Just three of those that the Centers for Disease Control and Prevention says it will no longer routinely recommend — against hepatitis A, hepatitis B, and rotavirus — have prevented nearly 2 million hospitalizations and 90,000 deaths in the past 30 years, according to the CDC’s own publications. 

Federal and private insurance will still cover the vaccines. 

Experts on childhood disease were baffled by the change, which the Department of Health and Human Services said followed “a scientific review of the underlying science.” 

The vaccines are “held to a safety standard higher than any other medical intervention that we have,” said Lori Handy, a pediatric infectious disease specialist at the Children’s Hospital of Philadelphia. “The value of routine recommendations is that it really helps the public understand that this has been vetted upside down and backwards in every which way.”

Public health officials say the guidance puts the onus on parents to research each vaccine and its importance. Here’s what they prevent: 

RSV. Respiratory syncytial virus is the most common cause of hospitalization for infants in the U.S. It spreads in fall and winter, producing cold-like symptoms and causing tens of thousands of hospitalizations and hundreds of deaths yearly. 

Hepatitis A. Hepatitis A vaccination, recommended for all toddlers since 2006, has led to a more than 90% drop in the disease since 1996. The foodborne virus, which causes a wretched illness, still plagues adults, particularly people who are homeless or abuse drugs or alcohol, with 1,648 cases and 85 deaths reported in 2023. 

Hepatitis B. The disease causes liver cancer, cirrhosis, and other serious illnesses and is particularly dangerous when contracted by babies and young children. The hepatitis B virus is transmitted through blood and other bodily fluids, even in microscopic amounts, and can survive on surfaces for a week. From 1990 to 2019, vaccination resulted in a 99% decline in reported cases of acute hepatitis B among children and teens. Liver cancer among American children also plummeted with universal childhood vaccination. 

Rotavirus. Before routine administration of the current rotavirus vaccines began in 2006, 70,000 young children were hospitalized and 50 died yearly from the virus, known as “winter vomiting syndrome,” said Sean O’Leary, a University of Colorado pediatrician. “It was a miserable disease that we hardly see anymore.” 

Meningococcal disease. About 600 to 1,000 U.S. cases of meningococcal disease are reported yearly, killing more than 10% of those it sickens and leaving 1 in 5 survivors with a disability. 

Flu. The virus has killed hundreds of children in recent years, though it tends to be much more severe in older adults.

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Solo tres de las seis vacunas que los Centros para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés) dejarán de recomendar de manera rutinaria —contra la hepatitis A, hepatitis B y el rotavirus— han prevenido casi 2 millones de hospitalizaciones y más de 90.000 muertes en los últimos 30 años, según publicaciones de la misma entidad.

Las vacunas contra esas tres enfermedades, así como contra el virus respiratorio sincitial (VRS), la enfermedad meningocócica, la gripe y covid, ahora solo se recomiendan para niños con alto riesgo de enfermedad grave o luego de “tomar decisiones clínicas de manera compartida”, es decir, una consulta entre médicos y padres.

Los CDC mantienen sus recomendaciones para 11 vacunas infantiles: contra el sarampión, las paperas y la rubéola; la tos ferina, el tétanos y la difteria; la enfermedad bacteriana conocida como Hib; la neumonía; la polio; la varicela; y el virus del papiloma humano (VPH).

Según una hoja informativa del Departamento de Salud y Servicios Humanos (HHS, por sus siglas en inglés), los seguros médicos públicos y privados seguirán cubriendo las vacunas contra las enfermedades que los CDC ya no recomiendan de manera universal; los padres que quieran vacunar a sus hijos contra esas enfermedades no tendrán que pagar las dosis de su bolsillo.

Expertos en enfermedades infantiles se mostraron desconcertados ante el cambio en la guía. El HHS explicó que las modificaciones se hicieron tras “una revisión científica de la evidencia” y que están alineadas con programas de vacunación de otros países desarrollados.

El secretario del HHS, Robert F. Kennedy Jr., un activista antivacunas, señaló a Dinamarca como modelo. Sin embargo, los calendarios de vacunación de la mayoría de los países europeos son más parecidos al estándar estadounidense que acaba de modificarse.

Por ejemplo, Dinamarca, que no vacuna contra el rotavirus, registra cerca de 1.200 hospitalizaciones al año por esta infección  en bebés y niños pequeños. Esa tasa, en un país de 6 millones de habitantes, es similar a la que tenía Estados Unidos antes de introducir la vacuna.

“Ellos aceptan tener 1.200 o 1.300 niños hospitalizados, lo cual es solo la punta del iceberg en cuanto al sufrimiento infantil”, dijo Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelphia y coinventor de una vacuna contra el rotavirus aprobada. “Nosotros no lo aceptamos. Deberían tratar de imitarnos a nosotros, no al revés”.

Funcionarios de salud pública señalaron que la nueva guía pone sobre los padres la responsabilidad de investigar y comprender cada vacuna infantil y por qué es importante.

El siguiente es un resumen de las enfermedades que previenen las vacunas que se han dejado de lado:

VRS. El virus respiratorio sincitial es la causa más común de hospitalización en bebés en Estados Unidos.

Este virus respiratorio suele circular en otoño e invierno y provoca síntomas parecidos a los de un resfriado, aunque puede ser mortal para los niños pequeños. Cada año causa decenas de miles de hospitalizaciones y cientos de muertes. Según la Fundación Nacional de Enfermedades Infecciosas (National Foundation for Infectious Diseases), aproximadamente el 80% de los niños menores de 2 años hospitalizados con el VRS no tienen factores de riesgo identificables. Las esperadas vacunas contra esta enfermedad se introdujeron en 2023.

Hepatitis A. La vacunación contra la hepatitis A, que se empezó a aplicar gradualmente a finales de los años 90 y se recomendó para todos los niños pequeños a partir de 2006, ha provocado una reducción de más del 90% de los casos desde 1996. Este virus transmitido por alimentos causa una enfermedad muy desagradable que aún afecta a adultos, especialmente personas sin hogar o que consumen drogas o alcohol. En 2023 se reportaron un total de 1.648 casos y 85 muertes.

Hepatitis B. Esta enfermedad provoca cáncer de hígado, cirrosis y otros padecimientos graves, y es particularmente peligrosa cuando la contraen bebés o niños pequeños. El virus de la hepatitis B se transmite por sangre y otros fluidos corporales, incluso en cantidades microscópicas, y puede sobrevivir en superficies durante una semana. Entre 1990 y 2019, la vacunación generó una reducción del 99% en los casos reportados de hepatitis B aguda en niños y adolescentes. El cáncer de hígado en menores también ha disminuido considerablemente gracias a la vacunación infantil universal. Sin embargo, el virus sigue presente, con entre 2.000 y 3.000 casos agudos reportados cada año entre adultos no vacunados. En 2023 se diagnosticaron más de 17.000 casos de hepatitis B crónica. Los CDC estiman que cerca de la mitad de las personas infectadas no saben que lo están.

Rotavirus. Antes de que comenzara la administración rutinaria de las actuales vacunas contra el rotavirus, en 2006, cada año se internaban a unos 70.000 niños pequeños, y morían alrededor de 50 a causa del virus. “Se conocía como el síndrome del vómito invernal”, explicó Sean O’Leary, pediatra de la Universidad de Colorado. “Era una enfermedad terrible, que casi ya no vemos”.

Sin embargo, el virus sigue siendo común en las superficies que tocan los bebés, y “si bajan las tasas de vacunación, habrá de nuevo niños hospitalizados”, advirtió Offit.

Vacunas meningocócicas. Estas vacunas han sido requeridas principalmente para adolescentes y estudiantes universitarios, quienes son especialmente vulnerables a enfermedades graves causadas por esta bacteria. En Estados Unidos se reportan entre 600 y 1.000 casos al año, pero más del 10% de los enfermos mueren, y 1 de cada 5 sobrevivientes queda con discapacidades permanentes.

Gripe y covid. Estos dos virus respiratorios han causado la muerte de cientos de niños en años recientes, aunque suelen ser más graves en adultos mayores. Actualmente hay un repunte de la gripe en el país, y durante la temporada pasada murieron 289 menores por esta causa.

¿Qué es la toma de decisiones clínicas compartida?

Con los nuevos cambios, la decisión de vacunar a los niños contra la gripe, covid, el rotavirus, la enfermedad meningocócica y las hepatitis A y B dependerá ahora de lo que las autoridades llaman “toma de decisiones clínicas compartida”, es decir, que las familias deberán consultar con un proveedor de salud para determinar si la vacuna es apropiada para sus hijos.

“Significa que el proveedor debe tener una conversación con el paciente para explicar los riesgos y beneficios y tomar una decisión personalizada”, dijo Lori Handy, especialista en enfermedades infecciosas pediátricas del Hospital Infantil de Philadelphia.

Antes, los CDC usaban ese término solo en circunstancias muy específicas, como al decidir si una persona en una relación monógama necesitaba la vacuna contra el VPH, que previene una infección de transmisión sexual y ciertos tipos de cáncer.

Según Handy, el nuevo enfoque de los CDC no se alinea con la evidencia científica, dado el beneficio protector comprobado que las vacunas ofrecen a la gran mayoría de la población.

En su informe justificando los cambios, los funcionarios del HHS Tracy Beth Høeg y Martin Kulldorff afirmaron que el sistema de vacunación de Estados Unidos requiere más investigación sobre seguridad y mayor elección por parte de los padres. Dijeron que la pérdida de confianza en la salud pública, causada en parte por un calendario de vacunación demasiado extenso, ha llevado a más familias a rechazar vacunas contra amenazas importantes como el sarampión.

