July 2022

Candace Gragnani, MD, MPH, FAAP

Franklin Pratt, MD, MPHTM, FACEP

Julia Heinzerling, MPH

This article is a revision of the "Understanding California's Child Care and School Immunization Requirements and Medical Exemptions" article last published in 2019.

This article is designed to help health care providers understand and navigate California’s child care and school immunization requirements and use an evidence-based approach to immunizations and medical exemptions, including for COVID-19 vaccines, to ensure the best health for their patients.

The article covers the following topics:

• Benefits of Maintaining High Immunization Rates
• Immunization Requirements for Child Care and School Attendance
  • Unconditional and Conditional Admission
  • Special Considerations
  • Required Immunizations
  • Screening for Required Immunizations
• Medical Exemptions to Required Immunizations
  • Documenting Medical Exemptions
  • Medical Exemption Review and Appeal Process
• Guidance for Contraindications and Precautions
  • Misperceptions Regarding Contraindications
  • Screening for Contraindications and Precautions
• Considerations for Coronavirus Disease 2019 (COVID-19) Immunization in Children Under 18 Years of Age
  • Clinical Considerations
  • Current Contraindications and Precautions to COVID-19 Vaccines
  • Additional Considerations
• Reporting of Adverse Events
• Conclusion
• Resources

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:

1. A valid permanent medical exemption or
2. 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.

Special Considerations

• 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.)

Required Immunizations

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.  

Table 1: California Immunization Requirements for
Pre-Kindergarten and TK/K-12 School Attendance

Click here to download Table 1 formatted for printing and posting.

This table was adapted from the California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8: www.eziz.org/assets/docs/IMM-1080.pdf.

Table Footnotes

1. Combination vaccines (e.g., MMRV) meet the requirements for individual component vaccines. Doses of DTP count towards the DTaP requirement.
2. Any vaccine administered 4 or fewer days prior to the minimum age is valid.
3. A pupil’s parent or guardian must provide documentation of a pupil’s proof of immunization to the governing authority no more than 30 days after a pupil becomes subject to any additional requirement(s) based on age, as indicated in this table.
4. Per ACIP, 1 Hib dose is recommended for children who are unvaccinated at 15–59 months of age. For the Hib requirement, 1 Hib dose must be given on or after the first birthday regardless of previous doses. This is required only for children who have not reached the age of 5 years. www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-hib
5. Requirements for TK/K‐12 admission also apply to transfer pupils.
6. For the 2021-2022 school year, proof of immunization is required for incoming first and eighth grade students in addition to kindergarten and seventh grade entrants, to address delayed screenings in the prior school year due to the COVID-19 pandemic. www.eziz.org/assets/docs/shotsforschool/2021August3AdditionalReporting.pdf
7. For the polio requirement, 3 doses of polio vaccine meet the requirement if 1 dose was given on or after the fourth birthday.
8. For the DTaP requirement, 4 doses of DTaP vaccine meet the requirement if at least 1 dose was given on or after the fourth birthday. Three doses meet the requirement if at least 1 dose of Tdap, DTaP, or DTP vaccine was given on or after the seventh birthday. One or 2 doses of Td vaccine given on or after the seventh birthday count towards the requirement.
9. For information regarding hepatitis B requirements for seventh grade admission, see Health and Safety Code § 120335, subdivision (c). www.leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=120335.&nodeTreePath=44.2.1&lawCode=HSC
10. Two doses of measles, 2 doses of mumps, and 1 dose of rubella vaccine meet the requirement, separately or combined. Only doses administered on or after the first birthday meet the requirement.
11. For 7th‐12th graders, at least 1 dose of pertussis‐containing vaccine is required on or after the 7th birthday.
12. For children in ungraded schools, pupils 12 years and older are subject to the seventh grade advancement requirements.
13. The varicella requirement for seventh grade advancement expires after June 30, 2025.

Screening for Required Immunizations

When screening patients for required immunizations for pre-kindergarten or school entry, only doses that are recorded on a written record that lists the patient’s name, birth date, vaccine given, date administered (month/day/year), and vaccine administrator should be considered valid.⁴ Records accessed via the California Immunization Registry or other state immunization registries are considered valid.⁵ See the Red Book for guidance for reviewing records of students arriving from outside of the United States.

