph][paragraph])
Puerto Rico                         23,142        1,384 (6.0)
U.S. Virgin Islands                  1,244          505 (40.6)

                                                          Local data
                                    Type of survey        available
                                      conducted             online
Immunization program                 ([section])        ([paragraph])

Median ([section][section])
Alabama ([paragraph]                    Census               Yes
  [paragraph])
Alaska ***, ([dagger][dagger]     Stratified 2-stage          No
  [dagger])                         cluster sample
Arizona ([paragraph]                    Census               Yes
  [paragraph])
Arkansas ([section][section]      Voluntary response          No
  [section])
California ([section][section]          Census               Yes
  [section])
Colorado ([paragraph]                   Census               Yes
  [paragraph])
Connecticut ([paragraph]                Census               Yes
  [paragraph])
Delaware                          Stratified 2-stage          No
                                    cluster sample
District of Columbia                    Census                No
  ([paragraph][paragraph])
Florida ([paragraph]                    Census               Yes
  [paragraph]), ***
Georgia ([paragraph]                    Census                No
  [paragraph])
Hawaii                            Stratified 2-stage          No
                                    cluster sample
Idaho ([paragraph][paragraph])          Census               Yes
Illinois                                Census                No
Indiana                           Voluntary response         Yes
Iowa ([paragraph][paragraph])           Census               Yes
Kansas ***, ([dagger][dagger]     Stratified 2-stage         Yes
  [dagger], [section]               cluster sample
  [section][section])
Kentucky ***, ([section]                Census               Yes
  [section][section])
Louisiana ([paragraph]                  Census               Yes
  [paragraph])
Maine                             Voluntary response         Yes
                                   (public), census
                                      (private)
Maryland ([section][section]            Census                No
  [section])
Massachusetts ([paragraph]              Census               Yes
  [paragraph], [section]
  [section][section])
Michigan ([paragraph]                   Census               Yes
  [paragraph])
Minnesota ***                           Census               Yes
Mississippi ([paragraph]                Census               Yes
  [paragraph])
Missouri ([paragraph]                   Census                No
  [paragraph])
Montana ([paragraph]                    Census                No
  [paragraph])
Nebraska ([paragraph]                   Census                No
  [paragraph], [section]
  [section][section],
  [paragraph][paragraph]
  [paragraph])
Nevada                            Stratified 2-stage          No
                                    cluster sample
New Hampshire ([paragraph]              Census                No
  [paragraph])
New Jersey ([paragraph]                 Census               Yes
  [paragraph])
New Mexico                        Stratified 2-stage          No
                                    cluster sample
New York (including                     Census               Yes
New York City) ([paragraph]
  [paragraph])
New York City ([paragraph]              Census                No
  [paragraph])
North Carolina ***, ([section]    Voluntary response          No
  [section][section])
North Dakota                            Census               Yes
Ohio                                    Census                No
Oklahoma ([section][section]            Census                No
  [section]), ****
Oregon ([paragraph]                     Census               Yes
  [paragraph], [section]
  [section][section])
Pennsylvania                      Voluntary response         Yes
Rhode Island ***, [section]             Census               Yes
  [section][section]
South Carolina                    Stratified 1-stage          No
                                    cluster sample
South Dakota                            Census               Yes
Tennessee ([paragraph]                  Census                No
  [paragraph]), ***
Texas (including Houston) ***,          Census               Yes
  ([section][section]
  [section])
Houston ***, ([section]            Census (public),           No
  [section][section])             voluntary response
                                      (private)
Utah ([paragraph][paragraph])           Census               Yes
Vermont ([paragraph]                    Census               Yes
  [paragraph])
Virginia ([dagger][dagger]        Stratified 2-stage         Yes
  [dagger])                         cluster sample
Washington ***                          Census               Yes
West Virginia ***                  Census (public),           No
                                  voluntary response
                                      (private)
Wisconsin ***, ([dagger]          Stratified 2-stage         Yes
  [dagger][dagger],                 cluster sample
  [section][section]
  [section])
Wyoming                             Not conducted             No
Guam                              Stratified 2-stage          No
                                    cluster sample
Marshall Islands                        Census                No
Federated States of                     Census                No
Micronesia (Kosrae)
Federated States of                     Census                No
Micronesia (Yap)
N. Mariana Islands                      Census                No
  ([paragraph][paragraph])
Palau ([paragraph][paragraph],          Census                No
  [paragraph][paragraph]
  [paragraph][paragraph])
Puerto Rico                       Stratified 2-stage          No
                                    cluster sample
U.S. Virgin Islands               Stratified 2-stage          No
                                    cluster sample