Las vacunas en el calendario que fue modificado por los CDC ya contaban con amplia investigación sobre seguridad cuando fueron evaluadas y aprobadas por la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés).

“Estas vacunas tienen un estándar de seguridad más alto que cualquier otra intervención médica que tenemos”, dijo Handy. “El valor de las recomendaciones rutinarias es que ayudan al público a entender que estas vacunas han sido examinadas por todos lados”.

Eric Ball, pediatra en el condado de Orange, California, apuntó que el cambio en la guía provocará más confusión entre los padres, quienes podrían pensar que es la seguridad de una vacuna lo que está en duda.

“Para la salud pública, es fundamental que las recomendaciones sobre vacunas sean muy claras y precisas”, dijo Ball. “Cualquier cosa que genere confusión solo llevará a que más niños se enfermen”.

Ball explicó que, en lugar de enfocarse en las necesidades médicas del niño, muchas veces tiene que usar el tiempo limitado de consulta para asegurar a los padres que las vacunas son seguras. El hecho de que una vacuna quede bajo “toma de decisiones clínicas compartida” no tiene nada que ver con preocupaciones de seguridad, pero muchos padres podrían interpretarlo así.

Los cambios del HHS no afectan las leyes estatales de vacunación y, por lo tanto, deberían permitir que los médicos responsables sigan recomendando las vacunas como hasta ahora, según Richard Hughes IV, abogado y profesor en la Universidad George Washington, quien lidera demandas contra Kennedy por los cambios en materia de vacunas.

“Uno puede esperar que cualquier pediatra siga la evidencia científica sólida y recomiende que sus pacientes se vacunen”, dijo. La ley protege a los proveedores que siguen las pautas profesionales de atención, agregó, y “el VRS, la enfermedad meningocócica y las hepatitis siguen siendo amenazas graves para la salud de los niños en este país”.

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Just three of the six immunizations the Centers for Disease Control and Prevention says it will no longer routinely recommend — against hepatitis A, hepatitis B, and rotavirus — have prevented nearly 2 million hospitalizations and more than 90,000 deaths in the past 30 years, according to the CDC’s own publications.

Vaccines against the three diseases, as well as those against respiratory syncytial virus, meningococcal disease, flu, and covid, are now recommended only for children at high risk of serious illness or after “shared clinical decision-making,” or consultation between doctors and parents.

The CDC maintained its recommendations for 11 childhood vaccines: measles, mumps, and rubella; whooping cough, tetanus, and diphtheria; the bacterial disease known as Hib; pneumonia; polio; chickenpox; and human papillomavirus, or HPV.

Federal and private insurance will still cover vaccines for the diseases the CDC no longer recommends universally, according to a Department of Health and Human Services fact sheet; parents who want to vaccinate their children against those diseases will not have to pay out-of-pocket.

Experts on childhood disease were baffled by the change in guidance. HHS said the changes followed “a scientific review of the underlying science” and were in line with vaccination programs in other developed nations.

HHS Secretary Robert F. Kennedy Jr., an anti-vaccine activist, pointed to Denmark as a model. But the schedules of most European countries are closer to the U.S. standard upended by the new guidance.

For example, Denmark, which does not vaccinate against rotavirus, registers around 1,200 infant and toddler rotavirus hospitalizations a year. That rate, in a country of 6 million, is about the same as it was in the United States before vaccination.

“They’re OK with having 1,200 or 1,300 hospitalized kids, which is the tip of the iceberg in terms of childhood suffering,” said Paul Offit, the director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and a co-inventor of a licensed rotavirus vaccine. “We weren’t. They should be trying to emulate us, not the other way around.”

Public health officials say the new guidance puts the onus on parents to research and understand each childhood vaccine and why it is important.

Here’s a rundown of the diseases the sidelined vaccines prevent:

RSV. Respiratory syncytial virus is the most common cause of hospitalization for infants in the U.S.

The respiratory virus usually spreads in fall and winter and produces cold-like symptoms, though it can be deadly for young children, causing tens of thousands of hospitalizations and hundreds of deaths a year. According to the National Foundation for Infectious Diseases, roughly 80% of children younger than 2 who are hospitalized with RSV have no identifiable risk factors. Long-awaited vaccines against the disease were introduced in 2023.

Hepatitis A. Hepatitis A vaccination, which was phased in beginning in the late 1990s and recommended for all toddlers starting in 2006, has led to a more than 90% drop in the disease since 1996. The foodborne virus, which causes a wretched illness, continues to plague adults, particularly people who are homeless or who abuse drugs or alcohol, with a total of 1,648 cases and 85 deaths reported in 2023.

Hepatitis B. The disease causes liver cancer, cirrhosis, and other serious illnesses and is particularly dangerous when contracted by babies and young children. The hepatitis B virus is transmitted through blood and other bodily fluids, even in microscopic amounts, and can survive on surfaces for a week. From 1990 to 2019, vaccination resulted in a 99% decline in reported cases of acute hepatitis B among children and teens. Liver cancer among American children has also plummeted as a result of universal childhood vaccination. But the hepatitis B virus is still around, with 2,000-3,000 acute cases reported annually among unvaccinated adults. More than 17,000 chronic hepatitis B diagnoses were reported in 2023. The CDC estimates about half of people infected don’t know they have it.

Rotavirus. Before routine administration of the current rotavirus vaccines began in 2006, about 70,000 young children were hospitalized and 50 died every year from the virus. It was known as “winter vomiting syndrome,” said Sean O’Leary, a pediatrician at the University of Colorado. “It was a miserable disease that we hardly see anymore.”

The virus is still common on surfaces that babies touch, however, and “if you lower immunization rates it will once again hospitalize children,” Offit said.

Meningococcal disease. Vaccines have been required mainly for teenagers and college students, who are notably vulnerable to critical illness caused by the bacteria. About 600 to 1,000 cases of meningococcal disease are reported in the U.S. each year, but it kills more than 10% of those it sickens, and 1 in 5 survivors have permanent disabilities.

Flu and covid. The two respiratory viruses have each killed hundreds of children in recent years — though both tend to be much more severe in older adults. Flu is currently on the upswing in the United States, and last flu season the virus killed 289 children.

What is shared clinical decision-making?

Under the changes, decisions about vaccinating children against influenza, covid, rotavirus, meningococcal disease, and hepatitis A and B will now rely on what officials call “shared clinical decision-making,” meaning families will have to consult with a health care provider to determine whether a vaccine is appropriate.

“It means a provider should have a conversation with the patient to lay out the risks and the benefits and make a decision for that individual person,” said Lori Handy, a pediatric infectious disease specialist at the Children’s Hospital of Philadelphia.

In the past, the CDC used that term only in reference to narrow circumstances, like whether a person in a monogamous relationship needed the HPV vaccine, which prevents a sexually transmitted infection and certain cancers.

The CDC’s new approach doesn’t line up with the science because of the proven protective benefit the vaccines have for the vast majority of the population, Handy said.

In their report justifying the changes, HHS officials Tracy Beth Høeg and Martin Kulldorff said the U.S. vaccination system requires more safety research and more parental choice. Eroding trust in public health caused in part by an overly large vaccine schedule had led more parents to shun vaccination against major threats like measles, they said.

The vaccines on the schedule that the CDC has altered were backed up by extensive safety research when they were evaluated and approved by the FDA.

“They’re held to a safety standard higher than any other medical intervention that we have,” Handy said. “The value of routine recommendations is that it really helps the public understand that this has been vetted upside down and backwards in every which way.”

Eric Ball, a pediatrician in Orange County, California, said the change in guidance will cause more confusion among parents who think it means a vaccine’s safety is in question.

“It is critical for public health that recommendations for vaccines are very clear and concise,” Ball said. “Anything to muddy the water is just going to lead to more children getting sick.”

Ball said that instead of focusing on a child’s individual health needs, he often has to spend limited clinic time reassuring parents that vaccines are safe. A “shared clinical decision-making” status for a vaccine has no relationship to safety concerns, but parents may think it does.

HHS’ changes do not affect state vaccination laws and therefore should allow prudent medical practitioners to carry on as before, said Richard Hughes IV, an attorney and a George Washington University lecturer who is leading litigation against Kennedy over vaccine changes.

“You could expect that any pediatrician is going to follow sound evidence and recommend that their patients be vaccinated,” he said. The law protects providers who follow professional care guidelines, he said, and “RSV, meningococcal, and hepatitis remain serious health threats for children in this country.”

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But in the upside-down world of Health and Human Services Secretary Robert F. Kennedy Jr., vaccines are on the ropes. A vaccine committee dominated by skeptics he chose for the panel voted 8-to-3 Friday to end a 34-year recommendation to inoculate newborns against hepatitis B, a practice that helped reduce childhood infections of the virus by 99%, from around 16,000 in 1991 to only seven in 2023.

While the committee went about its deliberations, the peril of abandoning vaccines was plain to see. The country’s worst year since 1992 for measles — an entirely vaccine-preventable illness — continued with flare-ups in Utah, Arizona, and South Carolina. A two-year outbreak of whooping cough, which vaccines can also check, has caused about 60,000 reported cases — including at least six infant deaths.

