Who qualifies, how approval works, and what varies by state
Medical exemptions are the only category of vaccine exemption available in all 50 states and the District of Columbia, according to the National Conference of State Legislatures (NCSL). These exemptions are intended for individuals with specific health conditions that may make vaccination unsafe or medically inadvisable.
The CDC distinguishes between two primary categories of medical conditions that may warrant an exemption, according to the ACIP General Best Practice Guidelines for Immunization:
Contraindications: Conditions in a recipient that increase the risk of a serious adverse reaction. A vaccine should not be administered when a contraindication is present.
Precautions: Conditions that might increase the risk of a serious adverse reaction, might make it harder to interpret later symptoms or test results, or might reduce the ability of the vaccine to produce immunity. Vaccination is generally deferred when a precaution is present but may be indicated if the benefit of protection outweighs the risk of an adverse reaction.
True permanent contraindications are rare, according to CDC guidance. Most medical conditions that affect vaccination timing are temporary precautions that resolve over time, after which vaccination can proceed. The national medical exemption rate for kindergartners was 0.2% for the 2023-24 school year, according to CDC data published in the Morbidity and Mortality Weekly Report (MMWR, October 17, 2024).
While medical exemptions are generally the least disputed exemption category in law and policy, several states have adopted more rigorous oversight of the medical exemption approval process since 2015 through legislation requiring standardized forms, state health department review, or limits tied to individual provider exemption patterns.
The CDC publishes guidelines identifying specific contraindications and precautions for each vaccine, according to the ACIP General Best Practice Guidelines for Immunization. The following table shows selected examples. For the complete list, see the CDC's full Guide to Vaccine Contraindications and Precautions at cdc.gov/vaccines/hcp/imz-best-practices/contraindications-precautions.html.
| Vaccine | Contraindications (Examples) | Precautions (Examples) |
|---|---|---|
| All Vaccines | Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component | Moderate or severe acute illness with or without fever |
| MMR / Varicella | Severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, or severely immunocompromised HIV infection); Pregnancy | Recent (within 11 months) receipt of antibody-containing blood product; History of thrombocytopenia or thrombocytopenic purpura |
| DTaP / Tdap | Encephalopathy (for example, coma, decreased level of consciousness, or prolonged seizures) not attributable to another identifiable cause within 7 days after a previous dose | Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy |
| Influenza (IIV) | Severe allergic reaction to any component of the vaccine | Guillain-Barre syndrome within 6 weeks after a previous dose of influenza vaccine |
| Hepatitis B | Severe allergic reaction to yeast | None identified |
Source: CDC, ACIP General Best Practice Guidelines for Immunization: Contraindications and Precautions (current edition).
Note: This table shows selected examples only. The CDC's full guide covers all routinely recommended vaccines and should be consulted for clinical decision-making.
Medical exemptions are classified based on the duration of the underlying condition, according to CDC guidelines.
Permanent exemptions are granted for conditions that are not expected to change over time. Examples include a documented severe allergic reaction (anaphylaxis) to a vaccine component that cannot be avoided in alternative formulations, and certain permanent immune system disorders such as congenital immunodeficiency.
Temporary exemptions are granted for conditions that are expected to resolve or change over time. Examples include:
Temporary exemptions require a specified expiration date, after which the individual must be vaccinated or submit a new exemption request, according to state-specific procedural rules.
State laws define which healthcare professionals are authorized to sign medical exemption forms and what level of state review is required, according to individual state statutes.
In the majority of states, medical exemptions must be signed by a licensed physician — either a Doctor of Medicine (MD) or a Doctor of Osteopathic Medicine (DO). Some states, such as Oregon and Washington, also allow Advanced Practice Registered Nurses or Nurse Practitioners (APRN/NP) and Physician Assistants (PA) to sign medical exemptions. Maine's law (HP 586) similarly allows nurse practitioners and physician assistants to sign medical exemptions (Me. Rev. Stat. tit. 20-A, Section 6355).
States differ in how much oversight they apply to the medical exemption process. Three general categories have emerged:
Physician Autonomy: In the majority of states (e.g., Florida, Texas), state law accepts the physician's certification without secondary clinical review. The physician determines whether a contraindication or precaution exists and completes the exemption form.
State Health Department Review: In California, under SB 276 (2019), the State Public Health Officer or designee reviews medical exemptions that meet certain criteria, such as those issued by a physician who has issued five or more exemptions in a calendar year. The California Department of Public Health (CDPH) may revoke exemptions that do not meet CDC, ACIP, or American Academy of Pediatrics (AAP) criteria.
Standardized State Forms: In New York, medical exemptions must be submitted on a standardized form issued by the state Department of Health. Schools must submit these forms to the state for audit. Following the elimination of religious exemptions in 2019 (A02371), New York clarified that medical exemptions must specify which vaccines are contraindicated and the duration of the exemption.
A full state-by-state table of approval authority and documentation requirements will be available on the companion page at /legal/mandates/exemptions/state-by-state.
Several states have enacted legislation that changed how medical exemptions are reviewed or approved. The following summary documents the specific provisions of these laws.
California enacted SB 276 and its companion bill SB 714 in 2019, creating one of the most detailed state-level medical exemption oversight systems in the country. Key provisions include:
(Cal. Health & Safety Code Sections 120370-120372; SB 276 statute available at leginfo.legislature.ca.gov)
Following the elimination of religious exemptions via A02371 in 2019, New York clarified requirements for medical exemptions. Medical exemptions must be granted by a physician licensed to practice in New York, must specify which vaccines are contraindicated, and must state the duration of the exemption. Schools are required to submit standardized medical exemption forms to the state Department of Health for audit.
(N.Y. Pub. Health Law Section 2164; guidance available at health.ny.gov/prevention/immunization/schools/)
Maine maintained medical exemptions following the elimination of religious and philosophical exemptions via HP 586 (effective September 1, 2021). Medical exemptions may be signed by a licensed physician, nurse practitioner, or physician assistant.
(Me. Rev. Stat. tit. 20-A, Section 6355)
The CDC publishes annual data on kindergarten vaccination coverage and exemption rates through the Morbidity and Mortality Weekly Report (MMWR).
For the 2023-24 school year, the national medical exemption rate for kindergartners was 0.2%, according to CDC MMWR data published October 17, 2024 (Vol. 73, No. 41). This rate has remained relatively stable over the past several years — it was also 0.2% in the 2020-21 school year and 0.3% in the 2019-20 and 2018-19 school years, according to prior MMWR reports.
By comparison, the total exemption rate (medical and nonmedical combined) was 3.3% for the 2023-24 school year, up from 3.0% in 2022-23 and 2.6% in 2021-22, according to the same CDC data. Nonmedical exemptions accounted for over 93% of all exemptions nationally.
State-level medical exemption levels varied, with most states reporting levels near the national average. States with centralized review processes, such as California, have seen changes in reporting patterns after new legislation took effect, according to CDC MMWR data.
Source: Seither R, Yusuf OB, Dramann D, et al. "Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2023-24 School Year." MMWR. 2024;73(41):925-932.