                                                           DTaP
                                      MMR **             ([dagger]
                                                         [dagger])

Immunization program                  2 doses             5 doses

Median ([section][section])             94.0                94.5
Alabama ([paragraph]             [greater than or    [greater than or
  [paragraph])                    equal to] 93.8      equal to] 93.8
Alaska ***, ([dagger][dagger]           89.0                89.1
  [dagger])
Arizona ([paragraph]                    94.0                93.9
  [paragraph])
Arkansas ([section][section]            91.9                89.2
  [section])
California ([section][section]          97.3                96.9
  [section])
Colorado ([paragraph]                   87.3                86.8
  [paragraph])
Connecticut ([paragraph]                96.7                96.7
  [paragraph])
Delaware                                98.5                98.7
District of Columbia                    85.6                82.2
  ([paragraph][paragraph])
Florida ([paragraph]             [greater than or    [greater than or
  [paragraph]), ***               equal to] 94.1      equal to] 94.1
Georgia ([paragraph]             [greater than or    [greater than or
  [paragraph])                    equal to] 93.3      equal to] 93.3
Hawaii                                  93.5                93.3
Idaho ([paragraph][paragraph])          89.9                89.8
Illinois                                94.9                95.0
Indiana                                 88.9                92.1
Iowa ([paragraph][paragraph])    [greater than or    [greater than or
                                  equal to] 92.6      equal to] 92.6
Kansas ***, ([dagger][dagger]           89.5                88.7
  [dagger], [section]
  [section][section])
Kentucky ***, ([section]                90.8                92.5
  [section][section])
Louisiana ([paragraph]                  97.1                98.0
  [paragraph])
Maine                                   94.9                96.3
Maryland ([section][section]            99.3                99.6
  [section])
Massachusetts ([paragraph]              96.1                96.1
  [paragraph], [section]
  [section][section])
Michigan ([paragraph]                   95.6                95.8
  [paragraph])
Minnesota ***                           92.8                93.2
Mississippi ([paragraph]         [greater than or    [greater than or
  [paragraph])                    equal to] 99.4      equal to] 99.4
Missouri ([paragraph]                   95.4                95.5
  [paragraph])
Montana ([paragraph]                    93.8                93.9
  [paragraph])
Nebraska ([paragraph]                   96.7                97.2
  [paragraph], [section]
  [section][section],
  [paragraph][paragraph]
  [paragraph])
Nevada                                  90.9                90.0
New Hampshire ([paragraph]       [greater than or    [greater than or
  [paragraph])                    equal to] 91.5      equal to] 91.5
New Jersey ([paragraph]          [greater than or    [greater than or
  [paragraph])                    equal to] 96.5      equal to] 96.5
New Mexico                              95.5                94.8
New York (including                     97.3                96.9
New York City) ([paragraph]
  [paragraph])
New York City ([paragraph]              97.7                97.0
  [paragraph])
North Carolina ***, ([section]          96.2                96.1
  [section][section])
North Dakota                            93.8                93.8
Ohio                                    92.6                92.4
Oklahoma ([section][section]             NA                  NA
  [section]), ****
Oregon ([paragraph]                     93.8                93.2
  [paragraph], [section]
  [section][section])
Pennsylvania                            93.6               NReq
                                                     ([dagger][dagger]
                                                     [dagger][dagger])
Rhode Island ***, [section]             95.1                95.6
  [section][section]
South Carolina                          96.0                96.2
South Dakota                           96.7                 96.4
Tennessee ([paragraph]                 96.9                96.8
  [paragraph]), ***
Texas (including Houston) ***,         97.3                97.2
  ([section][section]
  [section])
Houston ***, ([section]                96.1                96.1
  [section][section])
Utah ([paragraph][paragraph])          93.8                93.7
Vermont ([paragraph]                   93.6                93.5
  [paragraph])
Virginia ([dagger][dagger]             94.1                98.2
  [dagger])
Washington ***                         90.5                90.8
West Virginia ***                      95.9                95.7
Wisconsin ***, ([dagger]               94.0                96.6
  [dagger][dagger],
  [section][section]
  [section])
Wyoming                                 NA                  NA
Guam                                   90.3                93.5
Marshall Islands                       87.3                72.8
Federated States of                    88.7                91.8
Micronesia (Kosrae)
Federated States of                    91.3                92.0
Micronesia (Yap)
N. Mariana Islands                     89.8                75.3
  ([paragraph][paragraph])
Palau ([paragraph][paragraph],         59.8                64.9
  [paragraph][paragraph]
  [paragraph][paragraph])
Puerto Rico                            96.2                96.1
U.S. Virgin Islands                    88.9                88.5

