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Daniel A. Salmon, PhD, Saad B. Omer, MBBS, Lawrence H. Moulton, PhD, Shannon Stokley, MPH, M. Patricia deHart, ScD, Susan Lett, MD, Bryan Norman, PhD, Stephen Teret, JD and Neal A. Halsey, MD

Daniel Salmon, Saad B. Omer, Lawrence H. Moulton, and Neal A. Halsey are with the Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Shannon Stokley is with the National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Ga. M. Patricia deHart is with the Immunization Program, Washington State Department of Health, Olympia. Susan Lett is with the Immunization Program, Massachusetts Department of Public Health, Jamaica Plain. Bryan Norman is with the Immunization Program, Missouri Department of Health and Senior Services, Jefferson City. Stephen Teret is with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.

Correspondence: Requests for reprints should be sent to Daniel A. Salmon, PhD, Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room W5034, Baltimore, MD 21205 (e-mail: dsalmon{at}jhsph.edu).

Objectives. Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements.

Methods. We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models.

Results. School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions.

Conclusions. Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.

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