The most effective vaccine program in American history doesn’t require a single new drug, clinical trial, or breakthrough. It requires a form for school enrollment.

But that’s changing. School vaccination requirements are being threatened from multiple angles: rhetoric from the highest offices of the nation is trickling down to state legislatures, and more people are having questions at kitchen tables and in pediatricians’ offices.

We asked for your questions. We have answers.

1. What is the state of affairs for vaccine school requirements?

School and childcare vaccine requirements have always lived at the state level. For most of modern history, that didn’t matter much. All 50 states landed roughly in the same place: protect kids from measles, polio, chickenpox, and hepatitis B. Every state also has medical exemptions (a doctor confirms the vaccine isn’t safe for a specific child). The majority of states have non-medical exemptions (religious, philosophical, or personal belief).

Source: KFF

But things are shifting.

The strictest states may be becoming more lenient. Five states—California, New York, Maine, Connecticut, and West Virginia—allow only medical exemptions. And this is fairly new. That’s now under legal pressure, including a Supreme Court case expected this summer and active debates in West Virginia.

On the other hand, states that were already lenient are looking to become more so. More than 200 bills are being introduced about vaccines, including school requirements:

• In 2025, Idaho passed a “medical freedom” law that bars schools from conditioning enrollment on vaccination, making its existing requirements challenging to enforce.
• Ten other states passed legislation or took administrative action to weaken or eliminate requirements. Iowa and Florida have seen the most serious pushes, though Florida’s most aggressive proposals stalled this cycle.

Our read: this debate will largely stay at the margins. Three out of four Americans still support school vaccination requirements, including two-thirds of Republicans. But the pressure is real and worth watching.

2. Do school-entry requirements actually work?

Yes, but the reason might surprise you. Most people assume the logic is simple: you have to vaccinate to enroll, so you do. But the evidence points to something more interesting.

Requirements work in part by creating a structured moment of connection to health care, which is often a catch-up opportunity for overdue preventive care. They remove the friction that keeps well-meaning families from staying up to date. That mechanism has real implications for what’s lost when requirements are removed.

Several findings support this:

1. When families do come in to meet school requirements, they don’t just get the required vaccines. Requirements increase uptake of non-required vaccines like HPV, too.
2. The biggest gains show up among children who were simply behind, not among children of vaccine-refusing parents.
3. When states eliminate non-medical exemptions, families seeking medical workarounds barely budge (rising only about 0.4 percentage points).
4. Some Canadian provinces and the U.K. achieve comparable vaccination rates without requiring school entry by delivering vaccines directly in schools.

This health care connection matters far beyond vaccines. Developmental delays, lead exposure, vision problems, food insecurity, and signs of abuse are all routinely caught at these same visits. Weakening requirements doesn’t just lower vaccination rates but also cuts off one of the few reliable ways for children to connect with a doctor.

That said, requirements are only as equitable as the system behind them. In a 2024 survey, almost 1 in 4 parents who sought an exemption cited logistics, not philosophy, as the barrier. That’s an argument for pairing requirements with robust access.

3. Is there any point where those of us with vaccinated kids need to be worried? Should vaccinated school staff be worried?

It depends on the disease we are talking about. Vaccines do not all work the same way. Some, like measles, are extraordinarily effective at preventing infection, while others are meant to protect from severe illness, and many have protection that wanes over time.

For measles, the MMR vaccine is insanely effective (97% effective after two doses). But a few nuances matter:

1. Disruption. When measles enters a school, protocols require unvaccinated students and staff to be excluded for up to 21 days per exposure. Your vaccinated child may be fully protected, but still caught in weeks of school disruption.
2. Who’s at home? Vaccinated individuals can carry the virus before their immune system clears it. If you have an infant too young to be vaccinated (MMR starts at 12 months) or an immunocompromised family member, a school outbreak can reach your home.
3. Vaccine non-response. About 3–5% of people don’t develop full immunity after the MMR vaccine. You can check your antibody levels with a titer test, but even that doesn’t tell the complete story.