                                               Varicella

Immunization program                  1 dose              2 doses

Median ([section][section])             96.5                93.8
Alabama ([paragraph]             [greater than or          NReq
  [paragraph])                    equal to] 93.8
Alaska ***, ([dagger][dagger]           NA                  88.9
  [dagger])
Arizona ([paragraph]                    96.7               NReq
  [paragraph])
Arkansas ([section][section]            NA                  91.7
  [section])
California ([section][section]          98.5               NReq
  [section])
Colorado ([paragraph]                   NA                  86.1
  [paragraph])
Connecticut ([paragraph]                NA                  96.5
  [paragraph])
Delaware                                NA                  98.2
District of Columbia                    NA                  84.6
  ([paragraph][paragraph])
Florida ([paragraph]                    NA           [greater than or
  [paragraph]), ***                                   equal to] 94.1
Georgia ([paragraph]                    NA           [greater than or
  [paragraph])                                        equal to] 93.3
Hawaii                                  95.3               NReq
Idaho ([paragraph][paragraph])          NA                  89.1
Illinois                                NA                  94.5
Indiana                                 NA                  87.9
Iowa ([paragraph][paragraph])           NA           [greater than or
Kansas ***, ([dagger][dagger]           NA                  88.8
  [dagger], [section]
  [section][section])
Kentucky ***, ([section]                NA                  90.4
  [section][section])
Louisiana ([paragraph]                  NA                  96.5
  [paragraph])
Maine                                   96.7               NReq
Maryland ([section][section]            NA                  99.0
  [section])
Massachusetts ([paragraph]              NA                  95.7
  [paragraph], [section]
  [section][section])
Michigan ([paragraph]                   NA                  95.3
  [paragraph])
Minnesota ***                           NA                  92.3
Mississippi ([paragraph]                NA           [greater than or
  [paragraph])                                        equal to] 99.4
Missouri ([paragraph]                   NA                  95.1
  [paragraph])
Montana ([paragraph]                    NA                  92.9
  [paragraph])
Nebraska ([paragraph]                   NA                  95.8
  [paragraph], [section]
  [section][section],
  [paragraph][paragraph]
  [paragraph])
Nevada                                  NA                  90.5
New Hampshire ([paragraph]              NA           [greater than or
  [paragraph])                                        equal to] 91.5
New Jersey ([paragraph]          [greater than or          NReq
  [paragraph])                    equal to] 96.5
New Mexico                              NA                  94.6
New York (including                     NA                  96.9
New York City) ([paragraph]
  [paragraph])
New York City ([paragraph]              NA                  97.2
  [paragraph])
North Carolina ***, ([section]          NA                  95.9
  [section][section])
North Dakota                            NA                  93.5
Ohio                                    NA                  91.9
Oklahoma ([section][section]            NA                 NReq
  [section]), ****
Oregon ([paragraph]                     95.0               NReq
  [paragraph], [section]
  [section][section])
Pennsylvania                            NA                  94.6
Rhode Island ***, [section]             NA                  94.8
  [section][section]
South Carolina                          NA                  95.7
South Dakota                            NA                  95.4
Tennessee ([paragraph]                  NA                 96.7
  [paragraph]), ***
Texas (including Houston) ***,          NA                 96.6
  ([section][section]
  [section])
Houston ***, ([section]                 NA                 95.7
  [section][section])
Utah ([paragraph][paragraph])           NA                 94.6
Vermont ([paragraph]                    NA                 92.5
  [paragraph])
Virginia ([dagger][dagger]              NA                 92.7
  [dagger])
Washington ***                          NA                 89.3
West Virginia ***                       NA                 92.6
Wisconsin ***, ([dagger]                NA                 92.8
  [dagger][dagger],
  [section][section]
  [section])
Wyoming                                 NA                  NA
Guam                                   NReq                NReq
Marshall Islands                       NReq                NReq
Federated States of                    NReq                NReq
Micronesia (Kosrae)
Federated States of                    NReq                NReq
Micronesia (Yap)
N. Mariana Islands                      NA                 88.0
  ([paragraph][paragraph])
Palau ([paragraph][paragraph],         NReq                NReq
  [paragraph][paragraph]
  [paragraph][paragraph])
Puerto Rico                             NA                 95.9
U.S. Virgin Islands                     NA                 88.1