Receipt of homeopathic preparations, such as nosodes, does not satisfy immunization requirements since California regulations define a vaccine as “an immunization administered in the United States of America or other countries that is recommended by the federal Advisory Committee on Immunization Practices for the prevention of the respective diseases identified in section 120335 of the Health and Safety Code."⁴

Parental reports of prior immunization or childhood illnesses should not be considered sufficient evidence of immunity.⁷ If a child’s vaccine record cannot be located within a reasonable timeframe, a provider should consider the child to be susceptible and provide age-appropriate vaccine doses. Serologic testing can be considered as an alternative for certain antigens only for specific cases or when a vaccine is contraindicated.^7,8 For further information on the use of serologic testing and immunization records (or lack thereof) for special circumstances, including for children who have received childhood immunizations outside of the United States, see the Red Book⁷ and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices’ guidelines.⁸    

Medical Exemptions to Required Immunizations

California law allows children to be exempted from one or more immunization requirement(s) for child care or school entry if they have a valid temporary or permanent medical exemption on file. Exemptions can be issued no more than 12 months prior to the child entering a grade span and expire when one or more of the following is met:

• The child is enrolled in the next grade span (i.e., TK/K-6th grade, 7th-12th grade) and/or
• A temporary medical exemption has expired. (Temporary exemptions are valid for a maximum of 12 months from the date they were issued, at which point, the physician can reassess the need for the temporary exemption.) and/or
• The exemption has been permanently revoked.^6,9

As of 2021, medical exemptions can only be issued by a California-licensed physician (MD or DO) in the California Immunization Registry – Medical Exemption website (CAIR-ME). Please note: Access to CAIR-ME requires a separate log-in from CAIR2.

Licensed physicians cannot issue new medical exemptions if they are on probation for immunization-related practices, are determined to be a public health risk by CDPH or have a pending immunization-related practice accusation. If CDPH determines that a physician represents a public health risk, that physician will be barred from issuing exemptions for two years or longer.^5,6,9

California’s school immunization law requires that medical exemptions be consistent with applicable recommendations of the American Academy of Pediatrics (AAP) and ACIP.^6,10 When evaluating a patient for a medical exemption, physicians should use their best clinical judgment; adhere to contraindications and precautions; and consider pertinent medical history, physical findings, and/or diagnostic studies. When providing a medical exemption, physicians should also consider the duration of the contraindication since few are considered permanent and vaccines can be reconsidered at a later date after temporary medical exemptions expire.

Documenting Medical Exemptions

Documentation in the Patient’s Medical Record

When a medical exemption is provided, the patient’s medical record should clearly document findings, describe the reason for the medical exemption, specify the duration of the exemption, and demonstrate that it is consistent with standards of care for contraindications and precautions.⁷

Documentation for Pre-Kindergarten and TK/K-12 Admission

In addition to documenting a medical exemption in the medical record, the physician must also issue it in CAIR-ME. Typically, a physician will complete a form that the parent or guardian has entered into CAIR-ME but if the parent/guardian cannot submit the initial request, the physician can complete the parents’ section, confirm that they agree to authorizations on the Child and Parent Information tab, and complete the remaining physician sections. Physicians are encouraged to upload relevant documentation to support the exemption. After the exemption has been issued, the physician should provide the two-page exemption form to the parent or guardian to submit to the child’s school or child care facility.

Medical Exemption Review and Appeal Process

Valid medical exemptions that were issued prior to January 1, 2021 will remain valid until the earliest of the following: the child enrolls in the next grade span, the temporary exemption expires, or the exemption is revoked secondary to disciplinary action against the issuing provider by the appropriate licensing entity.⁶

All medical exemptions issued on or after January 1, 2021 are subject to review by CDPH and can be revoked. A clinically trained physician or registered nurse with the CDPH Immunization Branch will review all medical exemptions if any of the following conditions are met: (1) the child care facility’s or school’s immunization rates are under 95%, (2) the child care facility or school has failed to report its immunization rates, (3) a physician and surgeon has submitted 5 or more medical exemptions in a calendar year, or (4) CDPH determines that the review is necessary for the protection of public health.^6,9

Medical exemptions that are revoked can be appealed by a parent/guardian to the California Secretary of Health and Human Services.¹⁰ The parent or guardian and/or the physician who issued the exemption may submit supporting documentation for the appeal.

For more information on medical exemptions, CAIR-ME, and the medical exemption review process, see the Shots for School website or the California Immunization Handbook.⁵

Guidance for Contraindications and Precautions

Understanding contraindications and precautions for school-required immunizations is vital to ensuring safe receipt of recommended doses and issuance of appropriate medical exemptions for patients who are at risk of serious adverse reactions. A vaccine contraindication is a condition that increases the risk of a serious adverse reaction to a vaccine for patients with that condition, while a precaution is a condition that might increase risk for serious adverse reaction, increase severity of an adverse reaction, cause diagnostic confusion, or compromise the ability of the vaccine to produce immunity.^8,11

Vaccines that are contraindicated should never be given while the contraindication persists.⁸ Medical exemptions should be provided if the contraindicated dose(s) are required for pre-kindergarten or TK/K-12 school entry. If a patient has a condition considered to be a precaution to a vaccine, that vaccine may still be given if the physician believes the benefit of vaccine-induced protection outweighs the risk of an adverse reaction or the condition has resolved.^8,11 Temporary medical exemptions should be issued for temporary precautions if the dose(s) are required for child care or school entry.

