Former advisers identify adult access, early childhood doses and regional gaps
The US Advisory Committee on Immunization Practices remains unable to consider changes to federal vaccine guidance. A federal judge halted its work after finding that the Trump administration had failed to constitute the panel properly. The halt came months after Robert F Kennedy Jr, as secretary of Health and Human Services, replaced the panel’s advisers with members he selected. The original committee had monitored the outbreak early last year before Kennedy disbanded it, and Kennedy’s replacements did not publicly evaluate evidence about the outbreak. The CDC is now taking nominations for a new committee, though the appointment process can take months or years, and the process for making or changing recommendations is also lengthy.
ACIP makes recommendations to the US Centers for Disease Control and Prevention on vaccine policy. Four former advisers said the panel’s dismantling made it harder for the United States to respond to the measles outbreak, with vaccine recommendations staying the same during a historic rise in cases and deaths. They said a functioning committee would likely consider recommendations on reaching adults with vaccines, moving up the childhood schedule for measles, mumps and rubella vaccination in outbreak areas and pinpointing the groups and areas that need vaccination campaigns. Yvonne “Bonnie” Maldonado, chief of infectious diseases in the department of pediatrics at Stanford Medicine and a former ACIP member, said a functioning committee would “definitely” discuss updating its advice. She said, “we don’t have an ACIP,” then said, “That’s going to impact disease and deaths in the US.”
Noel Brewer, a distinguished professor of health behavior at the UNC Gillings School of Global Public Health and a former ACIP member, said, “It typically took between 12 to 18 months from the start of considering new recommendations to adopting them.” The Guardian reported that the outbreak continues accelerating.
Current CDC guidance already permits earlier MMR doses during outbreaks. In normal times, babies in the US do not receive their first MMR shot until they turn one, but during outbreaks, babies at risk of infection can receive it as early as six months. Experts said the six-month option was one of a handful of CDC outbreak recommendations receiving less attention than they would normally. The CDC also offers the option of giving the second MMR dose as soon as four weeks after the first during an outbreak, instead of the usual age of four to six, to help fully protect children in outbreak areas. Edwin Asturias, professor of pediatric infectious disease at the University of Colorado and a former ACIP member, said the outbreak advice could receive more attention and that recommendations could be changed to “tell the pediatricians and providers we are in a huge outbreak.”
Asturias said the delay between doses could contribute to what he called a “group of susceptibles” — people who were not protected from measles for decades and are now falling ill and dying. Some people are ideologically opposed to vaccines, while others do not have steady access to health care. “But that’s only part of the explanation,” Asturias said. Visits to doctors decrease dramatically after the second year of life, leaving fewer opportunities to receive the second dose. He asked, “By delaying the second dose of immunization to four to six years, are you more likely to miss or not to give a second dose to many children?” A properly appointed ACIP would examine such data to “try to understand how this immunization or protection gap came about,” he said.
In the US, vaccine mandates for children are set at the state and local level and tied to daycare and school attendance. Moving the recommendation earlier might increase vaccination rates, since families tend to have higher levels of trust in their doctors than in local officials, for example.
An unusually high number of adolescents and young adults are getting sick and dying from measles. Vaccine advisers would likely explore why and what could be done to reach them. Paul Offit, an infectious-diseases physician at the Children’s Hospital of Philadelphia and an ACIP member two decades ago, asked, “Are you really monitoring how many adults are getting infected? I doubt it,” and “Are we trying to vaccinate them? It’s harder. You can have school mandates, but what do you do for adults?”
Asturias said anyone beginning cancer therapy or other immune-suppressing treatments should make sure vaccines protect them first. He also said people born between 1968 and 1989 may have received only one shot and should receive a second dose.
ACIP should identify which groups and regions face the greatest risk and how to reach them, Brewer said. “Measles vaccination rates are pretty high in most places, but there are places where it’s very low, and the United States does not have a good mechanism for identifying these geographical areas and responding in them,” he said. The ACIP and CDC offer recommendations based on evidence that is sometimes not publicly available. But states can take action on their own to change vaccination recommendations. Maldonado said, “The decisions are up to the states and the counties.”
It is especially important to reach unvaccinated or undervaccinated people before they become pregnant because measles vaccines cannot be given during pregnancy. Pennsylvania officials warned recently that congenital measles cases — when a baby gets sick in utero — had risen sharply that year. Such infections threaten the lives of newborns and pregnant people alike. A 21-year-old woman in Pennsylvania died soon after childbirth from measles complications, officials announced that week. Earlier in the year, a measles-infected baby died soon after birth.
US officials announced three measles-associated deaths last week. The seven-month-old who died in New York had not been vaccinated against measles, officials said Monday, and another infant died in the measles outbreak in Wisconsin, officials announced Thursday. Both states marked their first measles-associated deaths in three decades. Maldonado said, “That’s the actual heart of the situation.” She added, “What we’re seeing now is something I literally have never seen myself, and I’m a seasoned infectious disease clinician.” She said, “To have even one case used to be a remarkable occurrence, but now they’re having so many.”
Maldonado said there were serious risks from measles and that “most of the bad stuff happens to young babies under a year of age.” Hospitalizations, complications and deaths are more common in that group, and the risks persist long after the rash fades. She said she had cared for two children who developed subacute sclerosing panencephalitis years after contracting measles. “They’re terrifying cases,” she said.
Maldonado said US officials had lagged in public communication about the risks and how preventable they are. Criticizing CDC director Erica Schwartz’s response to the outbreaks, she said, “She came into CDC in the middle of a huge set of outbreaks and didn’t talk about it for weeks.” For families seeking guidance, she said, “it’s already pretty chaotic right now, and it’s unfortunate – nobody knows where to turn.”
Brewer said US officials need to speak with “one voice” to outline a plan for addressing the outbreak. “The US has a terrible measles problem right now, one that is largely avoidable. We need to get vaccination rates up,” he said. He added: “That’s really the key priority: just get the shot.”