But neither of those diseases was discussed on the first day of the meeting by members of the Advisory Committee on Immunization Practices. The panel’s chartered purpose is to determine vaccination policies to counter such risks, but under Kennedy, it has focused on responding to doubts from vaccine skeptics and opponents.

Like previous gatherings of the committee, which was handpicked by Kennedy after he fired the panel’s 17 incumbent experts in June, the session was chaotically at odds with past practices of the Centers for Disease Control and Prevention. Kennedy has described the agency as a “cesspool of corruption.”

The committee’s chair, epidemiologist Martin Kulldorff, left three days before the meeting and was named to a senior HHS position. His successor, Kirk Milhoan, a pediatric cardiologist who has claimed that the mRNA technology used to make covid vaccines is “the biggest threat to humanity,” was on a plane or in Asia for most of the meeting, leaving Vice Chair Robert Malone holding the reins. Malone opposes vaccine mandates and became a darling of the anti-vaccine movement when he told podcast host Joe Rogan in 2021 that Americans were “basically being hypnotized” into taking the covid vaccine.

Typically, slides and data for the panel’s meetings are posted on the CDC’s website several days beforehand. This time they weren’t posted at all.

The committee’s working group that studied hepatitis B vaccines did not include recognized hepatitis experts. When a few panel members expressed reservations during the ACIP meeting, CDC hepatitis specialist Adam Langer was brought in to answer questions. He frowned on the proposed changes.

Surprising Choice of Experts

At 8 a.m. Dec. 4, the CDC finally listed the names of the meeting’s presenters. Aaron Siri, one of Kennedy’s former lawyers and a strident legal foe of vaccination, was set to headline Friday’s discussion of the pediatric immunization schedule.

Sen. Bill Cassidy, a Louisiana Republican and physician who cast a deciding vote for Kennedy to win confirmation to his job, said on the social platform X: “Aaron Siri is a trial attorney who makes his living suing vaccine manufacturers. He is presenting as if an expert on childhood vaccines. The ACIP is totally discredited. They are not protecting children.”

In replies to his post, some people demanded to know what Cassidy planned to do about it. While he has publicly criticized some of Kennedy’s moves on vaccines, the senator has made no visible effort to reverse them.

As the meeting began, Malone revealed that Vicky Pebsworth, a senior officer at the National Vaccine Information Center, a four-decade-old cornerstone of vaccine skepticism, was chairing a committee that is reviewing the entire childhood vaccine schedule. That’s the repository of ACIP recommendations that protect American children from measles, pertussis, influenza, tetanus, chickenpox, meningitis, and a host of other diseases.

Typically, seasoned CDC and FDA experts on vaccines and infectious disease present data about a disease and the options for its prevention before ACIP votes on a policy. Instead, Pebsworth, vaccine-skeptical climate scientist Cynthia Nevison, and businessperson Mark Blaxill, who helped lead another anti-vaccine group, presented the case — a negative one — on the hepatitis B vaccine on Dec. 4.

Sports medicine doctor Tracy Beth Høeg, who parlayed a year working with University of California-San Francisco epidemiologist Vinay Prasad, now the FDA’s vaccine chief, into a leading role at the agency, frequently chimed in. Nevison and Blaxill were co-authors of a 2021 autism study retracted for data misrepresentation and other problems.

Unsurprisingly, the picture they painted Dec. 4 suggested that the hepatitis B birth dose wasn’t necessary, and might be dangerous, notwithstanding years of scientific consensus to the contrary.

The presentations stunned Cody Meissner, an infectious disease specialist and one of the only vaccinologists on the CDC panel. “There were so many statements that I don’t agree with that it’s hard to be succinct,” he said.

Yvonne Maldonado, a Stanford University infectious disease specialist and one of the former ACIP members ejected in June, said she found it horrifying to watch unvetted presentations by nonexpert nonphysicians.

“Almost every statement made by this committee was misinformation, disinformation, or outright lies,” she said. “They are cherry-picking data, pulling up fringe papers, misunderstanding good papers. They are not the right people to be making decisions.”

Pebsworth said the committee was taking up the birth dose issue because of “pressure coming from stakeholder groups” — presumably including Kennedy and his allies. The U.S. is an “outlier” in its universal recommendation, she erroneously said.

In fact, the birth dose of the hepatitis B vaccine is given in 115 countries and is recommended by the World Health Organization. Many Western European countries limit the birth dose to targeted groups, however.

Arguments for the Birth Dose

Nevison said targeted measures to stop the virus in the 1980s, including promoting safer sex, increasing blood screening, and vaccinating the babies of hepatitis B-positive mothers, had achieved most of the reduction in cases since then. But most experts say the birth dose played a key role. And the virus remains a threat, with an estimated 640,000 carriers in the U.S.

The birth dose “is a safety net,” Meissner said. “It’s really for chronically infected mothers who for one reason or another do not get tested.”

“Where is the evidence of harm?” asked another panelist, psychiatrist Joseph Hibbeln.

In the years since the birth dose of hepatitis B vaccine was recommended, it has caused vanishingly few confirmed major side effects.

Blaxill, who 25 years ago helped advance the since-disproven theory that traces of mercury in vaccines were causing an epidemic of autism, said that hepatitis B vaccines were inadequately studied. He pointed to a study that showed high fevers in some children after the shot, which he said suggested brain inflammation.

Maldonado said that’s wrong. “I’ve seen thousands of children with fevers,” she said. “It’s not the same as encephalitis.”

Nevison said that a small number of vaccine court awards proved at least some harm by hepatitis B vaccinations. Reed Grimes, director of the Division of Injury Compensation Programs at the Health Resources and Services Administration, explained that an award does not necessarily signify proof of injury, but rather that the government decided not to contest a claim.

Speculation bloomed. Panelist Evelyn Griffin, an obstetrician, posited that rising cases of inflammatory bowel disease might be related to a medium — brewer’s yeast — used in the production of the hepatitis B vaccine. She did not cite a source for the idea.

Babies born with hepatitis B infections have a 90% chance of chronic liver infection later in life, and 25% of those with a chronic infection will die prematurely with chronic liver disease.

Panel members pushing to end the universal birth dose argued that blood tests of pregnant women should show who needs the shot. But only 35% of women who test positive receive all recommended follow-up care, and the virus can spread easily through contacts as common as a toothbrush or a bath towel. Ending the birth dose could result in nearly 500 deaths a year, according to a recent study.

The meeting was preceded by a heavy round of briefings for journalists and “prebunking” papers from established medical experts who view the new ACIP as a sounding board for anti-vaccine views — “inflating speculative risks while downplaying well-established vaccine benefits,” as three recent CDC officials wrote.

They noted that the hepatitis B birth dose is already optional, although doctors strongly recommend it. But recommending that it be a shared decision based on individual choice, as the ACIP voted Dec. 5, could add paperwork for doctors and introduce doubts in parents’ minds.

ACIP recommendations aren’t binding but have been used by health insurers in the past to establish coverage decisions. Federal agencies and private insurers will in most cases continue to pay for the hepatitis B vaccination if parents want it, said Andrew Johnson, who represented the Centers for Medicare & Medicaid Services during the meeting. But studies have shown that ambiguous advice leads to lower vaccination rates, said Kathryn Edwards, a Vanderbilt University vaccinologist.

Anti-vaccine activists have long targeted the hepatitis B birth dose. At one time they baselessly claimed it caused sudden infant death syndrome.

But within a decade of the universal dose implementation, the rate of SIDS had fallen by nearly half. That was thanks to an HHS-American Academy of Pediatrics’ “back to sleep” campaign, which urged parents to avoid suffocation risk by not letting their babies go to sleep on their stomachs.

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Many scientists and public health officials fear that the Centers for Disease Control and Prevention’s website, which now baselessly claims that health authorities previously ignored evidence of a vaccine-autism link, foreshadows a larger, dangerous attack on childhood vaccination.

“This isn’t over,” said Helen Tager-Flusberg, a professor emerita of psychology and brain science at Boston University. She noted that Kennedy hired several longtime anti-vaccine activists and researchers to review vaccine safety at the CDC. Their study is due soon, she said.

“They’re massaging the data, and the outcome is going to be, ‘We will show you that vaccines do cause autism,’” said Tager-Flusberg, who leads an advocacy group of more than 320 autism scientists concerned about Kennedy’s actions.

Kennedy’s handpicked vaccine advisory committee is set to meet next month to discuss whether to abandon recommendations that babies receive a dose of the hepatitis B vaccine within hours of birth and make other changes to the CDC-approved vaccination schedule. Kennedy has claimed — falsely, scientists say — that vaccine ingredients cause conditions like asthma and peanut allergies, in addition to autism.

The revised CDC webpage will be used to support efforts to ditch most childhood vaccines, said Angela Rasmussen, a virologist at the University of Saskatchewan and co-editor-in-chief of the journal Vaccine. “It will be cited as evidence, even though it’s completely invented,” she said.

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Kennedy personally ordered the website’s alteration, he told The New York Times. The CDC’s developmental disability group was not asked for input on the changes, said Abigail Tighe, executive director of the National Public Health Coalition, a group that includes current and former staffers at the CDC and HHS.

Scientists ridiculed the site’s declaration that studies “have not ruled out the possibility that infant vaccines cause autism.” While upward of 25 large studies have shown no link between vaccines and autism, it is scientifically impossible to prove a negative, said David Mandell, director of the Center for Autism Research at Children’s Hospital of Philadelphia.

