State and Local Policies on School Vaccine Requirements: Overview and Current Status

Key Points

• The Constitution gives authority to state and local governments, not the federal government, to set school vaccine requirements and currently all 50 states and DC currently require certain vaccines for school attendance. All jurisdictions require MMR, DTaP, polio, and varicella vaccination for school-age children, while requirements for several other vaccines vary by state. All states allow for exemptions to these requirements.
• Jurisdictions differ substantially in how they allow parents to claim exemptions from school vaccine requirements. All states permit medical exemptions, while 45 states and DC permit religious and/or personal belief exemptions. States also vary widely in the documentation, review, and other requirements for obtaining an exemption.
• Due to actions by the Trump administration, which has questioned the safety and effectiveness of vaccines and sought to reduce the number of recommended childhood vaccines, a growing number of states has begun to delink their recommendations from those of the federal government, which may have implications for school vaccine requirements. As of August 2026, 30 states and DC had announced that they would no longer follow Centers for Disease Control and Prevention’s (CDC) Advisory Committee for Immunization Practices (ACIP) recommendations for one or more childhood vaccines, with 27 states delinking from CDC/ACIP recommendations for all childhood vaccines. Because state and local school vaccination policies may be linked to states’ broader childhood vaccine recommendation policies, these moves could have implications for school entry requirements.
• Recent state policy changes have generally made non-medical exemptions easier to obtain. Since 2025, at least nine states have enacted changes that make non-medical exemptions more permissive, including by reducing documentation or procedural requirements. Research indicates that easier-to-obtain non-medical exemptions are associated with higher exemption rates and, in turn, declining childhood vaccination coverage.

These trends are taking place in the context of falling national childhood vaccination rates since 2019, declines that are entirely attributable to the growth in non-medical exemptions. Higher exemption rates have been associated with increased incidence of diseases such as measles and pertussis, indicating continued outbreaks that place more children at risk for vaccine-preventable diseases in the U.S. are likely. 

Evolution of School Vaccine Requirements

Under the U.S. Constitution, states (and local governments) have the authority to impose immunization requirements, not the federal government (see Box 1). The earliest known school vaccine requirements in the U.S. were put in place by a local government in the 19^th century, when Boston enacted a city-wide requirement for smallpox immunization for school entry in 1827. In 1855, Massachusetts enacted the first state-level school vaccine mandate, also for smallpox. As more childhood vaccines were developed and recommended for routine use over time, states began adding additional requirements for diphtheria, tetanus, pertussis, and polio. By 1963, 20 states required at least one vaccine for children to attend school.

In the 1960s, the federal government also increased its support to states for vaccinations and broadened its immunization-related policy-making efforts. In 1962, Congress created the Public Health Service Section 317 Immunization Grants Program, which allowed federal funds to be directed to state and local jurisdictions for purchasing vaccines. In 1964, a new specialized expert committee called the Advisory Committee on Immunization Practices (ACIP) was established at the federal level to provide guidance regarding vaccines. ACIP was designated an official federal advisory committee and placed organizationally under the Centers for Disease Control and Prevention (CDC) Director in 1972. The 1960s and 1970s also saw the licensure of new combination measles, mumps and rubella (MMR) vaccines, coinciding with a number of measles outbreaks among children that drew national attention, and  spurred expanded federal and state efforts to strengthen and update vaccination laws (the measles vaccine was added to the federal 317 program in 1965). In the 1970s, large measles outbreaks in Alaska (1976) and Los Angeles, California (1977) led policymakers in those states to enact stricter measles vaccination requirements for school children that resulted in lower measles incidence, demonstrating to policymakers nationwide that enforcement of immunization requirements was possible, acceptable, and effective for most communities. Subsequently, CDC encouraged all states to implement school immunization requirements. 

By 1981, all 50 states and DC had some form of school immunization requirements, and in the 1981-82 school year, vaccination levels in school entrants nationwide had reached 96% or higher for diphtheria-tetanus-pertussis (DTP), polio, and measles vaccines. In 1983, CDC/ACIP published the first general federal recommendations for childhood vaccinations, which were updated in 1989 and eventually merged with the recommended schedule issued by the American Academy of Pediatrics (AAP) in 1995. Throughout the 1990s and 2000s more vaccines were added to the CDC/ACIP recommendations for children and adolescents, including Hepatitis A, Hepatitis B, Haemophilus influenzae type b (Hib), pneumococcal, rotavirus, varicella, human papillomavirus (HPV), and meningococcal vaccines. Over time, states have integrated many of these vaccines into their school immunization policies as well, though the specific set of required vaccines varies across states, as described below.

Current state policies on school vaccination requirements

As shown in Figure 1, all 50 states and DC require MMR, DTaP, polio, and varicella vaccines for school-age children. Forty-nine states and DC also require Hepatitis B (Alabama is the exception), with three of those states requiring Hepatitis B for childcare settings only (Maine, Montana, South Dakota). Thirty-five states require meningococcal vaccines for school-age children, while 27 states require Hepatitis A. Just four jurisdictions require HPV vaccines for school-age children (DC, Hawaii, Rhode Island, and Virginia).

