A sign at a University of Utah health clinic warns visitors about the spread of measles. Under the Trump administration, federal health officials have cut back the number of recommended vaccines, and more states are offering exemptions for parents who don't want to vaccinate children entering public schools. (Photo by McKenzie Romero/Utah News Dispatch)

States that were leaders in childhood vaccination before the pandemic are among those losing ground as exemptions and unfounded skepticism take hold, encouraged by the Trump administration’s stance under U.S. Health and Human Services Secretary Robert F. Kennedy Jr.

Expanded exemptions for parents are likely to drop both Mississippi and West Virginia from the top national rankings they held before the pandemic, according to a Stateline analysis of federal data. Other states like Florida, Idaho, Louisiana and Montana also are pushing the envelope on vaccine choice.

At least 33 states were below herd immunity in the 2024-25 school year, compared with 28 states before the pandemic in 2018-2019, the analysis found. Herd immunity refers to the percentage of people who must be vaccinated or otherwise immune from an infectious disease to limit its spread.

Research shows that in the case of measles — a highly contagious disease — states need to maintain at least 95% vaccination rates to protect people who can’t get vaccinated. Other diseases have similar herd immunity rates. People who can’t be vaccinated might include infants too young to receive certain vaccines and those with underlying health conditions.

Misinformation and expressions of distrust from influential leaders have an effect on parents, doctors say, as do new state exemptions making it easier for families to avoid the vaccines.

Some people who never questioned vaccines before notice a national debate and get confused, said Dr. Patricia Tibbs, a pediatrician in rural Mississippi and president of the Mississippi chapter of the American Academy of Pediatrics. New religious exemptions may already be fueling an increase in pertussis, also known as whooping cough, in Mississippi, she said.

“If they hear something about it in the news, then it must be right, they think,” Tibbs said. “We’re just following the guidelines and informing patients that this is a scientific discussion. Nothing has changed about the science. But people who don’t know science are making decisions.”

Under Kennedy’s leadership, federal support for vaccination has continued to slide, and many states have joined a movement to set their own course by following more science-based recommendations from doctors. On Jan. 26 the Governors Public Health Alliance, a group of 15 Democratic governors, endorsed child and adolescent vaccination standards from the American Academy of Pediatrics rather than the federal government.

Federal health officials in Trump’s administration have cut back the number of recommended vaccines. The chair of a vaccine advisory committee, pediatric cardiologist Kirk Milhoan, suggested in a Jan. 22 podcast that individual freedom was more important than protecting community health with vaccines, even for measles and polio.

New leading states

Before the pandemic, Mississippi and West Virginia had the highest kindergarten vaccination rates in the nation, according to the Stateline analysis. About 99% of kindergartners in each state had their required vaccinations before entering public schools in the 2018-2019 school year.

In the latest statistics for the 2024-25 year, Connecticut gained the No. 1 spot, followed by New York and Maine. Those states have reined in exemptions to school vaccine requirements, while Mississippi and West Virginia have begun to allow more exemptions.

West Virginia didn’t report vaccinations to the federal Centers for Disease Control and Prevention for the 2024-25 school year. The state department of health told Stateline the data wouldn’t be available until later this year.

But the state is likely to be pushed out of the top 10. Republican Gov. Patrick Morrisey issued an executive order a year ago giving parents the right to ask for religious exemptions. To date, the state has approved 693 such requests for the current school year, spokesperson Gailyn Markham wrote in an email. That alone is enough to shift the state’s ranking significantly.

Stateline computed an average of required kindergarten vaccination rates to compare states. The analysis uses 2018-19 as a pre-pandemic baseline because a large number of states did not report the information in 2019-20 in the chaos that followed the early COVID-19 spikes and school closings.

A January study published by JAMA Pediatrics found increased vaccination rates among kindergartners in states that had repealed nonmedical exemptions, suggesting the repeals “played a role in maintaining vaccination coverage in repeal states during a period of heightened vaccine hesitancy.”

