Binary Medicine is an Oxymoron

Binary is a word thrown around a lot lately. I know one area that word has no place in—Medicine. Still, we in Medicine fight like children... us against them, no matter the issue.

During COVID, because I was on a certain TV channel more than others, one of my best friends and a great physician said, 'You know, EVERYONE thinks you're a Republican now.' I responded, 'That's wrong for two reasons. First, while on TV, I never said anything remotely political. I talked about COVID—the disease, the risk factors, the data on treatments, etc. I never once said something political. And second, what if I were Republican? Why would that be so horrible? Didn't President Reagan go out to dinner with Speaker Tip O'Neill?'

Medicine started becoming binary before COVID. I tried through online forums to stem the tide, but my efforts had little to no effect. For the first time in U.S. Medicine, debate became frowned upon—and later quashed. Absurdity became accepted as reality. If you didn’t join the Group‑Think, then you were an outcast and wrong inherently. I am the leader of the inherently wrong outcasts.

Vaccines are now talked about as a singular noun. Currently, there has been screaming—not debating—between groups who are pro‑vaccine or anti‑vaccine. It’s among the stupider things I have watched, and I watched Gilligan’s Island.

For more than three decades, I have studied and practiced Infectious Diseases. I know a fair amount about vaccines—even compared with other ID doctors. Each vaccine must be studied in different groups, and those data must be debated fairly.

Now, if you’re a doctor who disagrees with any of the ACIP recommendations, you’re labeled an anti‑vaxxer. I disagree with several of the ACIP recommendations; I am certainly NOT an anti‑vaxxer.

I’m like the General in War Games—I’d piss on a spark plug if I thought it would work. But like all good doctors, I am also from Missouri, meaning, 'Show me.' I support, prescribe, and take vaccines when the data support their use or continued use. I also take vaccines when I’m forced to by the hospital or government.

I’m going to use this forum to discuss different vaccines and their diseases, the ACIP’s recommendations, and disagreement with states’ requirements for childcare and K‑12 vaccines.

I’ll start with influenza since no one is cynical about dessert, I mean, the flu. You’ll see very quickly how non‑binary influenza vaccination requirements are. In general, vaccines are given for one or both of two reasons:1. Protect the person from illness and/or serious disease.2. Protect the person’s contacts or community.

Influenza can cause severe disease or serious complications in people with known risk factors. The CDC states, 'The risk for complications and hospitalizations from influenza is higher among persons age 65 years and older, pregnant and post‑partum women, children younger than age 5 years, and persons of any age with certain underlying medical conditions.' (1)Healthy, school‑aged children (K‑12) have a very low risk of severe disease or serious complication from influenza. Prior to 2008, the ACIP did not recommend routine, annual vaccination of healthy, school‑aged children, but did recommend vaccination if they lived with someone at increased risk. Surveys revealed such kids had a low rate of flu vaccination.

For the 2008‑2009 flu season, the ACIP changed its recommendation to include all school‑aged children. The ACIP cited two reasons—[1] evidence that influenza vaccine is effective and safe for school‑aged children, and [2] evidence that influenza has substantial adverse impacts among school‑aged children and their contacts. The real driver, in my opinion, was [3] the expectation that a simplified, universal recommendation would improve vaccine coverage among the roughly 50% of school‑aged children who already had a risk‑ or contact‑based indication. (2)

Currently, as the joke goes, the CDC recommends flu vaccination for anyone who has a shoulder. Starting at 6 months of age, the ACIP/CDC (same thing, really) recommend annual flu vaccination for everyone. Influenza affects young kids a lot worse than older kids.

Each state and D.C. has its own vaccine requirements for school attendance, pre‑K, and childcare (who knew childcare and pre‑K were different?). Again, the ACIP/CDC’s recommendation is that everyone over 6 months old be vaccinated each year. So this should be a no‑brainer, right? All these kids should be required to get the flu shot annually, correct?

If you said or thought 'Damn straight,' 'Yes,' or 'Probably,' then you were extremely incorrect [see Table below]. Only 5 states and 1 city require flu vaccination for kids in childcare and/or pre‑K. Stranger still, some have age restrictions—so if a child is 62 months old and in childcare, only Ohio and Pennsylvania require flu vaccination. Stranger yet, NYC, Ohio, and Pennsylvania require flu vaccination for childcare enrollees. If a kid goes to pre‑K only, that child doesn’t need a flu vaccine. For example, in NYC, if a child of any age goes to a pre‑K school or is over 59 months old, no flu vaccine is required. Finally, the coup de grâce of strangeness: no state or jurisdiction requires annual flu vaccination for K‑12 students. If someone has a good explanation for this mess, please let me know.

 Table. Flu vaccine mandates of all states, DC and NYC. (3)  

Jurisdiction*	Before Elementary School Requirement?	Childcare and/or pre-K	Age restriction?	Year implemented	K–12 school requirement
Connecticut	Yes	childcare & pre-K	age 6–59 months	2011	No
New Jersey	Yes	childcare & pre-K	age 6–59 months	2008	No
New York City	Yes	childcare only	age 6–59 months	2018	No
Ohio	Yes	childcare only	none	2015	No
Pennsylvania	Yes	childcare only	none	2015	No
Rhode Island	Yes	childcare & pre-K	age 6–59 months	2018	No
All other states & DC	No	—		—	No

* - Includes all states, DC and NYC.

Note: Pre-K covered only when regulated as childcare (NYC, OH, PA); otherwise, no flu vaccine mandate for stand-alone school-district pre-K.

References

1. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 2025 [cited 2025 Oct 28]. Chapter 12: Influenza. Available from: https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-12-influenza.html

2. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008 [Internet]. [cited 2025 Oct 28]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm

3. Influenza Vaccine Requirements for Childcare and Pre-K 2025 [Internet]. Immunize.org. 2025 [cited 2025 Oct 28]. Available from: https://www.immunize.org/official-guidance/state-policies/vaccine-requirements/influenza-childcare-2025/