Position

The American Academy of Nursing (Academy) has long supported immunization as a critical intervention to reduce the incidence of vaccine-preventable disease and promote healthy lives for all people.^1,2,3  Declining immunization rates due to vaccine hesitancy, vaccine-related misinformation, increased nonmedical exemptions,⁴ disparities as well as coverage, access, and financial barriers⁵ presents a public health crisis. To reduce the spread and resurgence of vaccine-preventable diseases and prevent higher rates of morbidity and mortality across the lifespan, a comprehensive approach involving clinicians, health systems, industry partners, communities, and local, state, and federal government as well as global networks is necessary.

Background

Vaccines support individual health across the lifespan as well as the health of communities and nations. Over the past thirty years (1994–2023), routine childhood vaccinations in the United States have prevented approximately 508 million cases of illness, 32 million hospitalizations, and 1.1 million deaths.⁶ This has also resulted in economic benefits, with estimated direct savings (such as from disease treatment costs avoided) of $540 billion and societal savings (such as from lost productivity avoided) of $2.7 trillion.⁶ Vaccination programs globally support cost savings for countries, productivity gains and greater life expectancy that can support increased prosperity, reduced burden and cost on health care systems, and improved health protection and prevention of unnecessary illness and hospitalization for individuals.⁷ It is difficult to overstate the impact vaccination and in turn immunization has had on health in the United States and worldwide. Smallpox, once considered one of the deadliest diseases in the world, has been eradicated globally due to vaccines, and the endemic spread of some diseases including polio and measles was eliminated in the United States.⁸ Prior to the measles vaccine becoming available in the United States, an estimated 400-500 people died and 48,000 hospitalizations as well as 1,000 cases of measles-induced encephalitis (brain swelling) occurred each year.⁹ Extensive research demonstrates the safety and efficacy of vaccines.^10,11 All vaccines on recommended schedules have been and continue to be rigorously evaluated for safety and efficacy.¹¹ Furthermore, systems including the Vaccine Adverse Event Reporting System (VAERS) allow any adverse events and side effects reported from vaccinated people to be tracked and analyzed.¹² Research findings provide evidence of only rare serious adverse events associated with vaccines.¹¹

Trends in Immunization Coverage

Despite considerable research showing vaccine safety and efficacy, vaccination rates among adults in the United States are low for most vaccines and routine vaccination rates for young children continue to decline, a trend with concerning implications for public health.^13,14 For example, measles, mumps, and rubella (MMR) vaccine coverage among U.S. kindergartners has fallen below the coverage target of >95%, decreasing from 95.2% during the 2019–2020 school year to 92.7% in the 2023–2024 school year, leaving approximately 280,000 kindergartners at risk of infection during the 2023–2024 school year.¹⁵ The three recorded deaths from measles in the United States in 2025¹⁵ are the first deaths attributed to measles in the United States in a decade.¹⁶ At current immunization rates, it has been predicted that measles could become endemic again in the United States within approximately two decades.¹⁷ Outbreaks generally occur among unvaccinated communities,¹⁵ making vaccination a key strategy to promote sustained health and well-being. Notably, the vast majority of states allow certain nonmedical (including personal belief and religious) exemptions for required vaccines for school, and these policies continue to be evaluated.^18,19 Of concern, studies have indicated that the type and availability of nonmedical exemptions increase exemption rates and put areas with high exemption rates at risk of disease outbreaks.^20,21

Immunization coverage is critical to protect people across the lifespan and against a wide range of diseases. Pregnant women, older adults, and children have differing needs and vaccine schedules. Importantly, vaccination protects populations from seasonal respiratory illnesses including influenza (flu), COVID-19, and respiratory syncytial virus (RSV). The Centers for Disease Control and Prevention (CDC) estimated that in the 2023-2024 flu season, flu vaccination prevented 9.8 million flu-related illnesses, 4.8 million medical visits, 120,000 hospitalizations, and 7,900 deaths.²² However, flu vaccination coverage among adults has continued to decline since the 2020–21 flu season despite an increase in coverage during the season following the start of the COVID-19 pandemic.²³ Flu vaccination coverage was 55.4% among children and 44.9% among adults in the 2023–24 season—the lowest levels since the 2011–12 season for children and the 2017–18 season for adults. Similarly, despite high initial public interest in receiving COVID-19 vaccination, uptake in the years following the pandemic has been low with 23% of adults and 13% of children reported receiving 2024-25 COVID-19 vaccination.^24,25,26 Among pregnant women, 14.4% reported receiving 2024-25 COVID-19 vaccination.^26* Among older adults for whom RSV vaccination (administered in a single lifetime dose) is recommended, 47.5% of adults 75 years and older and 38.1% of adults age 60─74 years with a high-risk condition for RSV had received an RSV vaccine as of April 26, 2025.²⁷ For pregnant women, 38.5% had received the RSV vaccine as of January 31, 2025.²⁷ Flu, COVID-19, and RSV vaccination not only reduce the incidence of illness but also protect against severe outcomes including hospitalization and death.^28,29,30,31 Addressing these significant gaps in recommended vaccination coverage from childhood across the lifespan is therefore a critically important priority.