Requirements and exemptions

All 50 states and the District of Columbia require students to have certain vaccines before attending public school. They also all allow exemptions for children who cannot receive vaccinations for medical reasons, and most states allow nonmedical exemptions, often for religious or sometimes personal reasons. But Florida Republican Gov. Ron DeSantis’ administration has proposed dropping all requirements, and Idaho enacted a 2025 law allowing vaccination exemptions for any reason. Idaho had the lowest rate of kindergarten vaccination, about 80% in the 2024-25 school year before the law took effect in July last year.

Louisiana in 2024 enacted a law dropping COVID-19 vaccine requirements for public schools, and the state has opted to halt publicity about flu vaccination and end public vaccine clinics.

A Florida bill that progressed out of committee in January would maintain school vaccine requirements but expand exemptions to include “conscience” as well as medical and religious reasons.

Dr. Jennifer Takagishi, a Tampa pediatrician and vice president of the Florida chapter of the American Academy of Pediatrics, said the organization opposes both the DeSantis administration proposal to revoke vaccine requirements and the bill that would expand exemptions. Florida’s kindergarten vaccination rate fell from 94% before the pandemic to about 90% in 2024-25, according to the Stateline analysis.

“They’re ignoring the 90% of their constituents who want vaccines and want to stay safe,” said Takagishi. “The legislators are listening to the louder voice of those who want to oppose vaccines instead of the majority. We also know that there are teachers in the school system and school nurses who are fighting this because it puts them at risk.”

All states except Montana report kindergarten vaccine statistics to the federal government. Montana enacted a 2021 law making vaccine status private and unavailable for statistical reports, over the objections of medical experts. The law also made medical exemptions easier for families who think their children have been injured by vaccines.

Dr. Lauren Wilson, a pediatrician and then-vice president of the Montana chapter of the American Association of Pediatrics, said in a hearing that the law would make “vaccination information unavailable for responding to and mitigating public health emergencies.”

“Vaccines have saved millions of lives. I personally have seen cases of tetanus, pertussis, measles and meningitis and the tragedies that these mean for families,” Wilson said in her testimony.

A 2023 court order forced Mississippi to accept religious exemptions. West Virginia allows religious exemptions following the governor’s order last year.

Tibbs, who practices pediatrics in rural Jones County, Mississippi, said she has been seeing more pertussis than usual, and thinks vaccine exemptions could be a factor.

In Mississippi, which reported 394 religious exemptions for the 2024-25 school year, overall rates remained high enough that year, at about 97.8%, to ensure “herd immunity” in most cases.

Mississippi has granted 617 religious vaccination exemptions for kindergartners this school year, about 1.8% of the class, according to Amanda Netadj, immunizations director for the state health department. About 96.3% of kindergartners have all required vaccinations this year.

But the state’s whooping cough cases last year were the highest they’d been in at least decade, and in September health officials announced an infant had died of the disease — the state’s first whooping cough death in 13 years.

“We do have a lot of people getting the religious exemption,” Tibbs said. ”But still, on any given day, the majority of my patients will still get their vaccines. We are keeping our fingers crossed that the numbers stay high enough.”

Stateline reporter Tim Henderson can be reached at thenderson@stateline.org.

A child receives a COVID-19 shot. A reduction in the list of federally recommended childhood immunization has sparked alarm among public health experts. (Photo by Chip Somodevilla/Getty Images)

A federal government announcement this week dropping some vaccines from the list recommended for routine childhood immunization has drawn opposition from medical professionals nationwide and concern from the Wisconsin health department.

The Wisconsin Department of Health Services is reviewing information from the Centers for Disease Control and Prevention (CDC) about the change in vaccine recommendations “and is doing so with great concern for the health of children in our state,” Jennifer Miller, a DHS communications specialist, told the Wisconsin Examiner in an email message Tuesday.

“Health professionals and parents deserve accurate, credible information,” Miller wrote. “We have not yet seen new scientific evidence that would justify changes to longstanding recommendations that have and continue to protect the health of children in the United States.”

