When it comes to vaccines, Dr. Paul Offit is a household name. He is a Professor of Vaccinology at the University of Pennsylvania’s Perelman School of Medicine and director of the Vaccine Education Center at Children’s Hospital of Philadelphia. He co-invented RotaTeq, one of the rotavirus vaccines routinely recommended to infants in the U.S., and has served on both the ACIP and the FDA’s vaccine advisory committee. And for decades, he’s been the person the media call when a vaccine story breaks, making him both a trusted face of vaccine science for so many Americans and a frequent target for anti-vaccine attacks.

When I sat down with Paul to discuss the next era of vaccine governance, several things stood out to me. First, his candid willingness to admit the mistakes we have made and what public health can learn from them. Second, his ability to hold both ideas that our existing systems weren’t perfect, but abandoning them entirely is dangerous. Third, his emphasis on the importance of a public face representing experts and trusted messengers who can translate rigorous science compassionately. And finally, despite understanding how bleak our current moment feels to just about anyone, he has a lot of hope grounded in the strength of science.

What follows is our conversation, lightly edited for length and clarity.

Hi Paul, thank you for sitting down with me today. To start, what does vaccine governance look like from your perspective right now?

It’s totally broken. We have a Secretary of Health and Human Services who, for 20 years, has been an anti-vaccine activist and science denialist, who previously was shouting his anti-vaccine rhetoric from the sidelines, and now he’s making policy. He’s doing everything he can to make vaccines less available, less affordable, and more feared. And he puts his people in place to make sure that happens. The world has turned upside down.

Look at what’s happened recently. Trump put forward an executive order arguing that the vaccine schedule should be reduced from 17 routinely recommended vaccines to 10. On March 16th, a federal judge shot that down. And then about a week ago, you had RFK standing right next to President Trump, saying that’s still what they’re going to do: reduce the schedule from 17 to 10, and separate the MMR vaccine into its three parts, because as President Trump says, when it’s combined into one vaccine, it’s “explosive and can be lethal.”

It would be nice to do something other than react to these things, because that’s pretty much all we’re doing right now. But, until we get people in power who care enough about children in this country to do something, we’re going to keep living with this.

You mentioned that we are mostly reacting to what’s coming out of Washington. Before we get to that reaction, why do you think fewer parents fear these diseases than earlier generations did?

We ask a lot of parents in this country. In the first few years of life, we ask them to give vaccines to prevent 14 different diseases. That’s as many as 25 inoculations, sometimes five shots at once, to prevent diseases most people don’t see, using biological fluids most people don’t understand.

I’m a child of the 1950s. I had measles, mumps, rubella, and chickenpox. I saw what those diseases could do. My own children didn’t grow up with these diseases, and young doctors today didn’t either. We didn’t just eliminate measles from this country in 2000; we eliminated the memory of measles. That’s a big part of it. We aren’t scared of these viruses and bacteria the way we used to be.

When I was a resident at Children’s Hospital in Pittsburgh, between 1977 and 1980, we’d do these 12-hour-on, 12-hours-off emergency department shifts. I’d do two or three spinal taps a night. We didn’t have a Hib vaccine, a meningococcal vaccine, or a pneumococcal vaccine. Most pediatric residents at our hospital today don’t know how to do a spinal tap. It’s a different time, and I don’t think people realize how much that’s changed things. And it’s not just that people aren’t scared of the diseases anymore; now they’re scared of the vaccines, because there’s so much bad information out there that’s easy to find, and the anti-vaccine movement has tens of millions of dollars behind it.

How is this landing with parents today, given all the chaos happening at the federal level?

Most parents approve of vaccines. Polling done by Republican pollsters has shown that. After the recent White House press conference, the sun came up the next morning, and people took their kids to the pediatrician, got their vaccines on the AAP schedule, and life went on. I think most parents saw that press conference and largely ignored it. Honestly, I think it might have helped the case for vaccines. When President Trump said kids got “a soda bottle’s worth” of fluid in one shot, any parent who’s actually had their kid vaccinated knows it’s not a soda bottle. A soda bottle holds about 2,000 milliliters, and a dose of vaccine is about half a milliliter. That bottle would’ve held 4,000 doses.