State Exemption Policies for School Vaccine Requirements

While all states allow for individual exemptions to state school vaccination requirements, the extent of these exemptions vary. They fall into two general categories: “medical” (exemptions based on medical contraindications) and “nonmedical” (exemptions based on religious beliefs or other personal/philosophical beliefs). Currently, all states allow for medical exemptions, while 45 states and DC allow for religious and/or personal belief exemptions (the exceptions are California, Connecticut, Maine, New York, and West Virginia). Of the jurisdictions allowing non-medical exemptions (see Figure 2):

• 30 states allow religious exemptions only
• 15 states allow religious and personal belief exemptions
• 1 state (Minnesota) allows personal belief exemptions only

States also vary in how difficult it is to obtain an exemption and in their oversight of exemptions. All states require some form of documentation from a health care professional to grant a medical exemption, though how rigorous the process is differs across states. Likewise, in states that allow for nonmedical exemptions, documentation and approval processes can vary in their rigor and requirements. For example:

• In California, physicians issuing medical exemptions must use a centralized system, all exemption requests are reviewed by the state’s health department that has the authority to invalidate inappropriate requests, and justifications must adhere to standards for medical contraindications (previously, the state linked its standards for medical exemptions to CDC/ACIP recommendations, but as of 2025 uses AAP criteria instead). In New York, review and enforcement for exemption requests is the responsibility of school officials (the state has also delinked its standards for medical contraindications from CDC/ACIP, linking to AAP instead). In Mississippi, the state health department reviews all medical and non-medical (religious) exemption requests.
• In West Virginia, medical exemptions are reviewed by the state health department and must adhere to guidance from ACIP, AAP, and AAFP. In January 2025, the governor issued an executive order newly allowing religious and personal belief exemptions in the state, setting off a legal battle with the Department of Education. Currently, religious and personal belief exemptions in West Virginia are on hold while the state Supreme Court considers the case. 
• In Oregon, nonmedical exemptions are allowed but parents must receive counseling about disease risks and vaccine benefits before their child can be granted the exemption. In Washington, religious exemptions simply require parents to complete a form, while personal belief exemptions require parents to receive counseling prior to granting the exemption.
• In states such as Arizona, Idaho, Oklahoma, and Texas, nonmedical exemptions are granted after parents submit a form requesting them, with no counseling or health professional certification required.

Since 2025, at least 9 states have enacted policy changes that are more permissive for non-medical exemptions. For example, in Texas a new law allows parents to download the state’s non-medical exemption form directly rather than first having to submit a written request to the state’s health department for the form, and Utah has made a student’s vaccine exemption form a part of their permanent school record, allowing the form to remain valid even if a student transfers schools. In New Hampshire, advanced practice registered nurses and physician associates have recently been added as health care providers with the authority to sign school vaccination exemption forms and a new law requires that materials about school vaccine requirements include the statement “Medical and religious exemptions are available under New Hampshire law.”

State Procedures for Setting School Vaccination Requirements

Each state has its own legal and organizational process for setting school entry immunization requirements, which can range from a more statutory process where state legislatures determine most key school vaccination policies, to a more administrative, one where state health departments or other agencies have the responsibility and authority to determine these requirements. Many states have a mix of these elements, such as using a statutory process for some vaccines and an administrative process for others, or where state law determines which vaccines are required while administrative processes determine the specifics such as dosages and schedules. For example:

• Pennsylvania, Mississippi, South Carolina, and Virginia are states with a more administrative approach, where state health (or other) agencies have significant responsibilities in determining school vaccination requirements. In these cases, the state legislature has established the general requirement that children attending school must be immunized but has delegated authority to state agencies to determine the specific vaccines, dosages, and other technical requirements.
• In Arkansas and Florida, state legislation sets school vaccination requirements for specific vaccines, while giving the health department responsibility for other vaccines. In Florida, for example, state laws set the requirement that Diphtheria-Pertussis-Tetanus (DPT), MMR, and polio vaccines are required for school entry, but allow the health department to set requirements for other vaccines such as hepatitis A, pneumococcal, and varicella.
• In Kentucky, Maine, and West Virginia, state laws identify the full set of diseases students must be immunized against, but health departments and/or education departments are empowered with the responsibility to establish dosages, schedules, exemption policies, and other technical requirements.

In many states, childhood vaccination recommendations in the past have been linked to guidance from the CDC/ACIP and in some cases this has included school vaccination policies, such as when states link their allowed medical contraindications for exemptions to CDC/ACIP guidance, as mentioned above. However, since 2025 the Trump administration has sought to make changes to federal vaccine recommendations for children, including by issuing a new federal childhood vaccine schedule in January 2026 (which has been temporarily blocked by a federal judge) and issuing an Executive Order (EO) in August 2026 calling for changes to the federal childhood vaccine schedule and specifically asking States and territories to “consider updating relevant laws and regulations that define the scope of immunization requirements for contexts such as school enrollment and attendance.” In anticipation of and in reaction to the Trump Administration’s policy changes, starting in 2025 a number of states began announcing they will no longer link their own recommendations to those of CDC/ACIP. As of July 30, 2026, most states (30 states, including DC), announced they would no longer follow the CDC/ACIP general childhood vaccine recommendations for one or more childhood vaccines, with 27 doing so for all childhood vaccines, and instead rely on prior recommendations, state recommendations, and/or those of external entities such as AAP. No states have made policy changes in line with the August 2026 EO.  At least 10 state and local jurisdictions have announced specifically that their school vaccine requirements have not changed as a result of the EO.