Vaccine Exemptions Among School-Aged Children

By Sarah de Ruiter, RN, BSN, MA, Immunization Nurse Educator, Michigan Department of Health and Human Services, Division of Immunization

Since 1978, Michigan has required a series of immunizations for preschoolers and kindergarteners. Additional vaccines, including one to protect against meningococcal disease, are also required by the time children reach seventh grade. Vaccination requirements for daycare and school entry are important tools for maintaining high vaccination coverage rates, and in turn, lowering rates of vaccine-preventable diseases.

Notwithstanding, all states allow medical exemptions, and 47 states offer nonmedical exemptions for religious or philosophical reasons. Michigan allows for all three types of vaccine exemptions. Before 2015, in order to opt their child out of the required vaccines, a parent or guardian simply had to sign a vaccine waiver form that was kept in the school office.

In 2014, Michigan had the fourth highest vaccine exemption rate in the United States.
In an attempt to continue maintaining high vaccination coverage rates and slow the increase in nonmedical vaccine exemptions, Michigan changed its state Administrative Rules, effective January 1, 2015, to require parents to attend an in-person vaccine education session at their local health department before obtaining a nonmedical exemption. The rule applies to all children who are enrolled in licensed childcares, preschools, and Head Start programs as well as kindergarteners, 7th graders, and any newly enrolled students into a school district.

With Michigan having one of the highest waiver rates in the country at that time, this proactive approach was established to help inform vaccine hesitant parents and guardians of the benefits of vaccinations and the risks of disease. Vaccine waiver education sessions vary from county-to-county. There is no standard curriculum; rather, the one-on-one sessions are meant to be tailored to answer each parent’s unique concerns. Concerns commonly addressed include vaccine safety, number of antigens, the importance of staying on schedule, pain, number of doses in vaccine series, autism and the MMR vaccine, natural immunity versus vaccine immunity, and how vaccines are made.

Following the rule change, Michigan experienced a decrease in nonmedical vaccine waivers. Unfortunately, this decline did not last as nonmedical waiver rates have slowly rebounded to nearly pre-2015 levels. According to a University of Michigan study wavier rates fell by one third the first year education was required but ticked up slowly in the years that followed.

Figure 1 below indicates that nationally, nonmedical waiver rates are climbing. One county in Michigan has a nonmedical waiver rate of 20%. Individual school buildings have even higher waiver rates. In total, 10,398 school-aged children in Michigan – 5690 kindergartners and 4708 7th graders – had a nonmedical waiver for the 2022/23 schoolyear, resulting in over 10,000 Michigan children vulnerable to vaccine preventable diseases.

Figure 1 Source:

High rates of nonmedical vaccine exemptions are a public health threat that has begun to reverse decades of public health success in the mitigation of vaccine preventable diseases. It is critical that providers be aware of nonmedical vaccine waiver trends in Michigan to inform their practice. Immunization education and conversations are key. Conversations promoting vaccination with all patients should occur at every encounter to increase awareness of the importance of vaccines and help stem the rising trend in nonmedical vaccine exemptions in Michigan. Questions or assistance with having immunization conversations can be sent to:


Masters, N. B., Zelner, J., Delamater, P. L., Hutton, D., Kay, M., Eisenberg, M. C., & Boulton, M. L. (2021). Evaluating Michigan’s Administrative Rule Change on Nonmedical Vaccine Exemptions. Pediatrics, 148(3), e2021049942.

Quinn, S. C., Jamison, A. M., & Freimuth, V. S. (2020). Measles outbreaks and public attitudes towards vaccine exemptions: some cautions and strategies for addressing vaccine hesitancy. Human vaccines & Immunotherapeutics, 16(5), 1050–1054.

Michigan Department of Health and Human Services. (2023, March 31). County Immunization Report Cards.

Michigan Department of Health and Human Services. (2023, April) Michigan School/Childcare Immunization Requirements.