This transcript was automatically generated from the video recording and may contain inaccuracies, including errors or typographical mistakes.

Voices for Vaccines: Science, Skepticism, and Pediatric Perspectives on Contemporary Challenges

Okay. We move now to our first segment where we're going to be talking about thoughts on myths becoming mainstream.

This is an unprecedented time in immunization. I will tell you that. Because I am retired from clinical medicine, I let my AAP membership lapse. But I was so proud of how AAP has reacted to the assault on vaccines that I rejoined. I feel like so proud to be a pediatrician right now.

Do you guys want to say anything more about any of those?

Dr. Yvonne (Bonnie) Maldonado (Lucile Packard Children’s Hospital): We don't have two hours. But…

Dr. Humiston: Yeah.

Dr. Maldonado: Let me just say that these are topics that we have been discussing at great length, Tina and I and Sharon as well. And many of us have really been discussing these changes.

And let me just say that the CDC staff people – I trained at CDC many years ago as an EIS officer and a lot of the people who have been there are fabulous staff people. They are still doing – my research scientist in my lab that I hired during COVID is now an EIS officer. They are doing their best to keep the work going. These are very driven and data-driven scientists. And they are really battling for all of us to really keep information front of mind as much as possible. But they obviously are being hampered.

I was on the ACIP. I served as a liaison for six years on behalf of the American Academy of Pediatrics. And then I was one of the 17 people who was fired last year by the Secretary of HHS.

ACIP – and we'll talk a little bit about this later. But it doesn't exist right this minute. We can talk a little bit more later.

Dr. Humiston: Yeah.

Dr. Maldonado: But it's not in place. We have to figure out what to do. And there are things that we can talk about later about how to support that. And VICP was started under Ronald Reagan in 1988. That program has billions of dollars in it to support vaccine injuries, real ones. And it has worked incredibly well. It has an open transparent website that you can look at, and it is openly run by the National Vaccine Injury Program.

There are anti-vax groups that are really pushing to turn this into a plundering of this pool of money for non-scientific and non-practical reasons. They are really trying to go after that pot of money, not just for the money, but really to turn this into a vaccine injury. Turn – a list of several dozen or more what they call adverse events that are not scientifically proven or data-driven.

And this has been a very specific campaign that's being run by people within the anti-vax community. So it's really unfortunate. We, all of us, as members of whatever national society that you belong to, should really be supporting your societies. And if you can, write in to your – your government representatives to really support this program.

It has been in place, like I said, since 1980. It works incredibly well. They get the job done. The data are out there to see. And whatever you've been hearing about how bad it's working is not true. These are people who want to take that money and they want to label vaccines as unsafe.

Discussion: Countering False Narratives by Building Trust

Dr. Tina Tan (Ann & Robert H. Lurie Children’s Hospital of Chicago): [Inaudible].

Dr. Maldonado: Yeah.

Dr. Tan: [Inaudible].

Dr. Maldonado: Yeah. Tina and I were on that committee for many years, and we've been tracking it. And if anything, I think they've done a better job more recently. Right, Tina?

Dr. Tan: Right.

Dr. Humiston: All right. I'm going to ask you guys my first question. How can healthcare providers or healthcare professionals, because we do have some pharmacists. If you're a pharmacist in the room. We have just – oh, just one. Okay. How can healthcare professionals with limited touch points among parents and caregivers, unlike social media, which is invasive, effective – how can we infect – effectively counter false narratives? You want to talk about that for a minute.

Tina, you want to start? Tina's going to be using speeches.

Dr. Tan: HCPs with limited touchdowns among parents and caregivers can effectively counter false narratives by taking advantage of the time they have, by listening to parent concerns and providing true information regarding the false narratives and explaining why the narratives are false.

Dr. Humiston: Bonnie, do you want to add anything?

Dr. Maldonado: Yeah. And if you have limited time with – obviously, you are the front line to these families. These are young people. I don't know if all of you remember or if you have been in that situation. I had – we – my husband had had three children. They're all adults now. But even as a pediatrician, I remember having questions and concerns. We all did. But you can imagine, and you all know this better than I, the barrage that they are faced with every day, with all this information that comes through social media, they really just want answers most of the time.

Paul Offit, who I've known since we were both fellows together at Stanford has really made it his life's pursuit to really go to these groups and just talk to people and answer their questions. Most of the time – I would say, as you all probably know, the majority of people just need to hear from somebody that they trust, and they do trust pediatricians, and they do trust their healthcare providers.

