Immunization: A Cornerstone of Public Health

December 12, 2022


legislative-prospectus-2023-immunization-card.jpgVaccination is one of public health’s most powerful and cost-effective tools to prevent disease, disability, and death among children and adults. During the 2021-2022 flu season, 57.8% of children between six months and 17 years old and 73.9% of adults 65 and older received the flu vaccine. Getting an annual flu vaccine not only reduces the risk of illness and death, it also lowers the risk of hospitalization and time away from school or work. During the 2019-2020 flu season, vaccination prevented approximately 7.5 million influenza illnesses, 105,000 hospitalizations, and 6,300 influenza-associated deaths. For these and a variety of other public health-related reasons, CDC recommends an annual flu vaccination for everyone six months and older. In November 2022, CDC issued a Health Alert Network Health Advisory warning of sharp increases in respiratory disease—including influenza and COVID-19—earlier in the year than anticipated. CDC recommends “prompt vaccination” to prevent hospitalization and death associated with influenza and COVID-19.

Legislative Trends

Reducing Barriers to Access

The COVID-19 vaccine distribution effort revealed systemic inequities in vaccine access, including barriers to internet access for scheduling vaccination appointments, availability of paid time off to account for potential vaccine side effects, and difficulty in traveling to a vaccination site. In 2021, at least 22 states enacted laws expanding medical professionals’ scope of practice to increase the vaccination workforce, a trend that continued into 2022 legislative sessions.

In 2022, at least 11 states (Alaska, Arizona, California, Connecticut, Florida, Illinois, Iowa, New Hampshire, Pennsylvania, Virginia, and Wyoming) enacted laws expanding medical professionals’ scope of practice to increase the vaccination workforce. While many states had already empowered pharmacists to administer influenza and COVID-19 vaccines, Alaska expanded its pharmacist’s scope of practice to include prescribing vaccines. At least two states—California and Illinois—expanded their optometrist’s scope of practice to allow them to administer influenza and COVID-19 vaccines.

Childhood Vaccination Requirements

All states and territories require children to be vaccinated against certain diseases to enroll in school, with all 50 states and Washington, D.C. requiring students to be immunized against diphtheria, measles, mumps, rubella, pertussis, polio, and tetanus. Additionally, 24 states require college or university students to receive the meningococcal ACWY vaccine and 15 states and Washington, D.C. require certain college and university students receive the hepatitis B vaccine. These vaccination requirements always include a medical exemption, and at least 44 states and Washington, D.C. also grant a nonmedical exemption based on a person’s religious or personal belief.

At least 15 states and the District of Columbia considered bills relating to school vaccination requirements during the 2022 session. All proposals to remove specific vaccines from the state protocol, prohibit the inclusion of additional vaccines to the protocol, or exempt religious or parochial schools from the state immunization requirements failed. A new Arizona law prohibits requiring immunization against the human papillomavirus or COVID-19 as a condition of school enrollment.

Several states considered bills to adjust the qualifications for an exemption to the vaccine requirements. For example, New Hampshire removed a requirement that requests for a religious exemption be notarized. Massachusetts considered a bill strengthening its medical exemption requirements to require a physician to personally examine a child and annually submit a medical certificate asserting that vaccination would risk the health of the child.

Immunization Information Systems

All states and territories and the District of Columbia maintain confidential, population-based electronic databases, known as immunization information systems (IISs), that record immunizations administered by participating providers in the jurisdiction. Each IIS is maintained within its jurisdiction, with state laws outlining the scope of the system and how information from the system can or cannot be shared. For IISs that can share data across jurisdictions, CDC developed the Immunization Gateway (IZ Gateway). The IZ Gateway enables IISs, provider organizations, and consumer applications to exchange data to support improved immunization data sharing, integration, and access across the nation.

At least four states (Arizona, California, Maryland, and New Hampshire) enacted laws relating to their IIS in 2022. California enacted a law to include race and ethnicity data collection within the state IIS. A new Maryland law requires healthcare providers who administer vaccines at continuing care retirement communities, nursing facilities, and assisted living programs to report all vaccines to the state IIS.

Looking Ahead

ASTHO expects more states to consider laws changing their existing vaccination requirements and establishing exemptions from those requirements. Specifically, states are likely to consider:

  • Removing or expanding exemptions—including religious and philosophical exemptions—for existing vaccination requirements.
  • Expanding the scope of practice for medical professionals to administer vaccinations.
  • Expanding funding to provide immunizations to children, seniors, and low-income adults.
  • Building connections between IISs and health information exchanges.