The decision to stop recommending certain vaccines is “dangerous and unnecessary,” the president of the American Academy of Pediatrics said in a statement posted Monday at the professional association’s website.

What does the new childhood vaccine schedule actually mean for your family?

Among the diseases dropped from those recommended for routine immunization are hepatitis A and B, rotavirus, respiratory syncytial virus (RSV), flu, and meningococcal disease.

“AAP continues to recommend that children be immunized against these diseases, and for good reason; thanks to widespread childhood immunizations, the United States has fewer pediatric hospitalizations and fewer children facing serious health challenges than we would without this community protection,” said Dr. Andrew Racine, AAP president, in the statement.

Miller said that DHS will continue its assessment of the CDC’s recommendation changes as well as those from “other trusted medical and public health agencies.” The department plans to issue more information on Thursday, she said.

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Medical Assistant Janet Casamichana gives a flu shot to a child in Coral Gables, Fla., in September. Measles cases nationwide rose to 1,958 this year as of Dec. 16. (Photo by Joe Raedle/Getty Images)

The number of measles cases is continuing to grow, reaching 1,958 confirmed cases in 43 states through Dec. 16 and threatening to undo next year the United States’ status as a nation that has eradicated the disease, according to a report released Dec. 17 by the federal Centers for Disease Control and Prevention.

The increase of 46 cases in one week, including dozens more in South Carolina alone, raises concerns for holiday travelers.

Cases have now reached 803 in Texas, 182 in Arizona, 142 in South Carolina, 122 in Utah, and 100 in New Mexico this year.

West Texas has been the epicenter this year, but recently South Carolina has seen measles “spread quickly in unvaccinated households” in the Spartanburg County area, and 168 people were quarantined as of Dec. 16, according to the state health department.

The state urged employers to accommodate people with quarantine orders to help avoid more spread, warning that the disease is highly contagious for days before a person is aware of being sick.

Towns with low vaccination rates along the Arizona/Utah border also have seen recent outbreaks.

By July, national case numbers had already surpassed a 2019 outbreak, bringing this year’s caseload to the largest in 33 years. The last time there were more cases was 1992, when there were 2,126, according to the CDC report.

The continued outbreak, reflecting a worldwide increase in the disease but also a rise in vaccine hesitancy that has been encouraged at times by U.S. Secretary of Health Robert F. Kennedy Jr. threatens the hard-won measles eradication declared in 2000 for the United States.

The status has already been taken away from Canada, where the Pan American Health Organization found an outbreak lasting 12 months invalidated the “eradicated” status, and the United States faces an assessment next year. The CDC maintained in November that it was still possible to eliminate measles in the U.S. by ensuring every child has two doses of vaccine, but vaccination rates have been falling further away from the 95% minimum rate that limits spread.

Even as cases have risen this year, the CDC has communicated less about the highly contagious disease on social media, according to Johns Hopkins University research published this month.

The agency posted 10 times on social media this year between January and August, compared with an average of 46 times in the previous four years, according to the report, despite a rising number of cases.

Ruth Lynfield, Minnesota state epidemiologist, said vaccine hesitancy may not be the whole story of low vaccination rates, in a video interview published Dec. 16 by Contagion, an infectious disease news service. Minnesota has 26 measles cases this year, down from 70 last year.

“Overall, there is vaccine confidence. Ninety-two percent of our kids [nationally] are vaccinated against measles. However, in particular communities, that number can be quite low,” Lynfield said. “One of the reasons is not that people may be vaccine hesitant, but they have other priorities.”

Physicians can counteract some of the low rates by gaining trust and listening to concerns, she said, and also just by making things simpler with reminders and easy choices.

“One thing we can do is ensure that we can make it as simple and convenient as possible for parents and families to bring kids in to get vaccinated,” she said.

Stateline reporter Tim Henderson can be reached at thenderson@stateline.org.