All you can do is passionately, compellingly, and compassionately explain what decisions like this actually mean for parents, and that work mostly happens at the pediatrician’s level. I feel for them. They’re overwhelmed with these questions now, and it’s a reasonable thing to ask about. Parents should ask questions about anything going into their child’s body, especially a vaccine, since it’s given to a healthy child.

We’ve spent decades telling people to trust federal vaccine guidance. Now we’re urging caution about those same institutions. At some point in the future, we may be asking people to trust it again. Do you trust the federal government’s vaccine guidance right now? And do you think trust can actually be rebuilt?

That’s the critical question. I don’t trust the CDC right now. They changed their website on vaccines and autism to open the door to the possibility that vaccines do cause autism, citing studies that were never published in a scientific or medical journal. Do I trust the CDC? No. We’ll see whether the ACIP gets reconfigured into something trustworthy.

I do believe we’ll get through this. I believe we’ll come to our senses eventually. Right now, the real educators are the viruses and bacteria themselves. People are starting to get scared of diseases like measles and whooping cough. Lower immunization rates enough, and polio comes back. Maybe that’s what it takes: when you see an actual case, you immediately think, I need to be protected from this.

I like to say, “You can ignore the science all you want, but eventually you’re going to run into a pathogen that doesn’t ignore you back.”

I agree. I asked Maurice Hilleman about this. Hilleman is, in many ways, the father of modern vaccines. He invented the strain of measles vaccine we’ve used since 1968. He passed away in 2005. In 2004, he was diagnosed with disseminated pancreatic cancer and given six months to live. I talked to him in that final stretch and asked him: “Do you think we’ll be able to educate people about the importance of this vaccine and the seriousness of the disease, given that measles was already starting to come back after Wakefield’s false MMR-autism claim?” He thought for a long time before he answered. Then he said, “No, I think the disease is going to have to come back.”

Let’s discuss an elephant in the room. A not-insignificant number of Americans are expressing some support for vaccine policy coming out of HHS right now. What’s your honest reaction to that, and how do you engage with someone who finds some of this appealing?

That’s the hard part, and in many ways it’s the key question. Let me give you an example; one of the many not-great things I’ve said on television. When the bivalent COVID vaccine came out in 2022, I was on the FDA’s vaccine advisory committee. The data weren’t compelling; it didn’t look any better than the monovalent vaccine we already had. I wrote a perspective piece for the New England Journal of Medicine laying that out.

That landed me on CNN with Pamela Brown, across from the White House’s COVID response coordinator. She asked him to tell us about the vaccine, and he said, “It’s better, you need to get it, it includes the Omicron variant.” Then she turned to me and asked, “Do you agree with him?” That’s not the question you want to answer. So I said it doesn’t matter what he says or what I say; the only thing that matters is what the data show. But the fact is, it does matter what people say. Nobody’s going to read the New England Journal of Medicine. So you do have to trust people. The question is who.

When the Secretary of Health and Human Services stands up and says these vaccines should be optional, the reasonable assumption from people is that he wouldn’t say that without new science behind it — even though there isn’t any. So he calls the rotavirus, coronavirus, and flu vaccines matters of “shared clinical decision-making” and you can reasonably choose to get them or not. But this is what we’re seeing: kids hospitalized again with severe dehydration from rotavirus, and a lot of kids dying of flu, with almost 300 last year, close to 200 this year. We haven’t seen numbers like that since 2009. It breaks my heart that this man is misleading the country.

Looking back at the COVID vaccine rollout, is there anything you wish had been communicated differently?

If I could go back and change anything (besides the outcome of the 1969 Jets-Eagles Super Bowl), it would be this: when that vaccine came out at the end of December 2020, the studies we looked at on FDA’s vaccine advisory committee showed 95 percent efficacy against mild, moderate, and severe disease. There was no way that would hold for mild or moderate disease. We should have said that from the start: this is a three-month study; people just got their second dose, of course, the antibody response looks high right now, but that’s not the actual goal. The goal is to keep people out of the hospital, out of the ICU, and at work. You might still get a moderate infection. You’re home, coughing, feverish, and that’s not trivial, but the goal was always the hospital, not zero infection. We didn’t say that clearly enough, because we were so anxious to reach the third of the country that didn’t want to get vaccinated, and we overpromised what the vaccine could do.