The webpage’s new statement that “studies supporting a link have been ignored by health authorities” apparently refers to work by vaccine opponent David Geier and his father, Mark, who died in March, Mandell said. Their research has been widely repudiated and even ridiculed. David Geier is one of the outside experts Kennedy hired to review safety data at the CDC.

Asked for evidence that scientists had suppressed studies showing a link, HHS spokesperson Andrew Nixon pointed to older reports, some of which called for more study of a possible link. Asked for a specific study showing a link, Nixon did not respond.

Expert Reaction

Infectious disease experts, pediatricians, and public health officials condemned the alteration of the CDC website. Although Kennedy has made no secret of his disdain for established science, the change came as a gut punch because the CDC has always dealt in unbiased scientific information, they said.

Kennedy and his “nihilistic Dark Age compatriots have transformed the CDC into an organ of anti-vaccine propaganda,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.

“On the one hand, it’s not surprising,” said Sean O’Leary, a professor of pediatrics and infectious disease at the University of Colorado. “On the other hand, it’s an inflection point, where they are clearly using the CDC as an apparatus to spread lies.”

“The CDC website has been lobotomized,” Atul Gawande, an author and a surgeon at Brigham and Women’s Hospital, told KFF Health News.

CDC “is now a zombie organization,” said Demetre Daskalakis, former director of the National Center for Immunization and Respiratory Diseases at the CDC. The agency has lost about a third of its staff this year. Entire divisions have been gutted and its leadership fired or forced to resign.

Kennedy has been “going from evidence-based decision-making to decision-based evidence making,” Daniel Jernigan, former director of the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, said at a news briefing Nov. 19. With Kennedy and his team, terminology including “radical transparency” and “gold-standard science” has been “turned on its head,” he said.

Cassidy Goes Quiet

The new webpage seemed to openly taunt Sen. Bill Cassidy (R-La.), a physician who chairs the Senate Health, Education, Labor, and Pensions Committee. Cassidy cast the tie-breaking vote in committee for Kennedy’s confirmation after saying he had secured an agreement that the longtime anti-vaccine activist wouldn’t make significant changes to the CDC’s vaccine policy once in office.

The agreement included a promise, he said, that the CDC would not remove statements on its website stating that vaccines do not cause autism.

The new autism page is still headed with the statement “Vaccines do not cause Autism,” but with an asterisk linked to a notice that the phrase was retained on the site only “due to an agreement” with Cassidy. The rest of the page contradicts the header.

“What Kennedy has done to the CDC’s website and to the American people makes Sen. Cassidy into a total and absolute fool,” said Mark Rosenberg, a former CDC official and assistant surgeon general.

On Nov. 19 at the Capitol, before the edits were made to the CDC website, Cassidy answered several unrelated questions from reporters but ended the conversation when he was asked about the possibility Kennedy’s Advisory Committee on Immunization Practices might recommend against a newborn dose of the hepatitis B vaccine.

“I got to go in,” he said, before walking into a hearing room without responding.

Cassidy has expressed dismay about the vaccine advisory committee’s actions but has avoided criticizing Kennedy directly or acknowledging that the secretary has breached commitments he made before his confirmation vote. Cassidy has said Kennedy also promised to maintain the childhood immunization schedule before being confirmed.

The senator criticized the CDC website edits in a Nov. 20 post on X, although he did not mention Kennedy.

“What parents need to hear right now is vaccines for measles, polio, hepatitis B and other childhood diseases are safe and effective and will not cause autism,” he said in the post. “Any statement to the contrary is wrong, irresponsible, and actively makes Americans sicker.”

Leading autism research and support groups, including the Autism Science Foundation, the Autism Society of America, and the Autism Self Advocacy Network, issued statements condemning the website.

“The CDC’s web page used to be about how vaccines do not cause autism. Yesterday, they changed it,” ASAN said in a statement. “It says that there is some proof that vaccines might cause autism. It says that people in charge of public health have been ignoring this proof. These are lies.”

What the Research Shows

Parents often notice symptoms of autism in a child’s second year, which happens to follow multiple vaccinations. “That is the natural history of autism symptoms,” said Tager-Flusberg. “But in their minds, they had the perfect child who suddenly has been taken from them, and they are looking for an external reason.”

When speculation about a link between autism and the measles, mumps, and rubella vaccine or vaccines containing the mercury-based preservative thimerosal surfaced around 2000, “scientists didn’t dismiss them out of hand,” said Tager-Flusberg, who has researched autism since the 1970s. “We were shocked, and we felt the important thing to do was to figure out how to quickly investigate.”

Since then, studies have clearly established that autism occurs as a result of genetics or fetal development. Although knowledge gaps persist, studies have shown that premature birth, older parents, viral infections, and the use of certain drugs during pregnancy — though not Tylenol, evidence so far indicates — are linked to increased autism risk.

But other than the reams of data showing the health risks of smoking, there are few examples of science more definitive than the many worldwide studies that “have failed to demonstrate that vaccines cause autism,” said Bruce Gellin, former director of the National Vaccine Program Office.

The edits to the CDC website and other actions by Kennedy’s HHS will shake confidence in vaccines and lead to more disease, said Jesse Goodman, a former FDA chief scientist and now a professor at Georgetown University.

This opinion was echoed by Alison Singer, the mother of an autistic adult and a co-founder of the Autism Science Foundation. “If you’re a new mom and not aware of the last 30 years of research, you might say, ‘The government says we need to study whether vaccines cause autism. Maybe I’ll wait and not vaccinate until we know,’” she said.

The CDC website misleads parents, puts children at risk, and draws resources away from promising leads, said Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Kennedy thinks he’s helping children with autism, but he’s doing the opposite.”

Many critics say their only hope is that cracks in President Donald Trump’s governing coalition could lead to a turn away from Kennedy, whose team has reportedly tangled with some White House officials as well as Republican senators. Polling has also shown that much of the American public distrusts Kennedy and does not consider him a health authority, and Trump’s own approval rating has sunk dramatically since he returned to the White House.

But anti-vaccine activists applauded the revised CDC webpage. “Finally, the CDC is beginning to acknowledge the truth about this condition that affects millions,” Mary Holland, CEO of Children’s Health Defense, the advocacy group Kennedy founded and led before entering politics, told Fox News Digital. “The truth is there is no evidence, no science behind the claim vaccines do not cause autism.”

Céline Gounder, Amanda Seitz, and Amy Maxmen contributed to this report.

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These officials were thrilled Oct. 29 when FDA Commissioner Marty Makary announced the agency’s plan, which he said would halve the time and money needed to get what are called “biosimilar” drugs to market. Biosimilars are essentially generic versions of biologics — such as Humira, Keytruda, and Xolair — which are made from living organisms. Biosimilars can cost up to 90% less.

Under the guidance the FDA proposed, the agency would begin overseeing biosimilars similarly to the way it regulates generics, which are copies of simpler molecules, usually pills. This change in approach could allow companies to save up to $100 million for each drug they develop, enabling them to make more products for underserved patients, said Stefan Glombitza, CEO of Formycon AG, a maker of biosimilars based in Germany.

But President Donald Trump’s patent office is working at cross-purposes with the FDA, biosimilar makers charge, by narrowing the opportunities for companies that try to challenge the throngs of patents that brand-name drugmakers file to protect their products from competition.

In the past, biosimilar makers have been able to invalidate some of those patents through a sped-up process called “inter partes review,” or IPR. But the new administration has denied most IPR requests and issued a proposed rule in October that makes IPRs harder to get.

Heavyweights on Pricing

Biosimilars have the potential to nibble or even gouge away at a major U.S. health care cost. Only 5% of prescriptions are for biologic drugs, but they account for more than half of the $600 billion the nation annually spends on medicines.

“Generic and biosimilar competition is the crucial way that we bring down prescription drug prices,” said William Feldman, a pharmaceuticals policy researcher at UCLA.

The FDA announcement “is a good thing that may ease barriers,” he added, “but there are a lot of caveats.”

In fact, biosimilar industry officials say, FDA regulation is often the least of the three major hurdles they face in marketing their products.

To protect their market share, brand-name biologics makers file scores or even hundreds of patents, continuing to do so long after their drugs hit the market. The “patent dance” that occurs when biosimilar makers seek to launch competitor drugs can drag on for many years.

For example, the FDA approved the first biosimilar of the rheumatoid arthritis drug Humira in 2016, but legal battles delayed competitors from entering the market — until nine FDA-approved products were launched in 2023. At his Oct. 29 news conference, Makary blamed FDA “red tape” for the delay, but it was mostly due to the baffling patent machinery, industry officials say.

The new rules, which could take effect next year, would formalize recent FDA practices aimed at speeding along approval for biosimilars. For example, the FDA has recently allowed drugmakers to waive expensive clinical testing contemplated under a 2009 law. The agency now lets companies employ less costly analytical tests, if they can show that the biosimilar has no clinically meaningful differences from the brand-name drug.

A ‘Switching’ Burden

Because biologic drugs are large molecules produced from live cells, copies of them cannot be chemically identical. So the FDA had required biosimilars to go through clinical studies like the ones required for the original drugs. But research has shown that analytic techniques can replace the need to test biosimilars on large numbers of patients.

The new rules would also confirm the FDA’s move away from requiring what are known as “switching” tests, in which patients first go on the brand-name drug and then the biosimilar, or vice versa, to see if their responses are the same. Such tests are required in many states for the biosimilar to obtain “interchangeable” status, which enables pharmacists to substitute an often cheaper version for the prescribed brand-name drug.