For diseases like whooping cough or mumps, the concern is different. The vaccines work well at preventing serious illness, but they’re not as effective at stopping the spread of disease. This means even vaccinated people can sometimes transmit these diseases without realizing it.

High vaccination rates in your community protect everyone, including the small percentage of vaccinated people whose immunity didn’t fully take.

4. Is this playing out elsewhere in the world?

Yes. Several countries have already gone through versions of this debate, and their experiences reveal a few consistent patterns worth understanding.

Italy’s story is possibly the most instructive. Italy had requirements on the books for decades, but rarely enforced them. A 2012 court ruling falsely linking MMR to autism went viral, and coverage collapsed. A 2017 outbreak with 5,000 measles cases and four deaths led to stricter requirements. However, the hard mandates also triggered fierce public backlash, giving the incoming populist government the political opening to weaken it almost immediately. Measles surged again. Italy has since reinstated stronger requirements, but the cycle illustrates two lessons: rollbacks will cause outbreaks, and how you implement requirements may shape whether they survive the next election.

5. What are tips for talking to neighbors, friends, and policymakers about vaccine school requirements?

How you talk about this matters just as much as what you say. The right approach also depends on who you’re talking to.

Talking to friends and neighbors

Don’t lead with science and data. When people feel like their values are being challenged, facts alone rarely change minds. Start with shared values, then let the evidence support the conversation.

Begin with common ground. Most parents, regardless of their politics, want their kids to be safe at school and for school to run normally. Saying “I just want to make sure schools aren’t shut down for weeks because of a preventable outbreak” is something almost everyone can agree with. Start there.

If someone brings up studies or claims that seem to contradict the evidence, resist the urge to debate every detail. Instead, acknowledge the concern and emphasize that what matters most is the totality of the evidence.

Words matter. Avoid the word “mandate.” It tends to put people on the defensive immediately. Try “school immunization requirements” instead, and use “immunizations” rather than “vaccines” to sidestep some of the charged associations from COVID-19 debates. This framing also helps because school immunization requirements are just one part of standard enrollment paperwork, like getting a vision screening or a physical. Framing it that way makes it feel less like a political battle and more like a routine part of keeping kids healthy.

Talking to policymakers

For policymakers, the financial argument is often the most persuasive when other arguments stall. The 2019 measles outbreak in New York cost over $8 million to contain. Requirements are cheap, and outbreaks are expensive.

It’s also worth emphasizing that there’s a range of middle-ground options that don’t require choosing between eliminating requirements entirely and keeping them exactly as they are. Policymakers can make exemptions harder to obtain without eliminating them, require families to complete vaccine education before receiving an exemption, or restrict exemptions on a disease-by-disease basis rather than all at once. As Italy showed, going too far too fast can turn supporters into opponents. The goal is durable policy, not just bold policy.

Bottom line

School vaccine requirements do important, quiet work: they keep preventable outbreaks out of classrooms, keep kids in school, and create reliable moments for families to access health care they might not otherwise get. Three out of four Americans support keeping these requirements. The challenge now is to make sure the majority is heard.

Love, YLE and DH

David Higgins, MD, MPH, is a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. He publishes the newsletter Community Immunity, where he writes about vaccines and public health. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn and Instagram.

Your Local Epidemiologist (YLE) is founded and operated by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, wife. YLE reaches more than 425,000 people in over 132 countries with one goal: “Translate” the ever-evolving public health science so that people will be well-equipped to make evidence-based decisions. This newsletter is free to everyone, thanks to the generous support of fellow YLE community members. To support the effort, subscribe or upgrade below:

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A lot is changing in U.S. health policy, and New York is feeling the ripple effects. Changes are showing up in New Yorkers’ appointments, prescriptions, and prevention tools.

This week’s Dose covers disruptions to youth gender-affirming care in NYC, a vaccine access package moving through the state legislature, and an update on measles cases in Rockland County.