Dr. Humiston: Well, that brings us to the next question. Tina, you want to say something?

Dr. Tan: HCPs can build trust over time by providing parents with opportunity to tell them what their concerns are, listen empathetically and explain to the parents the true information. This will give parents the impression that the HCP really wants to provide the best care for their child.

Dr. Maldonado: Yeah. I agree, I think that first question in the pre-test about asking what is it that you're worried about, that really opens the door for them, because then they realize that you want to listen to them and you're not just going to talk at them. And again, you're all – I'm preaching to the choir here. You're all very good at that. But I think it is helpful because I – you know, I've been in practice. Well, I've stopped seeing patients, unfortunately, after COVID because of my other work. But I've been in practice over 30 years. And I just remember how important it was for people to see you as somebody who understands their concerns.

And when I was very young, they said, “Well, you're too young to be a doctor.” I'm sure some of you get that. And now I'm not – they don't say that anymore, but then people do relate to you. Well, how are they going to relate to you? It's really important to build on that because then they will listen and they want to be sure that they're heard and then they can bring – and as you said, we've all had those moments, by the way, when we've said the wrong thing, all of us.

And so we learned from those. And, you know, I think there is something to say, “Look, I'm really sorry. I may have – you know, you may have misunderstood my reaction, but I really do take this seriously.” And so there's always a way to rebuild that trust if you feel like it might have been lost, because people are so jittery right now.

Honestly, people are very jittery. They don't know what – and I've heard from – I chaired the AAP task force on the safety of the pediatric workforce. And one of the things – and Lisa Green is there in the audience there, who actually put – was on my – task force with me. One of the things we heard is that pediatricians and providers are really hurting as well, and are afraid to approach issues without feeling like they're going to either get attacked themselves or like not be – not feel that their family member – the family member will trust them.

And so we just need to try to be open and honest with them and recognize that they're probably feeling pretty jittery with what's all going on, as you said, in these unprecedented times.

Building Trust With Parents and Caregivers

Dr. Humiston: Okay. Bonnie, do you want to talk about this slide? Building trust.

Dr. Maldonado: Yeah, sure. Well, so as you may have seen there, Tina and I both have done this, but we're both global health work – most of my research, I did all my patient care at Packard Children's at Stanford, but I also did a lot of work in sub-Saharan Africa, worked in indigenous populations there and indigenous populations in Latin America and Mexico.

And one of the things I've really learned – and when I was training at CDC is one of the things I really learned is by the time when you're in the field, wherever you are, people really know what's going on. They really get the culture. You might not really get that culture. When you see your patient, I think, but at the same way, they have their own little culture within their family unit.

And so establishing that safe relationship is really paying homage to that culture, whatever that might be. You may not be from that culture, but if you acknowledge it, I think that goes a long way. And I realized that establishing that safe relationship, being willing to have it as a partnership. And, you know, my – I'm older, so we weren't always trained that way. We were trained – believe it or not, we were trained to say, “Well, remember, you're the smartest person in the room.” And that's really probably not true. You might have different kind of book learning than other people did, but you're not always the smartest person in the room. In fact, I learned more from my patients than I think they probably do for me.

So establishing that bilateral relationship. And I think, again, you all probably know this, but it's really helpful to repeat that to you. So you – you validate that you're doing the right thing. And then understanding – and in doing that, you can then understand what matters most. Why are you know, why are you here?

Well, they might – as we all learned in med school, the chief complaint might be one thing, but you know that there's probably going to be some other underlying things. And I know how busy you all are. But if you can try to get to that nugget, what is it that might really be bothering them underneath the usual well baby work, that really helps as well.

And then offering information. What I always do – and again, I don't get to see patients. I've stopped about three years ago. But one of the things that we would try to do is build, you know, to that community. So for example, I know young people want online resources, so I always lead them to their societies, our societies. So American Academy of Pediatrics has the healthychildren.org website and others. Immunize.org is a great spot too.

There are just so many great resources. So I usually try to keep those. And if I can, I used to keep them information about those in the office so that people could look at those while they were waiting as well.

And then, again, clarifying what you had to say, try to recap what you said at the end. Okay, so here are the two things we decided we were going to do today. Does that make sense to you? Do you feel comfortable with that? And here's two – or one or two other things that we can talk about next time. So it’s – and you're building this long-term relationship and it's very exciting.

I started the pediatric HIV clinic at Stanford because that's when it started. I had just come out of CDC and we had – didn't know anything about the disease at the time, and we fortunately had to shut it down because there weren't any more kids that they all grew up, where, sadly they passed away. But we still see some of those kids come back to us as adults.