In short, the new rules would mean biosimilar makers would spend less money getting drugs to market, said Sean Tu, a law professor at the University of Alabama. “What that won’t do is get you on the market earlier,” he added.

After biosimilars launch, it can take years for them to gain a foothold. In 2023, Humira biosimilars made barely a dent in the market, and in 2024 they accounted for only about a quarter of sales, though they cost as little as 10% of the roughly $6,500 monthly price tag for the brand-name drug.

That’s because brand-name drug companies offer lucrative rebates for sales of their drugs to the go-between companies that design formularies — tiered lists that tell doctors and pharmacies which drugs are covered by insurance. These middlemen, pharmacy benefit managers, pass along some of that money to health plans.

Essentially, the insurance plans are “charging higher costs to people who require expensive drugs as a way to subsidize the whole population,” said Wayne Winegarden, an economist at the Pacific Research Institute.

The Patent Thicket Thickens

Biosimilar makers are particularly worried about the direction the U.S. Patent and Trademark Office has taken under Trump.

Patent challenges are already 10 to 20 times as expensive in the United States as in Europe, and restricting inter partes reviews is making it worse, said Formycon’s Glombitza.

The FDA recently gave his company a waiver from conducting a costly clinical trial of its biosimilar substitute for Keytruda, a blockbuster cancer drug. But Merck & Co., which got about half of its $17 billion third-quarter revenue from Keytruda, is expected to fight tooth and nail to protect its many patents on the drug. The Trump administration’s new obstacles to challenge them “counteract the waiver,” Glombitza said.

Merck protects its innovations, said spokesperson Julie Marie Cunningham. However, noting that Merck is touting a new, injectable Keytruda formulation, she said the company does not expect it to affect “the potential marketing” of biosimilars for the older, intravenous form of the drug.

The Pharmaceutical Research and Manufacturers of America, or PhRMA, the industry group representing most large brand-name companies, “welcomes the administration’s focus on increasing biosimilar access and affordability,” said spokesperson Alex Schriver.

But Big Pharma companies favor the patent office’s swing toward more protection of filed patents, according to attorneys who work in intellectual property litigation.

“I don’t think the Trump administration has any kind of coherent plan here,” said Mark Lemley, director of the Stanford Program in Law, Science & Technology. While Trump officials want to bring drug costs down, “they also want to make it more expensive to figure out whether patents are valid by effectively eliminating IPRs,” he said.

The patent office did not respond to repeated phone calls and emails.

Patents and patent litigation are the biggest impediments to getting biosimilars onto the market, UCLA’s Feldman said.

For instance, the FDA licensed Sandoz’s biosimilar for Enbrel, a popular drug to treat autoimmune disorders, in 2016, but Sandoz won’t be able to market its competitor in the U.S. until 2029 at the earliest because of patent challenges. Without insurance, Enbrel costs about $7,000 to $9,000 a month.

A Patient’s Perspective

Judy Aiken, a retired Portland, Maine, nurse who has taken Enbrel since 2007 to treat psoriatic arthritis, would be interested in trying the copycat if it costs her less. After retiring in 2019 and going on Medicare, she has spent thousands each year on the drug.

The Biden-era Inflation Reduction Act capped her out-of-pocket drug costs at $2,000 this year, and Aiken and her husband used the savings to replace their roof and furnace. But with health care changes on the horizon, “now I’m scared the other shoe is going to drop,” she said.

Only about 10% of the 118 biologics set to come off patent in the next decade have biosimilars in development, reflecting poor incentives in a system that biosimilar makers and patient advocates say is stacked against them.

But lower costs could enable companies like Formycon to expand their product lines — focused now on cancer and autoimmune diseases — to less common or even rare conditions, said CEO Glombitza.

“People have talked about the promise of biosimilars reducing out-of-pocket costs and creating more choices for consumers, and I feel like we’re still waiting,” said Anna Hyde, chief of advocacy and access for the Arthritis Foundation, which lobbies for research and treatment.

Although biosimilars could save everyone money, patients generally don’t care whether they get one or not, Hyde noted. Some don’t want to switch if they’ve found a brand-name drug that works for them, since the search can be grueling for people suffering from autoimmune diseases, she said.

“Generally, they can’t access them anyway,” she said, “because they are not available on the formulary.”

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The event, titled “The 3 Big C’s: Courage, Censorship & Cancer,” was sponsored by the We the People Health and Wellness Center, a clinic, funded by a Jan. 6 marcher, where patients can bask in red light, sit in ozone-infused steam baths, or get their children treated for autism with an experimental blood concentrate.

In Venice, in Sarasota County, a “medical freedom” movement forged in opposition to covid lockdowns blends wellness advocates, vaccine-haters, right-wing Republicans, and angry parents in a stew of anti-government absolutism and mystical belief.

Ladapo’s wife, Brianna, a self-proclaimed “spiritual healer” who says she speaks with angels and has prophetic visions, chaired a panel at the event at the Venice Community Center. The keynote speech was by William Makis, a litigious covid conspiracist who, after losing his medical license in 2019, has made a living treating cancer patients with antiparasitic drugs including ivermectin, which was also championed in some circles as a covid treatment during the pandemic.

Clinical trials showed that ivermectin didn’t work, but covid skeptics viewed medicine’s rejection of it as part of a conspiracy by Big Pharma against a cheap, off-patent drug. Some of the patients in his care have what he calls “turbo cancers,” Makis says, blaming alleged impurities in mRNA vaccines that he says have killed millions of people.

For Makis, it’s all one big conspiracy — the virus, the vaccine, and the suppression of his therapies.

Brianna Ladapo has her own take on medicine, based on the idea of good and bad spiritual energy. She wrote in a memoir that as the pandemic began she intuited that it had been planned by “sinister forces” to “frighten the masses to surrender their sovereignty to a small group of tyrannical elites.” She has written that the government hides vaccination’s risks.

She sees “dark forces” all over the place, including, she said in a podcast interview earlier this year, in “chemtrails” shaped like a pentagram. “They’ve been plastering it in the sky right outside our house for the last few weeks,” Ladapo said. The chemtrails “they are dumping on us,” she said, had sickened her and her three sons. “The dark side are no fans of ours.”

(“Chemtrails” are a favorite topic of conspiracy theorists who say they think that contrails, the condensation formed around commercial airplane exhaust, contain toxic substances poisoning people and the terrain. Although there is zero evidence of that, Health and Human Services Secretary Robert F. Kennedy Jr. plans to look into whether they are part of a clandestine effort to use toxic chemicals to change the weather.)

Ladapo’s husband hasn’t publicly endorsed all her beliefs, but as surgeon general he’s reversing decades of accepted public health practice in Florida and embracing untested therapies. “We’re done with fear,” Joseph Ladapo said after being named surgeon general in 2021. He wants to ban mRNA vaccines in Florida, and on Sept. 3 he announced plans to end childhood vaccination mandates in the state.

A few days after the Venice event, Ladapo said he hoped to support Makis’ work — though his treatments are unproven and potentially dangerous — through a new $60 million cancer research fund created by Florida Gov. Ron DeSantis and his wife, Casey.

Vic Mellor, CEO of a local concrete business, founded and owns We the People. He’s an associate of retired Army Lt. Gen. Michael Flynn, who was briefly President Donald Trump’s national security adviser in 2017 before being dismissed for lying to the FBI about his contacts with Russians. Trump later pardoned him, and Flynn since has become a leader of the Christian nationalist movement.

We the People provides vitamin shots but no vaccines. In fact, many of its offerings are treatments for supposed vaccine injuries. Part of the We the People building is a broadcasting studio, where conservatives hold forth on what they see as the villainy of liberals and the American Academy of Pediatrics.

Mellor was at the U.S. Capitol during the riot on Jan. 6, 2021 — he said he “just knocked on front doors,” according to a Facebook post described by The Washington Post. He returned home and started building a 10-acre complex that hosts weddings and right-wing assemblies, with playgrounds, a butterfly garden, a zip line over a pond visited by alligators, and an attached, separately owned gun range.

Visitors who travel down a dirt road to The Hollow — named for the hollow-core concrete that made Mellor wealthy — can enter the compound through a dark, cavernous passage lined with neon signs illuminating maxims from the likes of Thomas Jefferson, Thomas Paine, and Flynn.

The Hollow has hosted clinics for unvaccinated kids and events for Ladapo, anti-vaccine activist Sherri Tenpenny (who in 2021 told legislators at an Ohio House hearing that covid vaccine made people magnetic), and other “medical freedom” advocates. Mellor created a medical home for such ideas by opening We the People in 2023.

The year before, three “medical freedom” candidates had won seats on the board overseeing Sarasota’s public hospital and health care system, after protests over the hospital’s refusal to treat covid patients with ivermectin and other drugs of choice for covid contrarians.

On a recent afternoon at The Hollow, manager Dan Welch was clearing brush when approached by KFF Health News. As a foe of vaccinations, he welcomed Ladapo’s move to end vaccine mandates. “Maybe in their inception, vaccines were created to prevent what they were supposed to prevent,” Welch said. “But now there’s so much more in there, the metals, aluminum, mercury. Since they started vaccination, the autism rate went through the roof, and I believe these vaccines are part of it.”

The theory that vaccines cause autism has been debunked, and manufacturers removed mercury from childhood vaccines 24 years ago, although Welch said he doesn’t believe it.

