Back-to-school vaccinations: What pediatricians need to know for the back-to-school season

As summer comes to a close and families prepare for the back-to-school season, pediatricians are navigating an unusually complex and changing landscape regarding vaccine recommendations. Significant uncertainty surrounds the childhood immunization schedule, stemming from divergent guidance between the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP), which has required a federal court proceeding. It is more important than ever to follow scientific, evidence-based vaccine recommendations and to communicate clearly with families about the safety and efficacy of these preventive care measures. Although specific mandates vary by state, most states align closely with one another. This guide provides an overview of commonly required vaccines, a summary of supporting evidence, and a practical FAQ section for clinical use.

Commonly required vaccines for school entry across US states

Although each state sets its own immunization requirements, the following vaccines are required for school entry in most states.¹ Requirements typically differ by grade level (kindergarten vs middle school entry).

Diphtheria, tetanus, and acellular pertussis (DTaP/Tdap)

DTaP is required for children entering kindergarten in all states, with most states mandating 4 to 5 doses (except for Nebraska, which allows 3 doses), typically administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years of age. After receiving all 5 doses on schedule, DTaP protects 98% of children within the year after the last dose and approximately 71% of children 5 years after the last dose.

Tdap (the adolescent/adult booster formulation) is required in all states for middle school entry, typically around ages 11 to 12. Tdap contains lower amounts of diphtheria and pertussis proteins to reduce the likelihood of injection-site reactions observed in adolescents and adults who received DTaP.

Hepatitis B (HepB)

A 3-dose HepB vaccine series is required for school entry in most states (excluding Alabama and Montana), typically initiated at birth. HepB vaccination is critical because chronic hepatitis B infection acquired in early childhood carries a significantly higher risk of progression to cirrhosis and hepatocellular carcinoma than infection acquired in adulthood.

Hepatitis A (HepA)

A 2-dose HepA vaccine series is required for kindergarten entry in fewer than half of US states, while most states require it through grade 12. In some states, it is only a requirement for child care, not necessarily for school entry. This requirement has been established in an increasing number of states, following ACIP’s universal recommendation for children, beginning in 2006. Recent outbreaks have disproportionately affected unvaccinated adults, highlighting the importance of childhood vaccination as a long-term public health strategy.

Haemophilus influenzae type b (Hib)

Hib vaccination is a requirement in all states. Although it is primarily required for childcare and entry to preschool rather than for kindergarten (because the series is completed in early childhood), it is a cornerstone of the early childhood immunization schedule. The Hib vaccine series (typically 3-4 doses, depending on the brand) has led to a reduction in invasive disease in the US of more than 99% since its introduction.²

Human papillomavirus (HPV)

The HPV vaccine series (2 doses if initiated before age 15; 3 doses if initiated at age 15 or older) is required for school entry for grade 7 in a small number of states, including Hawaii, Rhode Island, Virginia, and Washington, DC. Routine HPV vaccination is recommended at ages 11 and 12, with catch-up vaccination through age 26. The HPV vaccine safely and effectively prevents over 90% of cancers caused by HPV.³

Influenza (Flu)

The flu vaccine is required for preschool entry in a few states, including Connecticut, New Jersey, and Rhode Island. Flu vaccination reduces the risk of flu-related death by more than 85% in healthy children.^2,3

Meningococcal Vaccines (MenACWY and MenB)

MenACWY is required for entry into middle and high school in most states, with the first dose recommended at ages 11 to 12 and a booster at age 16. Currently, 36 states require the initial dose for middle school entry, 26 require the booster around age 16, and more than half require vaccination for college attendance.⁴ Data from one study⁵ showed that the incidence of invasive meningococcal disease (IMD) in the US without vaccination would have been 110% higher among children aged 11 to 15 years and 47% higher among individuals aged 16 to 23 years compared with the reported 155 and 691 IMD cases, respectively, during the vaccine era from 2005 to 2021.⁴

MenB (serogroup B meningococcal vaccine) is recommended through shared clinical decision-making for adolescents and young adults aged 16 to 23, with a preferred age range of 16 to 18 years. Although the vaccine is not universally mandated for school entry, some states and individual school districts have begun recommending or requiring it, particularly for college dormitory living. Pediatricians seeing college-bound adolescents for a visit have an opportunity to initiate the 2-dose series (6 months apart) for those who choose to receive it.⁴

MenABCWY is a pentavalent vaccine option for children who would receive MenACWY and MenB at the same office visit.