And so you are building these relationships. As you know, some of you have done this for a long, long time. They will come back and they will bring their children to you. And that is really one of the biggest gifts that we can have for us as providers, that people trust their children with you as well.

Dr. Humiston: Do you want to do poll questions?

Poll 4

Dr. Maldonado: Yes. So let's go with poll – poll question number four. So what vaccine misconceptions stemming from misinformation do you most frequently encounter? Is it – and, you know, we only want you to pick one. I know you probably hear more than one, but pick the one you hear the most. Vaccine…

1. Vaccines are dangerous;
2. Vaccines are ineffective;
3. Vaccines are unnecessary for disease prevention; and
4. Too many vaccines are given at a single visit or my baby is too young.

Dr. Humiston: Wow. A lot of vaccines are dangerous.

Dr. Maldonado: Very sad.

Dr. Humiston: And a lot of too many vaccines at a single visit. I know that a lot of people are being faced with the being like, “Oh, let's just do one at a time and I'll come back.” That's a big one. And then the vaccines are dangerous. A lot of times they just don't want that vaccine go on. COVID vaccine, people were so afraid of it. I think that's one of the ones that turned public opinion against vaccines in general.

Dr. Maldonado: Yeah.

Stages of an Immunization Program

So this is an interesting slide. I use this a lot in my own lectures that I give to. I have teach-to classes at Stanford. One is Global Child Health to the undergrads. And then the other one is epidemiology of infectious disease to the Masters and PhD students. And this is one of the slides I use for both of those classes.

This is something that Bob Chen developed and Mike – Martin Myers used in one of his books years later. And this is basically, as an epidemiologist, we like to track the epidemiology of different diseases. Well, this is the epidemiology of vaccine immunizations. And so what happens is, over time, you have a very high level of disease prevalence.

For example, if you look back at the year 1900. Between 1900 and 2000, our lifespan doubled in the United States, doubled. So not just increase. It doubled. So we are living longer. And the major reason for that is children under five are not dying. In 1900, 30% of children under five in this country died. Can you imagine if one in three of the kids right now in this country died and they died from tuberculosis, diarrhea, pneumonia and water-borne diseases and food-borne diseases.

So these are mostly things that are preventable today because obviously our death rate is about 1%. So we are seeing chronic illnesses. Part of – there’s – that is a very complicated issue, but it's not because of vaccination. There are other things going on.

So when we started to see these diseases taper off and you all know this. I mean, we don't see – now we're starting to see measles again, but we didn't see measles for a long time. Or whooping cough came and went a bit. But as you start to see more and more prevention, lives are always a risk-benefit ratio. We always think about what's the risk and what's the benefit.

Well, when you're in the middle of an outbreak or when you're living with endemic disease, you're going to do anything you can to keep your children safe and alive. And as that risk goes down because of your prevention, you're going to start to see the risk being, “Well, my child got a fever from that vaccine or my child got a, you know – been sore arm or other side effects.”

And so but the benefit of not having the disease is lost on them because they're not seeing the disease. And this is where public health works best when you don't know that it's working. And this is a problem, right? So I have a cup that somebody gave me at work that says, “Remember when you had polio? Well, we don't remember that anymore and we hope it goes away.”

So this is what that slide is trying to tell you, that as we go down this slope of losing disease, people are more and more worried about the intervention. But as we know, we have to keep talking about this because it doesn't happen overnight. If you stopped, for example, a diabetic control their blood glucose and then they stopped their intervention, you would find out within a week or two that that – you know, that they needed to get back on.

With vaccines, it's not the same thing. It could take weeks and months and sometimes even years before we see diseases come back.

Discussion: Paths Forward for Pediatricians 

Dr. Humiston: All right. So one of the things you said earlier was about talking to parents. And so like, you get the information to them before they hear the social media backlash about the vaccine. So the word a lot of people are using is pre-bunking. Rather than having to debunk, you pre-bunk. So it's getting the information to the family first. What's the value of pre-bunking vaccine misinformation, if it's even possible now to get it out before social media starts coming up with the newest? Tina, you want...

Dr. Tan: [Inaudible].

Dr. Humiston: All right. Can we inoculate parents and caregivers by helping them identify misinformation and disinformation where it's specifically designed?