Abbreviations: DTaP = diphtheria, tetanus, and acellular pertussis
vaccine; MMR = measles, mumps, and rubella vaccine; NA = not available
(i.e., not collected or reported to CDC); NReq = not required for
school entry.

* Estimates were adjusted for nonresponse and weighted for sampling
where appropriate. Estimates based on a completed vaccination series
(i.e., not vaccine-specific) use the "[greater than or equal to]"
symbol. Coverage might include history of disease or laboratory
evidence of immunity.

([dagger]) The kindergarten population is an approximation provided by
each program.

([section]) Sample designs varied by state-area: census = program
attempted to include all schools (public and private),and all children
within schools in the assessment, and had a student response rate of
[greater than or equal to] 90%; 1-stage or 2-stage cluster sample =
schools were randomly selected, and all children in the selected
schools were assessed (1-stage) or a random sample of children within
the schools was selected (2-stage); voluntary response = a census with
a student response rate of <90% (does not imply that participation was
optional).

([paragraph]) Some programs publish kindergarten vaccination data
online that are more detailed than the state-level estimates in this
table. Examples of more detailed data include county, parish, school
district, and school-level estimates.

** MMR is the only measles containing vaccine available in the United
States. Most 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,
Pennsylvania, and Virginia require 2 doses of measles and mumps, 1
dose of rubella vaccines. Iowa requires 2 doses of measles and 2 doses
of rubella vaccines.

([dagger][dagger]) Pertussis vaccination coverage might include some
diphtheria, tetanus toxoids, and pertussis vaccine (DTP) vaccinations
if administered in another country or by a vaccination provider who
continued to use DTP after 2000. Most states require 5 doses of DTaP
for school entry; Illinois, Maryland, Virginia, and Wisconsin require
4 doses; Nebraska requires 3 doses. Pennsylvania does not require
pertussis vaccine. The reported coverage estimates represent the
percentage of kindergartners with the state-required number of DTaP
doses, except for Kentucky, which requires [greater than or equal to]
5 but reports [greater than or equal to] 4 doses of DTaP.

([section][section]) Median calculated from data from 48 states and
the District of Columbia (i.e., does not include Oklahoma, Wyoming,
Houston, New York City, Guam, Marshall Islands, Federated States of
Micronesia, N. Mariana Islands, Palau, Puerto Rico, or U.S. Virgin
Islands). Coverage data were reported for 3,973,172 kindergartners.

([paragraph][paragraph]) The proportion surveyed likely was <100%, but
is reported as 100% based on incomplete information about the actual
current enrollment.

*** Did not include some types of schools, such as online schools or
those located in military bases or correctional facilities.

([dagger][dagger][dagger]) Kindergarten vaccination coverage data were
collected from a sample, and exemption data were collected from a
census of kindergartners.

([section][section][section]) 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.

([paragraph][paragraph][paragraph]) For Nebraska, estimates represent
coverage among children in kindergarten and first grade. For Palau,
estimates represent coverage among children in first grade.

**** Reported public school data only.

([dagger][dagger][dagger][dagger]) Pertussis vaccine is not required
in Pennsylvania. Coverage for tetanus and diphtheria toxoids was
94.8%.

TABLE 2. Estimated number and percentage * of children enrolled in
kindergarten with reported type of exemption from vaccination and
grace period-provisional enrollment, by immunization program
([dagger])--United States and territories, 2016-17 school year

                                                        Nonmedical
                                                        exemptions
                                        Medical
Immunization                          exemptions,       Religious,
program                                 no. (%)             no.

