Maryland needs mandatory flu vaccination

Maryland should implement mandatory influenza vaccination for children in licensed child care and preschool programs.

Influenza, a serious preventable viral disease that peaks in frequency during the winter season, is associated with high morbidity and mortality in younger children and the elderly. It is easily prevented through vaccination. Among all age groups, influenza infection rates are highest in pre-school and school-aged children. The Centers for Disease Control estimates that 20 percent to 50 percent of children under age 5 are infected with the influenza virus annually. Children also carry a higher viral load and stay contagious for longer time periods compared to adults. These findings have major public health implications, as the disease burden associated with influenza in children ultimately leads to a domino effect and can help cause an influenza epidemic.


The public health ramifications of an influenza outbreak are significant, resulting in huge social and economic burdens. In the United States, about 1 out of every 1,000 children infected with influenza annually is hospitalized. The CDC estimates that an average of 73 hours of work time is lost for caregivers of hospitalized children. One U.S. study demonstrated that for every 100 children followed during the influenza season, 28 developed influenza. This was associated with 68 missed school days, 20 missed work days by parents, and 22 transmissions of influenza to other household members. This translates to a high loss of productivity for children in terms of missed schoolwork and for adults in terms of missed work.

Most states, including Maryland, have mandatory childhood vaccination requirements for tetanus, whooping cough, hepatitis B, Haemophilus influenza type b, measles, mumps, rubella, pneumococcal, polio and chickenpox. There are, however, only three states that mandate influenza vaccination for children attending preschools or licensed child care programs. New Jersey was the first state to implement a mandate in 2008, followed by Connecticut in 2010. Recently, Rhode Island also implemented the mandate, effective August 2015.

The lack of a mandate for the influenza vaccine in the state of Maryland is a policy issue because voluntary requirements have not been effective in achieving the targeted 70 percent immunization rates set by the national Healthy People 2020 initiative, much less the 80 percent vaccination rate necessary for herd immunity to be effective at containing the spread of an outbreak. Since 2010, the Advisory Committee on Immunizations Practices has recommended that everyone older than 6 months receive vaccination for influenza. Despite this recommendation, data from the CDC showed that only 58.9 percent of children from 6 months to 17 years of age in the United States received the influenza vaccine for the 2013-2014 season. The state of Maryland outperforms the national average with 66 percent vaccination rate for children during the 2013-2014 influenza season; while these results are promising, they still fall short of the goals.

Implementation of influenza vaccination mandates for children attending licensed child care or preschool programs has been effective in increasing immunization rates and decreasing influenza-related morbidity. Most notably, a Yale School of Public Health study showed that after the mandate took effect in Connecticut, immunization rates in preschool aged children increased from 67.8 percent in the 2009-2010 school year to 84.1 percent for the 2012-2013 school year — a whopping 16.3 percentage point increase. Furthermore, following the mandate, CDC data showed a 12 percent decline in the number of influenza related hospitalizations in children of day-care age in Connecticut for the 2012-2013 influenza season compared to the 2008-2009 season.

The dramatic decline in influenza morbidity and increase in childhood influenza vaccination coverage following the mandate help substantiate the effectiveness of such a policy in improving influenza related outcomes and vaccine compliance. Therefore, it makes the case for imposing an influenza vaccination mandate for Maryland children who are attending either preschools or licensed child care programs.

Pre-school and school-aged children have the highest risks for influenza exposure and infection given the amount of time they spent in a crowded environment. Imposing an influenza vaccination mandate for children in licensed child care or preschool programs in Maryland will have the potential to substantially decrease transmissions of this vaccine-preventable disease.

Dr. Pearlene Lee is a preventive medicine resident physician at the University of Maryland School of Medicine; her email is