Barbara Loe Fisher, who was a famous anti-vaccine person, used to say, “You don't have to convince people. You just have to plant a doubt.” And I think that that's one of the most toxic approaches is just plant a doubt. So disinformation as well as people giving misinformation. Can we inoculate people against that?

Dr. Maldonado: Well, so, you know, I also in back in the day I did a lot of work in prevention of mother to child transmission of HIV in the US. And we were very successful with that here in the US. And then I started a program in sub-Saharan Africa as well, and that's still going on.

One of the things that we found in the US, and it's true, sadly elsewhere, is that if you look at the diseases like HIV, even a fatal disease like that, untreated, right. The biggest predictor of behavioral change was knowing somebody who had succumbed to that disease. So unfortunately we're losing that – in a good way, we are losing these diseases because they're not around anymore. It's really hard to do that unless they are seeing the disease around them, like I said. If you're aware of something in your environment that's a threat, you're going to do something about it.

So but we can do it. But it's harder to do with these infectious diseases, because it does take a long time for them to show up.

So one of the ways that we've really tried to do this, and we did this during COVID. To a certain extent, it worked, is to really look to trusted leaders in your community and you are trusted leaders in your community, but sometimes young parent groups, young adult groups as well by them getting engaged and really helping to try to spread the word. They will listen to each other. And then sometimes you can try to bring that message into your office as well.

But it is hard to do because these diseases don't come back as quickly as – fortunately for us, don't come back quickly enough for that to be an impact. That will make behavioral change.

And I think trying to support the messaging that we've been doing this now. So AAP has been making vaccine recommendations since the 1930s. It's almost 100 years. And they have done a fabulous job. The ACIP has been around since the 1960s. We hope it will come back in a normal, rational format, and we'll see what happens. But that's why we put our trust in these organizations that take care of children.

Dr. Humiston: Tina, do you want to add something?

Dr. Tan: We can definitely work with parents and caregivers to help them identify misinformation and disinformation. [Inaudible].

Dr. Humiston: One of the things that I know that was exciting about having you all here today was – how many of you teach residents?

Yeah. And one of the things that we have found through survey work was that a lot of the residents have the same misinformation that the general public. And so we need to be working with that nascent group of residents to become pediatricians that are advocates for vaccination, I mean, so that AAP can keep doing its work, but also so that the trusted individual – I have to say that when we looked at the same survey results about family medicine residents, it was really scary.

And so that's another whole – when residents rotate through the clinic to do their pediatric rotation, you have a real opportunity to make a difference for the future.

Evidence-Based Communication Is Crucial

All right. Tina, do you want to talk about evidence-based communication?

Dr. Tan: Evidence-based communication is vital and crucial. Using motivational interviewing techniques, employing interactive, empathetic and respectful engagement, and asking about parental concerns and providing scientifically true information about the importance of vaccines are essential in building trust and getting parents to understand that you are wanting to do what is best for their child.

The SHARE Approach

Dr. Humiston: I'm going to take us to the SHARE approach, if you want to talk about that.

Dr. Tan: The CDC SHARE approach to discussing vaccines is a great method. You first want to share why a vaccine is important for the patient based on a number of risk factors, including age. You want to strongly highlight the positive experiences you have had in using vaccines to protect patients by explaining the benefits. You then want to empathetically listen and address all patient and caregiver questions.

You also want to remind parents that vaccines help protect their child and everyone in their family. And you want to explain the potential serious complications, financial cost, and spread of the disease to more vulnerable family members if the child gets the natural disease. Then highlight the vaccine benefits of protection against the disease.

Dr. Humiston: I think that one of the things in this is, a lot of times – well,  the shared clinical decision-making. The truth of the matter is that every vaccine interaction is a shared clinical decision-making opportunity. Because parents – I mean, it's not like we – you know, like that we can force anybody to do this.

And so having them understand that there are personalized reasons why I'm recommending this, not – it's routine for everyone, but for you, it's specifically because I don't want you to get Hib disease. I don't want you – and if you know the family and you can say, “Well, I want to prevent influenza for this child, but I also know that you have a five-month old at home.” Like that's another whole level of personalization of the recommendation that I think is extremely effective because people understand that I'm not just saying this as a knee jerk. I actually want you specifically protected. All right.

Posttest 1

Dr. Tan: We can definitely work with parent. The CDC SHARE approach. Let's vote on the post-test one question. If using evidence-based techniques, how would you respond to a caregiver who is concerned about their infant receiving so many vaccines at once?

Dr. Humiston: I like this song, particularly for this setting. We didn't start the fire. Yeah. So yeah. Good.