Median ([paragraph])                     (0.2)              --
Alabama                                 62 (0.1)             367
Alaska                                 149 (1.5)             514
Arizona                                134 (0.2)         ([dagger]
                                                         [dagger])
Arkansas                                24 (0.1)             169
California                           2,928 (0.5)        ([section]
                                                        [section])
Colorado ([paragraph][paragraph])       NA                    NA
Connecticut                            107 (0.3)             701
Delaware                                 7 (<0.1)            133
District of Columbia                    47 (0.6)              42
Florida                                841 (0.4)           4,725
Georgia                                198 (0.1)           3,613
Hawaii                                  20 (0.1)             455
Idaho                                   86 (0.4)             127
Illinois ([paragraph][paragraph])       NA                    NA
Indiana                                112 (0.1)             697
Iowa                                    79 (0.2)             622
Kansas                                 115 (0.3)             569
Kentucky                               217 (0.4)             366
Louisiana                               54 (0.1)              32
Maine                                   32 (0.2)              36
Maryland                               391 (0.5)             628
Massachusetts                          191 (0.3)             702
Michigan                               213 (0.2)             872
Minnesota ([paragraph][paragraph])      NA                    NA
Mississippi                             31 (0.1)         ([dagger]
                                                         [dagger])
Missouri ([paragraph][paragraph])       NA                    NA
Montana                                 53 (0.4)             391
Nebraska ***                           186 (0.7)             367
Nevada                                  53 (0.1)           1,585
New Hampshire                           29 (0.2)             365
New Jersey                             196 (0.2)           1,881
New Mexico                               6 (<0.1)            604
New York (including New York City)     345 (0.2)           1,975
New York City                           78 (0.1)             581
North Carolina                         174 (0.1)           2,073
North Dakota                            24 (0.2)              64
Ohio                                   414 (0.3)        ([section]
                                                        [section])
Oklahoma ([dagger][dagger]              79 (0.2)             290
  [dagger])
Oregon                                  55 (0.1)        ([section]
                                                        [section])
Pennsylvania                           537 (0.4)           1,256
Rhode Island                            22 (0.2)             109
South Carolina                          55 (0.1)           1,124
South Dakota                            21 (0.2)             219
Tennessee                              103 (0.1)             882
Texas (including Houston)              822 (0.2)        ([section]
                                                        [section])
Houston                                 69 (0.2)        ([section]
                                                        [section])
Utah                                    88 (0.2)               4
Vermont                                 15 (0.2)             234
Virginia                               225 (0.2)           1,048
Washington                             805 (0.9)             257
West Virginia                           75 (0.3)         ([dagger]
                                                         [dagger])
Wisconsin                              194 (0.3)             271
Wyoming                                 NA                    NA
Guam                                     0 (<0.1)              7
Marshall Islands                         0 (0.0)               0
Federated States of Micronesia           0 (0.0)               0
  (Kosrae)
Federated States of Micronesia           0 (0.0)               0
  (Yap)
N. Mariana Islands                       0 (0.0)               0
Palau ***                                0 (0.0)        ([section]
                                                        [section])
Puerto Rico                             43 (0.2)              57
U.S. Virgin Islands                      0 (<0.1)             12

                                          Nonmedical exemptions

Immunization                         Philosophical,        Total,
program                                    no.             no. (%)

Median ([paragraph])                         --             (1.8)
Alabama                                      **            367 (0.6)
Alaska                                       **            514 (5.2)
Arizona                                   4,106          4,106 (4.9)
Arkansas                                    344            513 (1.3)
California                             ([section]        3,217 (0.6)
                                       [section])

