It is perhaps an indication of what a nerd I am, but one of the thrillers I vividly recall from my childhood was a short movie I saw in 6th grade about the World Health Organization’s Smallpox Eradication Program. Seriously. I was spellbound by the story of health workers traveling around Bangladesh, Ethiopia, and Somalia, the last countries known to have the disease, tracking down reports of individuals who might have contracted the disease and then vaccinating everyone around them who was at risk. They were on the brink of completely eradicating one of humankind’s deadliest foes – smallpox having nearly wiped out the indigenous population of the Americas after its arrival with Europeans in 1492, and killing an estimated 300 million people in the 20th century alone – and victory was finally declared in 1980. Man, what an exciting public health adventure!
Ask any expert about the greatest public health advances in human history, and vaccines are almost sure to be in the top three, along with clean water/sanitation and maternal health. And now, as with so many other things in 2020s America, we appear to be moving backwards. Earlier this month, the US Department of Health and Human Services dropped 6 vaccines – hepatitis A and B, rotavirus, COVID-19, influenza, and meningococcal disease – from the list of those routinely recommended in childhood, reducing that number from 17 to 11. It’s a move that is frankly bewildering. It is opposed by essentially all experts in child health and infectious diseases, including the American Academy of Pediatrics (AAP) and the Center for Infectious Disease Research and Policy (CIDRAP).
Now, in the spirit of full disclosure, I have had a certain skepticism about routine vaccines in the past. When I started my pediatric training in the mid-1980s (yes, I am that old), we basically gave 3 shots for a total of 7 diseases, a recommendation that had been in place for nearly 20 years. During my residency one more was added, for Haemophilus influenzae type b (Hib). Then starting in the mid-1990s, the number seemed to explode. By 2005 there were 13 diseases on the schedule. As a pediatrician, and as a parent, it raised some questions. The earlier vaccines were for things that had significant mortality or morbidity. Smallpox vaccine is kind of a no-brainer. And stories of polio panics and the thrilling race to deliver diphtheria antitoxin to Nome via dog sled to contain a deadly oubreak, now fortunately historical artifacts, showed just how dangerous and terrifying those illnesses were. But chicken pox? Flu? Do we really need vaccines for those?
Decisions like those require a careful balancing of many considerations. How effective are the vaccines, what are the side effects, what are the costs? How many and which people are at risk of the diseases, what is the morbidity and mortality? What are the treatment options? In short, what are the risks and benefits? And as importantly, who bears the risks, and who reaps the benefits? Vaccines are one of those things where there is both and individual and a societal benefit. Herd immunity refers to the concept that for most infectious diseases, there is a certain pool of susceptible individuals required to maintain the disease in the population. If enough people are immune, either from prior infection or from vaccines, then the disease ceases to spread in that population. Those who cannot be vaccinated or develop natural immunity (immunosuppressed, cancer, etc.) are thus protected. Routine immunization may therefore be justified even when few people are at risk of more severe disease, if costs and risks are sufficiently low and herd immunity can be expected. These newer vaccine recommendations made sense in that context.
These are not simple decisions. They require lots of data, and a balanced view across many stakeholders with varying perspectives. Which is exactly how these decisions have been made since the mid-1960s, when the Advisory Committee on Immunization Practices was established by the US Surgeon General.
Until now.
It was bad enough that DHHS Secretary Robert Kennedy, Jr., fired all of the members of ACIP and replaced them with individuals of varying levels of expertise, and nearly all with demonstrated anti-vaccine bias. But the most recent de-listing of vaccines was done without even their input. It was done by the Secretary to comply with an executive order from the White House.
Anti-vaccine activists like Kennedy often cite safety concerns. Clearly, safety is paramount. It is one of the major things considered before vaccines are approved. And with post-licensing monitoring and the provisions of the National Childhood Vaccine Injury Act of 1986, vaccines may be among the most closely scrutinized pharmaceutical products in the country. Yet no new evidence of significant safety concerns has emerged for previously recommended vaccines. Indeed, the most widely circulated concerns, such as MMR-linked autism, have been so thoroughly debunked it’s hard to believe even hard-core conspiracy theorists truly believe them.
Safety is not really the issue here. I suspect this is part of a larger agenda. The most recent announcement emphasized the need for individual decision making about vaccines. Each person needs to decide what is right for them and their child. But this has always been an element of medical care. These vaccines are recommended for routine use. Individuals have the option of not following those recommendations, and often do, though a recommendation that all children should receive a particular vaccine, versus a recommendation that a vaccine should be considered, carries a lot of weight when parents are deciding. So what is the rationale for reclassifying some of these vaccines as recommended for every child, and others only recommended based on shared clinical decision-making?
A look at some of the diseases that have been demoted gives some hints. One of them is COVID-19. This has become a libertarian lightning rod for reasons that have nothing to do with the safety of the vaccine. But a large part of the rationale (though not the only one) for giving the vaccine to all children, even though the majority of children are not themselves at high risk, is to reduce the chance that a child will spread the disease to higher-risk contacts. The compelling rationale for universal COVID-19 vaccines for kids is societal protection, rather than protection of the individual. The same is true for hepatitis A (another reclassified vaccine).
Even more telling is the case of hepatitis B. The most common routes of infection in the US are perinatal transmission from an infected mother, and sexual or bloodborne transmission later in life. The recommendation for universal newborn immunization was based in part on the fact that many infected individuals are asymptomatic, and therefore unaware they are at risk of transmission to their infant. It also recognizes that whether we like it or not, adolescents frequently experiment with risky behaviors; early childhood vaccine offer them protection. I suspect that removing hep B from the recommended-for-all list is a way to further stigmatize and marginalize at-risk groups.
By putting more of the emphasis on what the risks and benefits are for the individual, rather than for the individual and others, DHHS and CDC appear to be engaging in an ideologically motivated effort to de-emphasize the societal benefit of vaccines. It’s taking the public out of public health.
Starting With Curious 