Only 2 conditions are generally considered to be permanent contraindications for immunizations required for pre-kindergarten or TK/K-12 school entry:

• All vaccines: Severe anaphylactic allergic reaction to a vaccine component or following a prior dose of the same vaccine¹¹
• Pertussis-containing vaccines: Encephalopathy occurring within 7 days of pertussis immunization not due to another identifiable cause.¹¹

See Tables 2 and 3 for examples of contraindications and precautions for school-required vaccines.

Most contraindications and precautions are temporary, and the vaccine can be given when the condition no longer exists.⁸ For instance, pregnancy is a temporary contraindication to live, attenuated vaccines. Severe immunosuppression may also be considered a temporary contraindication in certain circumstances. For example, an individual’s clinical status or medication changes may result in the resolution of a previously immunosuppressed state, thereby making them eligible for immunizations they were previously unable to receive. See Table 2 for additional guidance and resources regarding immunizations for those with immunosuppression, including an important note about how the MMRV vaccine should never be given to any patient with HIV.^7,8

Family medical history of hereditary or congenital immunodeficiency is rarely a contraindication or precaution to vaccines but can be a factor in granting medical exemptions from certain required immunizations.⁷ Based on ACIP recommendations, there is no family history that would provide a permanent contraindication to any immunization that is required for pre-kindergarten or TK/K-12 school attendance in California. However, a family history of hereditary or congenital immunodeficiency in first degree relatives (i.e., parents or siblings) is a temporary contraindication to MMR and varicella immunizations until an individual has clinical or laboratory proven immunocompetence. In addition, a family history of seizures is a precaution to MMRV combination vaccines.⁸

Table 2: Contraindications to Immunizations Required for
Pre-Kindergarten and TK/K-12 School Entry

Click here to download Table 2 formatted for printing and posting.

Recommendations were derived from guidance published by the American Academy of Pediatrics, Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention, Immunization Action Coalition, and Infectious Diseases Society of America.^a

Table Footnotes

1. Recommendations were derived from the following sources: American Academy of Pediatrics’ Red Book,⁷ Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization,⁸ Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine‐Preventable Diseases,¹¹ Immunization Action Coalition’s Guide to Contraindications and Precautions to Commonly Used Vaccines,¹² and Infectious Diseases Society of America’s 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host.¹³
2. Severe allergic reaction may include symptoms of anaphylaxis, such as hives, wheezing, trouble breathing, circulatory collapse, or shock. For a summative table of vaccine ingredients, see the CDC's Vaccine Excipient Summary.
3. Hypersensitivity to yeast is also considered a contraindication to hepatitis B immunization.⁸
4. Congenital immunodeficiencies considered to be contraindications to MMR and Varicella include, but are not limited to, severe combined immunodeficiency disease (SCID), most patients with DiGeorge syndrome, Wiskott‐Aldrich syndrome, and Chediak‐Higashi syndrome. For a full list of congenital immunodeficiencies for which MMR and Varicella vaccines are contraindicated, as well as additional guidance on immunizations for people with congenital immunodeficiency, see recommendations from the Red Book,⁷ACIP,⁸ and IDSA.¹³
5. For additional guidance on immunizations for children and adolescents who are hematopoietic stem cell or solid organ transplant candidates or recipients, see recommendations from the Red Book,⁷ACIP,⁸ and IDSA.¹³
6. Varicella and MMR vaccines can be administered to HIV‐infected children and adolescents without severe immunosuppression based on clinical status and specified criteria, including age‐dependent CD4+ T‐lymphocyte counts and/or percentages.⁷ Of note, the MMRV vaccine should never be given to any patient with HIV.^7,8 For additional guidance on immunizations for HIV‐infected children and adolescents, including details regarding what comprises severe immunosuppression, see recommendations from the Red Book,⁷ ACIP,⁸ and IDSA.¹³

Table 3: Precautions to Immunizations Required for
Pre-Kindergarten and TK/K-12 School Entry

Click here to download Table 3 formatted for printing and posting.

Recommendations were derived from guidance published by the American Academy of Pediatrics, Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention, and Immunization Action Coalition.^a

