The Impact of Vaccine Hesitancy on National Immunization Rates

By Katelyn Wells, PhD, Research and Development Director, Association of Immunization Managers

Image credit: Immunization Action Coalition

Image credit: Immunization Action Coalition

Outbreaks of measles, mumps, and pertussis (whooping cough) threaten the health of children across the United States. Most of these vaccine-preventable disease outbreaks have been fueled by deliberately unvaccinated children. In addition, stagnant human papillomavirus (HPV) vaccination rates limit the vaccine’s potential to prevent cancers. Vaccines are the cornerstone of a healthy society—and vaccine delay or refusal threatens to undercut their success.

An increasing number of parents are “vaccine-hesitant,” falling on a spectrum from delaying or selectively choosing vaccinations to not vaccinating their children at all. Their apprehension may be the result of false or confusing media claims, general public distrust of “the system,” or the fact that young parents have never encountered vaccine-preventable disease firsthand. Simply recommending and providing accurate information about vaccines has not been enough.

A critical gap remains in understanding how to promote vaccine confidence. Researchers are trying to understand vaccine hesitancy and improve vaccine confidence; however, each year a new cohort of infants in need of vaccines is born. Public health practitioners need to act on what they do know. The 64 state, city, and territorial immunization programs have information on successful strategies and lessons learned in addressing vaccine hesitancy.

A recent Association of Immunization Managers (AIM) survey demonstrates that most (87%; 47 of 57) immunization programs have prioritized activities to address vaccine hesitancy. These include changing personal belief exemption policies, collaborating with stakeholders, implementing public mass media campaigns, and educating physicians about how to address the issue with parents. The lessons learned from state, city, and territorial counterparts translate to the local level:

  • Support and promote state-level polices to avoid new personal belief exemption policies and strengthen existing exemption policies to ensure that exemptions are available only after parents receive education and acknowledge the associated risks of not vaccinating to their child and community. To find information about national organizational support for policies that do not support personal-belief exemptions, see the AIM Position Statement on Personal Belief Exemptions from State Vaccination Mandates and the NACCHO policy statement Eliminating Personal Belief Exemptions from Immunization Requirements for Child Care and School Attendance.
  • Strengthen partnerships with local stakeholders, such as a state, city, or territorial immunization program, department of education, immunization coalition, parent advocacy groups, and local chapter of American Academy of Pediatrics for a coordinated campaign to highlight the importance of timely immunizations. Public health practitioners can benefit by sharing resources during times of increased workloads, budget cuts, and staff shortages.
  • Promote documentation of vaccine refusal in Immunization Information System (IIS) to monitor local trends. As of 2013, 51 of 64 states, cities, and territories had an IIS with functionality to record the date of an exemption/parental refusal of vaccine.
  • Target and tailor the approach according to characteristics of the vaccine-hesitant population in a specific area. Part of addressing the problem is knowing where and how to focus efforts. Conduct parent focus groups, investigate recent research, and ask for lessons learned from public health colleagues.
  • Collaborate with local universities to research local vaccine hesitancy trends. Thesis-driven graduate students can analyze data and publish results, helping to expand the knowledge base. To protect and improve the health of all people and all communities, each stakeholder must do its part to improve the public’s trust in vaccines.

More information about U.S.-based policy and characteristics related to exemptions, vaccine hesitancy, and IIS is available at The website includes information about demographics and rates, fiscal environment, law and policy, strategies and initiatives, and the structure of immunization programs. Users may customize their experience by searching the data by jurisdiction or topic and printing reports.

This article was originally published in NACCHO Exchange. To read the entire issue, download the newsletter from NACCHO’s online bookstore. (Login required).

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