One version of the argument for rebuilding trust is: restore the right people to ACIP, return to the prior way of doing things, and trust will follow. Is that enough? If not, what else needs to happen?

That would go a long way toward helping. But we have to get past this administration. Nothing good happens as long as this administration is in place. But they won’t be in place forever.

In the meantime, I’ve been encouraged watching people like AAP Presidents Dr. Sue Kressly or Dr. Andrew Racine get on national television and say: we’re listening to your questions, we’re trying to answer them, and here’s a science-based, routinely recommended childhood schedule, and here’s why it looks the way it does. I think people assume someone is always doing that communicating, but they’re wrong. You have to actually get out there and do it.

With professional societies like the AAP, states, and others stepping in where federal guidance has become unreliable, can a patchwork of bodies like that do the job the federal government used to do? What do we lose if that patchwork becomes permanent?

I don’t think it becomes permanent. What used to happen was: when we were deciding what vaccines to give and when, you looked to ACIP, with 17 experts across virology, immunology, statistics, and epidemiology, who worked through the data at the working-group level and then brought it to the full committee for a vote. That worked really well. ACIP has been around since 1964, and because of it, we’ve saved millions of lives and millions of hospitalizations. Thank goodness for ACIP. The CDC had the same kind of expert infrastructure.

But you’re right that in the meantime it’s fragmented. Now there’s no single place to go. There are all these different places, and they don’t always agree on exactly how or when vaccines should be given. Chaos and confusion make people less likely to get vaccinated. I do think we’ll have a federal government we can trust again. We just don’t have it now, and we won’t for the next couple of years.

If you were redesigning our vaccine governance process from scratch, what would you build into it to create more connection between the public and the rigorous, legitimate scientific debate you’ve been part of?

Let’s go back to COVID for a second. When Pfizer and Moderna submitted their data to FDA’s vaccine advisory committee for us to decide on authorization, that was an open meeting. It was live-streamed, anyone could watch. The day after they submitted, all of that data went up on FDA’s website. You could go read it yourself. The problem is, it was 400 pages (200 from the company, 200 from the FDA’s own review) to ensure nothing was misrepresented or omitted. People aren’t going to read that. Not because they don’t care, but because they don’t have the expertise or the time.

So you do have to trust experts, but who? My conclusion is: you trust advisory bodies. It’s the old “Who Wants to Be a Millionaire” logic of the lifelines — “ask the audience” beats “phone a friend” by a wide margin. There’s something to group expertise. The FDA’s vaccine advisory committee, ACIP, the AAP’s Committee on Infectious Diseases, and IDSA. They have the expertise. What they don’t have is a face. When we get back to a real ACIP, as opposed to the one RFK Jr. forced on us, it needs a face — people who can explain what they’re doing and why in language people actually understand.

You said these advisory bodies need a face. They need someone who can translate the science into a language people understand. How do those people bridge the gap so that the public feels the science is actually approachable, not just technically available?

People need to be able to tell a story and to be compassionate in telling it. I thought Rochelle Walensky was genuinely great during the pandemic. She was upset, really upset, about what was happening to people who were being hospitalized and dying. She was so empathetic that you couldn’t help but identify with her. And she was good at explaining, in story form, what we were actually trying to do.

Science communication, as Tip O’Neill said about politics, is local too. I think we communicate science best by finding who’s actually influential in a given community and giving them what they need to explain it themselves. The answer is local. People get their information locally.

That kind of nuance, that protection was always going to be limited in duration, was part of the conversation happening in the vaccine world, but it was not communicated well to the public. Do you think that’s part of why people feel like science let them down?

You’re right. I think we could have done a better job on so many fronts, and that’s where we lost trust. Once people stopped believing us, they’d say what you’re describing: I don’t trust the science. It wasn’t the science, it was how we communicated it. I understand not trusting a science communicator who oversold something. But don’t give up on science itself.