Colorado ([paragraph][paragraph])            NA                NA
Connecticut                                  **            701 (1.8)
Delaware                                     **            133 (1.2)
District of Columbia                         **             42 (0.5)
Florida                                      **          4,725 (2.1)
Georgia                                      **          3,613 (2.7)
Hawaii                                       **            455 (2.7)
Idaho                                     1,265          1,392 (6.2)
Illinois ([paragraph][paragraph])            NA                NA
Indiana                                      **            697 (0.8)
Iowa                                         **            622 (1.6)
Kansas                                       **            569 (1.5)
Kentucky                                     **            366 (0.7)
Louisiana                                   364            396 (0.7)
Maine                                       622            658 (4.8)
Maryland                                     **            628 (0.9)
Massachusetts                                **            702 (1.0)
Michigan                                  3,262          4,134 (3.5)
Minnesota ([paragraph][paragraph])           NA              NA
Mississippi                                  **           ([dagger]
                                                        [dagger]), **
Missouri ([paragraph][paragraph])            NA              NA
Montana                                      **            391 (3.3)
Nebraska ***                                 **            367 (1.4)
Nevada                                       **          1,585 (4.3)
New Hampshire                                **            365 (3.0)
New Jersey                                   **          1,881 (1.7)
New Mexico                                   **            604 (2.2)
New York (including New York City)           **          1,975 (0.9)
New York City                                **            581 (0.6)
North Carolina                               **          2,073 (1.6)
North Dakota                                244            307 (3.1)
Ohio                                   ([section]        2,836 (2.1)
                                       [section])
Oklahoma ([dagger][dagger]                  620            910 (1.7)
  [dagger])
Oregon                                 ([section]        2,992 (6.5)
                                       [section])
Pennsylvania                              1,523          2,778 (1.9)
Rhode Island                                 **            109 (1.0)
South Carolina                               **          1,124 (1.9)
South Dakota                                 **            219 (1.8)
Tennessee                                    **            882 (1.1)
Texas (including Houston)              ([section]        6,078 (1.6)
                                       [section])
Houston                                ([section]          333 (0.8)
                                       [section])
Utah                                      2,391          2,395 (4.9)
Vermont                                      **            234 (3.7)
Virginia                                     **          1,048 (1.0)
Washington                                3,187          3,444 (4.0)
West Virginia                                **           ([dagger]
                                                        [dagger]), **
Wisconsin                                 3,238          3,509 (5.2)
Wyoming                                      NA              NA
Guam                                         **              7 (0.2)
Marshall Islands                             **              0 (0.0)
Federated States of Micronesia                0              0 (0.0)
  (Kosrae)
Federated States of Micronesia                0              0 (0.0)
  (Yap)
N. Mariana Islands                            0              0 (0.0)
Palau ***                              ([section]            0 (0.0)
                                       [section])
Puerto Rico                                  **             57 (0.2)
U.S. Virgin Islands                          **             12 (0.9)

                                            Any exemption

Immunization                          2016-2017,     2016-2017,
program                                  No.             %

Median ([paragraph])                      --             2.0
Alabama                                   429            0.7
Alaska                                    663            6.8
Arizona                                 4,240            5.1
Arkansas                                  537            1.4
California                              6,144            1.1
Colorado ([paragraph][paragraph])          NA            NA
Connecticut                               808            2.1
Delaware                                  140            1.2
District of Columbia                       89            1.1
Florida                                 5,566            2.5
Georgia                                 3,811            2.8
Hawaii                                    474            2.8
Idaho                                   1,478            6.5
Illinois ([paragraph][paragraph])          NA            NA
Indiana                                   809            1.0
Iowa                                      701            1.8
Kansas                                    683            1.8
Kentucky                                  583            1.1
Louisiana                                 450            0.8
Maine                                     691            5.0
Maryland                                1,019            1.4
Massachusetts                             893            1.3
Michigan                                4,347            3.7
Minnesota ([paragraph][paragraph])         NA            NA
Mississippi                                31            0.1
Missouri ([paragraph][paragraph])          NA            NA
Montana                                   444            3.7
Nebraska ***                              553            2.0
Nevada                                  1,638            4.4
New Hampshire                             394            3.2
New Jersey                              2,077            1.9
New Mexico                                610            2.3
New York (including New York City)      2,320            1.0
New York City                             659            0.6
North Carolina                          2,247            1.8
North Dakota                              332            3.4
Ohio                                    3,251            2.4
Oklahoma ([dagger][dagger]                989            1.9
  [dagger])
Oregon                                  3,047            6.7
Pennsylvania                            3,315            2.3
Rhode Island                              131            1.2
South Carolina                          1,180            2.0
South Dakota                              241            2.0
Tennessee                                 985            1.3
Texas (including Houston)               6,900            1.8
Houston                                   401            1.0
Utah                                    2,483            5.1
Vermont                                   249            3.9
Virginia                                1,273            1.2
Washington                              4,161            4.8
West Virginia                              75            0.3
Wisconsin                               3,702            5.5
Wyoming                                    NA            NA
Guam                                        7            0.2
Marshall Islands                            0            0.0
Federated States of Micronesia              0            0.0
  (Kosrae)
Federated States of Micronesia              0            0.0
  (Yap)
N. Mariana Islands                          0            0.0
Palau ***                                   0            0.0
Puerto Rico                               101            0.4
U.S. Virgin Islands                        12            0.9