Gender-affirming care disrupted at NYC’s major hospitals: what the whole community should know

NYU Langone has closed its gender-affirming care program for trans youth, and Mount Sinai has reduced or cut some services, leaving families scrambling for alternatives.

For a lot of families, gender-affirming care isn’t an abstract policy, it’s part of daily life. It’s a standing appointment. A prescription refill that keeps things steady. A clinician who knows their child, their history, what’s worked, what hasn’t.

So when that care changes suddenly, it can be destabilizing, with families describing abrupt changes and referrals to private clinics.

And this isn’t a small slice of NYC. While we don’t have data available on the number of trans youth in NYC, we do have an estimate for adults. Based on NYC survey data, about 0.6% of NYC adults identify as transgender—roughly 50,000 people. If kids make up about 20% of NYC’s population, the back-of-the-envelope math suggests there may be at least 10,000 transgender youth in NYC, too.

Sexual and gender identification among NYC adults. Gender minority refers to individuals who identify with a gender identity other than cisgender, including transgender. Sexual minority refers to individuals who identify with a sexual orientation other than heterosexual. Figure from the NYC Epi Data Brief.

Why are there disruptions?

These stories are unfolding because federal funding cuts and regulatory pressure are disrupting gender-affirming care for minors across the country, including in New York.

The Trump administration has threatened to pull funding from hospitals and practices associated with hospitals that provide these services. They are also trying to end Medicaid coverage for gender-affirming care, which would mean that even if a family can find non-hospital-based care, they wouldn’t be able to access it if their insurance is through Medicaid.

I also want to call out some of the fear-based language in these federal documents.

Phrases like “sex-rejecting procedures” and “chemical and surgical mutilation” are meant to alarm and make people think of non-reversible treatments or “removing body parts.”

But that’s not what most families are facing right now. Most of the access being cut off is for puberty blockers—medication which pauses puberty and is reversible (when stopped, puberty resumes). Puberty blockers actually give families, children, and their clinical teams more time to make longer-term decisions. For a more detailed explanation, Those Nerdy Girls has a helpful post on puberty blockers.

It’s also worth putting surgery in context: a 2024 analysis of insurance data found that among minors aged 15–17, gender-affirming surgeries were rare—for every 100,000 minors, there were only ~2.1 surgeries.

The ray of light is that New York is pushing back.

The attorney general’s office told NYU Langone to resume care, noting the federal funding threats they cited aren’t currently in effect, and raising concerns the pause could violate state anti-discrimination law.

There is also a bill going through NY state legislature that would ensure that Medicaid covers gender affirming care in the absence of federal funding.

What this means: continuity of care is a health issue

For many families, “just go somewhere else” isn’t a real option—it’s waitlists, insurance challenges, travel across the city (or out of state), and clinical disruption piled onto a situation that can be stressful and sensitive. And when care gets interrupted, the ripple effects aren’t just medical, they also affect mental health, school, stability, and trust.

What to do: practical steps for families and caregivers

If your child is currently receiving care:

• Ask for a written transition plan that includes a timeline, prescription guidance, referral list, a record transfer process, and any important points of contact.

• Request copies of records now (visit notes, medication history, labs, etc.) and keep them for your records and for finding new care.
• Ask for prescriptions with plenty of refills if they are at a stable point in their care.
• Read this amazing piece by my friend MK that describes how to help kids feel emotionally safe during these uncertain times.
• Know these resources are available:
  • Trevor Project hotline for LGBTQ+ young people
  • Trevor Project’s Finding Support & Building Community Amid Political Uncertainty guide
  • Trans Lifeline
  • LGBT National Help Center
  • Organizations hosting in-person support spaces, including HMI, The Center, and The Black Trans Liberation Kitchen, among others
• Encourage hope. Here are some success stories you can share:
  • Society for Research on Adolescence: Trans Stories
  • Human Rights Campaign: Trans Stories are Everyone’s Stories: Daniel
  • The Trevor Project: Stories of Pride: Sophia

If you’re searching for care:

• The NYCHealthMap lists clinicians offering gender-affirming care for adults and youth (select LGBTQ Health Services > Gender Affirming Care >Youth).
• Connect with trusted local advocacy groups that often keep updated provider lists. Community Support Resources are listed on this NYC DOH Transgender Health page.
• When you call practices, ask directly: Are you accepting new adolescent/minor patients? What’s the wait? Do you take my insurance? What documentation do you need?