Table Footnotes

1. Recommendations were derived from the following sources: American Academy of Pediatrics’ Red Book,⁷ Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization,⁸ Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine‐Preventable Diseases,¹¹and Immunization Action Coalition’s Guide to Contraindications and Precautions to Commonly Used Vaccines.¹²
2. The decision to give additional doses should be made on the basis of consideration of the benefit of further immunization versus the risk of recurrence of GBS.¹⁶
3. Note that a history of extensive limb‐swelling after DTP, DTap, or Td that is not an Arthus‐type reaction is not a contraindication to Tdap immunization.⁷
4. While progressive or unstable neurologic disease is a precaution to DTaP, a family history (i.e., siblings or parents) of seizures or a personal history of well‐controlled seizures is not. Whether and when to administer DTaP to a child with a proven or suspected underlying neurological disorder should be determined on a case-by-case basis.⁸
5. See ACIP recommendations for additional details on recommended vaccine intervals and considerations when receiving immune products.
6. While ACIP recommends postponing the TST or IGRA for at least 28 days after immunization (if MMR cannot be administered on the same day as the TST or IGRA),⁸ the Red Book recommends delaying testing for 4‐6 weeks after immunization.⁷ Given that there is also some evidence that suggests varicella immunization may have similar effects on TST, CDC and the Red Book recommend applying the same spacing rules to TST or IGRA after varicella-containing vaccines.^7,11 If there is an urgent need for TST or IGRA less than 4 weeks after vaccination, testing can be completed with the understanding that reactivity may be reduced.⁸ See the CDC’s Tuberculin Skin Testing FAQ.
7. While ACIP recommends avoiding specific antivirals (e.g., acyclovir, famciclovir, or valacyclovir) for 24 hours before immunization and up to 14 days after varicella immunization,^8,11 the Red Book recommends avoiding specific antivirals for 1 day before immunization and up to 21 days after immunization.⁷
8. While no adverse effects have been documented in pregnant women or the fetus after IPV vaccination, it is recommended that vaccination be avoided on theoretical grounds. However, if a pregnant woman is at an increased risk for infection and needs immediate protection, IPV may be given per the recommended schedules. Please see additional CDC guidance on vaccination in pregnant individuals for more details.
9. While there have been no reports of adverse events with the use of aspirin or aspirin‐containing products after varicella immunization, the vaccine manufacturer recommends that vaccine recipients avoid using aspirin or aspirin-containing products for 6 weeks after receipt of a varicella-containing vaccine because of the association between aspirin and Reye syndrome after varicella. For children with an underlying medical condition that requires the therapeutic use of aspirin (e.g., rheumatoid arthritis), vaccination with subsequent close monitoring should be considered. The risk of serious complications associated with aspirin use is likely to be greater in children who develop natural varicella than it is in those who receive an attenuated varicella vaccination.⁸

Misperceptions Regarding Contraindications

Patients, parents, and health care providers may misperceive certain conditions to be contraindications to immunization, which can lead to missed opportunities to immunize. Common misperceptions are listed in Table 4. For a more complete list, see the ACIP guidelines.

The CDC’s Provider Resources for Vaccine Conversations website and the Communicating with Parents and Caregivers Resources List include resources that can help you when discussing vaccines with parents and adult patients. Examples include a video explaining 5 research-based strategies to improve vaccine conversations with parents, the CDC’s Preparing for Questions Parents May Ask About Vaccines webpage, and a list of science-based resources for responding to vaccine-hesitant parents from the Immunization Action Coalition.

Table 4: Common Misconceptions about Medical Contraindications or Precautions
to Immunizations Required for Pre-Kindergarten and TK/K-12 School Entry

Click here to download Table 4 formatted for printing and posting.

Information was derived from the following sources: American Academy of Pediatrics, Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention, and the What You STILL Need to Know About Medical Contraindications to Immunization Under SB 277 presentation (Randy Bergen, MD).^a

Table Footnotes

1. Information was derived from the following sources: American Academy of Pediatrics’ Red Book,⁷ Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization,⁸ Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine‐Preventable Diseases,¹¹ and the What You STILL Need to Know About Medical Contraindications to Immunization Under SB 277 presentation (Randy Bergen, MD).¹⁷
2. Note that receipt of specified antivirals may be a precaution to varicella immunization. See Table 3.
3. For individuals with severe immunodeficiency or HIV, see ACIP recommendations regarding severe immunocompromise and the approach to proper immunization.
4. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) is a proposed syndrome that consists of four autoimmune/autoinflammatory conditions, one of which is post‐vaccination phenomena, believed to occur in genetically predisposed individuals after exposure to environmental triggers.¹⁸ These triggers are believed to include things like pollutants, aluminum salts, and adjuvants found in some vaccines. The exact role of specific vaccines and vaccine‐adjuvants in these processes has not been clearly delineated or defined, nor have the appropriateness of proposed diagnostic criteria for ASIA been validated or fully evaluated in the pediatric population.¹⁸ There are no current ACIP recommendations specifically regarding the consideration of ASIA when determining patient eligibility for immunizations.⁸
5. ACIP guidance states that if a vaccinee develops a presumed vaccine-related rash 7-25 days after varicella vaccination, the person should avoid any direct contact with immunocompromised individuals for the duration of the rash.⁸
6. ACIP guidance states that while current, recent, or upcoming general anesthesia/surgery/hospitalization is not a contraindication to vaccination, there may be certain factors that lead a provider to consider current, recent, or upcoming general anesthesia/surgery/hospitalization as a precaution.⁸
7. Hepatitis B immunization should be deferred for infants weighing <2,000 g if the mother is documented to be HBsAg‐negative at the time of the infant’s birth. Immunization should commence at chronological age 1 month or at hospital discharge. For infants born to HBsAg‐positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 hours after birth, regardless of weight.⁸

Screening for Contraindications and Precautions

Providers should screen for contraindications and precautions before each vaccine dose is administered and reassess for vaccine eligibility if doses were delayed due to a temporary contraindication or precaution. Consider using a screening checklist, such as the Immunization Action Coalition’s Screening Checklist for Contraindications to Vaccines for Children and Teens and the CDC’s Prevaccination Checklist for COVID-19 Vaccination.