Posttest 1: Rationale

Dr. Tan: The correct response is D, given that building trust through motivational interviewing starts with understanding what concerns the individual has.

Navigating a Changing Childhood Vaccine Landscape

Dr. Humiston: All right. We move now to navigating a changing childhood vaccine landscape and working on the news. I do a newsletter, IZ Express, and it is amazing how much work this is now as opposed to four years ago, because every week there's something that's changing.

Poll 5

Let's do this poll question. What future scenarios do you see as the biggest threat to childhood vaccination in the United States? Again, this is going to be one of the word clouds. So just give me a word or two.

What future scenarios do you see as the biggest threat to childhood vaccination in the United States?

Misinformation is the winner as the biggest one. Oh, this is interesting. Social. Social and media are up there. Insurance is up there. That's an interesting piece.

Dr. Maldonado: Influencers.

Dr. Humiston: Influencers, yeah. Mandates. And that's an interesting word. Pandemic. Okay, interesting. All right.

Timeline for Contemporary Challenges and Changes to CDC Vaccine Recommendations

Dr. Maldonado: Great. So we can't spend a lot of time on what's happened in the last year and a half. I mean, I've been working in vaccines since my fellowship days. I started my fellowship years ago working on rotavirus vaccines and then polio and then measles, etc.. So we've always had this environment of anti-vax sentiment. It's always been with us. It goes back to the 1700s when the first vaccines were used. So we've always had these individuals who feel uncomfortable and, yes, they're – you know, I think ideas can always be challenged, but we obviously have seen this as the status quo now, where now it is almost accepted that we have to actually walk back the fact that vaccines are safe.

So people are now just assuming in many cases that they've heard that vaccines aren't safe, as you mentioned in your polls here. And so – but I'm just going to go through a very brief timeline.

So basically last year – I'm trying to remember now who it was, but I can't remember who it was – I think it was HHS. So it came straight from the director, the Secretary of Health. And interestingly enough, this didn't even come from a CDC Director because we didn't have one. So this is from the Secretary of HHS, the Head of the FDA, and other people. So not even ACIP or CDC. These were non-CDC people.

And traditionally changes to vaccines are supposed to come from CDC. They came from – directly from HHS. And so there – and the director of HHS changed the COVID-19 vaccine recommendation for healthy children and pregnant women. And I remember when this happened because they published just before they made the change in April in the New England Journal, Marty Makary, who's the head of the FDA, and his colleagues published an op-ed or actually a piece in the New England Journal that outlined what COVID vaccines would be helpful for.

And it was actually pretty decent. It was a pretty good article. And in it, it did support vaccination of pregnant women and immunocompromised people. I think they held off on healthy children. And I think there is some dispute about whether that should be regular – routine or not.

But then what happened is their own – they turned around a couple weeks later and then did not support the use of COVID vaccines for pregnant women, even though they published themselves in a peer reviewed, very well-respected journal that they should be used. And we never got an answer for why that happened. And we, at Stanford, have published since then a piece demonstrating that we could save three to five – 3,000 to 7,000 pregnant women lives and children's lives by using COVID vaccines in those populations.

So this is evidence-based data. And they have actually gone against data that they themselves recommended. So that was one of the first changes.

Dr. Tan: And no lawsuit.

Dr. Humiston: No lawsuit, yes.

Dr. Maldonado: Yes, no lawsuit started back then too. Yeah. So that's when the American Academy of Pediatrics went forward and developed a lawsuit with an outside law firm who've done a very good job. We'll talk about that at the end.

So they then – so at that point, the secretary let 17 – so there were 17 of us on the ACIP. And by the way, it took us an average of one year to two years to be appointed. You don't just get appointed overnight, you have to go through a lot of vetting and paperwork and conflict of interest stuff and all kinds of training.

We got on that committee over the past, you know, couple of years before that, and actually some of the people were rotating off. We were – and one day we were all summarily let go and nobody let us know. We found out because some reporters started texting us to say, “Look at – read the Wall Street Journal today.” So that's how we found out that we were no longer part of the ACIP. We were getting ready for the June meeting which we didn't have. It was postponed for logistical reasons.

And we were let go for, you know – because they wanted to move ahead – move, move on with  new members. And at that time, they also then had a meeting in later in June with their new advisory committee, which they stood up in 48 hours after they'd let us all go. And these were about seven to eight people. One of them had to drop off because of a pretty severe conflict of interest. The others have never disclosed their conflicts to-date, and they all – almost all of them, had known published anti-vaccine pieces or statements in their background.