If you’re a clinician or educator:

• This is a moment to tighten safety nets: proactive check-ins, mental health supports, and warm handoffs are important.
• Don’t assume families have a backup plan. Encourage or help them set one up if possible.

At the end of the day, the most important things for kids affected right now are making them feel safe and maintaining access and continuity of care. This means steady and coordinated, not abrupt and fragmented.

Something to watch: a vaccine package going through the NY Senate

In response to the rapidly shifting federal vaccine landscape, New York State Senate Democrats are moving a package of vaccine-access bills through the state legislature this week.

Together, these seven bills would protect insurance coverage for vaccines regardless of changes in federal recommendations, expand who can vaccinate (like pharmacy techs, nursing students, and medical assistants), and ensure clinicians are reimbursed for the full cost of vaccination.

These bills still need to pass through the state assembly and be signed by Governor Hochul to become law, and the package could reach the Assembly as early as next week.

This isn’t about changing the science, it’s about protecting the infrastructure that helps maintain vaccine access in New York—insurance coverage, staffing, reimbursement—when federal guidance is actively damaging those systems.

Infectious disease “weather report”

Measles: Three measles cases were just reported in Rockland County, all international tourists visiting the county. Residents who were exposed to these measles cases have been notified and are being closely monitored.

Rockland County has had large outbreaks of measles previously—last year there were more than 20 cases, and in 2019 there were more than 300. The county has some pockets vulnerable to measles—in some zip codes, fewer than 50% of eligible infants are vaccinated, far below the 95% needed for community protection.

The best thing to do right now is check the vaccination status of everyone in your family, and get up to date if needed. If you’re unsure whether you or your child is immune, talk to your healthcare provider.

RSV: For the tenth week in a row, RSV remains quite high.

Who should pay extra attention right now because of RSV risks:

• Older adults
• People with chronic conditions
• Pregnant people (to protect newborns)
• Families with young infants

RSV cases in NYC. Figure from the NYC Department of Health Respiratory Illness Dashboard. Annotations by YLE.

What to do:

• Same as last week—if you’re eligible and haven’t gotten protected yet this season, it’s still worth doing because we have weeks ahead of us of elevated activity.
• Layer in protections when you can: avoid visiting newborns or older people when sick, mask in crowded indoor spaces, and keep an eye on breathing symptoms in little kids (fast breathing, retractions—when the skin sucks in around the ribs, collarbone, or stomach with each breath—or dehydration).

Flu: Across New York state and in NYC, flu cases have increased slightly. Flu is still relatively low compared to the season so far, but it’s something to keep an eye on.

New York state flu hospitalizations, this season and last season. Figure from New York state respiratory report. Annotations by YLE.

Covid: Covid cases are holding steady, while ED visits are going down. Overall, Covid remains low compared to previous winters.

Covid cases in NYC. Figure from the NYC Department of Health Respiratory Illness Dashboard. Annotations by YLE.

Bottom line

If you or your loved ones are affected by disruptions to gender affirming care, prioritize continuity (records, refills, and a written transition plan) and supporting mental health. For other community members, now’s the time to support the kids and families navigating these disruptions.

Love,

Your NY Epi

Dr. Marisa Donnelly, PhD, is an epidemiologist, science communicator, and public health expert. This newsletter exists to translate complex public health data into actionable insights, empowering New Yorkers to make informed and evidence-based health decisions.