Benefits of Maintaining High Immunization Rates
Maintaining high immunization rates protects immunized individuals from vaccine-preventable diseases (VPD) and prevents the spread of these diseases to people who cannot be immunized. Examples of those who cannot be immunized include young infants as well as persons for whom immunization is contraindicated due to serious medical conditions and/or immunosuppression related to HIV, cancer, or other conditions. High coverage levels prevent VPD cases and outbreaks, decrease morbidity and mortality, and reduce absenteeism from school or work for people who were exposed to cases.
In Los Angeles County, pediatric immunization coverage levels increased following the elimination of personal beliefs exemptions (PBEs) for child care and school immunization requirements in 2016. However, coverage levels have subsequently leveled off as rates of medical exemptions have increased.1,2
To maintain high immunization rates in Los Angeles County, providers should:
- Adhere to the ACIP-recommended immunization schedules. Following these recommended schedules also ensures that children will meet California’s child care and school immunization requirements.
- Follow expert guidance on vaccine contraindications and precautions.
- Discuss the benefits and potential adverse events of immunizations and any concerns or fears with parents and caregivers,3 considering cultural beliefs and health literacy. Use an approach that avoids assumptions about which parents may accept vaccines, decline vaccines, or raise concerns. The required Vaccine Information Sheets, COVID-19 Fact Sheets, and the CDC's Provider Resources for Vaccine Conversations with Parents webpage are helpful tools for these discussions. Additional resources for communicating with parents/guardians can be found in this article's Resource List.
- Use practice-based strategies such as client reminder-recall and provider reminders.
Immunization Requirements for Child Care and School Attendance
California’s immunization requirements apply to children who attend a:
- Pre-kindergarten facility, which includes public or private child care centers, day nurseries, nursery schools, family day care homes, or development centers
- TK/K-12 school, which includes transitional kindergarten and kindergarten through 12th grade.
Children must meet all immunization requirements unless they have an appropriately documented medical exemption or a valid and pre-existing personal beliefs exemption (PBE) that was granted prior to January 1, 2016.4,5
Unconditional and Conditional Admission
Per California law, parents/guardians must submit proof of immunization when:4
- A child is newly admitted to a pre-kindergarten facility or TK/K-12 school.
- A child attending pre-kindergarten reaches the next immunization checkpoint (based on age).
- A student advances to the seventh grade.
In addition, for the 2021-2022 school year, there was an additional immunization checkpoint for students starting first grade or entering eighth grade in addition to the routine checkpoints at kindergarten and seventh grade.
Depending on their immunization status, children will either be excluded from attendance until they meet all requirements or are granted unconditional or conditional admission.
- Unconditional Admission: Children are granted unconditional admission if their parent/guardian provides written documentation of receipt of all mandatory immunization doses except for those for which the child has:
- A valid permanent medical exemption or
- A valid PBE for the child’s current grade span (i.e., pre-kindergarten span; TK/Kindergarten through 6th grade span, or 7th through 12th grade span) that was filed in California prior to January 1, 2016.4
The criteria for a valid PBE are detailed in the California Department of Public Health’s (CDPH) California Immunization Handbook.
Children who are admitted unconditionally at a younger age or in younger grades will be required to provide additional proof of required immunizations when additional doses are due at a later age or grade (i.e., when they reach the next vaccine checkpoint).4,5
- Conditional Admission: Under certain circumstances, children who have not received all required doses may conditionally attend a pre-kindergarten facility or TK/K-12 school. Conditional admission may be granted for a child who has not received all required vaccine doses if they:
- Have started all of the required vaccine doses for their age/grade span and are not due for additional doses at the time of admission or
- Are less than 18 months old and have received all required doses for their age but need future doses or
- Have documentation from a physician (MD or DO) who is licensed in California, for a temporary medical exemption for missing required doses.4
Continued attendance is dependent upon documented receipt of all remaining required doses. Providers should ensure that patients who are catching up on immunizations receive required immunizations as soon as possible. Of note, if providers follow ACIP’s Catch-up Immunization Schedule, children will be compliant with the conditional admission schedule in the California regulations.
- Students who attend home-based private schools or participate in independent study programs that do not include classroom-based instruction are exempted from school entry immunization requirements.5,6 Note: Schools and child care centers will typically notify the parent or guardian if a child was not required to meet immunization requirements.
- Children with individualized education programs (IEPs) should continue to receive all necessary services listed in the IEP regardless of their immunization status.5,6
- Children who are homeless or in foster care who transfer into a new school can be admitted immediately, even if their immunization records are not available at the time of admission.5 Providers are encouraged to ensure that these vulnerable students are caught up on any missing doses as soon as possible and to record doses administered into the California Immunization Registry (CAIR2). (See ACIP’s Catch-up Immunization Schedule.)
On July 1, 2019, new California school immunization regulations went into effect for the 2019-2020 and future school years. Revisions included changes to the number of doses and age restrictions for varicella immunization.4,5 Though California school entry immunization requirements do not currently include COVID-19 vaccines, it is anticipated that they will be added to the list of vaccines required for in-person school attendance, after full Food and Drug Administration (FDA) approval, but no sooner than July 1, 2023.
See Table 1 for current California immunization requirements. Additional information and resources regarding California requirements, including Frequently Asked Questions (FAQs) and a webinar and slides for physicians can be found at the CDPH School Immunization website.