                                            Any exemption

                                                    Percentage point
                                                       difference
Immunization                          2015-2016,      (2015-16 to
program                                   %             2016-17)

Median ([paragraph])                      1.9              0.1
Alabama                                   0.8             -0.1
Alaska                                    5.9              0.9
Arizona                                   4.7              0.4
Arkansas                                  1.3              0.1
California                                2.5             -1.4
Colorado ([paragraph][paragraph])         4.3              NA
Connecticut                               2.0              0.1
Delaware                                  1.2              0.0
District of Columbia                      1.0              0.1
Florida                                   2.2              0.3
Georgia                                   1.9              0.9
Hawaii                                    2.9             -0.1
Idaho                                     6.1              0.4
Illinois ([paragraph][paragraph])         NA               NA
Indiana                                   1.2             -0.2
Iowa                                      1.8              0.0
Kansas                                    1.6              0.2
Kentucky                                  0.9              0.2
Louisiana                                 0.8              0.0
Maine                                     4.5              0.5
Maryland                                  1.3              0.1
Massachusetts                             1.3              0.0
Michigan                                  3.6              0.1
Minnesota ([paragraph][paragraph])        NA               NA
Mississippi                              <0.1              0.1
Missouri ([paragraph][paragraph])         NA               NA
Montana                                   3.8             -0.1
Nebraska ***                              2.0              0.0
Nevada                                    2.0              2.4
New Hampshire                             2.6              0.6
New Jersey                                1.8              0.1
New Mexico                                1.3              1.0
New York (including New York City)        0.9              0.1
New York City                             0.4              0.2
North Carolina                            1.1              0.7
North Dakota                              3.3              0.1
Ohio                                      2.3              0.1
Oklahoma ([dagger][dagger]                1.6              0.3
  [dagger])
Oregon                                    6.3              0.4
Pennsylvania                              2.2              0.1
Rhode Island                              1.1              0.1
South Carolina                            1.6              0.4
South Dakota                              1.6              0.4
Tennessee                                 1.1              0.2
Texas (including Houston)                 1.6              0.2
Houston                                   0.9              0.1
Utah                                      4.6              0.5
Vermont                                   5.7             -1.8
Virginia                                  1.2              0.0
Washington                                4.5              0.3
West Virginia                             0.2              0.1
Wisconsin                                 3.3              2.2
Wyoming                                   NA               NA
Guam                                     <0.1              0.2
Marshall Islands                          NA               NA
Federated States of Micronesia            NA               NA
  (Kosrae)
Federated States of Micronesia            NA               NA
  (Yap)
N. Mariana Islands                        0.0              0.0
Palau ***                                 NA               NA
Puerto Rico                               0.3              0.1
U.S. Virgin Islands                       0.6              0.3

                                     Grace period/
                                      Provisional
Immunization                          enrollment,5
program                                 No. (%)

