Mandatory vs. Recommended Vaccines: An Overview

Pretty girl getting a bandaid after receiving her shot
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It's a common scenario. A parent brings a child into the doctor's office for their annual physical, and the healthcare provider makes a recommendation to get a vaccine.

"Is it required for school?" The parent asks. "If it's not, then we'll pass."

Maybe they're in a hurry. Or perhaps they are hesitant to pay any more than what's absolutely necessary. But are "recommended" vaccines still medically necessary—even if they aren't mandated?

There is a lot of confusion surrounding the distinction between "recommended" and "required" vaccines—even among medical professionals. But understanding the differences is crucial to protecting the health and safety of yourself and your family. Here's what you need to know.

Who Sets Vaccine Recommendations?

Every year, the Centers for Disease Control and Prevention (CDC) publish a recommended vaccination schedule for the whole country. This schedule is put together by a panel of 15 experts known as the Advisory Committee on Immunization Practices (ACIP). Members of the panel have experience in public health and medical fields, such as physicians, researchers and disease specialists, including a community representative that can give perspective on the social aspects of vaccination.

This schedule is meant to provide the maximum amount of protection as safely as possible for everyone, starting with the very first vaccine given the day you're born.

The schedule is divided up by ages. For example, the ACIP recommends that typical, healthy 11-year-olds should receive four vaccinations that year to protect against meningitis, HPV-related cancers, whooping cough, and the flu.

This schedule is updated every year to ensure it is always based on the most up-to-date research regarding vaccine safety and effectiveness.

It's used by medical professionals across the country to vaccinate patients, and sometimes by state governments to determine what vaccines should be required for school.

Mandatory Vaccinations

For school-required vaccines, each state makes its own list of what vaccines students need before entering specific grades or by specific ages, or they won't be allowed to attend school. As a result, vaccine mandates vary widely throughout the country. Students in Kansas City, Missouri might be required to have at least one dose of meningococcal vaccine on file before they can start 8th grade, while their neighbors in Kansas City, Kansas are not.

How frequently these schedules are evaluated or updated also varies. Because some state legislatures meet only once every 2 years, newer vaccines already recommended by the CDC can take years to be added—if ever.

Who within state government decides what vaccines are required also varies by state. Some states might pass legislation to mandate vaccines for certain students, while others might dictate that the state health department determine what should be required for school. Like the ACIP, these bodies often rely on research to guide them on what vaccines to include, but other factors might also be considered—such as political optics, cultural norms, or practicality.

For example, the flu vaccine is recommended by the CDC every year to adapt to the changing viruses that circulate each flu season. But verifying every student received his or her flu shot every school year would be a monumental task for school nurses, and may not be considered feasible by state governments.

States can also require vaccines for other groups, like college students or child care workers, and individual organizations and companies can also require vaccines for their employees, such as hospitals requiring staff be vaccinated against hepatitis B.

Mandatory Vaccination vs. Forced Vaccination

The concept of "forced vaccination" is a terrifying and violent one.

But while allusions to children being pinned down by government officials while their parents helplessly scream objections are certainly compelling—the reality is much less dramatic.

All 50 states 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 still have options.

In every state, kids who shouldn't receive vaccines for medical reasons—such as transplants or allergies—can receive medical exemptions to vaccine requirements. And in all but three states—California, Mississippi, and West Virginia—parents have the ability to opt out of vaccines for non-medical reasons, such as religious objections to vaccination. In some states, the process for obtaining a non-medical exemption for a child is as simple as signing a form. The most laborious processes involve parents undergoing an educational module or counseling by a physician on the risks and benefits of vaccination before they can get an exemption. And while it might not always be the most palatable or realistic option for parents, homeschooled children are exempted from school vaccine requirements, too.

Even with these opportunities to opt out of vaccines, however, only about 2 percent of students actually do.

The Importance of Recommended Vaccines

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

For example, while many states require meningococcal and pertussis—or "whooping cough"—vaccination for adolescent students, only two require the HPV vaccine, and not one state requires influenza. This is despite the fact that influenza and HPV kill far more people in the United States.

According to a report by the University of Texas MD Anderson Cancer Center in Houston, just three of the six cancers linked to HPV kill roughly 7,000 people per year in the United States, compared to about 500 from meningitis and pertussis. Both pale in comparison to the estimated 12,000-56,000 deaths caused annually by the flu. This is why the CDC schedule recommends vaccines against all four of these diseases for adolescents at ages 11-12. They are equally important in the eyes of the ACIP to protect the health of adolescents, but they aren't all required for school.

If a vaccine isn't really necessary for everyone to get, the ACIP has ways of indicating that it's more optional. For example, the committee granted the meningococcal B vaccine a "provisional" recommendation in 2015, essentially leaving it up to health care providers to decide with patients if the vaccine is appropriate on a case-by-case basis.

A Word From Verywell

Bottom line: Vaccine requirements are minimum standards. Because the recommended schedule is more comprehensive, those who follow it will have no problem meeting requirements for school or work. However, getting only what's needed will leave you vulnerable to preventable—and potentially serious—infections.

Sources:

Ashrawi D, Javaid M, Stevens L, Bello R, Ramondetta L. The University of Texas MD Anderson Cancer Center. HPV Vaccine Uptake in Texas Pediatric Care Settings: 2014-2015 Environmental Scan Report.

Centers for Disease Control and Prevention. Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017.

Immunization Action Coalition. State Information.

National Conference of State Legislatures. States with Religious or Philosophical Exemptions from School Immunization Requirements.

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