So at that meeting, they recommended only giving the MMR vaccine and monovalent varicella vaccine at separate injection sites at less than five years of age. And that in itself isn't a terrible thing because you have the choice now, right, to either do MMRV or MMR plus V separately.

But the thing that happened that was very different is they never used evidence to recommendation. They didn't use grade. They used no outcome measures or metrics by which to measure why they would make a decision. They just spouted a lot of misinformation. And those of us who are on the ACIP, the 17 of us, wrote a very detailed description of what they did and what was missing from their recommendations, and we published that in JAMA.

We subsequently have published follow ups to the other two meetings as well. But this was not evidence-based and not so much the recommendations. 85% of people already do this. The problem was that they did it without good evidence. It was a lot of hearsay and a lot of - they cited two papers that were really very poorly done papers.

So that was what happened in June on top of having to listen to a lot of misinformation about vaccines. Remember, this is a public meeting that's broadcast on YouTube. So the public can hear this and they start hearing ACIP and CDC supposedly talking about issues that are completely untrue or that really take data out of context.

So then in January – and there were other things that happened at the September meeting very similarly, where they – and we'll talk about that in a bit, but they've really altered the vaccine schedule in very similar ways, in much more impactful ways, but also without solid data. The data that they presented was either completely false or non-existent.

And we actually documented that again in peer reviewed papers that we wrote to document what happened at these meetings. So then in January of this year what was very shocking, this happened in the first week of January is the Secretary of HHS, on his own authority, basically completely changed the immunization schedule, which, to-date, we don't have a copy of. We don't know what it looks like. We don't know what the recommendations are.

And you all know this. I mean, you can try to find them. They broke the categories down into recommended, shared clinical decision-making or risk groups only. They really didn't define any of that. And they put vaccines into these categories almost seemingly in random fashion. They said they cited numerous experts and hundreds of hours and thousands of hours of review of papers. They cited none of that anywhere. We don't know who went – did – made these recommendations or where the data came from.

Dr. Tan: [Inaudible].

Dr. Maldonado: Yeah,  I think we don't know where it came from. And we never got any confirmation from anybody about this, but this was posted on the CDC website. And then fortunately, the lawsuit that the American Academy of Pediatrics – so first I want to go back. The American Academy of Pediatrics throughout this time made a very difficult decision. And I chaired that Committee on Infectious Diseases for some time.

And I was on that committee for over 10 years. We – they made the decision to withdraw from the ACIP, which was a really big deal. And there were a lot of opinions back and forth about that, but in the end, they said they felt that it was best not to sit on a panel where there was misinformation – absolute misinformation and disinformation being shared.

So it was a tough decision. But they did that. And at the same time, then they filed a lawsuit against HHS, against the Secretary and HHS, because they were violating federal laws that dictate exactly how the ACIP has to run. And I don't have time to go into detail, but it was very well documented that what they were doing was contrary to the way ACIP was founded in the 60s. It was a congressional mandate.

So if they wanted to do the things they wanted to do, they needed to go back to Congress and re-legislate this particular act, the FACA. And they never did that. In fact, they really kind of blew it off. And the law firm that AAP retained actually fought this. And they kept throwing delays and delays and delays. But finally in February and then March of this year, a federal judge threw out the ACIP membership because they were not picked in the way that was mandated by this congressional mandate.

They threw out the votes and they threw out the immunization schedule totally. Everything that had happened from June of 2025 until that moment was gone. Now, we were lucky that this week, in fact, it was just yesterday. So things are happening very quickly. The July 2025 – no, was it July 2025 immunization schedule is now posted on the CDC website and it's not identical to, but it's very similar to the American Academy of Pediatrics immunization schedule. So now they are back in harmony. They're not identical, but they're in harmony.

So – but we don't know what's going to happen next. We're waiting to see what action, if any, the federal government is going to take around CDC and ACIP.

Now, they do, as you know, have a nominee for a new CDC director who sounds like she could be a very good candidate. We don't really know yet because they haven't vetted her through Congress yet.

What Remains Unchanged

So what remains unchanged, of course, as we all know, the science. And this is the one of the sad things, is that we have not been able to move forward. We're just basically defending where we've been for 60 years plus. We – for example, major thing we wanted to talk about HPV vaccine. We could go to one dose from two, but we can't do that yet because ACIP didn't get a chance to look at the data with CDC to see what the data looks like.