Immunization Action Coalition Screening Checklist

Download the checklist with additional instructions for healthcare professionals in English and other languages.

Reproduced with permission from the Immunization Action Coalition.¹⁹

Prevaccination Checklist for COVID-19 Vaccination

Download the checklist for information regarding precautions and contraindications, observation periods, potential characteristics of reactions and vaccine side effects, and additional clinical considerations.

Considerations for Coronavirus Disease-2019 (COVID-19) Immunizations in Children Under 18 Years of Age

California became the first state in the nation to announce that students will be required to be vaccinated for COVID-19 for in-person learning starting the term that follows full FDA approval of the COVID-19 vaccine for their respective grade span. The FDA has not yet fully approved COVID-19 vaccines for persons of all ages within the TK/K–12th grade span and the State of California announced that it will not initiate the regulatory process for a COVID-19 vaccine requirement for the 2022-2023 school year, to ensure sufficient time for successful implementation of the new vaccine requirements. As a result, any State vaccine requirements for schools will not take effect sooner than July 1, 2023.²¹  

At the time of publication, there are two COVID-19 vaccines available for use in pediatric populations aged 6 months through 17 years, Pfizer-BioNTech COVID-19 Vaccine/COMIRNATY and Moderna COVID-19 Vaccine/SPIKEVAX. These are both mRNA vaccines.²⁰ There are no COVID-19 vaccines currently available for children under 6 months of age.²⁰  However, studies have shown that vaccinating pregnant people against COVID-19 reduces the risk of COVID-19 hospitalization for infants younger than 6 months of age.²⁰ Details on the effectiveness and safety data evaluated and analyzed for the most recently authorized COVID-19 vaccines for children 6 months through 17 years of age can be found on the FDA website. 

CDC and AAP recommend that all children aged 6 months and older should remain up-to-date with COVID-19 vaccination using the age-appropriate vaccine formulation, unless vaccination is contraindicated.^20,22,23 Recommendations for additional doses and booster doses are variable and dependent on age, the COVID-19 vaccine product, immunocompetence, and time since  vaccination.²⁰  For detailed information, see COVID-19 Vaccination Guidance for People Who Are Not Moderately or Severely Immunocompromised. For information on vaccination considerations in moderately or severely immunocompromised children, see COVID-19 Vaccination Guidance for People who are Moderately or Severely Immunocompromised.

Clinical Considerations

COVID-19 clinical guidance changes frequently and this article does not address considerations such as dosing, the vaccine schedule, interchangeability of vaccine products, coadministration with other vaccines, recommendations for patients who are transitioning from a younger to an older age group, considerations in special populations, or post-vaccination symptoms and safety considerations. Please refer to the ICC and the links below for recommendations and guidance for administering COVID-19 vaccines to children.

CDC Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States 

Consult the CDC’s ICC often for the latest recommendations and resources.

Summary Document for Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized or Approved in the United States  

Download CDC’s Summary for key clinical considerations for use of COVID-19 vaccines including information regarding vaccine indications, pre-vaccination counseling, precautions and contraindications, post-vaccination observation periods, and antibody testing.
 

At-a-Glance Immunization Schedules  

Review these At-a-Glance Schedules to determine how many COVID-19 vaccine doses are recommended based on the primary series product, age, and immune status.

Interim COVID-19 Immunization Schedule for 6 Months of Age and Older

Download this summary of the COVID-19 vaccination schedules based on age and medical condition.

Current Contraindications and Precautions to COVID-19 Vaccines

COVID-19 vaccination is recommended for children, ages 6 months and older, regardless of a history of symptomatic or asymptomatic COVID-19 infection.²⁰ Providers should screen for contraindications and precautions before each COVID-19 vaccine dose is administered and reassess for vaccine eligibility if any doses were delayed.

To reduce the risk of transmission to others, individuals with known active SARS-CoV-2 infection should defer any COVID-19 vaccination at least until recovery from acute illness (e.g., symptoms) and after isolation is discontinued. Individuals with recent SARS-CoV-2 infection can consider delaying their next COVID-19 vaccine dose (primary or booster) by 3 months from onset of symptoms or from positive test if the infection was asymptomatic.  Viral testing to assess for acute SARS-CoV-2 infection or serologic testing to assess for prior infection are not currently recommended for the purpose of vaccine decision-making.²⁰

Because research is ongoing and CDC guidance is expected to change, please follow the latest CDC guidance for contraindications and precautions as outlined in the ICC.