We also should have had an open, honest conversation with businesses about how to keep people working while minimizing transmission, and the same with schools. I don’t think we should have closed them as long as we did, and definitely not unilaterally. And I think natural infection should have counted toward vaccination status. People were fired from jobs for declining a vaccine after being naturally infected, when they had a reasonable argument that they already had some protection. All of that got decided behind closed doors. I know it did. It shouldn’t have been.

Thank you for your time today. One final question I am asking of all guests. What gives you hope?

Science wins out. It always does. It doesn’t matter how many more times over the next two years Robert F. Kennedy Jr. says vaccines cause autism, or diabetes, or MS, or ADHD — or how many congressmen, media figures, or discredited scientists he gets to back him up. He’s wrong, and time will show it. Science wins out in the end, and it’s a powerful thing to have on your side. When I go on television, I know good scientific data is standing right behind whatever I’m saying. That’s genuinely hopeful to me.

Dr. Paul Offit is the Director of the Vaccine Education Center at Children's Hospital of Philadelphia and the Maurice R. Hilleman Professor of Vaccinology at the University of Pennsylvania's Perelman School of Medicine. In addition to his multiple books and academic writing, he writes the Beyond the Noise newsletter. This conversation has been lightly edited for length and clarity.

Thanks, as always, for being part of this community.

-DH

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, and Bluesky.

This newsletter is free for everyone. However, if you want to support the work that goes into creating it, a paid subscription means a lot.

Subscribe now

Share

I have heard this sentiment many times from concerned parents over the past few years. It occurs more often when headlines appear about vaccine coverage, such as those this week covering the CDC’s announcement that kindergartners' vaccine exemption rates nationwide have hit another new record high at 4.2%. Every media outlet covering this announcement led with this concerning trend because it is clean and fits the story of increasing vaccine hesitancy, falling trust, and more vaccine-preventable disease outbreaks. While all of that may be true, it is an unhelpful number for what most people want to know: where outbreaks might occur and what my child’s risk is.

Here is the problem with the national numbers. Measles doesn’t spread across the country; it spreads in small communities. A national or even state vaccination rate tells you almost nothing about the actual risk facing any individual kid or family because vaccination rates cluster at the hyper-local level. A state can be comfortably within the 95% target herd immunity threshold for preventing a measles outbreak, while still containing multiple local pockets of coverage below 60%. Those local pockets are where measles outbreaks start and spread, not across the entire state. My own state’s data shows this exact pattern.

I have seen this play out with parents in my own practice. The national and state numbers may be actively reassuring parents who shouldn’t be reassured and alarming parents who don’t need to be. A parent who reads about a state’s lower Kindergarten vaccination rate may unnecessarily worry about their child’s risk and avoid travel. I have had parents who are so concerned about traveling to a state with a low vaccination rate that they change plans until I point out that the vaccination rate in the specific community they are traveling to within a low-vaccination state is actually higher than in their own community. On the other hand, a parent may be sending their kids to a school with a very low vaccination rate but have no idea, because the state- or county-level number masks it.

The topline national numbers are important for recognizing trends. But it is not helpful for most families and individual communities, as it lacks context and can be misleading. It would be like saying the average national temperature this week is 82 degrees and rising year over year for a decade. Maybe that is a useful trend to monitor, but someone in 111-degree heat in Phoenix and someone in 72-degree heat in northern Minnesota are not having the same experience.

So, what is actually helpful? Sub-county-level data, such as zip code and school-level data. In most states, this level of data exists, but it may not be publicly reported, may be buried in hard-to-find places, or may be overly complex. Each state and community is different, and good efforts are underway to make this data more useful and accessible.

A study published this week in Nature Medicine illustrates this problem. Researchers built a nationwide vaccination database from 45 states, 50,000 schools, 13,000 districts, and 3,000 counties, dating back to 2013, to model measles transmission risk at the school level. They found that measles vulnerability in schools increased significantly after the pandemic, with the share of unprotected students nationally doubling, but those vulnerabilities remain clustered and relatively invisible in our current data monitoring at the national, state, or even county levels.

