{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:28:09Z","timestamp":1787027289067,"version":"build-2736575974"},"reference-count":15,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T00:00:00Z","timestamp":1777507200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"\n Background<\/jats:title>\n High kindergarten vaccination coverage is essential to sustain herd immunity against measles and other vaccine-preventable diseases. In recent years, rising state-level non-medical exemption rates and pandemic-related disruptions have threatened this protection in the United States.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n We analyzed 8 years of Centers for Disease Control and Prevention (CDC) kindergarten vaccination surveillance data (2016\u20132017 through 2023\u20132024) to assess national and state-level trends in vaccination coverage and exemption rates. Descriptive analyses and scatterplots were used to examine patterns across years. A cross-sectional state-level linear regression model using 2024\u20132025 data (\n N<\/jats:italic>\n \u202f=\u202f39 jurisdictions) was used to quantify the association between exemption prevalence and MMR vaccination coverage.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n National MMR coverage declined from 96.0% in the 2018\u20132019 school year to 92.7% in 2023\u20132024, while exemption rates increased from 2.5% to 3.3%. Updated 2024\u20132025 national estimates indicate that coverage remained near 92.5% and exemption rates increased further to 3.6%. In a cross-sectional analysis of 2024\u20132025 data, each 1% increase in exemption prevalence was associated with an approximately 1.1 percentage-point decrease in MMR coverage (\n p<\/jats:italic>\n \u202f&lt;\u202f0.001), with exemption prevalence accounting for approximately two-thirds of observed variation in coverage. States permitting broad non-medical exemptions, including Idaho and Alaska, consistently reported coverage below the 95% herd immunity threshold, whereas states with more restrictive exemption policies maintained near-universal coverage.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Non-medical exemptions are strongly associated with state-level differences in kindergarten vaccination coverage in the United States. These findings suggest that exemption policies may play an important role in shaping population-level protection, although causal relationships cannot be established from this analysis.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1795927","type":"journal-article","created":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:38:51Z","timestamp":1777527531000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Non-medical exemptions and state-level variation in kindergarten MMR vaccination coverage, United States, 2016\u20132024"],"prefix":"10.3389","volume":"14","author":[{"given":"Diego R.","family":"Hijano","sequence":"first","affiliation":[{"name":"Department of Infectious Diseases, St. Jude Children\u2019s Research Hospital","place":["Memphis, TN, United States"]},{"name":"Department of Pediatrics, University of Tennessee Health Science Center","place":["Memphis, TN, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,4,30]]},"reference":[{"key":"ref1","volume-title":"Vaccines for Children (VFC) Program: Impact and Cost Savings","year":"2025"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"577","DOI":"10.1542\/peds.2013-0698","article-title":"Economic evaluation of the routine childhood immunization program in the United States, 2009","volume":"133","author":"Zhou","year":"2014","journal-title":"Pediatrics"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"682","DOI":"10.15585\/mmwr.mm7331a2","article-title":"Health and economic benefits of routine childhood immunizations in the era of the vaccines for children program - United States, 1994-2023","volume":"73","author":"Zhou","year":"2024","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"e2021056007","DOI":"10.1542\/peds.2021-056007","article-title":"Value of the immunization program for children in the 2017 US birth cohort","volume":"150","author":"Carrico","year":"2022","journal-title":"Pediatrics"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"911","DOI":"10.1093\/cid\/cir007","article-title":"Herd immunity: a rough guide","volume":"52","author":"Fine","year":"2011","journal-title":"Clin Infect Dis"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"532","DOI":"10.1001\/jama.2020.26553","article-title":"Mandating COVID-19 vaccines","volume":"325","author":"Gostin","year":"2020","journal-title":"JAMA"},{"key":"ref7","volume-title":"SchoolVaxView: Kindergarten Vaccination Coverage and Exemption Estimates \u2013 United States, 2016\u201317 through 2024\u201325 School Years","year":"2025"},{"key":"ref8","volume-title":"State Vaccine Exemption Laws","year":"2025"},{"key":"ref9","volume-title":"Senate Bill No. 277 (SB-277): Public Health\u2014Vaccinations","year":"2015"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1585","DOI":"10.1001\/jama.2023.16995","article-title":"Kindergarten vaccination status in California after changes to medical exemption policy","volume":"330","author":"Delamater","year":"2023","journal-title":"JAMA"},{"key":"ref11","volume-title":"Measles Cases and Outbreaks \u2014 United States, 2025","year":"2025"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"732","DOI":"10.1016\/j.vaccine.2018.12.012","article-title":"Characterizing the impact of spatial clustering of susceptibility for measles elimination","volume":"37","author":"Truelove","year":"2019","journal-title":"Vaccine"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"840","DOI":"10.15585\/mmwr.mm7023a2","article-title":"Impact of the COVID-19 pandemic on routine vaccination coverage \u2014 United States, 2020","volume":"70","author":"Patel Murthy","year":"2021","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1981","DOI":"10.1056\/NEJMsa0806477","article-title":"Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases","volume":"360","author":"Omer","year":"2009","journal-title":"N Engl J Med"},{"key":"ref15","volume-title":"Progress and challenges with achieving universal immunization coverage: 2024 WHO\/UNICEF estimates of national immunization coverage (WUENIC)","year":"2025"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1795927\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:38:53Z","timestamp":1777527533000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1795927\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,30]]},"references-count":15,"alternative-id":["10.3389\/fpubh.2026.1795927"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1795927","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,30]]},"article-number":"1795927"}}