Vaccination faces additional challenges in a century-old Sarasota County neighborhood of low-slung bungalows called Pinecraft, home to about 3,000 Mennonites — and double that number when Amish snowbirds arrive in the winter. Pastor Timothy Miller said that while Sarasota’s Mennonites are less culturally isolated than the Mennonite community in West Texas, site of a measles outbreak in January, many in his community also shun vaccination.

His cousin Kristi Miller, 26, won’t vaccinate her 9-month-old daughter or any of the other children she hopes to have, she said, because she thinks vaccines probably cause autism and other harms.

As for vaccine-preventable diseases like measles, she doesn’t worry about them. Like the Ladapos, “I don’t live in fear,” she said. “I have a God who’s bigger than everything.”

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Con el apoyo del gobernador republicano Ron DeSantis, Joseph Ladapo, cirujano general del estado, anunció el 3 de septiembre su intención de eliminar todos los requisitos de vacunación para niños en edad escolar.

“Cada una de esas normas está equivocada y destila desprecio y esclavitud”, dijo ante una multitud de personas contrarias a las vacunas en Tallahassee. “¿Quién soy yo, como gobierno o como individuo, para decirte qué debes poner en tu cuerpo?”, agregó.

La historia demuestra que los mandatos aumentan el uso de vacunas.

Sin embargo, si las tasas de vacunación bajan, aumentan los casos de enfermedades como sarampión, hepatitis, meningitis y neumonía —e incluso podrían regresar enfermedades como la difteria y la poliomielitis—.

Muchas de estas enfermedades son una amenaza no solo para quienes no están vacunados, sino también para quienes los rodean, incluidos bebés y personas mayores con sistemas inmunes debilitados.

Pero ese hecho científico ha sido ignorado en Florida. Las autoridades de salud se han mantenido en silencio frente a la campaña de Ladapo —y no porque estén de acuerdo—. La Universidad de Florida ha silenciado a especialistas en enfermedades infecciosas, según el profesor emérito Doug Barrett, ex jefe de pediatría y vicepresidente senior de asuntos de salud de esa universidad.

“Les dicen que no hablen con nadie sin permiso de sus supervisores”, aseguró. Voceros de la universidad no respondieron a solicitudes de comentarios.

Lo mismo ocurre con los funcionarios de los departamentos de salud de los condados, según John Sinnott, profesor jubilado de la Universidad del Sur de Florida, quien tiene amistad con uno de esos líderes locales.

El departamento de salud del condado de Sarasota remitió a un reportero a las autoridades estatales en Tallahassee, quienes respondieron con una declaración señalando que las vacunas “seguirán estando disponibles” para las familias que las quieran. El estado no respondió a otras solicitudes de entrevista con Ladapo ni a otras preguntas.

Muchos pediatras también guardan silencio, al menos públicamente.

“Muchos no se pronuncian con claridad sobre si los niños deben vacunarse”, dijo Neil Manimala, urólogo y presidente electo de la Asociación Médica del Condado de Hillsborough. “No quieren perder pacientes. Y hay suficientes personas antivacunas como para destrozarte con reseñas en Google, contando que los médicos quieren ‘inyectar veneno’”.

Historia de los mandatos en la vacunación moderna

Varios estados eliminaron mandatos de vacunación a principios del siglo pasado, cuando la viruela era la única vacuna ampliamente utilizada, según el historiador Robert Johnston, de la Universidad de Illinois-Chicago.

Ningún estado lo ha hecho desde que se sumaron otras vacunas al calendario. (La vacunación rutinaria contra la viruela terminó en 1972).

En los años 70, brotes persistentes de sarampión llevaron a que las autoridades reforzaran la protección infantil con mandatos escolares obligatorios en todos los estados. Hoy, la polarización política sobre las vacunas luego de la pandemia de covid ha cambiado el panorama.

Y esto se nota especialmente en Florida, aunque legisladores en Texas y Louisiana también están considerando eliminar requisitos de vacunación, y en Idaho basta con que los padres soliciten una exención.

“Este es un momento decisivo para muchas familias que ya tenían dudas sobre vacunar a sus hijos y que ahora reciben el mensaje de que no es necesario”, dijo Jennifer Takagishi, vicepresidenta de la filial de Florida de la Academia Americana de Pediatría.

No está claro qué tan rápido podrían volver las enfermedades prevenibles por vacunas si Florida elimina los mandatos, ni cómo respondería la población.

Consultado en una entrevista sobre si su oficina había diseñado posibles escenarios epidemiológicos antes del anuncio de septiembre, Ladapo respondió: “Absolutamente no”. Según el cirujano general, la libertad parental no es un asunto científico, sino de “lo que está bien o mal”.

Un mes después, el Departamento de Salud de Florida no respondió a preguntas sobre si estaba elaborando planes de contingencia ante posibles brotes. Durante un brote de sarampión en el condado de Broward en 2024, Ladapo envió a los padres una carta autorizando que los niños no vacunados asistieran a la escuela, desafiando las recomendaciones basadas en evidencia de los Centros para el Control y la Prevención de Enfermedades (CDC).

En 1977, un brote de sarampión que mató a dos niños en el condado de Los Ángeles provocó una fuerte reacción nacional contra quienes rechazaban las vacunas.

Pero durante una epidemia reciente que causó la muerte de dos menores en Texas y 14 personas en México, el gobernador republicano de Texas, Greg Abbott, firmó una ley que facilita a los padres el proceso para evitar vacunas obligatorias.

“¿Cuántas muertes o enfermedades graves se necesitarán para que la gente diga: ‘No, sí queremos vacunas’?”, se preguntó Takagishi. “No sabemos cuál será ese punto de quiebre”.

“No tengo la respuesta”, dijo Walter Orenstein, profesor emérito de la Universidad de Emory, quien trabajó en temas de sarampión durante sus 26 años en los CDC y dirigió el programa de inmunización de la agencia entre 1988 y 2004. “En el pasado, los brotes de sarampión generaban la voluntad política para apoyar los programas de vacunación. Esta vez no ha sido así. Es muy triste”.

Los niños en Florida ya están entre los menos vacunados del país, debido a una aplicación laxa de los requisitos, al rechazo de las vacunas tras la pandemia y a la postura libertaria de las autoridades estatales.

En todo el estado, solo alrededor del 89% de los niños de jardín de infantes están completamente vacunados, y el condado de Sarasota tiene la tasa más baja, con alrededor del 80%. Para evitar la propagación del sarampión, una comunidad debe tener al menos el 95% de inmunización.

Con el secretario de Salud y Servicios Humanos Robert F. Kennedy Jr. recortando fondos para la investigación de vacunas, incorporando activistas antivacunas a la agencia y generando desconfianza sobre la seguridad y utilidad de las vacunas, poco se interpone en las decisiones que podrían hacer que las tasas de vacunación en Florida bajen aún más.

El Departamento de Salud liderado por Ladapo ya está eliminando los requisitos de vacunas contra la hepatitis B, la varicela y las bacterias que causan meningitis y neumonía.

A comienzos del próximo año, se espera que la Legislatura de Florida analice la revocación de una ley de 1977 que exige que los niños en escuelas y guarderías estén vacunados contra otras siete enfermedades infantiles potencialmente mortales: tos ferina, sarampión, poliomielitis, rubéola, paperas, difteria y tétanos.

Después del sarampión, ¿qué enfermedad volverá?

Ante estos ataques, la comunidad científica intenta prever qué enfermedades podrían reaparecer primero y cuándo.

Un estudio publicado en abril por el epidemiólogo Mathew Kiang, de la Universidad de Stanford, estimó que, incluso con los niveles actuales de vacunación, el sarampión —declarado eliminado en Estados Unidos en el año 2000— podría volver a convertirse en una enfermedad habitual. Si la cobertura contra el sarampión cae un 10% más, podrían registrarse alrededor de 450.000 casos anuales, con cientos de muertes y lesiones cerebrales.

Pero ese estudio podría exagerar la amenaza, señaló Shaun Truelove, experto en modelado de enfermedades epidémicas en la Universidad Johns Hopkins, quien expresó preocupación por perder la confianza pública con predicciones alarmistas.

Aun así, advirtió que los brotes de sarampión seguramente se intensificarán. El país ya enfrenta su peor año en tres décadas, con más de 1.500 casos y brotes activos en Carolina del Sur y Minnesota.

“No hace falta modelar el sarampión si se dejan de aplicar las vacunas”, dijo Truelove. “En los lugares donde haya brotes, cada niño no vacunado se va a contagiar”.

El sarampión es “el canario en la mina” de otras enfermedades prevenibles, afirmó Sal Anzalone, pediatra de Healthcare Network en Naples, Florida. “Cuando empieza a aparecer el sarampión, hay otras enfermedades que están por venir”.

Ladapo ha dicho que quienes quieran vacunarse podrán seguir haciéndolo, incluso sin mandatos.

Pero el mensaje del estado confunde a las familias, especialmente a las de bajos recursos o desatendidas, según Anzalone. Para muchas de ellas es difícil llevar a sus hijos a citas médicas si no es obligatorio, explicó. En su consulta, el 80% de los pacientes tiene cobertura de Medicaid. Si las políticas trasladan más costos a los padres, menos niños serán vacunados, agregó.

Y si bajan las tasas de vacunación y aumentan las infecciones, los niños no serán los únicos afectados. Personas con cáncer y adultos mayores —muy numerosos en Florida— también estarían en riesgo.