This is important beyond individual families. Our data shapes our collective response. If health departments and policymakers respond to a topline number, they may reach for topline solutions, such as a statewide messaging campaign not tailored to any specific community, or a general call to restore confidence in vaccines that falls only on the ears of people who are already confident. These efforts aren’t wrong, but they can be a poor match for a problem that is concentrated rather than diffuse.

I am concerned that rising exemptions and declining vaccination rates across the country create more opportunities for preventable diseases. And these trends need to be studied and reported on. But it feels like we have the same conversation every time the CDC releases new school vaccination data. There is shock at the topline numbers, even if they moved only a little, and then a return to baseline attention until next year. But the actual addressable risk is in local communities that people never consider with this topline-only framing.

If you want to know whether your kids, patients, or community is at risk and what you can do, ask your school or health department. If that isn’t readily available, make it clear to your leaders that this is the information you need.

-DH

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, and Bluesky.

This newsletter is free for everyone. However, if you want to support the work that goes into creating it, a paid subscription means a lot.

Subscribe now

Share

This new EO should not be read in isolation. It is the next action in a line of actions starting with a Presidential Memorandum in December 2025 directing HHS to compare the U.S. childhood vaccine schedule to “peer nations”, leading to an HHS/CDC decision to overhaul recommendations in January 2026, followed by a May 2026 Executive Order directing the CDC and ACIP to realign recommendations with peer nations after a federal judge blocked the HHS decision in March, and ending with the new presidential order this week.

There are important throughlines to notice across all these actions. Let’s discuss.

Same “scientific assessment” cited again and again

Each of these actions references a scientific assessment that compared the U.S. childhood schedule against 20 peer nations and concluded that the U.S. currently recommends more vaccines than selected peers. The assessment was authored by Tracy Beth Høeg, then Acting Director of FDA's drug center and FDA's representative to the ACIP, and Martin Kulldorff, the recently departed ACIP chair turned HHS chief science officer. Høeg was fired from the FDA in May.

This assessment wasn’t a fair review of the evidence, and, as I wrote about previously, it started from the flawed assumption that protecting against more diseases is bad. The U.S. protecting against more life-threatening diseases than many other countries means we are leading the world, not that we have a problem.

Each action is a new attempt to get a desired outcome after the last one was blocked

The January HHS/CDC decision memo to overhaul the childhood schedule was blocked by a federal judge in March for bypassing required agency processes. May’s EO responded by routing the same outcome through the ACIP, which is the legally correct channel. However, a compliant ACIP has not been formed, so this week’s EO skips the ACIP entirely and declares the same three-tier schedule released by HHS/CDC in January as presidential policy instead of agency action.

The pattern here is clear: when one lever fails, try another. While legal experts tell me this EO is unlikely to immediately impact vaccine insurance coverage, the Vaccines for Children program, liability, or school requirements, because these are governed by the ACIP, existing insurer commitments, or state law, that doesn’t mean the EO is harmless. Litigation pressure, threats of lost funding, and confusion are real levers with long-lasting impact. I worry this EO will contribute to an already fractured response by states, which means having access to life-saving vaccines may depend on your zip code.

“Peer nations” framing is selectively applied

The EO is fundamentally inconsistent in its appeal to international standards. While the justification for trimming the recommended schedule is centered on what peer nations do, it simultaneously calls for spreading out vaccines and breaking the measles, mumps, and rubella (MMR) vaccine into separate components—something no peer nation is doing. There is no scientific justification for these recommendations, even in the cited “scientific assessment”. Single-antigen vaccines for measles, mumps, and rubella are not even manufactured or licensed in the U.S. And spreading out vaccines means forcing more visits, higher out-of-pocket costs to families, and more time when children are unprotected against preventable diseases.

So, which is it? How can select peer nations have better recommendations that justify an overhaul of our own schedule, while somehow completely missing the mark on offering individual MMR components and spreading out childhood vaccines? As I told the Washington Post, the administration seems to want to take what's convenient in that argument and leave the rest.