Contraindications and Precautions to COVID-19 Vaccines

Consult this summary of COVID-19 contraindications and precautions and use the CDC’s Pre-Vaccination Checklist for COVID-19 Vaccine  to screen for vaccination.

Additional Considerations

Please consider the following additional recommendations and resources when vaccinating children against SARS-CoV-2.

• As is the case with other vaccines, underlying health conditions may be incorrectly perceived to be contraindications to COVID-19 vaccines. In fact, people with certain underlying medical conditions are at increased risk for severe COVID-19 illness, including hospitalization and death, and COVID-19 vaccines can be safely given to most people with these conditions to help prevent severe illness. Thus, underlying medical conditions are often a reason to be immunized, not a contraindication.²⁴
• Most people deemed to have a precaution to a COVID-19 vaccine can be vaccinated and in many cases, it’s not necessary to defer a dose to a later time. However, there are some scenarios where the vaccine should generally not be administered (e.g., as a precaution, those who developed myocarditis or pericarditis after a dose of mRNA COVID-19 immunization should generally not receive any subsequent doses). There are also instances where the CDC provides additional criteria and/or consultation considerations when making vaccine decisions (e.g., for children and adolescents with a history of Multisystem Inflammatory Syndrome in Children).  See the CDC’s ICC for guidance.²⁰
• While a 15-minute observation period is recommended for most COVID-19 vaccine recipients, a 30-minute observation period is recommended for some people, including those with certain precautions. See “Triage of people with a history of allergies or allergic reactions” in the ICC for recommended observation periods.
• When considering vaccinating an individual with a precaution to COVID-19 immunization, a risk assessment may be helpful or warranted. Consider referring those with a contraindication or precaution to COVID-19 immunizations to an allergist-immunologist or other appropriate clinical specialist to clarify their risk assessment and determine if they may be eligible for COVID-19 immunization.
• Request a consultation from the Clinical Immunization Safety Assessment COVID (CISA) Project if you have a complicated COVID-19 vaccine safety question about a patient who resides in the U.S.

Reporting of Adverse Events

As longitudinal safety data on COVID-19 vaccines in adults and children continue to be gathered, it is important to report any adverse events that occur following COVID-19 or other immunizations. Reporting is also encouraged for other clinically significant adverse events regardless of certainty regarding their relationship to immunization. For information on submitting a report to the Vaccine Adverse Event Reporting System (VAERS), visit www.vaers.hhs.gov or call 800-822-7967.

In addition, providers should encourage parents or guardians to register their children in v-safe, a smartphone-based tool that notifies CDC of self-reported side effects after vaccination. This tool helps CDC to monitor COVID-19 vaccine safety in near real time and also reminds parents/guardians of any additional vaccine doses their child needs.

Conclusion

In recent years, policy changes, along with the combined efforts of health care providers, public health, and community partners led to increases in pediatric immunization rates in Los Angeles County. To sustain improvements and continue to protect children and others from VPDs, it remains as important as ever for providers to:

• Understand State and local immunization requirements, including the State’s new medical exemptions process.
• Openly discuss vaccine recommendations with parents, caregivers, and children.
• Carefully assess for contraindications and precautions.
• If benefits outweigh risks for COVID-19 vaccines, consider immunizing children with precautions on-schedule, with a 30-minute observation period when recommended by CDC, or at a later, preferably set, time as described in the ICC guidance. Vaccinate as clinically indicated for all other vaccines.
• Refer to specialists (e.g., cardiologist, allergist-immunologist) for difficult clinical circumstances requiring advanced risk assessment in regard to vaccination(s) when needed.
• Have cogent reasons for granting medical exemptions or deferring vaccine doses.

By taking these steps, providers can help to protect all children from serious, preventable diseases through vaccine-induced immunity and community immunity.

Resources

Immunization Recommendations

• ACIP: General Best Practice Guidelines for Immunization
  www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html
• ACIP: Guidelines on Conditions Incorrectly Perceived to be Contraindications or Precautions to Vaccines
  www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html#t-02
• ACIP: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2022
  www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
• ACIP: Recommended Catch-Up Immunization Schedule
  www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html#table-catchup 
• AAP: Red Book: 2021-2024 Report of the Committee on Infectious Diseases (32nd edition)
  www.redbook.solutions.aap.org/book.aspx?bookid=2591
• Immunization Action Coalition: Screening Checklist for Contraindications to Vaccines for Children and Teens
  www.immunize.org/catg.d/p4060.pdf  
• CDC Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States
  www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
• CDC COVID-19 Vaccination for Children  
  www.cdc.gov/vaccines/covid-19/planning/children.html
• CDC Prevaccination Checklist for COVID-19 Vaccination
  www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
• CDC Summary Document for Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized or Approved in the United States
  www.cdc.gov/vaccines/covid-19/downloads/summary-interim-clinical-considerations.pdf

