Employee health professionals should be aware that the national antivaccine movement is lobbying state legislatures to restrict or limit use of vaccines critical for public health. Such antivaccine sentiments are largely responsible for the 1,261 measles cases in 2019 as of Nov. 7.1

That is the most since 1992, and comes two decades after measles was declared eradicated in the United States due to routine administration of the highly effective measles, mumps, rubella (MMR) vaccine. Vaccine avoidance based on misinformation — including the thoroughly rebuked falsehood linking autism to the MMR shot — threatens herd immunity and vulnerable populations that cannot be immunized. The Association for Professionals in Infection Control and Epidemiology (APIC) is staying abreast of this trend, and advising vaccine advocates to speak up if they see such laws appear on their state dockets.

This effort is not limited to the MMR vaccine, as the antivaccine movement is lobbying state legislatures to widen exemptions against childhood school immunizations and other mandates. A recent U.S. poll found that 45% of respondents have doubts about the safety of vaccines. The primary reasons for these doubts included “past secrets/wrongdoing” by the pharmaceutical industry and the government. Also cited were social media interactions and content, information from medical “experts,” and advice from family and friends. Somewhat surprisingly, given that the majority of states have exemptions for some version of religious or philosophical beliefs, only 4% of those doubting vaccine safety cited religious beliefs as the reason.2

“There are about 45 states that have some kind of religious or personal belief exemption in addition to a medical exemption,” said Richard Capperell, APIC associate director of public affairs. “Overall, we saw about 200 [state] bills dealing with vaccines this [legislative] cycle, and we expect to see just as many next year.”

That is due in part to antivaccine activists lobbying state legislators, some of whom sympathize with their cause and/or see an opportunity for political gain, Capperell said at a recent APIC webinar. The ongoing vaccine fight at the state level includes proposed laws to provide broader exemptions for school immunizations, and legislation and delay tactics to spread out or undermine the childhood immunization schedule, he said.

Capperell said there is concern with efforts that would place the burden on schools and healthcare facilities to justify vaccination or spurious “informed consent” bills that would require providers to overstate the risk of vaccine contraindications. However, the U.S. measles outbreaks have led to some pushback from vaccine advocates, as there are now five states that allow only medical exemptions to childhood vaccinations: California, Maine, Mississippi, New York, and West Virginia.

“New York and Maine are the newest additions to the list this year,” he said. “Every year in West Virginia and Mississippi, we are seeing legislation to put the exemptions back on the books. The antivaccine movement is quite vocal in their opposition to vaccine requirements and, unfortunately, they are very effective at getting their folks active when the time comes.”

In addition, Washington state has repealed personal or religious exemptions for the MMR vaccine. “Most of the legislation we are looking at is regarding requirements for school and childcare facilities,” he said. “These do not include just MMR, but an entire spectrum of vaccines, including meningitis and HPV.”

Some states also are trying to expand or restrict employer-mandated vaccinations, which have been most controversial in policies requiring annual flu shots for healthcare workers. “This has long been a top priority for APIC,” Capperell said. “We have talked a lot about this regarding healthcare facilities. Most bills opposing employer mandates target influenza vaccines.”

Eight states have introduced legislation that would prohibit employers from requiring employees receive certain vaccines: Oregon, Montana, Oklahoma, Minnesota, Iowa, Mississippi, Ohio, and Maine. “One concern is that some of the Midwestern states were actually targeting all vaccines — not just influenza,” Capperell said. “[These proposed bills say] for any vaccine, an employer would not be allowed to require vaccination of the employee. That is a little bit of a scary trend we saw.”

On the plus side, Texas, Colorado, Arkansas, New York, and New Jersey were considering legislation that would expand healthcare worker vaccine requirements. “But we also saw some states introducing laws either strengthening current exemptions or trying to find new avenues to make exemptions a little more lenient,” he said. With most states already allowing some sort of nonmedical exemption, there are efforts to make applying for an exemption easier.

“There is another trend we are seeing as well: making the ability to apply for an exemption easier,” Capperell said. “A [proposed Texas] bill made it so all you had to do is go to an online portal and request an exemption.”

Several states are drafting variations of bills that would require healthcare providers or school officials to provide information on vaccines. The legislation targets both healthcare facilities and schools. These bills may require a school system to send literature to students reminding them of exemptions.

Other versions of “informed consent” bills for healthcare facilities require that they highlight the rare but real risk of experiencing, for example, an allergic reaction to a vaccine. Some of this proposed legislation requires an explanation of the National Vaccine Injury Compensation Program. This federal program was set up in 1988 after lawsuits against vaccine manufacturers and healthcare providers threatened to cause shortages and undermine national immunization rates.

Such bills essentially emphasize risk over benefit of an established public health measure. For example, informed consent bills may include highlighting vaccine ingredients, emphasizing potential harm rather than the protective aspects of immunization.

“Generally speaking, these bills really kind of exploit the risk of vaccines vs. the actual benefits of being cost-effective, extremely efficacious, and saving hundreds of thousands of lives every year,” Capperell said. “The burden is actually put on some healthcare providers because this information can be required to be given days, maybe a week, before a vaccination.”


  1. Centers for Disease Control and Prevention. Measles cases and outbreaks. Available at: https://bit.ly/2iMFK71. Accessed Nov. 25, 2019.
  2. American Osteopathic Association. 45% of American adults doubt vaccine safety, according to survey. June 24, 2019. Available at: https://bit.ly/2OgVZrp. Accessed Nov. 25, 2019.