The misframing of parental choice

The new EO leans heavily into the idea of improving parental choice in vaccine decisions, and at least one major news outlet covered it this way. The irony is worth calling out: this order doesn’t expand choice; it is the President deciding, on behalf of every family in the country, which vaccines should be given to which children at which times. That is not returning a decision to parents.

Parents already have a choice today. Right now, they can talk to their pediatrician and decide for their own child whether to get these vaccines on schedule, and most do! That doesn’t mean their choices not to vaccinate are without consequences. We live in communities, and the choices we make don’t only affect the health of our child.

This order attempts to change what is routinely recommended and therefore offered, covered, and stocked in the first place. When a vaccine moves out of a clear recommendation, it inevitably becomes harder to get. Even without restricting specific vaccines, confusion among suppliers and providers may lead to fewer options for families, depending on where you live. You can’t choose something you were never offered.

Why now?

Poll after poll demonstrates that vaccines are popular, across party lines and in Republican-leaning states. Even many who associate with the Make America Healthy Again movement are generally supportive of routine childhood vaccines. In a January 2026 KFF poll, at least three in four MAHA supporters said they were confident in the safety of the MMR and polio vaccines.

That doesn’t mean there aren’t concerns; I speak with families about those every week, but Americans like their vaccines along with clean water, sanitation, and seatbelts. It makes sense that one of humanity’s greatest health achievements, built on the backs of American scientists and leaders, would remain so popular. While several news outlets have framed this as a political move, I am not sure what the political advantage is to doing this right now, which leaves the explanation that this isn't a calculated political play so much as a conviction that someone is willing to spend political capital to act on.

The bottom line

Your doctor, your child’s pediatrician, and your healthcare community still recommend the schedule published by the American Academy of Pediatrics, because it gives kids the best chance at staying healthy, growing, and thriving.

Unfortunately, with every one of these actions, I hear confusion from families. After one of the prior actions, I had a family tell me, “If the President said this, he must know what he is talking about because he has the whole government and all those scientists behind him.” This is more than just rhetoric or political theater; it affects people’s decisions and the health of our communities.

-DH

There is a lot more I could have covered here, but others have already done that. For additional context, here are great places to look:

• ’ legal explanation:

• New York Times Fact Check

• ’s review of the order:

  Unbiased Science

  Where Is the Line?

  There’s an episode of The Office where corporate sends over a sexual harassment training video that keeps earnestly asking, “Where is the line?” Michael talks through basically the entire thing, then spends the rest of the episode crossing the line in increasingly spectacular ways. It ends up being considerably more instructive than the video…

  Read more

  22 days ago · 31 likes · 3 comments · Unbiased Science and Jess Steier, DrPH

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, and Bluesky.

This newsletter is free for everyone. However, if you want to support the work that goes into creating it, a paid subscription means a lot.

Subscribe now

Share

We have been through this before and have a playbook, right? This certainly isn’t the first time the U.S. has dealt with nationwide measles outbreaks.

If you’re picturing isolated outbreaks in the 2010s, or the resurgences of the 60s, 70s, or late 80s, the last time case counts climbed nationwide, picture something else. On a chart, these may appear similar, but underneath, this is not your grandmother’s measles.

The gaps that have let measles back in recent years have not been driven by the same forces as prior times. In prior eras, significant access challenges, single-dose recommendation gaps, or targeted misinformation aimed at isolated communities opened the door. Now we are dealing with belief-driven vaccine refusal and widespread misinformation spread across dozens of communities nationwide at once.

The measles virus hasn’t changed, and neither has the effectiveness of the vaccine. What’s changed, every time, is the reason we gave it an opening. And every time, this remarkably contagious virus has done what it does best: find that opening and take it. The underlying cause is different this time, and the fix will need to be, too.

Measles vaccines became available in the U.S. in the 1960s. Through the 60s and 70s, measles cases dropped precipitously, but sporadic outbreaks and surges continued primarily due to the ramp-up of vaccination services and catch-up efforts to provide vaccines to every child.