We know there's a great New England Journal paper and other data demonstrating that one dose of HPV vaccine is just as good as two doses, but we haven't had a chance to analyze that data through our normal outcomes based and analytics that CDC does with us. So that has been sitting on the sidelines and has not been done. So, so far, we still have to use two doses.

We have to revisit the pneumococcal vaccine schedule with all the new vaccine changes that we've seen. There's a real opportunity to trim that down and clean it up and make it really easy – much easier to use. I haven't been able to look at any of those data.

And those are just the tip of the iceberg. There's other vaccines that are, you know, have gone away. The – oh my gosh, the – one of the other vaccines that got taken off. Now I'm trying to remember it's one of the arboviruses, chikungunya. Chikungunya, we had to take that away, but now we need to go back and revisit that.

Fortunately, it's not highly prevalent in the US. It's rare in the US, but we would like to go forward and build new vaccine policies to streamline the work for all of us. So the science hasn't changed, but we're also not moving forward with the science that is coming.

All of the healthcare organizations continue to make evidence-based recommendations and they're all working together. AAP has been in charge of pediatrics and each of ACOG, ACP, AAFP, IDSA. You may want to talk about that.

Dr. Tan: Yeah, [inaudible].

Dr. Maldonado: Yeah, absolutely. So where we have IDSA is recommending for immunocompromised individuals, ACP or the American College of Physicians is recommending for healthy adults, etc. That's all still being done.

Shared clinical decision-making, as you all know better than I do, you have to do that as part of your daily practice already anyway. That is not a new thing. And hepatitis B vaccine is now permitted. You know, that was never gone from the AAP schedule. It's now back on the CDC website. So the birth dose can now continue to be given.

Out-of-pocket costs. Vaccines for Children and Vaccine Injury Compensation are still alive and well right now, but with the caveats that we just mentioned is that they – we know that there are very significant efforts by people working behind HHS to try to take those away.

Dr. Tan: [Inaudible].

Dr. Maldonado: Yeah, the funding is back in place – or well, it really wasn't gone to begin with, but...

Dr. Humiston: Right. Because shared clinical decision-making still remains under Vaccines for Children programs, thank heaven.

Discussion: School Vaccine Mandates

If states relax or eliminate school vaccine mandates, what impact do you anticipate? So, you know, we are hearing that there are states that are going with CDC recommendations. And so – or they're just eliminating, like Florida just eliminated school vaccine mandates. What do you anticipate? You know, what's going to come from that?

Dr. Maldonado: So can I – I'm going to – I know Tina's writing.

Dr. Tan: If states relax or eliminate school vaccine mandates, this will open the door for large outbreaks of multiple vaccine preventable diseases, which we are already seeing with measles and pertussis.

Dr. Maldonado: So we actually a year ago this week, I remember because I was at the last PAS meeting when our paper came out in JAMA, I wrote it with Nathan Lo and his colleagues that we were at Stanford, they’re epidemiologist as well. And we wrote a paper forecasting what would happen to measles, polio, rubella, congenital rubella, and diphtheria over the next 25 years at current vaccination levels. And that was last year's current, not this year's current. I don't know what this year's is yet, because CDC used to do those analyses and we don't know what they are.

But last year's current, what if they dropped by 10, 25 and 50%, or what if they increased just by 5 or 10%? And it's obvious, right? I mean, why do we even need to do this study? But we have to because we have to prove it. And what we proved, unfortunately, with the model or we demonstrated with the model, is that, in five years, measles would become endemic in this country, and we would see up to one to 11 million cases of measles in the United States in the next five to 10 years. That polio might become endemic again in the US.

Fortunately, diphtheria wouldn't come back with a force because it's less transmissible. But again, congenital rubella would be back as well. And so we were able to really document these numbers and get them out to people to use. Like with immunize.org, with CIDRAP and a lot of the other organizations you see, so that they could actually say, here are the data that demonstrate what could happen.

Now what's really exciting is we also saw that even with a 5% increase in vaccination coverage, we could really drop our numbers of potential outbreaks. So we are still in good stead right now, even with this measles problem going on if we continue to fight back. And I know it must be exhausting for all of you to keep doing all of this work on top of all the other threats, for example, Medicaid issues, etc..

But we do think that we can overcome this if we can get a handle on the vaccine coverage rates.

Discussion: Vaccine Spacing  

I'm going to move us ahead to the vaccine spacing question. What's an appropriate response to parents requesting to space out their child's vaccines over a longer time period than the recommended immunization schedule?

