At South St. Marys Street Elementary School in Elk County, Pa., Jenna Zimmerman has seen a steady increase in the number of parents turning in vaccination exemption forms for their kindergarteners. They’re checking a box that confirms they have a “strong moral or ethical conviction” that precludes them from immunizing their children against diseases like the measles.
Pennsylvania is one of 15 states that permits parents to opt out of vaccinations for philosophical reasons, in addition to medical or religious reasons. Parents and legal guardians are not required to explain their rationale.
Zimmerman started as a nurse at the St. Marys, Pa., school district in 2018 and “every year there seems to be a few more,” she said. In Elk County, 3.3% of kindergartners were exempt for non-medical reasons in 2024-25, up from 1.5% six years ago.
St. Marys Area School District declined a records request detailing its kindergarten exemption and vaccination rates, however Zimmerman indicated that the school’s trends mirror what’s happening in the rest of the state: the rate of kindergartners receiving the recommended dose of the MMR (measles, mumps and rubella) vaccine has gradually declined since 2020.
“I don’t even think we have one medical exemption right now,” Zimmerman said. “They’re all religious, moral or philosophical.”
Six years ago, 95.5% of kindergarten students across Pennsylvania completed the measles immunization. In the 2024-25 school year, the number slipped to 93.7%, below the 95% needed to claim herd immunity — the threshold that prevents outbreaks and protects vulnerable populations, like those medically unable or too young to get vaccinated.
Meanwhile, the exemptions in school districts have doubled in the past five years. In 2024-25, 6,097 non-medical exemptions were submitted on behalf of Pennsylvania kindergartners, compared to 2,993 in 2020-21.
“I don’t know that you can really deny them,” Zimmerman said. “If parents sign the paper that says they have a strong moral or religious reason … you can’t argue with that.”
As of May, the Pennsylvania Department of Health reported 23 cases of measles in Pennsylvania, the majority of which were in Lebanon and Lancaster counties (of those cases, 22 people were unvaccinated). Nationwide, the CDC tallied more than 1,700 measles cases in the first three months of 2026 — already making it one of the two worst years for infections since 2000 and putting the U.S. at risk of losing its measles elimination status by the Pan American Health Organization.
Dr. Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security and a UPMC-affiliated infectious disease physician in the Pittsburgh area, calls measles the “canary in the coal mine.” It’s usually the first disease to spread when childhood vaccination rates decrease, because it’s highly contagious.
“There are many parts of the country, including Pennsylvania, where there is not sufficient immunity in the population,” Adalja said.
How do vaccine exemptions work?
In Pennsylvania, children are required to have 15 doses of various childhood immunizations — for tetanus, measles, polio, and other diseases — before entering kindergarten.
Although the U.S. Department of Health and Human Services, under the direction of Secretary Robert F. Kennedy Jr., reduced the number of vaccine recommendations for children and young adults beginning in 2025, a federal judge has since blocked the move, stating that the government could not change the policy without consulting appropriate scientific bodies. Pennsylvania bases its stipulations on the recommendations of the American Academy of Pediatrics, which endorses the original protocol.
But these state requirements also allow for exemptions. With a doctor’s note, a child may receive a medical release. With a parent’s signature, Pennsylvania also grants exceptions for families with “religious or philosophical/strong moral or ethical convictions.” The only caveat? Those who have not been immunized may be excluded from school in the event of an outbreak of any vaccine-preventable disease.
Exemptions are filed with school nurses like Zimmerman and Jessica Canner, who is a nurse at Moshannon Valley, located in Clearfield County where 93% of kindergartners were vaccinated for measles in 2024-25 and 6.3% had non-medical exemptions (up from 3.2% in 2020-21). Moshannon Valley School District has seen an uptick in exemptions. In 2020, 1.8% of kindergartners were granted an exemption. In 2025, that rate jumped to 11.4%.
“They’re all always approved, because it’s a parent’s choice,” Canner said, adding that most of the exemption forms she receives are for philosophical reasons.
Legal experts agree — even if a school district wanted to deny an exemption request, it would have little ground to do so. Pennsylvania has not seen any public court cases in which a parent has sued a school district for denying an exemption, said Lawrence Katz, an attorney for LLF National Law Firm, which has represented clients in vaccine exemption disputes, in an email.
“A school that demanded clergy letters, interrogated the parent about the specifics of their beliefs, or applied subjective sincerity judgments would be vulnerable to a legal challenge,” Katz said.
State Rep. Arvind Venkat (D., Allegheny), who is also an emergency department physician at Allegheny General Hospital, said he doesn’t see Pennsylvania’s policy shifting anytime soon — public health and vaccines have become so politically partisan, in large part due to Kennedy’s anti-vaccine views, it’s become impossible to legislate changes, he said.
As a physician, Venkat hasn’t come across any credible moral or religious traditions that would prevent vaccinations, he said. But he also knows that the U.S. Constitution protects individuals’ rights to make their own choices, he added.
“I don’t think we’re in any position, and nor do I immediately favor revoking philosophical and religious exemptions,” Venkat said. “I think the first step is to be far more systematic about how we communicate with the public and at the bedside about vaccines.”
Why are parents opting out of vaccines for their children in rural Pennsylvania?
Most medical professionals in Pennsylvania and beyond agree that the U.S. has always experienced varying degrees of vaccine hesitancy, but it started increasing exponentially during the COVID-19 pandemic, when public health communications became mixed and muddied.
In 2020, the country was already fragmented — political ideology and social media algorithms influenced what people knew and how they felt about policies related to COVID mitigation strategies, including school closings, masking and vaccinations. In addition, some feared the COVID vaccine was rushed — even though the mRNA technology had been studied for 30 years before the shot was approved — and questioned its safety. In many cases, misinformation and disinformation left a portion of the population feeling skeptical, angry or scared.
