Federal changes last month led major pharmacies in 16 states to stop administering COVID vaccines
without prescriptions. Last week, however, several states, including Pennsylvania, moved to successfully restart. This week, the CDC's Advisory Committee on Immunization Practices (ACIP) held its latest meeting, and considered changes to the vaccine schedule.
Much of the meeting devolved chaotically: a decision on pediatric vaccine funding was passed on Thursday by members who misunderstood the vote, only to be reversed on Friday; meanwhile, one panelist on a "hot mic" called another panelist an "idiot." A harmful proposal to withdraw universal recommendations for neonatal hepatitis B vaccination (HBV) was debated and then postponed due to "ambiguity."
Regardless of what transpired this week, Pennsylvania will be mitigated against further chaos from ACIP for the same reason their pharmacies are again administering COVID vaccines: they have formally aligned vaccine practices with professional medical organizations instead of ACIP -- specifically the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP).
Here lies a path forward through the relentless deterioration of federal institutions.
Upheaval at ACIP
In June, HHS Secretary Robert F. Kennedy Jr. fired the entire ACIP to the alarm of the medical community, replacing experts with many handpicked vaccination opponents. The resultant void of experience likely contributed to this week's disorganization. Additionally, major medical organizations that historically informed guidance, such as the American Medical Association (AMA) and Infectious Diseases Society of America (IDSA), have been defenestrated.
Fortunately, ACIP technically holds no power, their advice is just advice. In theory, they could issue recommendations to which nobody responds, a tree falling silently in the woods. But the CDC traditionally chooses to adopt them. Additionally, innumerable organizations around the country -- health systems, insurers, state governments -- elect to bind their own policies to ACIP. But they mostly do so freely. They can change. Many can electively align instead with professional organizations like AAP, ACOG, and AAFP.
This is exactly how Pennsylvania escaped the recent COVID vaccine quandary.
Looking for Alternative Vaccine Guidance
The AAP has already released a statement offering opposing recommendations to ACIP's vote that the combined measles, mumps, rubella, and varicella (MMRV) vaccine not be used before 4 years of age. Meanwhile, the vote to withdraw recommendations for universal neonatal HBV has been postponed, without guarantees that it will remain preserved. So pediatricians are left awaiting that decision.
Between now and the next vote, physicians should rally in defense of neonatal HBV, especially in the media and public forums. HBV is well demonstrated to be safe over decades of use. After initiating universal neonatal HBV administration in 1991, the rate of hepatitis B among children ages 1-9 years fell by a whopping 80%, a success alluded to by Sen. Bill Cassidy, MD (R-La.), a hepatologist, during a Senate hearing Wednesday.
But will this rallying effort be successful? We rallied in defense of COVID vaccination for children and pregnant patients, and against the cancellation of $500 million in funding for mRNA vaccines, all of which then proceeded ineluctably. Our appeals to science, research, public health, and even human suffering have fallen upon deaf ears at the federal level.
And even if we succeed in defense of neonatal HBV, the fight won't end with this vaccine. Inevitably our government will target the next vaccine for the next disease in the next demographic. Zooming out over the last months, the assaults upon vaccination have been sequential and relentless. We face an inexorable drip of insults, with one dangerous change followed by outcry, then the next change, then the next outcry -- an already weary cycle risking habituation.
Our federal situation is bleak. Any prior hope that Kennedy would become more moderate once empowered has now dissipated. His Senate testimony earlier this month, while certainly disputatious, is unlikely to manifest change.
When medicine now looks at our federal government, it is with increasing nihilism; the nihilism in turn risking inaction. But advocacy for our patients is never just federal but rather a rich palimpsest of local, departmental, hospital, city, county, and state layers. Last week's efforts in Pennsylvania actuated real vaccination access, and that is just one action in one state. The Association of State and Territorial Health Officials estimates that over 600 statutes and regulations are bound to ACIP across the country. So, encouragingly, there exists over 600 opportunities for healthcare professionals to advocate for change.
And those are just states. There are also health departments, medical societies, insurers, and healthcare systems. They may not all have policies linking explicitly to ACIP, but they can also still be aligned with professional organizations to varying degrees. A medical society could formally endorse AAP, ACOG, and AAFP recommendations. A hospital or even a single department can build institutional vaccination guidelines that link to their academies and societies. Coverage from individual insurers and payers can be lobbied.
In Support of Medical Organizations
Why should our policies everywhere now be specifically anchored to AAP, ACOG, AAFP, or similar organizations? In addition to mainstream, evidence-based guidance, such re-anchoring inoculates against future changes from ACIP rather than responding piecemeal to every future transgression.
After recommendations for the COVID vaccine were withdrawn for children and pregnant patients, local hospitals had to reiterate their continued best practice to providers and patients. If ACIP ultimately revises HBV recommendations, departments will again have to reemphasize usual HBV guidelines in order to adhere to evidence-based best practice. Far simpler are blanket policies in which all current and future recommendations align with professional societies, after which there's no need to respond individually to each future ACIP action. Collectively, we can make ACIP obsolete.
Right now, physicians should review the varying administrative layers in which we are all ensconced and see where policies can be changed and connections to ACIP mitigated. Regardless of our federal situation there is always something to do, and the defense of vaccination is a defense of our patients' lives.
David Hackney, MD, is a maternal-fetal medicine specialist, professor of reproductive biology at Case Western Reserve University, and District V Legislative Chair for the American College of Obstetricians and Gynecologists.
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