Common Barriers to Compliance with Student Immunization Requirements

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To help limit the spread of vaccine-preventable diseases, Washington has set a public health policy goal of a 95 percent immunization rate. Medical professionals often refer to this level of protection against disease as “herd immunity.”

State law makes it clear that schools play an essential role in helping achieve that goal. Schools must collect proof of immunization or a valid exemption for every student on or before the first day of school. Without these records, schools are not supposed to allow students to attend school.

This audit looked at eight school districts, four with high vaccination compliance rates and four with low rates.

  • Learn about actions schools and districts take to improve compliance with immunization records in this short booklet. It also contains links to a variety of helpful resources.

Read a two-page summary of the report.

Report Number 1025314 Report Credits

Key results

All schools are required to send their immunization data to the Washington Department of Health (DOH). DOH’s data shows not all schools in the state are following the law, nor are they collecting immunization records consistently. For this reason, DOH does not know the state’s true immunization rate. That is both bad and easy to fix.

Four audited districts that succeeded in complying with the state law regarding immunization records used clear, effective and simple practices. They clearly communicate the rules to parents, pay attention to whether parents comply, and enforce the law when necessary.

The intent of the law is to ensure herd immunity, not perfect paperwork collection. But it is impossible to know where the state stands on its public health goal without compliance with immunization record-keeping. In addition to the difficulty some districts have with immunization records, there are other districts that aren’t included in the immunization data compiled by DOH.

School districts told auditors families in their communities face a variety of barriers to vaccination. Problems included limited access to vaccination resources and language barriers that contribute to poor understanding of requirements. In several areas, school staff said they try to help families overcome these and other barriers to vaccinations.

Background

Vaccinating children improves public safety. Washington state law requires principals or someone they designate to collect proof of immunization or exemption before a child can attend school. Without this proof, state law requires that the school exclude the child from attending. Schools must report the data about student immunization to the Washington Department of Health (DOH) annually.

These school vaccination laws are part of an effort to reach a level of protection against disease often referred to as “herd immunity.” It means when enough people are immune to a disease, the entire community is less likely to spread illness from person to person. A child might develop immunity because they have had the disease or become immune through vaccination.

In an effort to improve public health, the state of Washington and public health experts have set a goal to reach 95 percent vaccination coverage. This is the point at which outbreaks are less likely to occur. However, the state has yet to reach this goal, and is still experiencing outbreaks of vaccine-preventable diseases. To address recent outbreaks of measles, in 2019 the Legislature removed the personal/philosophical exemptions for the measles, mumps and rubella (MMR) vaccination.

True vaccination rate is unknown

The audit looked at the DOH database of student immunization records for the state’s 295 school districts in the 2017-2018 school year. In that year, immunization data was present in the database for 90 percent of Washington schools. Schools in the remaining 29 districts either lacked immunization data in the database or were shown as having zero kindergarten enrollment. However, student enrollment data from the Office of Superintendent of Public Instruction shows that most of these districts do in fact have kindergarteners enrolled.

Of the schools whose data was included in the database, 8 percent of all kindergarteners lacked complete immunization or exemption records. But the number of districts and schools whose data was not included in the database means the actual percentage of kindergarteners without records may be greater. When officials lack complete and accurate information about children’s immunity status, they may not be able to protect students and others if there is an outbreak of disease. In addition, the state cannot know the completeness of its vaccination efforts.

Choosing not to exclude

State law makes school principals or someone they designate responsible for obtaining immunization records from their students. Principals must exclude students from school when their parents fail to provide one of the acceptable proofs of immunity.

We found school principals in the four low-compliance districts chose not to exclude out-of-compliance students. District and school staff offered several reasons for not excluding these children. Some said they would rather educate students than exclude them. Furthermore, by keeping students in school, they said they had a better chance to work with families and bring them into compliance.

Holding principals accountable

State law does not require any state agency to provide oversight of certain issues around immunization requirements. This includes ensuring school principals exclude children who lack vaccination records.

As a result, the burden of ensuring school administrators comply with the law rests with superintendents and elected school boards.

However, if schools, school districts and local leaders do not make immunization compliance a priority, state leaders might consider enacting a statewide accountability system to enforce the rules and help meet the goal of herd immunity.

Engaging with parents

Schools that actively monitored students’ progress saw greater compliance with both documents and vaccination.

High-compliance school districts used many tools to improve their compliance rates. For example, they made an effort to reach the district’s population, using materials in other languages if necessary. These schools told parents about vaccination requirements well before the new school year, and reminded them often. They gave parents complete information about how to meet requirements, including information about exemptions. And they told parents that exclusion is a legal requirement.

In addition, successful schools developed internal tools and practices. For example, they shared reports on immunization records with school administrators..  They created a calendar devoted to vaccination outreach efforts. In addition, these schools assigned staff specifically to the task of monitoring student immunization records. Finally, administrators gave these employees clear guidance around their responsibilities.

Schools with lower compliance rates generally did not use these strategies to the same degree.

Lower compliance school districts did not use the tools employed by districts that are more successful to the same degree. In some cases, schools gave parents incomplete information about ways they could comply with immunization requirements.. These schools did not follow up on conditional-status students to the same degree. Training for school staff was inadequate. Finally, they had an insufficient number of school or district staff to complete immunization compliance duties.

Schools can help

School districts said that families faced a variety of barriers to vaccination. These issues included:

  • Limited access to vaccination resources
  • Parents who choose not to vaccinate their children or vaccinate on a delayed schedule
  • Language barriers that contribute to poor understanding of immunization requirements

Schools do not cause these barriers. Indeed, staff said they could help parents overcome barriers in several areas. As a result, they were able to positively influence vaccination outcomes.

Solutions included arranging transportation to local clinics and opening on-site, short-term vaccination clinics. In addition, schools made extensive use of posters and flyers in languages spoken by families in the community.

The audit report mentions many of these solutions and resources. They are also available as a downloadable file from the Center for Government Innovation here.

Recommendations & guidance

We consider the audit results so broadly applicable that it is in the state’s best interest for every school district to learn from the high-compliance districts we studied. They told us about many relevant and repeatable good practices. These practices are listed in the audit report. They are also available as a downloadable file from the Center for Government Innovation here.

  • Districts and schools should help ensure parents are aware of legal requirements related to vaccination documentation, all of the ways to comply with those laws, and the consequences of noncompliance
  • Districts should provide materials about compliance and the benefits and risks of vaccinations in languages other than English when appropriate
  • Districts should ensure staff understand their roles and responsibilities related to immunization compliance and monitoring
  • Schools should exclude students who are out of compliance as is required by the law and districts should hold schools accountable for following the law