Despite incredible success, between 1989 and 1991, the U.S. recorded roughly 55,000 measles cases, 11,000 hospitalizations, and 123 deaths. It’s the most recent nationwide resurgence of measles in the U.S., and believe it or not, it had very little to do with vaccine hesitancy.

Eighty percent of vaccine-eligible preschoolers who got measles in those years were unvaccinated, concentrated in low-income, inner-city communities. When the CDC investigated why, the answer was cost and availability. The vaccine itself wasn’t reliably free or accessible. That finding is the reason the Vaccines for Children (VFC) program was created in 1994, ensuring free vaccines to eligible kids.

Those same years produced a second, unrelated problem. Outbreaks were occurring even among school-aged kids who had been vaccinated. A single dose of MMR left a small but real gap in protection. That’s why, in 1989, we moved to the two-dose schedule every child gets today.

Prior efforts to address nationwide measles surges in the U.S. have been largely structural. Now we are dealing with a predominantly ideological gap, and this demands a different response.

Ideological hesitancy-driven outbreaks are not new. For example, the 2014–15 Disneyland outbreak occurred almost entirely in clusters of kids unvaccinated by parental choice. In 2018-19, an outbreak tore through communities in New York, fueled by anti-vaccine literature specifically targeted at those communities. Multiple other isolated outbreaks have occurred in communities driven primarily by belief more than access.

But what’s happening now is different in scale and kind. What we are seeing now is more than belief in a small, single community that leads to a quick-burn outbreak. It’s dozens of large belief-driven outbreaks, occurring simultaneously, sustained and connected long enough that we will likely lose our elimination status. We have not, before now, had beliefs and vaccine refusal drive a sustained, simultaneous, multi-front national resurgence.

There’s a second difference that has nothing to do with belief at all: how much more connected we are amidst a worldwide measles surge. International travel today is significantly up from the 1960s to 90s volume. And the WHO recorded roughly 11 million cases globally in 2024, more than pre-pandemic 2019. More international arrivals, plus more virus circulating globally, means more imported cases landing on U.S. soil every year, regardless of anything happening domestically. This is a beautiful part of our country and a testament to advancements in technology, but every flight is a potential spark. A spark only catches fire if it lands in a community with a wide enough coverage gap.

Nationally, two-dose MMR coverage among kindergartners is roughly 93%, short of the 95% needed to stop transmission, but closer than most people assume. And I will once again beat the drum that most parents are choosing to vaccinate. But the problem isn’t the national number. In fact, many communities have high enough vaccination rates that a large sustained outbreak is nearly impossible. However, a growing number of community pockets fall well below those numbers.

What does that mean? Well, it’s part of the reason this will never look like COVID. I have heard concerns about overwhelming health systems and resources in a similar way, but that is extremely unlikely at a widespread level. COVID spread rapidly because the virus found nearly everyone susceptible, moving through the population in massive waves.

Measles, by contrast, faces huge swaths of the country with excellent vaccination coverage where it will not find a foothold. Instead, it is moving as dozens of separate fires across the country, each tied to its own local unvaccinated community, most never touching another. It isn’t one nationwide fire. It’s many fires, happening at once, for similar underlying reasons.

That distinction matters for what actually works. A U.S. population-wide problem calls for a population-wide fix. The VFC-style solution worked in the 1990s to provide broad access across the country. Adding a second dose to the recommended schedule helped stop transmission through kids at school who had only received one dose. But we now face a problem made of specific, scattered unvaccinated pockets, mostly in close-knit communities with unique ideologies, information sources, and beliefs. This calls for something much more targeted: knowing exactly which communities have gaps, and showing up in them, through people those communities already trust. A broad national campaign aimed at a problem that’s actually concentrated in a few dozen identifiable places is going to miss most of the fires it’s trying to put out.

This kind of work isn’t free, easy, or quick. It takes a local public health and healthcare workforce with the resources, funding, and standing relationships in each of these communities to do it. This resurgence will not be addressed until we double down on supporting local trusted messengers and health workers, and fostering relationships in communities. No national media campaign, new regulation, or recommendation can replace that.

To end, here’s a related provocative question I have seen floating around: if Kamala Harris were president right now, would we still be here? My honest take: probably, yes, largely as we are.

