Building Vaccine Confidence Among State and Territorial Legislatures

February 23, 2023 | Maggie Davis, Heather Tomlinson

Gavel, scales of justice, and a judge's arms and folded hands at the bench. ASTHO Health Policy Update banner in upper left cornerThe development and deployment of COVID-19 vaccines was an extraordinary success for public health leaders, preventing an estimated 1.1 million deaths and 10.3 million hospitalizations in the United States between December 2020 and November 2021. Despite the proven safety and success of these vaccines, there was widespread hesitancy and reluctance to uptake.

Strong public health policies set forth by state and territorial legislators are critical to maintaining and rebuilding vaccine confidence. Prior to the pandemic, there was strong support for vaccines throughout state legislatures. In recent years, however, many of the hundreds of bills introduced related to vaccine policy propose weakening vaccination requirements by prohibiting certain vaccine requirements or expanding exemptions to vaccine requirements. As of February 3, 2023, there were more than 250 vaccine-related bills being considered across 37 state legislatures.

ASTHO recently convened virtual learning opportunities to help public health leaders increase vaccine confidence among elected leaders and navigate current legislative sessions. Participants engaged with vaccine policy experts, public health leaders experienced in navigating legislative processes, and peers from across the nation. Two key considerations emerged.

Work with Trusted Messengers

In 2022, 36 states held elections for governor and 46 states held elections for legislative seats (88 of the country’s 99 state legislative chambers were up for election). Additionally, changing legislative district maps due to the decennial redistricting effort, retirements, and term-limits, resulted in 24% of all state legislative seats being open (without an incumbent).

With changes of leadership, public health officials have an opportunity to engage with newly elected officials on the history of vaccine policy in their jurisdiction. As such, public health leaders should consider which voices people know and trust. For example, research identified physicians and other clinicians as trusted professionals for providing accurate information about vaccines to parents.

Community voices and grassroots coalitions can also educate leaders and advocate for strong vaccine policies. Organizations such as the SAFE Communities Coalition and Vaccinate Your Family can support public health efforts to build vaccine confidence.

Public health leaders working to build trust with elected leaders can develop an engagement strategy. To help, the National Public Health Information Coalition (NPHIC) and ASTHO created a Prepare to Vaccinate resource to provide several considerations for developing such a strategy. Resources developed by the Association of Immunization Managers (AIM) outline ways public health leaders can build vaccine confidence, including their Connecting the Dots chart, Vaccine Confidence toolkit, and policy toolkit.

Craft Informative and Compelling Legislative Testimony

When state/territorial legislatures consider bills related to vaccines, public health leaders, grassroots coalitions, and trusted messengers can often contribute their support for strong vaccine policy through legislative testimony. Legislatures often accept written and oral testimony when considering legislation, providing an opportunity for public health leaders and vaccine advocates to add their voice to the official legislative record.

Testimony provides legislators context for how a proposed bill would impact public health, informing them whether the legislation would likely improve or negatively impact public health.

For example, in 2021, then-Kansas Health Official Lee Norman, MD, MHS, MBA, submitted written testimony in opposition to Kansas Senate Bill 213. In Norman’s assessment, the proposed legislation would have restricted an employer’s ability to inquire about an employee’s vaccination status and would hinder public health protections and endanger the public.

In his testimony, Norman directed legislators’ attention to how the proposed bill would conflict with existing laws promoting public health, such as requiring childcare workers and healthcare personnel who conduct newborn screenings to receive certain vaccinations in order to protect the children in their care who may not be eligible for vaccination or may be more susceptible to disease.

Partnering with agencies or organizations can add crucial subject matter expertise. In 2022, Rebecca Coyle, the Executive Director of the American Immunization Registry Association, submitted written testimony opposing New Hampshire House Bill 1606, which would change the state Immunization Information System (IIS) from an opt-out to opt-in system. Her testimony highlighted the additional cost and staff time burden associated with the proposed change. Additionally, she outlined the benefits of utilizing an opt-out system ranging from privacy protections, data accuracy, and data accessibility.

Beyond providing information, testimony that includes personal stories or experience can be compelling. Written testimony submitted by Kansas resident Andy Marso in opposition to a Kansas bill that would limit required vaccinations, tells his personal story in support of vaccinations required for school enrollment.

Marso, who survived a meningitis infection acquired as a student, had only received vaccinations required for school attendance. At the time, neither his home state nor the university required students to receive the meningitis vaccination. Unvaccinated, his infection was severe and resulted in months of intensive medical treatment and significant medical bills—all of which could have been prevented by a relatively inexpensive vaccine.

Lastly, testimony that highlights shared values and uses storytelling techniques can be compelling. In 2021, Ohio considered House Bill 248, which would have made it unlawful to exclude students and employees from vaccination or masking requirements as a form of “discrimination.” During a committee hearing on the bill, Ohio resident Eric Lichtenfeld provided compelling testimony in opposition of the bill, highlighting the shared value of fairness and identifying exclusion from a public space as a consequence to a personal choice.

Should ASTHO members need additional support as they work to address vaccine legislation, ASTHO can help with technical assistance, providing resources, and connecting state and territorial health agencies with subject matter experts. ASTHO will continue to monitor this important public health issue and provide updates as they become available.