Caring for Our Children (CFOC)

Chapter 7: Infectious Diseases

7.2 Immunizations

7.2.0 Unimmunized/Underimmunized Children

Standard was last updated 09/27/2022.

Immunizations are effective in preventing the spread of infectious diseases in early care and education programs. Children may not receive all age-appropriate immunizations due to medical, religious, or personal exemptions, or delays in getting recommended vaccines. Programs should work with families to get vaccine records and keep required documentation for the following situations:

  • Medical exemptions: Some children cannot receive certain vaccines due to medical conditions. Children with a medical exemption should have a statement from a healthcare provider documenting what vaccines are exempt and the reason for exemption.1 
  • Religious and personal exemptions: Some states allow parents/guardians to refuse some or all vaccines for their children based on religious or personal beliefs. Programs should keep any program, state-specific, health department, or other required documentation on file.1 
  • Delayed immunizations: Children who have not received all recommended age-appropriate vaccines should receive missing vaccines as soon as possible. Families should work with their healthcare provider to make a plan that follows the recommended immunization schedules (see Appendix G). Letting children who are unimmunized (not vaccinated) or underimmunized (partially vaccinated) attend a program can put other children, program staff, and close contacts at risk. Attendance for children who are unimmunized or underimmunized should depend on state, local, tribal, or territorial public health guidance, including how to handle the risk and if parents of other enrolled children should be informed about the risks.2

If a vaccine-preventable disease occurs in a program, the program should temporarily exclude all unimmunized and underimmunized children for the duration of the possible exposure or until they are fully vaccinated.2 Contact state, local, tribal, or territorial public health authorities for guidance. 


Immunizations at the appropriate age are the best ways to protect children from vaccine-preventable diseases. All states have mandates for age-appropriate immunization of children in early care and education programs.1 Some children and adults cannot receive certain vaccines because of a medical condition. Some states allow parents to refuse some or all vaccines for their children because of the parents’ religious or personal beliefs. Enrolling children whose parents refuse some or all vaccines, or allowing an underimmunized adult to work in a group care setting, increases the risk of spreading certain infectious diseases.3 Underimmunized children and adults increase their risk of getting a vaccine-preventable illness. When they do become sick from a vaccine-preventable infection, they  risk infecting others who have valid medical reasons for being unable to receive a specific vaccine or who are too young to have received enough doses of a vaccine to be protected.3 If they are exposed to a vaccine-preventable disease they will be excluded from child care or work for a long time.3

Allowing attendance of children or adults who do not have a medical reason to forego vaccines may result in legal liability for programs if refusal results in a preventable illness. Immunization laws and regulations differ between states, counties, and cities. Compliance with local legal immunization requirements may not meet national immunization recommendations. All early care and education programs must meet state licensing and federal Child Care Development Fund requirements for documentation of up-to-date immunization of children in their care.3

More information on state requirements and mandates can be found at: 

More information about vaccines is available from the Centers for Disease Control and Prevention (CDC):


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
Appendix G: Recommended Childhood Immunization Schedule
  1. State exemptions. State mandates on immunization and vaccine-preventable diseases. Web site. Last updated February 24, 2020. Accessed May 2 2022.
  2. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:122123. 
  3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022.

Standard was last updated 09/27/2022.