Vaccines - Where has the ACIP gone?

Why Vaccine Hesitancy Is Rising — And Why Our Health Agencies Aren’t Helping

Hello Martha,

You wrote: “If anyone is responsible for fueling the greater vaccine hesitancy occurring in this country, it’s our government health agencies.”I’m not sure exactly what you meant, but I can offer a broader perspective — one that many physicians and epidemiologists quietly share.

The ACIP Problem: Expanding Recommendations Without Strong Data

The Advisory Committee on Immunization Practices (ACIP) develops the vaccine schedules used in the United States. The CDC appoints its members, and although ACIP is technically independent, it operates closely alongside the CDC.

Here’s the issue: ACIP keeps expanding vaccine recommendations even when the supporting evidence is thin.That puts physicians, epidemiologists, and infectious-disease specialists — people who understand the diseases and vaccines — in an awkward position. Pointing out weak evidence suddenly makes you sound like an anti-vaxxer, even when nothing could be further from the truth.

For the record, I am decidedly not an anti-vaxxer. But I believe in the right vaccine, for the right patient, based on solid data — and that is not always what ACIP delivers.

A Case Study: The Flu Vaccine for Healthy Children

Take influenza vaccination in healthy grade-school children. ACIP did not have strong evidence to justify a universal recommendation. The change wasn’t driven by severe disease in healthy kids; it was driven by the fact that healthy kids weren’t getting vaccinated, even when they lived with high-risk relatives.

Instead of simply saying that, ACIP constructed a rationale for why every healthy child “needed” an annual flu shot.

Meanwhile, states disagreed: not a single U.S. state requires annual influenza vaccination for K–12 school attendance.

And that brings us to another point of confusion.

The CDC Doesn’t Control Vaccines — the States Do

People often assume the CDC has authority to mandate vaccines. It does not.Vaccination requirements for school attendance are set by the states, which is why New Jersey, New York, and Connecticut all have different lists — and always have. It’s not scientifically consistent, but it reflects the legal reality: states have the power to bar unvaccinated children from school; the CDC does not.

Which Vaccines Have Strong Evidence? Which Don’t?

There is legitimate debate here because childhood and adult schedules overlap. Some recommendations are rock-solid. Others are based more on tradition than data.

Let me illustrate using tetanus — something that came up recently in my own family.

Tetanus: A Story, a Vaccine, and an Unasked Question

My son asked me if I had ever seen a case of tetanus. I practiced in Newark for decades, mostly treating injection-drug users; rusty needles absolutely can cause tetanus. I told him I had seen one case. Then I waited a moment.

“You didn’t ask how old I was,” I said.He asked.I answered: “Eight. It was 1971.”

Many of you know I used to round with my father at St. Mike’s. I remember that patient vividly. He survived.

So how good is the tetanus vaccine?

No one knows precisely.We know it’s extremely good — wound-associated tetanus plummeted when the toxoid vaccine was introduced during WWII. But the vaccine predates randomized controlled trials (RCTs), which didn’t become standard until the mid-1970s. No one was going to run an RCT withholding tetanus vaccine once its benefit was obvious.

So we know it works very well — but we don’t know exactly how well.

The U.S. Schedule vs. the Rest of the World

In the U.S., tetanus vaccination begins with DTaP in infancy, followed by a Tdap booster at age 11–12. Then ACIP recommends tetanus boosters every 10 years for adults — indefinitely.

But here’s the surprise: many European countries do not.

• United Kingdom: 5 childhood doses; no routine 10-year adult boosters, except after a dirty wound. Their tetanus rate is not higher.

• Several European countries: booster intervals extended to 20 years.

• Spain: a single adult booster at age 65.

• The WHO does not recommend routine adult tetanus boosters.

Don’t take my word for it. You can check:

• European vaccine schedules: https://vaccine-schedule.ecdc.europa.eu/

• WHO recommendations: https://www.who.int/health-topics/tetanus#tab=tab_3

  
  
  
  

And the Laboratory and Clinical Data Back Them Up

A 2021 paper in Clinical Infectious Diseases — the official journal of the Infectious Diseases Society of America — analyzed more than 11 billion person-years of tetanus and diphtheria incidence.

Their conclusion was blunt:

“Review of >11 billion person-years of incidence data revealed no benefit associated with performing adult booster vaccinations against tetanus or diphtheria. … This analysis supports the WHO position on adult booster vaccination…”— Slifka et al., 2021 (Clinical Infectious Diseases)

In other words: ACIP is an outlier, and not in a good way.

So Who’s Fueling Vaccine Hesitancy?

It’s not just “anti-vaxxers.”It’s sane, well-informed doctors and public health officials, who correctly disagree with some of the ACIP’s recommendations. Once the public has legitimate experts criticizing one or more of the ACIP’s vaccine recommendations, then the public can find illegitimate reasons to criticize ALL vaccines.

Physicians are a large part of the problem. They have stopped reading and thinking for themselves. One colleague referred to them as “Guideline Followers”. There is no worse name or slur you can a physician. But what’s the reward for speaking the truth? Or even trying to debate? Take it from me. The only reward is ostracization.

If we want to reduce vaccine hesitancy, we need transparency, humility, and evidence-based recommendations — not one-size-fits-all policies.

We desperately need honest debate, not top-down, “Do as you are told!”

SMS

P.S. – 2 of my 4 children received the rabies vaccine, separately and because of different situations. The odds of that happening are extremely small, but as an ID doc, I evaluated each situation and had them get vaccinated. So, if I get called Anti-Vaxxer again….