Mandatory vs. Recommended Vaccines: An Overview

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It is not uncommon for a parent to bring a child into the pediatrician's office for their annual checkup and to be advised that one or more vaccines are needed. While many parents will follow the recommendations, others may question if the vaccinations are medically necessary.

A little girl getting a bandaid after receiving her shot
asiseeit / Getty Images

Given that a child is submitted to numerous vaccinations from the time of birth, it is not an entirely unfair question to ask. Even so, there remains a lot of confusion—even among medical professionals—about whether certain vaccines are recommended or mandated.

Understanding the differences may be crucial to protecting the health and safety of yourself and your family.

Who Sets Vaccine Recommendations?

Every year, the Centers for Disease Control and Prevention (CDC) publish a recommended immunization schedule for the United States. This schedule is put together by a panel of 15 experts known as the Advisory Committee on Immunization Practices (ACIP).

The ACIP panel is comprised of experts in medical and public health fields, including doctors, researchers, infectious disease specialists, and community representatives.

The schedule is intended to provide people with the maximum protection from vaccine-preventable diseases as safely as possible. The schedule is organized according to the age ranges in which the recommended vaccinations should be administered.

Currently, there are 16 vaccines recommended by the ACIP, scheduled from birth through the age of 18.

This schedule is updated every year to ensure that it is always based on the most up-to-date research. Medical professionals across the country use it to immunize their patients, and state governments follow the recommendations to determine which vaccines should be required (or mandated) for school.

Mandatory Vaccinations

Though the vaccines listed on the ACIP schedule are only recommended, some states may opt to mandate them to prevent the spread of vaccine-preventable diseases among school children.

For school-mandated vaccinations, each state makes its own list of vaccines that are required for a certain age or grade. Parents who don't comply and provide evidence of the vaccination will typically be barred from having their kids attend school.

As straightforward as this might seem, there are challenges and barriers that affect how these mandates are issued and implemented. These include:

  • Variations by region: Vaccine mandates vary widely throughout the country, and sometimes within individual cities or school districts. For example, students in one city may be required to have at least one dose of the meningococcal vaccine before 8th grade, while students in a neighboring city may not.
  • Variations by governing authorities: The body authorized to issue mandates also varies by state. Some states might pass legislation to mandate vaccinations statewide, while others let the state health department decide. Others still may offer city councils or school districts room to effect their own mandates when appropriate.
  • Variations in legislation sessions: The frequency of mandate reviews can also vary depending on how often the state legislature meets and how long it takes for legislation to be passed. In such cases, it may take years to update vaccine requirements after a new ACIP recommendation.

The federal government does not mandate vaccinations.

Challenges in Implementation

A number of variables can also influence how policies are enacted, including politics, cultural norms, and practicality. None of these issues should be minimized.

For example, while annual flu vaccination is recommended by the CDC and may be mandated for school children within a state, requiring families to prove compliance every year would not only be burdensome but costly.

Parents and public opinion also play a role. In recent years, states that have mandated the human papillomavirus (HPV) vaccine to prevent the spread of the sexually transmitted disease have been faced with protests from community members who believe that doing so promotes teen sex.

Such an event occurred in New York State in 2019 when state officials mandated the HPV vaccination for students age 11 to 12.

States can also require vaccines for specific groups, such as college students or nursing home employees, while individual schools or employers may issue mandates as well (such as hepatitis B and COVID-19 vaccinations for hospital workers).

Opting Out

The concept of "forced vaccination" is a concept largely promoted by anti-vaccination ("anti-vaxxing") activists. It suggests that the government is forcing them or their kids to receive medications they don't want out of the threat of retribution.

The reality is far less dramatic. All 50 states currently have vaccine requirements for children, but that doesn't mean kids are being forced to be vaccinated. The requirements are limited to those attending school, and, even then, parents who don't want to vaccinate their kids still have options.

In every state, children who shouldn't receive vaccines for medical reasons—such as organ transplants or severe allergies—can receive medical exemptions.

Opting out for non-medical beliefs is far more difficult. In all but five U.S. states, parents are not permitted to opt out of vaccines for non-medical reasons, such as religious objections to vaccination.

Where non-medical exemptions are allowed, the process for obtaining one may be as simple as signing a form. Other states require parents to undergo an educational module or counseling by a physician on the risks and benefits of vaccination before they can get an exemption.

Even with these various options to opt out of mandated vaccinations, only around 2% of parents actually do, according to a 2014 study in the American Journal of Public Health. With that said, states with easy exemption policies have more than twice the number of exemptions as those with difficult ones.

Are Current Mandates Enough?

While states continue to expand school vaccine requirements, they are not as comprehensive—and therefore not as protective—as the recommended schedule issued by the CDC.

For example, while many states require meningococcal and pertussis (whooping cough) vaccination in schools, only two require the HPV vaccine, and none require the flu vaccine. This is despite the fact that HPV and influenza kill over 11,000 and 70,000 people, respectively, every year.

This is why the CDC recommends vaccines against all four of these diseases for adolescents 11 to 12. They are each considered equally important in the eyes of the ACIP but are rarely required by schools.

That is not to say that all vaccines are equally important. If a vaccine isn't necessary for everyone to get, the ACIP has ways of indicating that it is optional.

In 2015, the ACIP granted the meningococcal B vaccine a "provisional" recommendation, essentially leaving it up to healthcare providers to decide whether vaccination is appropriate on a case-by-case basis.

A Word From Verywell

It is important to note that school-mandated vaccine requirements are minimum standards. Because the ACIP schedule is more comprehensive, those who follow it will have no problem meeting requirements for school or work.

By contrast, getting only what is mandated may leave you vulnerable to preventable—and potentially serious—infections. If in doubt, speak with your healthcare provider to check if your child is getting all of the recommended vaccinations on the ACIP list, not just the mandated ones.

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  7. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) summary report. June 24, 2015.