Barriers to Enforcing School Immunization Requirements in North Dakota

BACKGROUND:   North Dakota state law requires certain immunizations for school entry. School immunization coverage rates in North Dakota continue to fall below 95%, the coverage goal set forth by Health People 2020. Additionally, personal belief exemption rates in North Dakota continue to increase. High vaccination coverage rates among students are instrumental in preventing outbreaks of vaccine preventable diseases. Several studies have found that school vaccination requirements reduce the incidence of certain vaccine preventable diseases; this is even more evident when requirements are enforced through exclusion of noncompliant individuals from school (Hodge & Gostin, 2002).

METHODS:   In order to assess attitudes towards enforcing school immunization requirements, the North Dakota Department of Health surveyed schools in the state. In December 2013, a web-based survey was distributed via email to all school principals in the state of North Dakota using SurveyMonkey®.  All 419 schools in North Dakota with grades kindergarten through twelfth were invited to participate in the survey. Participants were asked a variety of questions concerning their current practices and attitudes regarding enforcement of the school immunization requirements.

RESULTS:   A total of 167 schools (40%) responded to the survey with 152 schools (36%) completing the survey in its entirety. When asked about enforcement of the school immunization requirements, 69% of schools indicated that they do not exclude non-compliant students and 16% reported informing parents of the personal belief exemption option as an alternative to catching up students missing necessary immunizations. Several respondents also cited lack of district approval and lack of principal support as reasons why children are not excluded if not up-to-date for required immunizations. 

CONCLUSIONS:   Of the respondents to the survey, the number of schools currently enforcing the school immunization requirements through exclusion is only about 31%. Additionally, parents are often not notified of the school immunization requirements or deficiencies in their child’s record until after school has begun. Frequent themes included the need for support from district offices, state offices and administration at individual schools and the need for additional education and resources. A common concern was that enforcement of the school immunization requirements would be at the expense of education.