Measles, mumps, and rubella (MMR)

A 2-dose MMR series is required for school entry in all US states, with the first dose given at 12 to 15 months and the second dose at 4 to 6 years. Iowa is the only state that requires measles and rubella but not mumps vaccination. Measles is among the most contagious infections known, and recent outbreaks in communities with lower vaccination rates have reinforced the critical importance of this requirement.

Pneumococcal conjugate vaccine (PCV)

The PCV series (currently PCV15 or PCV20) is required by most states for child care entry but not school entry. However, there are risk-based pneumococcal vaccination recommendations to consider by age group and dose history.⁶ Routine PCV vaccination reduces vaccine-type invasive pneumococcal disease and nasopharyngeal carriage. This was observed not only among vaccinated children but also among those who were unvaccinated, due to reduced transmission of vaccine serotypes.⁷

Polio (IPV)

All states require a 4-dose inactivated poliovirus vaccine (IPV) series, with doses given at 2 months, 4 months, 6 to 18 months, and 4 to 6 years. Salk created the first licensed polio vaccine in 1955, leading to a sharp decline in polio cases, paralysis, and deaths worldwide. Just 3 years prior, there were more than 20,000 cases of paralysis and 3,000 deaths in the US due to polio.

Varicella (Chickenpox)

All states require the varicella vaccine, with most requiring 2 doses: the first at 12 to 15 months and the second at 4 to 6 years. Since the US varicella vaccination program began in 1995, there has been a decrease of over 97% in chickenpox cases.

COVID-19

As of early 2025, COVID-19 vaccines had been added to the childhood immunization schedule, though no state has school-entry mandates.

What’s new in vaccine research

MMR and measles outbreak data

Per the CDC (as of July 24, 2026),⁸ there have been 2318 confirmed measles cases reported in the US in 2026, surpassing the 2289 cases reported in 2025. Among the cases, 70% were reported in children and adolescents; 93% of the patients were unvaccinated or had an unknown vaccination status. Cases have been reported in 45 jurisdictions, with the most cases in South Carolina (670), Utah (522), and Texas (188).

In a cross-sectional study⁹ on MMR vaccine hesitancy in US adults, 17% (n = 501) believed the risks of MMR outweighed the benefits. Increased odds of hesitancy were associated with engaging with politically affiliated media outlets, such as Breitbart (adjusted OR [AOR], 2.08), and with seeking information from nonauthoritative sources, including social media influencers (AOR, 1.41) and alternative health practitioners (AOR, 1.70). It is important to understand the factors that may be influencing parents as we approach conversations about vaccine hesitancy.

Safety and immunogenicity of a pneumococcal conjugate vaccine (PCV21)

The PCV21 vaccine is FDA approved for the prevention of invasive disease (caused by Streptococcus pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15B, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B) and pneumonia (caused by the above serotypes except for 15B) in children aged 2 through 17 years who are at increased risk for pneumococcal disease and in individuals 18 years and older.¹⁰ What makes PCV21 different is that it does not comprise the same serotypes as PCV13, PCV15, or PCV20 and contains 11 unique serotypes not covered by prior PCV vaccines (though only 8 unique serotypes compared with PPSV23). In a randomized, modified double-blind, active-controlled phase 2 study enrolling toddlers previously vaccinated with 3 doses of PCV13 (cohort 1; n = 140) and unvaccinated infants (cohort 2; n = 712), PCV21 and PCV13 showed generally comparable immunogenicity for shared serotypes, with numerically greater immunogenicity in the PCV21 groups for the additional serotypes.¹¹ There were no safety concerns in either cohort. Pediatricians should consider whether the PCV21 vaccine may be beneficial to their at-risk pediatric patients. Of note, other pneumococcal vaccines––PCV24, PCV25, and PCV31––are undergoing clinical trials, which may be worth following.

