On August 10, President Donald Trump — flanked by Robert F. Kennedy Jr., the Health and Human Services Secretary and Dr. Jay Bhattacharya, director of the National Institutes of Health — signed an executive order to reduce the number of vaccinations administered to children.
The announcement was met with a near-immediate rebuke from the medical community.
Alyssa Sharkey, a lecturer in the Princeton School of Public and International Affairs, specializes in maternal, newborn, child, and adolescent health, and equity and immunization. She explains the changes outlined in Trump’s executive order and what parents need to know as this topic continues to play out on the national stage.
At a high level, what changes is President Trump making with this new executive order?
Alyssa Sharkey: The August 10 executive order "Delivering Gold Standard Childhood Vaccine Recommendations for Americans” calls for several changes to America’s existing standard of practice for childhood immunization. These include that children should receive fewer routine vaccinations than they currently do and that multivalent vaccines — otherwise known as combination vaccines — should be discontinued. It also stipulates that alternatives should be found to the use of aluminum — an ingredient used for decades to strengthen the body’s immune response — within vaccines, and parents should generally be given more autonomy in deciding which vaccines their children receive. The executive order even encourages legal action against states that don’t offer religious or non-medical exemptions from school vaccine requirements. Even though the executive order instructs health officials to adopt these recommendations, it does not actually have any inherent legal power, because vaccination requirements are decided at the state and local levels in the United States.
One of the biggest changes involves the measles, mumps, and rubella (MMR) vaccine. Instead of getting one combined shot, children would receive three separate vaccines at different appointments. What kind of impact could that have?
AS: I think it’s important to state upfront that there is no scientific evidence supporting the idea that spreading out shots over multiple visits is safer for children, or that giving them together — as the combined MMR vaccine does — causes autism. Second, no country in the world separates these shots, and, importantly, pharmaceutical companies do not currently produce or sell single-dose measles, mumps, and rubella vaccines in the United States. It seems unlikely that companies will start investing in separate formulations when the effectiveness, efficiency, and safety of the current combined MMR vaccine have been proven in rigorous clinical trials over decades. And even if companies do decide to make this shift, the development and regulatory process the new formulations will have to undergo in this country may take years. So single-dose measles, mumps, and rubella vaccines won’t be available here anytime soon.
However, if these single-dose vaccines eventually do become available here, the most likely impacts are that fewer children will get vaccinated for these diseases, and children who do get vaccinated for these diseases will do so at later ages. For extremely contagious diseases like measles, even delaying vaccination for a few months could have important health consequences for a child.
A third, and more immediate, potential impact of this executive order is that more parents will question the safety of the MMR vaccine. This is particularly alarming in the current context when post-pandemic vaccine hesitancy continues to be an ongoing challenge and while the U.S. is having its worst measles outbreak in over 35 years. If MMR vaccination declines as a result of this executive order, more American children will be at risk for entirely preventable and extremely dangerous diseases.
For parents, what would these changes actually look like in practice? How could it change visits to the pediatrician, or requirements at schools and daycares?
AS: Although offering separate shots may appeal to parents who want to spread out the vaccines their children receive, it would also increase the burden that parents face to keep their children healthy. There would be additional pediatrician visits to attend and additional costs (copays and transport) associated with each. More visits would also place additional demands on healthcare workers and health systems, which are already constrained in many parts of the country.
Requirements at schools and daycares may loosen if states and localities change their vaccine policies to align with the executive order. However, it is expected that most will continue to follow guidance from the American Academy of Pediatrics, which, incidentally, has already released a statement calling the August 10 announcement “unscientific” and “dangerous.”
The best thing parents can do right now is to rely on their pediatricians for advice on how best to protect their children from preventable diseases. Pediatricians are the experts — not politicians. They know the risks associated with delayed vaccination, they know how safe vaccines are, they understand children’s individual medical histories, and they will be keeping an eye on local outbreaks.
What is the current childhood vaccine schedule in the U.S.? How does it compare with what's recommended in other countries?
AS: Our current childhood vaccine schedule protects against 18 diseases. Starting at birth, children receive a sequence of shots in the first two years of life protecting against hepatitis B (HepB), rotavirus, diphtheria, tetanus, pertussis (DTaP), Haemophilus influenzae type b (Hib), pneumococcal disease, polio, and MMR, among others. Booster vaccines are given at school entry (around ages 4-6 years) and again in early adolescence (around ages 11-12 years), when human papillomavirus (HPV) and meningococcal vaccines are also given. An annual influenza vaccination is recommended for all children from six months onward, and COVID-19 vaccination is also on the schedule.
The administration’s justification for a shift is based on comparisons to “peer countries” that recommend fewer vaccines. Although the executive order does not specify which peer countries it is referring to, most European countries recommend vaccines to protect against between 12 and 16 diseases, South Korea protects against 17 diseases, and Japan protects against 14. The Trump administration has explicitly cited Denmark — which has only 10 diseases on its vaccine schedule — as a model. But Denmark is very different from the USA, particularly with respect to its healthcare system, infrastructure, and population. Denmark has universal healthcare, 46 weeks of paid parental leave, near-universal prenatal screening for Hep B, centralized medical records, and reliable follow-up. Nearly every child in Denmark receives care on schedule. Because of all these investments, its disease burden is low.
The United States has gaps in all of these areas. For example, about 20 percent of our pregnant women are not tested for Hep B, and only about a third of those who test positive for Hep B complete their follow-up care. This is an important gap because Hep B is often asymptomatic and can lead to chronic infection, liver failure, cancer, and early death.
Our healthcare system is fragmented, expensive, and wildly variable depending on where you live, who you are, whether or not you have insurance, and what your state’s policies are. What works seamlessly in a small country with a well-funded healthcare system like Denmark will not work the same way in the United States. Vaccination helps protect us against these major gaps in our healthcare system.
Photo courtesy of Alyssa Sharkey.
