Vaccines are considered among the most significant public health achievements of the 20th century. These safe and effective tools play a critical role in keeping individuals and communities healthy by providing immunity against potentially dangerous diseases.
Thanks to vaccination programs, once prevalent diseases such as measles, mumps, whooping cough and chickenpox are becoming rare and some have been eliminated altogether. For example, the United States has been polio-free for more than 30 years because of a successful vaccination program. Routine vaccination is estimated to prevent 419 million illnesses, 26.8 million hospitalizations and 936,000 premature deaths among children born in the United States between 1994 and 2018, translating to hundreds of billions of dollars in direct cost savings. Globally, immunization prevents 4 million to 5 million deaths each year.
The Centers for Disease Control and Prevention sets the U.S. adult and childhood immunization schedules based on updated recommendations provided by the Advisory Committee on Immunization Practices. There are vaccine recommendations for more than 20 dangerous or deadly diseases, depending on age and travel situation. The advisory committee recommends children be vaccinated against 16 vaccine-preventable diseases, including measles, tetanus and seasonal influenza. Adults are also recommended to receive annual flu vaccines, in addition to others depending on their age, health conditions, job, lifestyle or travel habits.
Although most children receive recommended vaccines, tens of thousands of Americans get sick from vaccine-preventable diseases every year. Vaccination rates remain lower among adults, and disparities in racial and ethnic populations and geographic regions persist among all age groups. Some communities have immunization rates below recommended levels or high levels of individuals refusing vaccines, placing them at risk for outbreaks. Like many public health programs, immunization programs are invisible when they are working well. Measles outbreaks or emerging viruses like COVID-19 serve as reminders of the important role immunization plays in protecting the public’s health.
The State Legislature’s Role
States play an important role in determining and enforcing vaccine policy. All 50 states have laws requiring certain vaccines for students in K-12 public and private schools and day care facilities, and many require a meningococcal vaccine for admission to colleges and universities. All states allow medical exemptions from these requirements, and most also grant religious or philosophical exemptions.
State vaccine policy tends to focus on childhood vaccination, particularly the exemption process, vaccine access and insurance coverage. Lawmakers can increase awareness of vaccine recommendations through public awareness campaigns and direct state and federal dollars to support state and local vaccination programs and research for vaccines. State legislatures may play a key role in crafting policy in these areas, in addition to partnering with stakeholders, building vaccine confidence and prioritizing health equity. Sections 2-5 of this toolkit include many examples of state policy related to these areas.
Consideration for Your State
Each state has unique demographic characteristics—including differences in racial and ethnic minority populations, and rural or urban areas—which can create varying considerations around vaccine accessibility. For example, the South and southwestern United States have higher populations of Black, Hispanic or Indigenous communities—groups that may face barriers to access or distrust health care systems due to a variety of factors, including historic and contemporary inequities. Vaccine coverage among these populations is generally lower, even after controlling for other characteristics such as insurance coverage and employment status.
Rural communities also face distinct challenges, including higher rates of some chronic diseases and limited access to health care. Policymakers may consider particular vaccine access challenges that apply to their specific state populations to provide equitable vaccination and reduce the incidence of vaccine-preventable disease throughout their communities.
Key Partners at the State Level
A wide array of state and local partners stand behind successful vaccine programs, working together to keep communities healthy. Immunizations are provided and administered by a broad range of stakeholders, from state and local health departments to community health centers, private providers and pharmacists.
State and territorial health officials have the primary responsibilities of monitoring vaccine safety and effectiveness, building strong partnerships to ensure vaccine accessibility, and preparing for and responding to infectious disease outbreaks. These officials provide relevant guidance and information about vaccines and the important role of immunization. In particular, immunization managers play a key role in managing vaccine programs, coordinating statewide efforts and providing educational materials for health care providers and the general public. With firsthand knowledge of and close connections to their communities, local health departments are also important stakeholders who help maintain or increase vaccination rates through several activities, including organizing and implementing school-located influenza vaccination programs and engaging the community to increase vaccine confidence.
Many responsibilities of governors affect the status and success of immunization programs, such as setting the state health agency agenda and creating annual budget requests for programs and departments. Governors can help ensure systems for coordination across agencies and the private sector are in place and may collaborate with partners to conduct certain vaccine efforts. During the COVID-19 pandemic, for example, governors were responsible for a wide variety of activities to ensure successful distribution and administration of COVID-19 vaccines.
There are several other key players helping to shape vaccine policy, including state Medicaid agencies, state and local immunization coalitions, community-based organizations, health care systems and academic institutions, to name a few. State legislators can collaborate with these partners to ensure adequate resources for programs, reduce barriers to accessibility and help disseminate important information about vaccines.
Key Partners at the Federal Level
Although states are on the front lines of immunization programs, federal efforts support vaccine programs in a number of ways, including through funding opportunities, research projects and ensuring vaccine safety. State-federal partnerships are vital in ensuring comprehensive vaccine infrastructure for routine programs and during public health emergencies when the scale and speed of an infectious disease outbreak requires optimized coordination. During the COVID-19 pandemic, for example, the federal government worked with state and private partners to develop, manufacture and distribute safe and effective vaccines, and provide updated guidance to support state, territorial, tribal and local public health vaccination planning.
The Centers for Disease Control and Prevention, the Federal Drug Administration and the National Vaccine Advisory Committee offer a variety of guidance and programs related to vaccines. The Vaccines for Children program and Section 317 of the Public Health Services Act finance approximately 95% of all publicly funded vaccinations, helping to provide vaccines to different population groups, including uninsured children and adults. The federal government also sponsors the Vaccine Adverse Event Reporting System, which serves as an early warning system to detect problems that may be related to vaccines, and the Vaccine Safety Datalink project, which helps the CDC assess whether an adverse reaction is purely coincidental or is directly linked to an immunization.
The Vaccines National Strategic Plan 2021-2025, developed through input from many state, territorial and local partners, articulates a comprehensive strategy to provide safe and effective vaccination. State-federal immunization partnerships can promote vaccines and provide robust solutions to address pressing issues such as vaccine hesitancy, disparities in vaccination coverage and emerging public health threats. Key stakeholders at all levels of government can work together to ensure broad immunization against potentially dangerous diseases, avoiding costs and keeping communities safe.
NCSL acknowledges the research assistance by Aileena Roberts, health intern, for this publication.