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With schools set to start in a couple weeks, most parents of kindergartners are working to make sure to get required vaccinations for their children before sending them off to school.

But not all parents. Over the last decade, more parents have opted their children out of vaccination requirements through the use of nonmedical religious exemption 鈥� especially in recent years following the COVID-19 pandemic.

The number rarely rises above a percent or two of an incoming kindergarten class, typically accounting for no more than a couple hundred children per year. But that means that in the years since 2002, a total of more than 10,000 kindergartners have attended public and private schools without vaccination records, according to historical data from the Maryland Department of Health.

The rising percent of religious exemptions in recent years may point to increasing rates of vaccine hesitancy among families, said Daniel Salmon, a professor and director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health.

鈥淲e鈥檝e seen a post-COVID increase,鈥� Salmon said. 鈥淲ith COVID 鈥� things got really polarized with more misinformation and disinformation. Vaccinations became a very political topic. And that鈥檚 not helpful.鈥�

Maryland law requires that children have a handful of vaccinations when they enter kindergarten, in order to protect themselves and their classmates from transmissible diseases, such as measles, polio and chickenpox, among others. Children can be exempted if there is a medical reason they cannot receive a vaccine or a religious restriction against it.

The process to invoke the religious exemption in Maryland is simple. Parents can just sign a form that says: 鈥淏ecause of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child.鈥�

Elizabeth Elliott, president of the Maryland Association of School Health Nurses, said she understands the need for exemptions, but she said it is also important that as many children as possible be vaccinated.

鈥淗erd immunity is really important for those of us 鈥� kids, staff members, families 鈥� in a school community that, for medical reasons, can鈥檛 be vaccinated,鈥� Elliott said. 鈥淚t鈥檚 incumbent upon the rest of use to vaccinate ourselves and our children to protect those of use who can鈥檛 have the vaccine because it鈥檚 unsafe.鈥�

But tracking vaccine hesitancy is a tricky task, according to Salmon, and there are many factors that contribute to why some families don鈥檛 get their kids vaccinated.

鈥淚t鈥檚 really hard to answer that question based on data, based on how you measure vaccine hesitancy,鈥� he said. 鈥淪o the best measure we have is the proportion of children entering school who have a nonmedical exemption.鈥�

The earliest data readily available from the state is from the 2002-2003 school year, in which 0.2% of kindergartners got a religious exemption, or about 126 kids out of roughly 63,000 entering kindergarten that year.

The rate increased steadily over the years: Ten years later, for example, about 0.6% of kids had religious exemptions, resulting in about 419 kids not receiving vaccinations in 2012-2013.

Religious exemptions spiked in 2019-2020 when 2.7% of kindergartners, or 1,641 kids, opted out of vaccination requirements. The COVID-19 pandemic went into full swing in the spring of 2020, so those families would have opted out prior to the the rise in cases in the United States.

Since the 2021-2022 school year, at least 1 percent of kindergartners in Maryland had a medical exemption 鈥� a couple hundred a year.

While the percent and numbers have increased, Salmon believes the numbers are not rising high enough for major concern.

鈥淚t鈥檚 a pretty small number,鈥� he said. 鈥淚 guess it鈥檚 a big increase by percentage, it鈥檚 a fair number of kids, but the absolute numbers are fairly small.鈥�

He also noted that a state average does not tell the entire story of vaccine hesitancy.

鈥淚t鈥檚 also misleading because the exemptions tend to cluster geographically, socially, and the state average can can鈥檛 capture that social, geographical cluster issues,鈥� he said.

In the last school year, there were higher concentrations of religious exemptions in some of Maryland鈥檚 more rural counties. The highest rate of religious exemptions were in Worcester (4.21%) and Cecil (3.75%). But Baltimore City also ranked high for religious exemptions, at 2.05% of kindergartners.

Maryland tends to fall behind the national average of religious exemptions, according from the Centers for Disease Control and Prevention. In 2022-2023, the national average for nonmedical exemption was 2.8% of kindergartners, compared to Maryland鈥檚 1.4% for that year.

Salmon notes that there are many factors since the pandemic that have led to more parents seeking out exemptions from vaccination requirements.

鈥淭here鈥檚 not a simple answer. It鈥檚 a mixture of people not being aware of the diseases 鈥� people worried about the safety of vaccines, often full of misinformation and disinformation,鈥� he said. 鈥淲e need to do a better job of communicating to parents more broadly, listen to people鈥檚 concerns and be empathetic and address them with the best available science.鈥�

Elliott added that there are other underlying reasons why some families seek a religious waiver.

鈥淲hat I often see now is families signing the religious objection because it鈥檚 too difficult to get to their children their vaccines 鈥� It鈥檚 not surprising to hear, 鈥榃ell, I just couldn鈥檛 get to the clinic.鈥� So they just signed the religious waiver,鈥� she said, noting that this issue gets more common in middle school.

Elliott agreed with Salmon that the best way to reach families who are hesitant about vaccinating their kids is to be is to be understanding and respectful. She said that as a school nurse, it is part of her responsibility to help families understand why vaccines are important for health and safety in a school setting.

鈥淲e are the ones that will view the records and ensure compliance and reach out to families,鈥� she said. 鈥淚t is a state requirement that students are immunized. And we spend lots and lots and lots of time picking up the phone and having those conversations, politely and respectfully, informing those parents.鈥�

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Maryland Matters maintains editorial independence. Contact Editor Steve Crane for questions: [email protected]. Follow Maryland Matters on and .

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