National MMR coverage started declining long before this administration took office in January 2025. The global resurgence isn’t directly downstream of U.S. politics at all. And the beliefs driving low vaccination in communities have persisted under presidents of both parties. The dispersed ideological gap I am writing about wasn’t manufactured in the last eighteen months, and I don’t think it would have closed if a different person had won in November 2024.

That doesn’t mean federal leadership is irrelevant. Specific actions, like dismantling vaccine advisory processes, withholding funding from global immunization efforts, and failing to clearly and loudly articulate the benefits of vaccination, are devastating to efforts aimed at preventing and containing outbreaks. But the underlying problem, communities that don’t trust the message or the messenger, was years in the making, and is bigger than any single administration’s choices. Swapping out leadership wouldn’t have suddenly fixed the underlying mechanism driving this resurgence. Only the slower work described above will.

The 1989 epidemic was fixed because we correctly diagnosed it as an access problem and built an access fix. This one only gets fixed by going local, rebuilding trust, and engaging with people who have different beliefs.

-DH

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. In this newsletter, he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, and Bluesky.

This newsletter is free for everyone. However, if you want to support the work that goes into creating it, a paid subscription means a lot.

Subscribe now

Share

With so many new subscribers joining lately, I wanted to reintroduce myself. My name is David. I am a practicing pediatrician in Colorado, an immunization delivery and policy researcher, writer, speaker, and, most importantly, a dad. I bring all of these perspectives to the work I do here, writing about vaccines, public health, and community.

Thank you so much to those who have supported me with likes, thank-yous, and shares. This newsletter is a labor of love, fueled by caffeine, encouragement, and late nights. It is humbling to know that thousands of people read my thoughts.

Subscribe now

Between family summer chaos, travel, and watching too many World Cup games, I don’t have an essay to share this week. Instead, I am sharing several things I have been up to recently.

1. Can we eliminate a cancer? at and I posted about the latest incredible evidence out of England that the HPV vaccine really could eliminate cervical cancer as a public health threat. Between 2020 and 2024, researchers could not find a single woman aged 20–24 (the youngest group with high vaccination rates) who died of cervical cancer in England. We already have strong evidence that the HPV vaccine prevents persistent HPV infection and precancer, but a finding like this has never happened before. 

   Read more here:

   Your Local Epidemiologist

   Can we eliminate cervical cancer?

   Cancer finds all of us. A name or an experience has probably already popped into your mind. It’s the second leading cause of death in the U.S., and progress feels like it’s coming in inches…

   Read more

   2 months ago · 222 likes · 8 comments · Katelyn Jetelina and David Higgins, MD, MPH

   ---

2. A new partnership aimed at improving how the U.S. makes vaccine policy. The Vaccine Integrity Project (VIP) at the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP) and The Evidence Collective (TEC) announced complementary initiatives designed to improve U.S. vaccine policymaking and strengthen public trust in vaccines. The VIP will examine how the federal government can improve independent evaluation of vaccine safety and effectiveness and the issuance of recommendations. I will be leading the complementary TEC initiative to examine broader vaccine governance systems and the trust infrastructure surrounding those recommendations. This partnership grew out of my Next Era of Vaccine Governance series. The goal is to produce options that leaders of future U.S. health departments and agencies can evaluate and adopt.

   Learn more about TEC’s initiative here:

   The Evidence Collective

   It's time to rebuild trust in vaccine governance

   Happy Wednesday…

   Read more

   2 months ago · 7 likes · Elisabeth Marnik, PhD and David Higgins, MD, MPH

   ---

3. What the Missing ACIP Meeting Means for Your Fall Vaccines and a New Charter.

   First, a new ACIP charter was posted this week. Several things are notable. told STAT, “RFK Jr. is trying to retrofit the charter to make it so that the people that he brought in … qualify.” In addition, the new charter:

   • Softens the mandatory MMWR publication of adopted recommendations to a discretionary requirement, creating ambiguity about how guidance will formally reach the public.

   • Adds the Association of American Physicians and Surgeons, