Caring for Our Children (CFOC)

Chapter 7: Infectious Diseases

7.2 Immunizations

7.2.0 Unimmunized Children

If immunizations have not been or are not to be administered because of a medical condition (contraindication), a statement from the child’s primary care provider documenting the reason why the child is temporarily or permanently medically exempt from the immunization requirements should be on file. If immunizations are not to be administered because of the parents/guardians’ religious or philosophical beliefs, a legal exemption with notarization, waiver or other state-specific required documentation signed by the parent/guardian should be on file (1,2).

The parent/guardian of a child who has not received the age-appropriate immunizations prior to enrollment and who does not have documented medical, religious, or philosophical exemptions from routine childhood immunizations should provide documentation of a scheduled appointment or arrangement to receive immunizations. This could be a scheduled appointment with the primary care provider or an upcoming immunization clinic sponsored by a local health department or health care organization. An immunization plan and catch-up immunizations should be initiated upon enrollment and completed as soon as possible according to the current “Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States” from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Parents/guardians of children who attend an unlicensed child care facility should be encouraged to comply with the “Recommended Immunization Schedules” (6).

If a vaccine-preventable disease to which children are susceptible occurs in the facility and potentially exposes the unimmunized children who are susceptible to that disease, the health department should be consulted to determine whether these children should be excluded for the duration of possible exposure or until the appropriate immunizations have been completed. The local or state health department will be able to provide guidelines for exclusion requirements.

Routine immunization at the appropriate age is the best means of protecting children against vaccine-preventable diseases. Mandates requiring age-appropriate immunization of children attending licensed facilities exist in all states (1).

Exclusion of an unimmunized (susceptible) or underimmunized child from the child care facility in the event of a risk of exposure to an outbreak of a vaccine-preventable disease protects the health of the unimmunized or underimmunized child and minimizes potential for further spread of that disease to other children, staff, family, and community members (2).

A sample statement excluding a child from immunizations is: “This is to inform you that [NAME] should not be immunized with [VACCINE] because of [CONDITION, such as immunosuppression]. I expect this condition to persist for _______. [SIGNED], [PRIMARY CARE PROVIDER] [DATE]”

Vaccine Safety and Parental Choice – Some parents/guardians question the safety of routinely recommended vaccines. Sometimes they choose not to have their children fully vaccinated or to delay particular vaccinations. Unfortunately, this leaves the unimmunized child at risk for serious diseases and puts other children and caregivers/teachers who spend time with the unimmunized child at risk (2). Illness and death from vaccine-preventable diseases, including whooping cough and measles, have occurred in communities where there are unimmunized children who spread these diseases (3,4).

Vaccines are tested to establish safety and effectiveness before they are licensed by the U.S. Food and Drug Administration (FDA). The ACIP, a non-Federal advisory committee makes evidence-based recommendations to the Centers for Disease Control and Prevention (CDC) following review of all data before a new vaccine is recommended. ACIP is one of many reputable sources of information. The Committee on Infectious Diseases makes evidence-based vaccine recommendations to the board of directors of the AAP. There are biased, inaccurate sources of vaccine information which are not based on evidence and often can confuse parents.

Autism allegedly has been associated with specific vaccines or ingredients in vaccines or combinations of vaccines. There is no evidence-based literature to support this association (5). Hesitant parents/guardians should be referred to reputable sources where evidence-based information is provided to assist them in making informed decisions about the benefits of immunization. Sites where reputable information can be found are shown below.

Since 1999, the mission of the AAP’s Childhood Immunization Support Program (CISP) has been to improve the immunization delivery system for children across the nation by developing an infrastructure within the Academy to support its members and provide education and resources for parents and pediatricians on immunization and immunization-related issues (6).

Three sources of accurate information about immunizations are shown below. Each of the sites provides additional sources of information.

  1. -- CISP provides education and resources for parents/guardians and pediatricians on immunizations; CISP Goals are:
    1. Promote quality improvement and best immunization practices in community- and office-based primary care settings and other identified medical homes;
    2. Enable pediatricians and pediatric primary care providers to communicate effectively with parents/guardians;
    3. Promote system-wide improvements in the national immunization delivery system;
    4. Provide accurate and up-to-date resources to parents/guardians that address their most frequent immunization concerns (6).
  2. -- This CDC site provides information for health care professionals and parents/guardians about all aspects of immunization including vaccine recommendations, understanding vaccines and their purpose, vaccine misconceptions, and answers to commonly asked questions about vaccines (7).
  3. -- The mission of the National Network for Immunization Information (NNii) is to provide the public, health care professionals, policy makers, and the media with up-to-date, scientifically valid information related to immunization to assist with understanding the issues so that informed decisions can be made (8).
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Documentation of Exemptions and Exclusion of Children Who Lack Immunizations
  1. Immunization Action Commission. State mandates on immunization and vaccine-preventable diseases. http://www
  2. Omer, S. B., D. A. Salmon, W. A. Orenstein, M. P. deHart, N. Halsey. 2009. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New Eng J Med 360:1981-88.
  3. Centers for Disease Control and Prevention. 2009. Invasive Haemophilus influenzae type B disease in five young children – Minnesota, 2008. MMWR 58 (03): 58-60.
  4. Centers for Disease Control and Prevention. 2008. Update: Measles – United States, January-July 2008. MMWR 57 (33): 893-96.
  5. Institute of Medicine Immunization Safety Review Committee. Immunization safety review.
  6. American Academy of Pediatrics. Immunization. Childhood Immunization Support Program (CISP).
  7. Centers for Disease Control and Prevention. Vaccines and immunizations.
  8. National Network for Immunization Information. NNii.