Immunization Guiding Principles

September 20, 2017

Immunization is one of the most cost-effective means of public health promotion and disease prevention. Vaccines prevent disease, disability, and death in children and adults. Sustaining high vaccine coverage levels in children and adolescents, increasing coverage rates in adults, effectively communicating the safety and value of vaccines, and incorporating new vaccines into the routinely recommended immunization schedule requires vigilance and adequate resources

Evidence Based State and Territorial Policy

State laws mandating vaccines are one strategy to control vaccine-preventable diseases. States and territories are responsible for enacting vaccine requirements for entry into schools, child care facilities, and post-secondary institutions. Currently, all states and territories have school vaccination requirements, but both the requirements and the types of exemptions (medical, religious, or philosophical) permitted vary by jurisdiction. State and territorial health agencies (S/THAs) also have policies on vaccination requirements for personnel and patients in healthcare settings and correctional facilities. ASTHO supports the following principles to strengthen state and territorial immunization policies:

  • The authority of S/THAs to individually consider vaccine laws and regulations, employing a rigorous, evidence-based decision-making process that seeks input from subject matter experts and the public. This approach allows S/THAs to pursue appropriate policies and legislation, including limiting the adoption of easy-to-attain exemptions for vaccine requirements, which is contrary to efforts to improve vaccine coverage.
  • The development of immunization laws and reporting based on the recommendations made by the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP).
  • The authority of S/THAs to have the flexibility to tailor the implementation of evidence-based strategies for increasing vaccination uptake and reducing vaccine hesitancy to meet the needs of local and regional populations.
  • The authority to exclude unvaccinated and other non-immune persons from high-risk settings during an outbreak situation.

Quality Assurance and Accountability

S/THAs have the primary responsibility for ensuring vaccine accountability systems are in place for publicly funded vaccine programs. To ensure accountability, S/THAs will often conduct clinical office visits to ensure and reinforce appropriate vaccine storage and handling practices, and identify opportunities to improve vaccination coverage within the general population. ASTHO supports the following principles to ensure high quality state and territorial immunization programs:

  • The authority of S/THAs to maintain a strategic balance between program requirements and reporting requirements in order to maintain provider participation, understanding that minimum requirements may be necessary to ensure vaccine efficacy.
  • The use and improvement of technology systems to maintain or advance accountability within immunization programs.

Vaccine Financing

Federal funding for vaccines can be grouped into two programs: the Vaccines for Children program (VFC), an entitlement program which funds the purchase of vaccines for eligible children, and the Section 317 Immunization Grant Program, which provides funding for vaccine program infrastructure and provides flexible funding to states typically used to purchase vaccines for outbreak response or for uninsured adult populations not covered under VFC. Several states and territories have additional programs to support the provision of vaccines. ASTHO supports the following principles to ensure adequate resources for state and territorial immunization programs:

  • Increased, stable federal funding to support the broad public health infrastructure necessary for a successful vaccine delivery system, meet the increasing cost of vaccines, and provide safety-net coverage for those without adequate healthcare coverage.
  • Vaccine financing policies that recognize the value of vaccines and provide adequate compensation for vaccines and vaccine delivery, as well as incentives for continued vaccine research and development.
  • Vaccine billing systems that allow states and localities to bill adequately insured children, adolescents, and adults served in the public sector.
  • Sustaining adequate funding for the Section 317 Immunization Grant Program and the Vaccines for Children program to provide vaccines for the uninsured and underinsured populations.
  • Sustaining the Section 317 Immunization Grant Program to provide the core immunization functions that facilitate an efficient and effective immunization enterprise, which include immunization information systems, accountability, provider education, community outreach, and reaching vulnerable populations, among others.
  • Federal funding for immunization programs distributed to state, territorial, and local grantees in the most equitable manner based on four criteria: need, capacity, performance, and population, according to a methodology developed with state and territorial input and ensuring that funding for existing programs does not decrease.

Vaccine Access and Delivery

S/THAs play an important role in building strong partnerships to ensure that vaccines are accessible. Children and adolescents should receive immunizations in a setting that is linked to their primary healthcare, and often the optimal location is the medical home. S/THAs recruit and train networks of vaccine providers to assure access to the VFC program and promote the use of proven strategies to improve vaccination coverage through materials, training, and visits to clinical sites. ASTHO supports the following principles to enhance access to vaccines:

  • Evidence-based strategies to improve and sustain immunization coverage levels that can be adapted to state, territorial, tribal, and local needs.
  • Health policy and immunization goals based on the most comprehensive data available, including the use of multiple national surveys and state-level immunization information system data.
  • The National Immunization Survey (NIS) is the most cost-effective tool currently available for measuring state-by-state and territorial vaccine coverage levels and needs enhanced federal funding to measure coverage levels for the expanded child and adolescent immunization schedule. ASTHO supports timely release of comprehensive NIS vaccine coverage data for states and territories.
  • S/THAs partnerships with alternative providers within the immunization neighborhood (e.g., pharmacies, schools, workplace, and other clinical sites) to support suitable alternative venues for vaccination, recognizing that every person may not be reliably linked to a healthcare provider.
  • Strategies to improve and sustain adult and adolescent immunization coverage.
  • The National Adult Immunization Practice Standards.
  • Targeted interventions and tailored programs to reduce disparities in immunization coverage rates.
  • Research to determine optimal coverage levels for newly recommended vaccines and to assess the barriers to reaching these levels. This data should be used to develop programs and interventions to improve coverage levels.
  • Research to identify continued gaps in coverage and the best options for addressing them.