Las escuelas y empresas podrían enfrentar interrupciones. La industria turística, que atrajo a 143 millones de visitantes el año pasado, también podría verse afectada. (La Cámara de Comercio de Florida no respondió a solicitudes de comentarios).

“Las enfermedades infecciosas no se detienen en quienes dicen estar dispuestos a asumir el riesgo”, dijo Meagan Fitzpatrick, experta en vacunas de la Universidad de Maryland. Por su capacidad de propagación, explicó: “en el caso de una enfermedad contagiosa, la vacunación nunca es solo una decisión individual”.

Los profesionales de salud temen que el fin de los mandatos permita el regreso de la hepatitis B, una enfermedad hepática crónica, ya que se estima que 2 millones de personas en el país portan el virus.

También podrían volver los días en que los bebés con fiebre alta debían someterse a punciones lumbares dolorosas y análisis de sangre para descartar meningitis o infecciones bacterianas que las vacunas han evitado desde la década de los 90.

Barbara Loe Fisher, co fundadora del movimiento moderno contra los mandatos de vacunación a inicios de los años 80, después de que su hijo sufriera una reacción adversa a una vacuna contra la tos ferina (que desde entonces fue reemplazada por una más segura), duda que los floridanos dejen de vacunarse en masa, pese al fin de los requisitos.

Fisher, presidenta del National Vaccine Information Center, se mudó de Virginia al suroeste de Florida en 2020. Cree que las lesiones por vacunas están subregistradas y que se vacuna a niños sin consentimiento informado. Admitió que los mandatos aumentan la cobertura, pero opinó que su eliminación fortalecerá la confianza en la salud pública y en la medicina.

“Es hora de que productos biológicos como las vacunas estén sujetos a la ley de oferta y demanda”, dijo, “igual que cualquier otro producto del mercado”.

Por su parte, Sinnott anticipa el regreso del sarampión, acompañado de brotes más intensos de tos ferina, gripe y covid.

“Ellos creen que no pasará nada. Tal vez tengan razón”, dijo Sinnott, el profesor jubilado. “Es un experimento”.

La poliomielitis también podría volver. Y para Sinnott, de 77 años, eso no es una teoría.

Tenía 7 años cuando contrajo la enfermedad y pasó seis meses en silla de ruedas. En los últimos años ha sufrido el síndrome pospoliomielítico: dificultad para tragar, rigidez y dolor en las extremidades.

La primera vacuna contra la polio se autorizó en 1955, el año en que se enfermó. “Recuerdo una vez que mi madre me dijo: ‘La fila era demasiado larga’”, contó.

Sinnott perdona a sus padres, y también a los padres actuales que dudan sobre vacunar a sus hijos. Es menos tolerante con ciertos líderes de salud pública. “Ellos sí deberían saberlo”, dijo.

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With the support of Republican Gov. Ron DeSantis, Surgeon General Joseph Ladapo on Sept. 3 announced his plan to end all school-age vaccination mandates in the state.

“Every last one of them is wrong and drips with disdain and slavery,” he told a cheering crowd of vaccination foes in Tallahassee. “Who am I, as a government or anyone else,” he said, “to tell you what you should put in your body?”

History shows that mandates increase the use of vaccines. Lower vaccination rates will mean increased rates of diseases like measles, hepatitis, meningitis, and pneumonia — and even the return of diphtheria and polio. Many of these diseases threaten not just the unvaccinated but also those they come in contact with, including babies and older people with weakened immunity.

But that scientific fact is being left unsaid in Florida. Health officials have largely been silent in the face of Ladapo’s campaign — and not because they agree with him. The University of Florida muzzled infectious disease experts, said emeritus professor Doug Barrett, formerly the university’s chief of pediatrics and senior vice president for health affairs.

“They’re told not to speak to anyone without permission from supervisors,” he said. University spokespeople didn’t respond to requests for comment.

County-level Department of Health officials across the state got the same message, said John Sinnott, a retired professor at the University of South Florida who is friends with one of the county health leaders.

Sarasota County’s health department referred a reporter to state officials in Tallahassee, who responded with a statement that vaccines will “remain available” to families who want them. The state did not respond to other requests for comment or for an interview with Ladapo.

Many pediatricians are silent, too, at least in public.

“A lot of them don’t take a strong stance on whether kids need to be vaccinated,” said Neil Manimala, a urologist and the president-elect of the Hillsborough County Medical Association. “They don’t want to lose business. And there are enough anti-vax people who can lambaste you on Google, spreading stories about clinicians who ‘want to instill the poison jabs.’”

History of Modern Vaccine Mandates

Several states ended vaccination mandates early last century when smallpox was the only widely given vaccine, said historian Robert Johnston of the University of Illinois-Chicago. None has done so since other vaccines were added to the schedule. (Routine smallpox vaccination ended in 1972).

In the 1970s, persistent measles outbreaks provoked officials to strengthen child protection with enforced school mandates in every state. Today the partisan split on vaccine policy in the wake of the covid outbreak has changed the equation. This is nowhere more the case than in Florida, although legislators in Texas and Louisiana are also considering ending mandatory vaccination, and Idaho enables parents to get an exemption just by asking for it.

“This is really going to be a watershed moment for families who already were not sure they want to do vaccines and now are being told they don’t need them,” said Jennifer Takagishi, vice president of the Florida branch of the American Academy of Pediatrics.

It’s hard to know how fast vaccine-preventable diseases might return if Florida ends its mandates — or how the public will respond. Asked in an interview whether his office had modeled disease outcomes before his September announcement, Ladapo said “Absolutely not.” Parental freedom of choice isn’t a scientific matter, he said. “It’s an issue of right and wrong.”

Ladapo’s Department of Health did not respond a month later when asked whether it was making contingency plans for outbreaks. During a 2024 measles outbreak in Broward County, Ladapo sent parents a letter granting them permission to send unvaccinated children to school, defying the science-supported advice from the federal Centers for Disease Control and Prevention.

In 1977, a measles epidemic that killed two children in Los Angeles County spurred a dramatic crackdown on vaccine-shunning across the country. But during an epidemic this year that killed two Texas children and 14 people in Mexico, Republican Gov. Greg Abbott of Texas signed a bill making it easier for parents to opt out of getting required shots.

“When are we going to have enough of a groundswell of people dying or becoming severely ill that leads people to push back and say, ‘No, no, we want the vaccines?’” Takagishi said. “I don’t know if we know the tipping point yet.”

“I don’t have the answer,” said Emory University emeritus professor Walter Orenstein, who worked on measles for many of his 26 years at the CDC and led the agency’s immunization program from 1988 to 2004. “Measles resurgences created the political will to support our overall immunization program. For some reason it hasn’t worked this time. It’s just sad.”

Youngsters in Florida are already among the least vaccinated in the nation, because of relatively lax enforcement, the post-covid backlash against shots, and the libertarian attitude of state officials. Statewide, only about 89% of kindergartners are fully vaccinated, with Sarasota County having the lowest rate, at about 80%. To be safe from the spread of measles, a community must be 95% immunized.

With Health and Human Services Secretary Robert F. Kennedy Jr. cutting vaccine research, filling the health agency with anti-vaccine activists and spreading doubt about vaccination’s safety and value, little stands in the way of decisions by Florida officials that are likely to cause rates to sink further.

Ladapo’s department is ending mandates for shots against hepatitis B, chickenpox, and the bacteria causing meningitis and pneumonia. Early next year, the Florida Legislature is expected to take up reversal of a 1977 law requiring kids at school and day care to be vaccinated against seven other diseases that can kill children: whooping cough, measles, polio, rubella, mumps, diphtheria, and tetanus.

After Measles, Which Disease Returns Next?

In the face of these attacks, scientists are attempting to predict which diseases are likely to make a resurgence and when.

A study published in April by Stanford epidemiologist Mathew Kiang and colleagues estimated that even at current vaccination levels, measles, declared eliminated from the United States in 2000, is likely to become a routine illness again. If measles vaccination rates drop by an additional 10%, there could be an average of about 450,000 cases yearly, with hundreds of deaths and cases of brain damage.

But the study may exaggerate the threat, said Shaun Truelove, an epidemic disease modeler at Johns Hopkins University who said he’s worried about losing public trust with alarmist predictions. Still, he said, an intensification of measles outbreaks seems certain. The country is already in the midst of its worst measles year in three decades, with more than 1,500 cases and current outbreaks in South Carolina and Minnesota.

“You don’t really need to model measles if vaccines stop,” Truelove said. “In the pockets where there are outbreaks, every kid who isn’t vaccinated will get infected.”

Measles is the “canary in the coal mine” for other vaccine-preventable diseases, said Sal Anzalone, a pediatrician with Healthcare Network in Naples, Florida. “When you start seeing measles, there’s more to come behind that.”

People who want vaccinations will still be able to get them if mandates are eliminated, Ladapo has said.

But the state’s message confuses parents, especially the poor and underserved, Anzalone said. It’s typically hard for them to get children to appointments unless they have to, he said, noting that 80% of his patients are insured through Medicaid. If policies put more of the payment burden on parents, fewer will vaccinate, he said.

And if vaccinations fall and infections increase, children won’t be the only people affected. Cancer patients and people in Florida’s numerous elderly communities would be at risk. Schools and businesses would be disrupted. Disease could disrupt the tourism industry, which brought 143 million people to the state last year. (The Florida Chamber of Commerce did not respond to requests for comment.)

“Infectious diseases don’t stop with the people who say they are willing to bear the risk,” said Meagan Fitzpatrick, a University of Maryland vaccinologist. Because of their unpredictable spread, she said, “with an infectious disease, vaccination is never an individual choice.”

Clinicians fear that an end to mandates could allow hepatitis B, a chronic liver disease, to return with force, since an estimated 2 million Americans carry the virus. They also foresee a return to the days when infants with high fever had to undergo a painful and risky lumbar puncture and blood draw to rule out meningitis, as well as a blood infection caused by the bacteria Haemophilus influenzae type B that routine vaccination has prevented since the 1990s.

Barbara Loe Fisher, who co-founded the modern movement against vaccine mandates in the early 1980s after her son suffered a reaction to the pertussis vaccine then in use (and since replaced with a safer shot), is skeptical that Floridians will abandon vaccination en masse, despite the end to mandates.

Fisher, president of the National Vaccine Information Center, moved from Virginia to southwestern Florida in 2020. She said she believes that vaccine injuries are undercounted and that children are vaccinated without informed consent. She acknowledged that mandates have increased coverage but said their removal will increase trust in public health and medicine.

“It is time to allow biological products like vaccines to be subject to the law of supply and demand,” she said, “just like any other product sold in the marketplace.”

Sinnott, for his part, anticipates measles will come roaring back, along with intensified whooping cough, influenza, and covid outbreaks.

“They think nothing will happen. Maybe they’re right,” said Sinnott, the retired professor. “It’s an experiment.”

Polio could return, and that is not an abstraction for Sinnott, 77.

He was 7 years old when he contracted the disease, spending six months in a wheelchair. In recent years he’s suffered from post-polio syndrome — difficulty swallowing, and tightness and pain in his limbs.

The first polio vaccine was licensed in 1955, the year he got sick. “I remember one time my mother telling me, ‘The line was too long,’” he said.

Sinnott forgives his parents, and parents today who waver on vaccination. He’s less tolerant of certain public health leaders. They should know better, he said.

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But while the result seemed foretold, the debate was far from unanimous.

The Advisory Committee on Immunization Practices, or ACIP, met at a satellite campus of the Centers for Disease Control and Prevention because the agency’s headquarters were still smashed up from a deadly gun attack last month by a man who said the covid vaccine had made him depressed and suicidal.

Health and Human Services Secretary Robert F. Kennedy Jr. has made it clear he wants the panel to change the CDC’s childhood immunization schedule, which establishes, sometimes with legal authority, which vaccines are to be mandated, paid for, and administered by states, insurers, and doctors across the country.

Kennedy fired the 17-member panel in June and has so far restocked it with 12 people, including outspoken critics of vaccination. On Sept. 18, the new panel’s discussions reflected its thin expertise and ignorance of how the vaccination schedule came to be. Scientific questions answered decades ago were asked as if they were brand-new.

“We are rookies,” said biostatistician Martin Kulldorff, the committee’s chair, noting many “technical issues that we might not grasp as of yet.”

Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, watched the telecast anxiously.

“It reminds me when as children we would have a mock United Nations meeting,” he said. “This would be like that, except we would have actually made decisions for the United Nations.”

Kennedy’s CDC accomplished what 30 years of public health attempts to fight anti-vaccine sentiment hadn’t: a head-to-head comparison of evidence and arguments. But while the winner was clear in the eyes of most experts, some doubted the result would be good.

“The whole purpose of the people on this committee is to circulate these old recycled anti-vax talking points,” said Sean O’Leary, a professor of pediatrics at the University of Colorado who previously was a liaison from the American Academy of Pediatrics to ACIP. On Friday morning, he said, a colleague had a mother in his practice who refused the measles, mumps, and rubella vaccine “because she heard something bad in the news about it last night.”

Until now, public health owned places like ACIP, while vaccine foes and skeptics dominated social media. At this meeting, the skeptics had moved onto public health’s turf — where sometimes flimsy arguments and expertise were exposed.

Pharmacist Hillary Blackburn, for example, asked why children needed two measles, mumps, and rubella shots. ACIP began recommending a second shot in 1989 during a deadly measles outbreak. The two-shot regimen provided more than 95% immunity and led to the virtual elimination of measles from the United States. This year under the Trump administration more than 1,400 cases have been reported, mostly in unvaccinated people.

In one noteworthy gaffe, ACIP member Retsef Levi, a Massachusetts Institute of Technology operations management professor, misinterpreted data from a graph showing declines in hepatitis B in the United States since the 1980s. While rates had fallen in older groups, Levi said, cases in babies hadn’t declined substantially since 2005, when he inaccurately said a birth dose was first recommended.

“Where’s the argument to vaccinate even younger children at all,” he said. “Where is the benefit?”

In fact, the recommendation for a newborn shot began in 1991 and was reinforced and expanded in 2005. The first generation of hepatitis B-vaccinated babies are well into their 30s now.

“As time goes on,” CDC scientist Adam Langer patiently explained, “the people who benefited from the change in policy at the very beginning of the policy are moving into different age groups.”

Kulldorff, Levi, and committee member Evelyn Griffin, a gynecologist, also suggested that vaccines shouldn’t be recommended unless they are tested in placebo trials, which would require certain children not to be vaccinated — a practice considered unethical.

Kulldorff began the meeting defiantly. He did not mention the CDC shooting, but disparaged former agency officials Kennedy had forced out and challenged nine former CDC directors to a debate.

He also asked if anyone in the audience would eat a hot dog laced with thimerosal, the mercury-containing preservative the committee banned from influenza vaccines at its last meeting. (No one has ever offered thimerosal as a condiment, but years of study showed the minuscule amounts in vaccines did no harm).

At the June meeting, HHS censored a CDC appraisal of thimerosal while inviting an anti-vaccine activist to present an error-filled criticism of the substance. But on Sept. 18 the panel got what looked like straight science from CDC professionals.

As the committee prepared to debate ending a 34-year-old ACIP recommendation for babies to get a dose of the hepatitis B vaccine at birth, CDC career scientists Langer and John Su presented evidence of the vaccine’s safety and benefits.

Langer also laid out the history of the fight against hepatitis B — including the failed effort to control the disease by vaccinating people most at risk, including people who use drugs, sex workers, and pregnant women who tested positive for the virus. Years of trial and error showed that in the U.S., at least, it was necessary to vaccinate newborns to really knock down the disease.

Levi, who frequently mentions the vaccination status of his own six children, challenged the idea that a healthy baby from a “normal” household — one with no history of drug use or prostitution — needed the vaccine.

Cody Meissner, one of three panel members who put up a spirited defense of the status quo in the hepatitis debate, noted that when it comes to vaccination campaigns, “the more we try and define a target group to vaccinate, the less successful we are.” Meissner, a Dartmouth College professor, has published studies of vaccines and the diseases they fight since the 1970s.

Long-observed tropes of vaccine skepticism were abundant on the first day of the meeting. Levi praised a 2004 study from Guinea-Bissau, an outlier that suggested that babies, especially females, were more likely to die if they got a hepatitis B shot. Other panelists said the study, performed in a poor country with high infant mortality where children got an outdated vaccine, wasn’t relevant. But more studies were needed in general, Levi said. “We sit here with very lousy evidence,” he said.

Nurse Vicky Pebsworth of the National Vaccine Information Center, which opposes all vaccine mandates, frequently brought her own selective research into the meeting. She read off the names of studies other panelists hadn’t received to back her arguments that vaccines under discussion were not safe.

But while “too many, too soon” is a common anti-vaccine refrain, Judith Shlay from the National Association of County and City Health Officials, which had a nonvoting chair at the meeting, used it to support the current schedule. She pointed out that the panel’s debate over a combination measles, mumps, rubella, and varicella shot for children would result in a separate shot for the virus that causes chickenpox, adding to the number of inoculations on the childhood schedule.

“Some parents want to have fewer injections,” she said.

With an 8-3 vote at the end of the day, the committee nonetheless recommended separate vaccinations for MMR and chickenpox.

Everyone seemed puzzled about what had transpired with an ensuing vote on whether the Vaccines for Children Program, which pays for more than half of childhood vaccinations, should respond to ACIP’s new recommendation. The panel revoted on the issue on Sept. 19.

Nor could anyone provide a clear answer as to what prompted the committee’s discussion and planned vote on the birth dose of hepatitis B vaccine, since there was no new evidence suggesting any harm from it.

Two of Kennedy’s senior aides, both vaccine skeptics, pushed the hepatitis B discussion onto the ACIP schedule, according to testimony at a Sept. 17 Senate hearing by former CDC chief medical officer Debra Houry, who resigned to protest administration policies.

ACIP member Robert Malone, who has claimed that mRNA vaccines are dangerous, said hepatitis B was on the agenda because it is given to newborns at birth and of special concern to parents newly awakened to vaccine doubt. He appeared to nod off during a CDC staff presentation on the safety of the hepatitis B shot.

Vaccination of babies has always triggered parents. The 19th-century poet Alexander Hope Hume described evil vaccinators who turned “the rosy darling” who “crows with glee” into “a wailing infant” whose every vein “ferments with poison.”

The agenda item was not really about the merit of the hepatitis B vaccine, Malone acknowledged.

“The signal that is prompting this is not one of safety; it’s one of trust,” he said.

But in the end, the committee reconsidered what would have been its first drastic move to reverse a successful U.S. vaccination campaign. It postponed its vote on the hepatitis B birth dose.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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