Resources for Immunizing Students Immunized Outside of the United States

• ACIP: General Best Practice Guidelines for Immunization- Guidance for Persons Vaccinated Outside of the United States
  www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf#page=156
• ACIP Recommended Catch-Up Immunization Schedule
  www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html#table-catchup 
• CDC Guidance for Evaluating and Updating Immunizations During the Domestic Medical Examination for Newly Arrived Refugees
  www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/immunizations-guidelines.html
• Immunization Action Coalition Quick Chart of Vaccine-Preventable Disease Terms in Multiple Languages 
  www.immunize.org/catg.d/p5122.pdf 
• World Health Organization Prequalified Vaccines 
  https://extranet.who.int/pqweb/vaccines 
  https://extranet.who.int/pqweb/vaccines/prequalified-vaccines?page=1 

COVID-19 Resources 

• AAP: Critical Updates on COVID-19
  www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections
• AAP-CA, California Academy of Family Physicians, California Immunization Coalition, and CDPH: Preparing California for Infant/Toddler COVID-19 Vaccinations
  Webinar: www.youtube.com/watch?v=jU9xanu8XKY&feature=youtu.be  
  Slides: www.immunizeca.org/wp-content/uploads/2022/06/COVID-Conversations-Program-11-Final-Complete.pdf
• California Department of Public Health Educational Materials and Job Aides
  https://eziz.org/covid  
• Clinical Immunization Safety Assessment (CISA) Project
  www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/cisa/index.html
• V-safe After Vaccination Health Checker
  www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html
• Los Angeles County Department of Public Health
  • Healthcare Provider Hub
    www.ph.lacounty.gov/acd/ncorona2019/  
  • Isolation and Quarantine Guidelines
    www.ph.lacounty.gov/acd/ncorona2019/isolationquarantine/
  • COVID-19 Vaccine Website
    www.ph.lacounty.gov/Coronavirus/vaccine/
  • COVID-19 Vaccine Schedules At-a-Glance 
    www.ph.lacounty.gov/acd/ncorona2019/vaccine/schedules/
  • Vaccine FAQ Safety and Side Effects
    www.ph.lacounty.gov/Coronavirus/docs/vaccine/FAQ-VaccineSafetyAndSideEffects.pdf

Child Care and School Immunization Requirements ​

• California Department of Public Health
  • Shots for Schools Website 
    www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/shotsforschool.aspx
  • Conditional Entrance FAQ
    www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/laws-conditional.aspx
  • Exemptions FAQ
    www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/laws-exemptions.aspx
  • Medical Exemption Requirements for Child Care and School Admission
    Webinar for Physicians: www.youtube.com/watch?v=0QsIDH1FeII 
    Slides: www.eziz.org/assets/docs/shotsforschool/2021MedicalExemptionsPresentationMDs.pdf
• ​​Los Angeles County Department of Public Health Child Care and School Immunization Webpage 
  www.ph.lacounty.gov/ip/SchoolToolKit.htm

Communicating with Parents and Caregivers

• AAP: Immunization Information for Parents
  www.healthychildren.org/english/safety-prevention/immunizations/Pages/default.aspx
• Association of Immunization Managers: Managing Vaccine Hesitancy During an Outbreak:  A Focus on Cultural Competency 
  www.immunizationmanagers.org/content/uploads/2022/03/Vaccine-Confidence-Guide-Chapter-2_033022.pdf 
• California Immunization Coalition: Shot by Shot Website - Testimonials regarding the Impact of Vaccine-preventable Diseases on Families
  www.shotbyshot.org
• California Medical Association: Cultural and Linguistic Competency and Implicit Bias Resources 
  www.cmadocs.org/cme-standards#dg-19-3
• CDC
  • CDC Provider Resources for Vaccine Conversations with Parents
    www.cdc.gov/vaccines/hcp/conversations/index.html
  • A Guide for Community Partners Increasing COVID-19 Vaccine Uptake Among Members of Racial and Ethnic Minority Communities
    www.cdc.gov/vaccines/covid-19/downloads/guide-community-partners.pdf
  • Vaccine Information Statements (VIS)
    www.cdc.gov/vaccines/hcp/vis/current-vis.html
  • v-safe
    www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html
• Health Net and Physicians for a Healthy California: Cultural Approaches to Support Parents who are Vaccine Hesitant
  www.cmadocs.org/Portals/CMA/files/cme/CA_Vaccine%20Hesitancy_Child%20Immunization_FINAL%20PHC.pdf 
• Immunization Action Coalition
  • List of Science-Based Materials for Responding to Vaccine-Hesitant Parents
    www.immunize.org/catg.d/p2070.pdf
  • Talking about Vaccines Website
    www.immunize.org/talking-about-vaccines