Addressing Barriers to Promote Vaccine Uptake

Barriers to vaccination must be addressed to promote vaccine uptake and address disparities in immunization rates in the United States. These barriers include cost, location, access to health care, access to information on vaccines and related complacency due to beliefs that vaccination is not needed, and mistrust of health care institutions and public health data.^32,33 Immunization rates are lower for certain populations, including people from historically marginalized racial and ethnic populations, people living in rural areas, and people without health insurance coverage. ^32,13,34,36 The COVID-19 pandemic underscored these disparities, but disparities persist in immunization rates across a number of recommended vaccines.³² Notably, large disparities have long persisted in adult vaccination coverage by race, ethnicity, and other demographic factors.¹³ Furthermore, across all vaccines recommended for adults, adults without health insurance were less likely to be vaccinated than those with health insurance.¹³ Cost can be a prohibitive factor: the cost of a flu shot, for example, for a person without health insurance can range from $22 to $69.³⁵ In 2022, adults with health insurance were 3-10 times more likely to have received pneumococcal and zoster vaccination than those without health insurance. Though disparities in childhood and adolescent vaccination coverage are less prominent than for adult vaccinations, coverage gaps remain.³² For instance, adolescents living in rural areas are less likely to have received human papillomavirus (HPV) vaccination compared to those living in urban areas.³⁶

Increasing the availability of vaccines overall presents a key step to increase vaccine uptake. The most common and trusted point of access for vaccinations is a primary care provider (PCP), but approximately 20% of Americans do not have a PCP. ^32,37 Increasing access to clinicians can connect people with important information and resources to get vaccinated. However, for some communities, particularly rural communities in which travel to a clinician may present a significant challenge, other approaches are necessary. Furthermore, reasons for vaccine hesitancy or lack of intent to receive a vaccine can vary widely across populations and communities.^38,39,40 Community-based approaches are essential to partner with particular populations, address their specific needs around vaccination, and ameliorate underlying barriers to vaccination. Community access could be expanded through schools, mobile health units, pharmacies, public health departments, and community centers including religious or older adult centers.³²

Addressing misinformation is another critical step to promote vaccine uptake. Despite extensive evidence demonstrating the safety and efficacy of vaccines, misinformation about vaccines and mistrust of health care practitioners and institutions continue to spread.⁴¹ Misinformation on vaccines can result in vaccine hesitancy, delay, or refusal, making this a critical area for clinicians to address to improve vaccine acceptance.⁴² Clinicians remain influential in people’s vaccine decision-making processes and clinician recommendations have been shown to be a strong predictor of vaccine acceptance.⁴³

The Federal Government’s Role in Vaccination and Immunization

Federal funding for the CDC is critical for public health initiatives at all levels and particularly at the state and local level, as a substantial portion of the CDC’s annual budget is awarded to state and local health departments.⁴⁴ This funding helps support wide-ranging disease prevention and control activities including public health surveillance and data collection, dissemination of information, preventative health services such as vaccination, and public health emergency preparedness and response efforts.⁴⁴ Faced with decreasing immunization coverage for some diseases and the presence of outbreaks, such as for measles, it is essential to protect and promote federal funding for the CDC to enable prevention and control efforts at the local, state, and national levels.

Additionally, the Advisory Committee on Immunization Practices (ACIP) at the CDC plays an important role in developing evidence-based recommendations on how to use vaccines to control disease in the United States.⁴⁵ Health insurance plans generally cover the cost of vaccines recommended by ACIP.⁴⁶ Additionally, the CDC's Vaccines for Children (VFC) program provides vaccines at no cost to eligible children through health care providers enrolled in the program.⁴⁶ During the COVID-19 pandemic, the Federal Retail Pharmacy Program (FRPP) was used to provide COVID-19 vaccines through federal collaboration with pharmacies.⁴⁷ Ensuring that people have insurance coverage and access to vaccines at no cost is a critical measure to support vaccine uptake. Furthermore, it is essential to ensure that ACIP is comprised of members with robust expertise, research, and experience in vaccination and immunization to guide evidence-based recommendations on vaccine schedules.

Global Health Programs and Partnerships

Promoting access, coverage, and education for immunization is an important goal both nationally as well as globally. The potential for the rapid spread of infectious diseases clearly illustrates that promoting public health requires collaboration and investment in health across the globe. Global immunization programs such as the Essential Programme on Immunization launched by the World Health Organization (WHO) have led to marked improvement in routine childhood immunizations, resulting in an estimated 154 million deaths averted globally between 1974 and 2024.⁴⁸ Between 1980 and 2023, global rates of immunization against diseases including diphtheria, tetanus, pertussis, measles, polio, and tuberculosis nearly doubled, and the number of children who had never received a routine child vaccine reduced by more than 70%.⁴⁸ Other key organizations include Gavi, the Vaccine Alliance, which helps vaccinate more than half the world’s children against infectious diseases.⁴⁹ However, as in the United States, progress on reaching target goals for immunization coverage worldwide has been slowed following the disruptive effects of the COVID-19 pandemic.⁴⁸

