The lack of updated federal vaccine recommendations early in the 2025-26 US respiratory virus season—and a statement in May 2025 by the Health and Human Services secretary advising against COVID vaccines for children and pregnant women—created uncertainty for states with vaccine regulations based on federal guidance, leading most to strengthen and/or weaken COVID-19 vaccine access, with long-term implications for future vaccine policy, according to a research letter published yesterday in JAMA.
Researchers at the University of North Carolina at Chapel Hill led a systematic review of publicly documented vaccine-policy actions by all 50 states from April 1 to December 31, 2025, before and during the respiratory virus season.
The team characterized state actions as strengthening if they expanded or supported COVID-19 vaccine infrastructure or access or as weakening if they changed or limited policy mechanisms supporting vaccine infrastructure or access.
“The US Food and Drug Administration (FDA), Advisory Committee on Immunization Practices (ACIP), and Centers for Disease Control and Prevention (CDC) release vaccine regulatory decisions and recommendations, which states often reference in laws and regulations to govern clinician authority, insurance coverage, and, ultimately, vaccine access,” the study authors wrote.
5 states both fortified and softened policies
During the study period, 31 states (62%) enacted policies to strengthen COVID-19 vaccine infrastructure or access, 13 (26%) took steps that eroded it, and five enacted both types of policies.
“In the 5 states that enacted both strengthening and weakening measures, executive and/or administrative actions were most often targeted at preserving pharmacy vaccine access amid delayed updates to federal COVID-19 vaccination guidance, while legislative actions expanded exemptions or constrained public health authority,” the researchers wrote.
In the 5 states that enacted both strengthening and weakening measures, executive and/or administrative actions were most often targeted at preserving pharmacy vaccine access amid delayed updates to federal COVID-19 vaccination guidance, while legislative actions expanded exemptions or constrained public health authority.
Based on 2025 US Census Bureau data, states taking strengthening steps represented 57.9% of the population (197.6 million), while those that took weakening actions represented 25.0% (85.2 million), those that enacted both types represented 6.9% (23.7 million), and those that took no action represented 10.1% (34.6 million).
Policy mechanisms used to strengthen vaccine infrastructure or access included standing orders (18), health insurance directives and coverage policies (15), executive or regulatory directives (18), and legislation (8). Thirty states took at least one strengthening step affecting pharmacist scope-of-practice authority, which is important because pharmacists administer more than two-thirds of adult COVID-19 vaccines each year, the authors said. Many states used multiple policy mechanisms.
Fifteen states released their own COVID-19 vaccine recommendations. For strengthening actions, the professional medical society guidance referenced most often was from the American Academy of Pediatrics (21 states), the American College of Obstetricians and Gynecologists (20), and the American Academy of Family Physicians (20).
Fourteen states joined the Governors Public Health Alliance and/or regional collaboratives (ie, Northeast Public Health Collaborative or West Coast Health Alliance), which coordinated vaccine policy responses.
Reliance on medical societies rather than feds
State measures that weakened vaccine infrastructure or restricted access were changes to COVID-19 vaccine requirements, informed consent processes, and out-of-pocket costs (10 actions, such as expanding exemptions from or outlawing vaccine requirements, or raising vaccination fees).
“The most common actions that weakened vaccine infrastructure or access for COVID-19 vaccines were expanded exemptions or limitations on vaccine requirements, signaling a shift in priority from population-level immunization coverage to individualized risk-benefit assessment,” the authors wrote.
States frequently relied on evidence-based clinical guidance from national medical societies in the absence of updated ACIP recommendations.
Four states also changed clinician practice and liability frameworks, such as through scope-of-practice restrictions for COVID-19 vaccination and modifications to vaccine informed consent or liability. Three states limited state health department COVID-19 regulatory or communication authority.
“States frequently relied on evidence-based clinical guidance from national medical societies in the absence of updated ACIP recommendations,” the researchers wrote. “With further changes to the broader US Department of Health and Human Services childhood immunization schedule, 28 states as of January 2026 had announced they no longer solely rely on the CDC for vaccine recommendations.”
These actions showed how state authority can affect vaccination in a shifting federal landscape. “Sustained divergence in state policy may increasingly determine how and where vaccines are accessed,” the authors concluded. “A stable, evidence-based national recommendation and regulatory framework remains critical to maintaining coherence in the US immunization system.”