References

1. California Department of Public Health, Immunization Branch. 2015-2016 Kindergarten Immunization Assessment. www.eziz.org/assets/docs/shotsforschool/2015-16CAKindergartenSummaryReport.pdf. Accessed May 6, 2022.
2. California Department of Public Health, Immunization Branch. 2019-2020 Kindergarten Immunization Assessment - Executive Summary. www.eziz.org/assets/docs/shotsforschool/2019-2020CAKindergartenSummaryReport.pdf. Accessed May 6, 2022.
3. Kimmel SR, Wolfe RM. Communicating the benefits and risks of vaccines. J Fam Pract. 2005;54(1 Suppl):S51-57.
4. California Code of Regulations Title 17, Division 1, Chapter 4, Subchapter 8. California Department of Public Health, Vaccines for Children Program website. www.eziz.org/assets/docs/shotsforschool/IMM-1080.pdf. Accessed December 7, 2021.
5. California Department of Public Health, Immunization Branch. Pre-kindergarten (Child Care) and School Immunization Requirements: California Immunization Handbook for Pre-Kindergarten (Child Care) Programs and Schools. 11th ed. www.eziz.org/assets/docs/shotsforschool/IMM-365.pdf. Published January 2021. Accessed December 7, 2021.
6. California Department of Public Health, Immunization Branch. Medical Exemptions - Exemption FAQs. Shots for Schools Website.
   www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/laws-exemptions.aspx.
   Accessed May 30, 2022.
7. Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021- 2024 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021.
8. Kroger A, Bahta L, Hunter P. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accessed December 7, 2021.
9. California Health and Safety Code, Division 105, Part 2, Chapter 1. §120372. www.leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=120372. Accessed December 7, 2021.
10. California Health and Safety Code, Division 105, Part 2, Chapter 1. §120372.05. www.leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=120372.05.&nodeTreePath=44.2.1&lawCode=HSC. Accessed December 7, 2021.
11. Centers for Disease Control and Prevention. General recommendations on immunization. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 14th ed. Washington D.C.: Public Health Foundation; 2021. www.cdc.gov/vaccines/pubs/pinkbook/genrec.html.
12. Immunization Action Coalition. Guide to Contraindications and Precautions to Commonly Used Vaccines. Item #P3702a. www.immunize.org/catg.d/p3072a.pdf. Updated July 2021.
13. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):309-318. doi: 10.1093/cid/cit816. Updated July 1, 2014.
14. Ask the experts: precautions and contraindications. Immunization Action Coalition website. www.immunize.org/askexperts/precautions-contraindications.asp. Updated September 1, 2020. Accessed December 7, 2021.
15. Marin M, Güris D, Chaves SS, Schmid S, Seward JF. Recommendations of the Advisory Committee on Immunization Practices for Prevention of Varicella. MMWR Recomm Rep. 2007;56(RR04):1-40.
16. Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44. doi: 10.15585/mmwr.rr6702a1.  
17. Bergen R. Not-so-new school rules: What you STILL need to know about medical contraindications to immunization under SB 277. Presented at: California Immunization Coalition Summit; April 17, 2018; Sacramento, CA.
18. Esposito S, Prada E, Mastrolia MV, Tarantino G, Codecà C, Rigante D. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): clues and pitfalls in the pediatric background. Immunol Res. 2014;60(2-3):366-375. doi:10.1007/s12026-014-8586-0.
19. Immunization Action Coalition. Screening checklist for contraindications to vaccines for children and teens. www.immunize.org/catg.d/p4060.pdf. Accessed September 26, 2021.
20. Centers for Disease Control and Prevention. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html. Accessed July 7, 2022.
21. Statement on Timeline for COVID-19 Vaccine Requirements in Schools [news release]. Sacramento, CA. California Department of Public Health; April 14, 2022.  www.cdph.ca.gov/Programs/OPA/Pages/NR22-073.aspx. Accessed July 7, 2022.
22. Centers for Disease Control and Prevention. COVID-19 Vaccination for Children. www.cdc.gov/vaccines/covid-19/planning/children.html. Accessed July 7, 2022.
23. American Academy of Pediatrics Applauds CDC Approval of Safe, Effective COVID-19 Vaccines for Children Ages 6 Months and Older. [news release]. Itasca, IL,  American Academy of Pediatrics;  June 18, 2022. https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-applauds-cdc-approval-of-safe-effective-covid-19-vaccines-for-children-ages-6-months-and-older/. Accessed June 24, 2022.
24. COVID-19 Vaccines for people with underlying medical conditions. Centers for Disease Control and Prevention website. www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/underlying-conditions.html. Updated May 2, 2022. Accessed May 6, 2022.