Reducing the incidence of vaccine-preventable diseases through immunization requires sustained investments in global immunization programs. Participation in international partnerships, including the WHO, is a critical step to promote progress on improving global vaccination coverage.⁵⁰ Furthermore, beyond strengthening routine immunization programs, information-sharing is a crucial component of global health preparedness. Through global partnerships, agencies including the CDC can both provide and receive data on a wide range of topics that inform preparedness and response efforts as new global health threats emerge.⁵¹

Pandemic Preparedness and Response to Emerging Infectious Diseases

The COVID-19 pandemic illustrated the rapidity at which infectious diseases can spread and create a devastating impact on countries worldwide.⁵² In our interconnected world, it is critical to ensure effective treatments for global health emergencies including vaccines are distributed quickly through strong public health infrastructure. The federal government, states, global organizations, and the private sector must work effectively together to develop and distribute critical response elements including tests, treatments, and vaccines. The Administration for Strategic Preparedness and Response (ASPR) plays a critical role in leading the nation's preparedness, response, and recovery from disasters and public health emergencies, including with the Strategic National Stockpile (SNS), which holds supplies, medicines, and devices to be used in response efforts.⁵³ During recent public health emergencies, including COVID-19 and mpox, states reported challenges related to understanding the SNS inventory and coordinating on requesting and receiving SNS materials that had not expired including vaccines.⁵⁴ To improve response efforts, including with key aspects such as vaccine tracking and rollout, clarifying the roles and procedures of various agencies and stakeholders will be critical.⁵⁴

Nurses’ Role in Ethical Standards Related to Vaccine Information

Health promotion is at the core of nursing care. Nurses have a professional duty to provide evidence-informed education to the public regarding the importance and safety of vaccines to help individuals and the public make informed health care decisions. In alignment with the American Nurses Association’s (ANA) Code of Ethics for Nurses, nurses support patients’ informed decision-making by providing accurate information, and nurses have a responsibility to combat health misinformation and disinformation.⁵⁵

*In May 2025, Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. announced that COVID-19 vaccination would no longer be recommended for healthy children and healthy pregnant women. As of September 2025, this decision is being litigated. Additionally, in August 2025, the Food and Drug Administration (FDA) approved updated COVID-19 vaccines only for adults 65 and older and for children and adults with high-risk conditions. See Rosenbaum, S. (2025, August 12). Lawsuit Challenges Withdrawal of CDC Recommendations of COVID Vaccines for Pregnant Women and Children. Health Affairs Forefront, DOI: 10.1377/forefront.20250811.453218; and California Medical Association. (2025, September 4). FDA restricts COVID-19 vaccine approval, deepening confusion for physicians and patients. https://www.cmadocs.org/newsroom/news/view/ArticleId/50974/FDA-restricts-COVID-19-vaccine-approval-deepening-confusion-for-physicians-and-patients.

Immunization is critical for public health promotion and reducing the spread of vaccine-preventable diseases on an individual, community, national, and global level. Furthermore, immunization supports increased global prosperity, reduced burden and cost on health care systems, and improved health protection across the lifespan. The Academy urges increased action to address barriers to vaccination and expand access to vaccines.

1. Protect, increase, and promote federal funding for the CDC and maintain grounding in rigorous scientific evaluation to enable disease prevention, education, and control efforts at the local, state, and federal levels.
2. Support expansion of health insurance coverage (both public and private) to enable people to connect with clinicians, including PCPs, and receive vaccines in accordance with recommended schedules.
3. Encourage expanded funding for programs that connect individuals and communities with vaccines, such as the Vaccines for Children and Federal Retail Pharmacy programs, and maintain requirements for health insurance plans to cover the cost of recommended vaccines across the lifespan.
4. Improve access to vaccines with community-based approaches, by bolstering state and federal funding, and through avenues beyond clinician health offices, including making vaccines available in pharmacies, local health departments, schools, and community centers.
5. Track and examine data related to nonmedical exemptions for required vaccines to develop strategies to counteract public health implications for increased exemption rates.
6. Increase funding for federal health agencies to conduct public health research into the origins of misleading information, its effects on vaccine acceptance, and strategies to combat misinformation and promote trust in health institutions.
7. Invest state resources to increase the number of school nurses who can be hired to promote and manage childhood immunizations, educate families, identify immunization gaps, and offer clinics.
8. Ensure appointed members of the CDC’s Advisory Committee on Immunization Practices and other federal committees overseeing vaccination and immunization recommendations are experienced, credentialed, and have robust expertise and research in vaccines and immunization.
9. Support international partnerships with global organizations including the WHO to ensure that agencies such as the CDC can provide and receive data on trends that inform preparedness and response efforts for emerging global health threats.
10. Improve guidelines and procedures for the Strategic National Stockpile to promote efficient and effective response efforts for health emergencies, including with key aspects such as vaccine tracking, distribution, and expiration patterns.

[1] American Academy of Nursing. (2021, July 26). Joint Statement in Support of COVID-19 Vaccine Mandates for All Workers in Health and Long-Term Care. https://aannet.org/page/covid-19-vaccine-mandate

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