In rural areas of Pennsylvania, the COVID effect was pronounced. Politically conservative counties like Elk, Cameron, and Clearfield mirrored much of what other Republican-dominated regions experienced nationwide. An analysis of the 2020 presidential election by NPR showed that people living in counties that voted 60% or higher for Donald Trump had 2.73 times the COVID death rates of those who went for Joe Biden.
Rep. Venkat said the pandemic “magnified divisions within society.” Access to accurate information and healthcare was limited, especially in rural areas. The dynamic created increasing hesitancy.
“The combination of an environment that was so polarized to begin with, along with evolving understanding of a new disease, unfortunately created a recipe for the skepticism and the divisions that came out of COVID, then it spilled over into the childhood vaccine schedule,” Venkat said.
Add Kennedy’s increasing influence, and it’s created an environment with more anti-vaccination sentiment, or at least more vaccine hesitancy. The secretary has appointed skeptics to the CDC vaccine advisory committee and continues to link vaccines to autism, a theory that has been refuted and debunked by scientists after decades of research.
“It’s been very discouraging for pediatric providers,” said Dr. Maryann Rigas, former president of the Pennsylvania chapter of the American Academy of Pediatrics and pediatrician in Coudersport, Pa. (Potter County). “[Parents] will say to me, ‘I trust you as our child’s pediatrician, but I want to do my own research.’ And that worries me, because I think most research these days is done on social media and it doesn’t have the most up-to-date or scientifically based information.”
Dr. Zoe Hawkins, a family medicine physician at Penn Highlands Elk, has noticed a shift in how her patients approach their children’s medical decisions.
“We are seeing more parents requesting delays or alternative [vaccine] schedules,” Hawkins said in an email. “Since the COVID-19 pandemic, there has also been a noticeable rise in distrust toward healthcare systems and public health recommendations, which has made the vaccine discussions more complex.”
Alexandria Gribble, a former school board member and parent of three from Emporium, Pa., fully vaccinated her children because, at the time, she “didn’t really look too closely” at the standard recommendations. Her experience during the pandemic — when she felt dismissed by school leadership while advocating for more parent choice about masking — reshaped how she views health decisions in schools.
As a result, Gribble built a network of like-minded parents through social media and encouraged them to advocate for masking accommodations. Although she still supports vaccinations overall, she sees that many parents in her community want a greater sense of control and respect in healthcare decisions affecting their children.
Other parents described how they have a more deliberate approach to weighing the risks and their personal beliefs about shots like MMR and polio. Jared Shelly, who lives in south central Pennsylvania, said his family evaluates each vaccine individually, taking into consideration religious values, medical guidance from his wife, who is a nurse, and their perception of how serious a disease is. The couple decided against vaccinating their two children against COVID-19, he said.
“If it’s a higher risk … then it helps justify it,” Shelly said.
Josh Beidel and his family also decided against the COVID shot due to concerns about how quickly it was developed, he said, but his two children are fully vaccinated otherwise. He worries that other parents are opting out based on misinformation.
“I would be more concerned [about the increase in exemptions] if my kids weren’t vaccinated for those things,” Beidel said. “The polio vaccine and things like that have been around for a very long time. I think that people are not opting out of that for good reasons — they’re just kind of jumping on the bandwagon, so to speak.”
How are medical professionals coping with distrust?
It’s also because the immunizations have been so effective over a long period of time that some parents simply don’t know how contagious or even how fatal the vaccine-preventable diseases can be for children.
Adalja, of Johns Hopkins, predicted that measles will become endemic again (transmitted continuously for 12 months) in the U.S. before its spread is brought back under control.
“It’s not a foregone conclusion that civilization always progresses forward,” Adalja said. “You have a very dangerous situation where people are rejecting the science and technology that makes their lives better in favor of a time when measles killed people and disrupted lives.”
Hawkins, the family medicine physician in Elk County, said she reserves judgement while listening to parents’ concerns, answering questions with evidence-based information and addressing “misconceptions in a respectful and understandable way.”
She also pointed out that rural communities face other unique challenges that contribute to the decline in vaccinations. Many families have limited access to healthcare providers and transportation. It’s also difficult for caregivers to schedule appointments during working hours.
“Some families may also lack awareness of vaccine programs that reduce or eliminate cost. Additionally, missed well-child visits and limited health literacy can contribute to children falling behind on immunizations,” Hawkins said.
Rigas has worked in pediatrics for 35 years, she’s watched attitudes toward childhood vaccinations ebb and flow. Today, she and her colleagues must walk the fine line between encouraging parents to vaccinate their children and respecting their beliefs.
“Some pediatric practices actually decline to care for children who don't receive immunizations,” Rigas said. “The American Academy of Pediatrics encourages pediatricians … to keep these families in their practice and obviously continue to encourage them at each visit to vaccinate.”
In her own practice with UMPC Cole Medical Center Pediatrics, Rigas said she offers hesitant parents a staggered schedule. In Potter County, the kindergarten MMR vaccination rate has slipped to 92.6% while the non-medical exemptions have climbed from 2.6% in 2020 to 7.3% in 2025.
“I will allow families, if they prefer, to give one vaccine at a time or two vaccines at a time,”
Rigas said.“I definitely continue to see these kids and continue to talk to the family every single time about vaccinations. I never give up. I'm hoping, hoping that at some point they will see the light and make the decision that's safest for their children.”
This work was produced by a team in the News Lab at Penn State where student journalists focus on critical coverage gaps across the Commonwealth of Pennsylvania with an emphasis on the issues most important to rural communities. This work is made possible by funding from the Arthur P. Miller Newsroom Fund and Hearst Foundations.