Influenza vaccine effectiveness (VE) against pediatric death

In children with or without known underlying medical conditions, influenza vaccination reduced the risk of fatal influenza. A case-cohort analysis compared influenza vaccination status among reported influenza-associated pediatric deaths with survey estimates of vaccination coverage. From August 2016 through July 2025, there were 1234 laboratory-confirmed influenza-associated pediatric deaths reported among children 6 months to 17 years. Of 1086 reported deaths with available influenza vaccination information, 124 (23%) of 530 children with underlying medical conditions and 70 (13%) of 556 children without known conditions were fully vaccinated against influenza. The average influenza vaccination coverage was 49% across survey cohorts, and the overall VE was 80% (95% CI, 75%-84%).³

Clinical scenarios for pediatricians

“I heard from another parent that their older child was diagnosed with autism after receiving the MMR vaccine.” What is the evidence-based response?

When parents raise concerns about vaccine safety, it is important to understand where these concerns stem from and which discussion points may be most effective. In this case, the parent provided a reason for the concern, but it may be beneficial to open the conversation with where they may have heard or read this information. The claim that MMR vaccination is associated with autism has been thoroughly and repeatedly investigated and refuted by large-scale epidemiological studies involving millions of children across multiple countries. The original Wakefield study (1998) that sparked this concern was retracted due to serious ethical violations and data manipulation, and Wakefield subsequently lost his medical license. Pediatricians should acknowledge concerns empathetically, especially with the degree of circulating misinformation. Provide clear and accurate information about the safety data and offer to share reputable resources (eg, HealthyChildren.org¹² or the Vaccine Education Center¹³).

A child is behind on their vaccines due to missed appointments. The caregiver asks if they can be caught up before school starts.

Yes. ACIP (per July 2025 guidelines) publishes a catch-up immunization schedule that allows accelerated dosing intervals for most vaccines, enabling children who are behind to complete their series more quickly than the standard schedule. It is important to follow age- and minimum-interval requirements between doses to ensure an adequate immune response. Respecting the caregiver’s current willingness to vaccinate, even if they delay, and continuing to build a trusted partnership are imperative and can lead to completion of the vaccine series in a more timely manner.

A parent asks whether their child can receive multiple vaccines at the same visit. Is this safe?

Administering multiple vaccines at the same visit is safe and follows current recommendations and standards of care. Reassure parents that their child’s immune system can respond to multiple antigens simultaneously and that combination vaccines have been developed to reduce the number of injections required. Studies have not identified any increased risk of adverse events from the co-administration of recommended vaccines. This also reduces the number of clinic visits, improves adherence to the vaccine schedule, and shortens the window of vulnerability to vaccine-preventable diseases.

A parent refuses all vaccines for their child on religious or philosophical grounds. What are your obligations as their pediatrician?

Most states allow certain nonmedical exemptions from school immunization requirements, though the availability of religious exemptions and personal-belief exemptions varies significantly by state.¹⁴ Pediatricians’ obligation is to the health of their patients and the broader community. Provide the family with accurate information about the risks of vaccine-preventable diseases, including long-term complications and death, and seek to understand the specific concerns informing their decision. Document the conversation thoroughly, be approachable, and revisit the discussion at follow-up appointments. Maintaining a trusting relationship may increase the likelihood of future vaccine acceptance.

“My child has a cold, and I want to hold off on vaccines until they are better.” How would you advise this parent?

Minor illnesses such as mild upper respiratory infections, low-grade fever, or mild diarrhea are not contraindications to vaccination. Postponing vaccines for minor illnesses can lead to missed opportunities for vaccination and delays in adherence to schedules. Determine whether it is beneficial to explain to the parent what true vaccination contraindications are (eg, anaphylaxis).

A parent questions the HPV vaccine, saying their child is “too young” to need it at age 11. How should you explain the rationale for the timing?

Explain that the HPV vaccine is most effective when administered before any potential exposure to HPV or sexual contact. It may be helpful to remind parents that they do not always have control over when this contact occurs, and that vaccinating at ages 11 to 12 ensures that children are well protected before the age at which exposure is likely to occur. Remind parents that children vaccinated before age 15 require only 2 doses, not 3. Framing the HPV vaccine for cancer prevention, rather than focusing on its connection to sexual activity, is often a more effective communication strategy with hesitant parents.

