School-Entry Vaccine Policies: States’ Responses to Federal Recommendations Varied from Swift to Substantially Delayed

Devon R. Minnick, Spreeha Choudhury, Richard H. Hughes, IV, attorneys in the Health Care & Life Sciences practice, and Anna Larson, Advisor, co-authored an article in Health Affairs, titled “School-Entry Vaccine Policies: States’ Responses to Federal Recommendations Varied from Swift to Substantially Delayed.”

Following is an excerpt:

School-entry immunization requirements are a valuable strategy to reduce the spread of vaccine-preventable diseases. This research examined the temporal relationship between recommendations issued by the federal Advisory Committee on Immunization Practices (ACIP) and corresponding school-entry requirements adopted by states for adolescent meningococcal ACWY (MenACWY) and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. A legal epidemiological review of statutes, regulations, and state agency guidance identified school-entry policies across fifty states and Washington, D.C. Researchers measured the number of months between the date of an ACIP recommendation and the effective dates for state policies that were in place through the 2023–24 school year. All fifty-one jurisdictions had school-entry requirement policies for Tdap vaccination, and thirty-six had school-entry requirements for MenACWY vaccination. The average period between ACIP’s recommendations and state policy adoption was 4.94, 9.61, and 8.24 years for Tdap and for MenACWY first and booster doses, respectively. This analysis found diverse timelines and notable delays for both Tdap and MenACWY school-entry requirement policies. This heterogeneity and patchwork of state requirements underscores the need for ACIP to evaluate the role of these policies in reducing vaccine-preventable diseases across the United States.

School-entry immunization requirements play an important role in preventing diseases and in protecting public health. Such policies have a long-standing precedent in the United States, dating back to 1827, when a Boston school committee first introduced a requirement to vaccinate against smallpox, and to 1855, when Massachusetts enacted a state law requiring vaccination for school entry. Since then, scientific advancements have led to new vaccines that protect against numerous diseases. Subsequently, vaccination as a prerequisite for child care and school attendance has been used as a tool to protect children and adolescents from many dangerous diseases such as measles, mumps, and rubella; invasive meningococcal disease; tetanus, diphtheria, and pertussis; hepatitis A and B; Haemophilus influenzae type B; influenza; varicella; human papillomavirus (HPV); pneumococcal disease; rotavirus; and polio. School-entry requirements are cited by the Centers for Disease Control and Prevention (CDC) as an important tool to use in maintaining high vaccination coverage rates.

School-entry requirements are supported by legal precedent dating back more than a century. In Jacobson v. Massachusetts, the United States Supreme Court upheld compulsory vaccination laws as a lawful exercise of state police powers to protect public health. Zucht v. King reaffirmed Jacobson and further held that states could exclude unvaccinated students from attending public schools where a disease was a probable but not imminent threat. Prince v. Massachusetts reinforced the state’s authority to require vaccination, emphasizing the precedence of public health and safety interests over individual objections.

State-level immunization policies are typically preceded by recommendations issued by the federal Advisory Committee on Immunization Practices (ACIP). Established in 1964, ACIP has been instrumental in guiding immunization practices in the US. ACIP applies an Evidence to Recommendations framework before issuing its recommendations. The framework includes factors for ACIP’s consideration, such as the vaccine’s safety and effectiveness at specific ages; disease severity; number of people affected without the vaccine; the vaccine’s effectiveness across different ages; and the practicality of implementing the recommendations, including feasibility and equity issues. The resulting recommendations shape national immunization schedules and policies, such as the development and modification of state-level school-entry requirements.

For adolescents, ACIP has recommended tetanus, diphtheria, and acellular pertussis (Tdap) vaccination, meningococcal conjugate (meningococcal ACWY, or MenACWY) vaccination in two doses, HPV vaccination, and certain catch-up vaccines for missed or incomplete vaccination series. Vaccinating adolescents before they face risks unique to this developmental stage protects them against the diseases and addresses critical health needs. Maintaining this “adolescent platform” strengthens herd immunity and addresses specific health risks at the individual and population levels.

Although ACIP provides guidance on the clinical use of vaccines, policies pertaining to mandatory immunization before school entry are left to the states. Although all fifty states and Washington, D.C. (hereafter referred to as “states”), have policies requiring vaccination for students to enter school, how these policies are put into practice varies, which can have differential effects on vaccine uptake within states that have requirements versus those that do not for particular immunizations. Delays between when the immunization is recommended by ACIP and when a state adopts a related policy could negatively affect timely immunization uptake and have downstream impacts on herd immunity and disease suppression.

To better understand the timing associated with these processes, particularly for the adolescent platform, we conducted a legal epidemiological review to document the amount of time between ACIP’s issuance of recommendations and subsequent state adoption of school-entry requirements for MenACWY and Tdap immunization.