Median ([paragraph])                     (2.0)
Alabama                                  NA
Alaska                                   NA
Arizona                                  NA
Arkansas                              3,014 (7.6)
California                           10,999 (1.9)
Colorado ([paragraph][paragraph])        NA
Connecticut                              NA
Delaware                                 NA
District of Columbia                     NA
Florida                               7,293 (3.2)
Georgia                                 308 (0.2)
Hawaii                                  310 (1.8)
Idaho                                   444 (2.0)
Illinois ([paragraph][paragraph])        NA
Indiana                                  NA
Iowa                                  1,478 (3.7)
Kansas                                   NA
Kentucky                                 NA
Louisiana                                NA
Maine                                   154 (1.1)
Maryland                                 NA
Massachusetts                            NA
Michigan                                885 (0.7)
Minnesota ([paragraph][paragraph])       NA
Mississippi                             210 (0.5)
Missouri ([paragraph][paragraph])        NA
Montana                                 209 (1.7)
Nebraska ***                            881 (3.2)
Nevada                                1,042 (2.8)
New Hampshire                           633 (5.2)
New Jersey                            1,191 (1.1)
New Mexico                              182 (0.7)
New York (including New York City)    4,444 (2.0)
New York City                         1,444 (1.4)
North Carolina                        2,138 (1.7)
North Dakota                             NA
Ohio                                  6,320 (4.6)
Oklahoma ([dagger][dagger]               NA
  [dagger])
Oregon                                   NA
Pennsylvania                         11,622 (8.1)
Rhode Island                             NA
South Carolina                          385 (0.6)
South Dakota                             NA
Tennessee                             1,007 (1.3)
Texas (including Houston)                NA
Houston                                  NA
Utah                                  1,061 (2.2)
Vermont                                 408 (6.4)
Virginia                                 NA
Washington                            1,824 (2.1)
West Virginia                         1,198 (4.2)
Wisconsin                             1,567 (2.3)
Wyoming                                  NA
Guam                                     NA
Marshall Islands                         NA
Federated States of Micronesia           NA
  (Kosrae)
Federated States of Micronesia           NA
  (Yap)
N. Mariana Islands                       NA
Palau ***                                NA
Puerto Rico                              NA
U.S. Virgin Islands                      NA

Abbreviation: NA = not available (i.e., not collected or reported to
CDC).

* Estimates were adjusted for nonresponse and weighted for sampling
where appropriate.

([dagger]) Medical exemptions, nonmedical exemptions, and grace
period/provisional enrollment status might not be mutually exclusive.
Some children might have both medical and nonmedical exemptions, and
some enrolled under a grace period/provisional enrollment might be
exempt from one or more vaccinations.

([section]) A grace period is a set number of days during which a
student can be enrolled and a([dagger][dagger])end school without
proof of complete vaccination or exemption. Provisional enrollment
allows a student without complete vaccination or exemption to
a([dagger][dagger])end school while completing a catch-up vaccination
schedule. In states with one or both of these policies, the
estimates represent the number of kindergartners within a grace
period, provisionally enrolled, or some combination of these
categories.

([paragraph]) Medians calculated from data from 45 states and District
of Columbia; states/jurisdictions excluded were Colorado, Illinois,
Minnesota, Missouri, and Wyoming. Houston, New York City, Guam,
Marshall Islands, Federated States of Micronesia, N. Mariana Islands,
Palau, Puerto Rico, and U.S. Virgin Islands were also excluded.
Exemption data were reported for 3,666,870 kindergartners. Grace
period/provisional enrollment median was calculated from data from 27
states; data were reported for 2,463,131 kindergartners.

** Philosophical exemptions were not allowed.

([dagger][dagger]) Religious exemptions were not allowed.

([section][section]) Religious and philosophical exemptions were not
reported separately.

([paragraph][paragraph]) Program 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 estimated
using the individual vaccines with the highest number of exemptions
are: for Colorado, 0.2% with medical exemptions, 0.3% with religious
exemptions, 3.1% with philosophical exemptions, and 3.6% with any
exemptions; for Illinois, 0.2% with medical exemptions, 1.2% with
religious exemptions, and 1.4% for any exemptions; for Minnesota, 0.2%
with medical exemptions, 3.1% with nonmedical exemptions, and 3.3% for
any exemptions; and for Missouri 0.2% with medical exemptions, 2.0%
with religious exemptions, and 2.2% for any exemptions.

*** For Nebraska, estimates represent exemptions among children in
kindergarten and 1st grade. For Palau, estimates represent coverage
among children in 1st grade.

([dagger][dagger][dagger]) Reported public school data only.
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Author:Seither, Ranee; Calhoun, Kayla; Street, Erica J.; Mellerson, Jenelle; Knighton, Cynthia L.; Tippins,
Publication:Morbidity and Mortality Weekly Report
Article Type:Statistical table
Geographic Code:1USA
Date:Oct 13, 2017
Words:8120
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