Guidance for pediatricians

In this uncertain environment, pediatricians play a critical frontline role in ensuring children are protected from vaccine-preventable diseases before returning to school. Key action items include the following:

Verify current requirements: Confirm your state and local school entry vaccination requirements and communicate these to families.

Leverage well-child visits: Back-to-school season is an ideal time to review each patient’s immunization record, address missed doses, and initiate catch-up vaccination as appropriate.

Counsel families clearly: With increased public discourse and mistrust of vaccines, be prepared to discuss each vaccine’s safety and efficacy while addressing hesitancy with empathy.

Monitor evolving guidance: Given ongoing litigation and policy changes, monitor updates from trusted medical organizations, follow evidence-based practice guidelines, and be prepared to adapt communications as needed.

Use Vaccines for Children (VFC) program resources: The VFC program is important for ensuring equitable access to vaccines for eligible patients, regardless of federal-level changes.

References

1. School and childcare vaccine-specific requirements: state laws and requirements by vaccine as of May 2025. Immunize.org. Updated February 26, 2026. Accessed July 11, 2026. https://www.immunize.org/official-guidance/state-policies/requirements/

2. Flannery B, Reynolds SB, Blanton L, et al. Influenza vaccine effectiveness against pediatric deaths: 2010-2014. Pediatrics. 2017;139(5):e20164244. doi:10.1542/peds.2016-4244

3. Leonard JS, Reinhart K, Lu PJ, et al. Influenza Vaccine Effectiveness Against Pediatric Death in the United States: 2016-2025. Pediatrics. 2026;158(2):e2026076453. doi:10.1542/peds.2026-076453

4. Meningococcal vaccine recommendations. CDC. March 30, 2026. Accessed July 11, 2026. https://www.cdc.gov/meningococcal/hcp/vaccine-recommendations/

5. Shin T, Wells CR, Shoukat A, et al. Quadrivalent Conjugate Vaccine and Invasive Meningococcal Disease in US Adolescents and Young Adults. JAMA Netw Open. 2024;7(11):e2443551. Published 2024 Nov 4. doi:10.1001/jamanetworkopen.2024.43551

6. Summary of risk-based pneumococcal vaccination recommendations. CDC. May 8, 2026. Accessed July 24, 2026. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html

7. King LM, Andrejko KL, Kobayashi M, et al. Pneumococcal Serotype Distribution and Coverage of Existing and Pipeline Pneumococcal Vaccines. J Infect Dis. 2025;232(4):e609-e620. doi:10.1093/infdis/jiaf376

8. Measles cases and outbreaks. CDC. June 24, 2026. Updated August 7, 2026. Accessed July 24, 2026. https://www.cdc.gov/measles/data-research/index.html

9. Jamison AM, Saiyed S, Gardner LM. MMR vaccine hesitancy in a polarized information ecosystem: Results from a cross-sectional survey of US adults. Vaccine. 2026;81:128568. doi:10.1016/j.vaccine.2026.128568

10. Capvaxive. FDA. Updated June 18, 2026. Accessed July 24, 2026. https://www.fda.gov/vaccines-blood-biologics/capvaxive

11. Pichon S, Ullery GM, Cousin L, et al. Safety and Immunogenicity of a Pneumococcal Conjugate Vaccine When Administered Concomitantly With Routine Pediatric Vaccines in Healthy Toddlers and Infants. Pediatr Infect Dis J. 2025;44(10):995-1008. doi:10.1097/INF.0000000000004913

12. Vaccine safety: Examine the evidence. HealthyChildren.org. Updated April 3, 2026. Accessed July 24, 2026. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Studies-Examine-the-Evidence.aspx

13. Vaccine Education Center. Children’s Hospital of Philadelphia. Accessed July 24, 2026. https://www.chop.edu/vaccine-education-center

14. Exemptions permitted for state childcare and school (K-12) immunization requirements. Immunize.org. Updated October 16, 2025. Accessed July 11, 2026. https://www.immunize.org/official-guidance/state-policies/vaccine-requirements/exemptions-child-school-2025/