I mean, one of the things I think we open ourselves up to errors anytime so we would have a very important person arrive in the emergency department. And instead of doing things in the routine way, we would, Oh, you know, like, let's do this. You know, we'll cut through this way and we'll cut through this way.

And we had more errors when we did things in non-routine ways. And I think that that same problem is going to show up with vax – when we try to do things in a personalized schedule way, we're going to have more errors where people get two vaccines at intervals that are too close, or that we miss vaccines altogether.

Are there other – what else do you say to parents to say, “Please don't do this in a strange way?

Dr. Tan: [Inaudible].

Dr. Maldonado: Yeah. So you might miss – you want the family to feel secure in the fact that your system is – our systems are set up to do these routinely, and people can fall through the cracks. And it does help sometimes if you explain that to them in more detail.

I think people feel like they're an exception and they'll remember, but it's very difficult to do that. And I think I worry about the mandates also now, and I don't know for those of you who are in Florida now, I know we are seeing that it may be – is it Florida? There's another state too that where they're saying that if, you know, you have to take – because, you know, some PD – we also in the American Academy of Pediatrics decided to recommend that you could take children in your practice if they did not want to be vaccinated, because that was a big issue.

It was really hard for us to make that decision because we didn't want to support lack of vaccination, but we also wanted people to have that right. But now I feel like it's being mandated in some places that it could be illegal for you not to take a family member who's – who doesn't vaccinate.

So I think I worry about liability issues as well, because you – you're damned if you do and you're damned if you don't unfortunately.

Dr. Tan: [Inaudible].

Dr. Maldonado: Strong recommendation is key. Yeah, absolutely.

Posttest 2

Dr. Humiston: All right. We are so running out of time, and I had to hope for much more question and answer time. So my post question number two. I have strategies to proactively strengthen parental and caregiver confidence in vaccines. Could you give me an answer before you leave.

1. Strongly disagree with that statement;
2. Disagree;
3. Neutral;
4. I agree with that statement; or
5. I strongly agree with that statement.

Okay. A shift towards strong agree.

[00:59:40]

Q&A 

Okay. And our next – we have 43 seconds left. Can you talk just a little bit about worst case scenario ACIP being reconfigured in a new light where the people being chosen for ACIP are not chosen because of medical information, knowledge, or expertise in pediatric care, but that they are chosen through backhanded ways, as best I can say.

Dr. Tan: [Inaudible] already happened.

Dr. Humiston: It's already happening.

Dr. Maldonado: Yeah, it happened and they lost. Now the question is, can they do it again the right way? Meaning can they follow the charter guidelines and still hire these people? They need to be vetted by somebody. And this is…

Dr. Humiston: And can they change the charter?

Dr. Maldonado: Oh, yeah. Absolutely. In fact, there is no charter right now. So the chart – it turns out, and again, this is what CDC staff people who many of whom are gone now know. They have to follow very strict guidelines, much to the chagrin of these people who seem to run this organization at a political level. They don't understand the organization they're running. But the ACIP charter has to be renewed every two years, and it has to go to a very rigorous process that they actually automatically know how to do, because they've been doing it for since the 1960s.

They didn't renew the charter. So it expired on top of what happened with the federal judge in revoking everything, it's now no longer in place. They published a statement saying, “Here's our new charter. It's done.” That you don't just stand up and say, “I hereby invoke a charter.” That's not how these things work. You need to put it through the Federal Register. You need to go through comments. There's all kinds of things that need to be done.

Now, the fact that they have a new nominee for the Head of CDC, who seems to be very good and competent and a great clinician and an epidemiologist is very encouraging. And now we have – we heard this week from the Secretary of HHS that he would let her make her own vaccine decisions. Hopefully that is true and he sticks to his word. And if that's the case, then she can help build. And if she gets approved, we could see a charter come into place that continues the process that we have seen for the last 60 years.

If it doesn't happen, we will sue them again, I think. We will have to stand by the law and stand by what public health means in this country. And the American Academy of Pediatrics, I think, and the other organizations I think have already been through this once.

And I think what we've learned during these times is that we need to stick to the guidelines and the science and defend the laws of this country, not make it up as we go along. So that's – that's...

Thank You for Attending  

Dr. Humiston: I want to just have a big round of applause for our panelists today. And I want a big round of applause for all of you for coming and for your hard work. I know that you are being faced with cutbacks in your grant funding, and that you are going over hurdles with your IRB, that you have a hard job. And I just want a round of applause for you all too.

Dr. Maldonado: Yes. Thank you for all that you're doing.