Vaccine Safety and Effectiveness

S/THAs implement several different approaches to monitor vaccine safety and effectiveness. After a vaccine is licensed in the United States, public health experts review epidemiologic data to monitor for vaccine safety and efficacy. National systems have been developed to compensate individuals harmed by rare vaccine side effects. ASTHO supports the following measures to improve and monitor vaccine safety:

  • Continuous evaluation of the safety and efficacy of existing vaccines, and ongoing research to improve the safety and efficacy of vaccines and vaccine delivery techniques.
  • Continued emphasis on the development of appropriate vaccine safety, vaccine hesitancy, and risk communication messages.
  • Research to ensure the safety of vaccines, to evaluate the effectiveness of vaccine delivery strategies, and to better understand disease transmission.
  • Incentives and policies to encourage vaccine development and ensure a stable, adequate, and safe vaccine supply.
  • The periodic reassessment of the National Vaccine Injury Compensation Program and the Vaccine Injury Table to determine their adequacy and appropriateness. ASTHO maintains that any changes should be made in consultation with S/THAs. Information explaining the risks and benefits of vaccines and the availability of compensation for vaccine-related injuries must be developed by the federal government and distributed in a timely manner through effective and appropriate education efforts by all entities and providers delivering vaccines.

Vaccination Related to Bioterrorism Preparedness

ASTHO supports the collaboration of federal, state, territorial, and local public health agencies to advance national security goals and address public health risks by formulating policies that include the rapid distribution of vaccine stockpiles and recommendations for vaccination of high-risk populations during a potential bioterrorism attack. Implementation of bioterrorism preparedness vaccination programs should include: clear communication about the threat of the agent in question, along with the risks and benefits of vaccination and recommendations for prioritizing populations for vaccination; liability protection for those administering the vaccine; compensation for injuries caused by the vaccine; standard consent and data collection forms when and where feasible, and, under certain warranted emergent circumstances, use of Emergency Use Authorization provisions as provided for by federal statute; and additional resources and funding flexibility.

Vaccination During an Influenza Pandemic or Public Health Emergency

Public health agencies at the local and state levels prepare for and respond to emerging infectious disease outbreaks. At every step, public health works closely to improve public awareness of disease transmission and risk reduction. During emergencies, vaccines must be effectively allocated, distributed, and administered. The needs and capacities of states and territories differ. ASTHO supports the following principles to strengthen vaccine preparedness efforts:

  • The collaboration of federal, state, territorial, local, and tribal governments to develop an effective and coordinated pandemic vaccination plan.
  • Implementing vaccine targeting protocols, if the vaccine is not immediately available to everyone during a pandemic, to maintain security, healthcare, critical infrastructure, and essential community services and to protect at-risk populations and workers with an occupational risk of infection with the goal of immunizing everyone who chooses to be immunized.
  • Developing guidance on the allocation and targeting of pandemic influenza vaccine that is evidence-based and reflects input from the government, stakeholders, and the general public.
  • Collaboration between government, stakeholders, scientists, and the general public is important to promote understanding and gain consensus of vaccine allocation and targeting plans. This collaboration should be inclusive of vulnerable and marginalized populations to help assure health equity in the emergency response and equitable distribution of limited vaccine resources.
  • The flexibility to implement a pandemic response plan and vaccine targeting guidance tailored to meet the specific needs of local and regional populations.
  • Access to a vaccine supply so that state, territorial, local, and tribal governments are able to provide an appropriate response to a routine outbreak of a vaccine-preventable disease.

Immunization Information Systems

Immunization information systems (IIS) are confidential, computerized systems that contain records of individual vaccination status, providing authorized providers immediate access to the immunization status of children and adults and reliable forecasting tools to maintain updated immunization status. The benefits of IIS include improved office efficiency, reduction of over-immunization, integration of additional public health services, and easier identification of persons at risk in the event of a disease outbreak or other public health emergency. ASTHO supports the following measures to support optimal use of IIS:

  • The development, continued use, and further improvement of IIS to assist in integrating several program strategies, including vaccine management, accountability, quality assurance and delivery, consumer information, surveillance, adverse events tracking, and assessment.
  • The IIS information exchange between authorized users in different states and localities.
  • The integration of IIS with electronic health records to facilitate information exchange between private providers and public health.

Approval History:

Infectious Disease Policy Committee Review and Approval: July 11, 2017
Board of Directors Review and Approval: August 23, 2017
Ratified by the ASTHO Assembly of Members: September 20, 2017
Policy Expires: September 30, 2020
Expiration Date Extension due to COVID-19: September 2022

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO's actions and external communications.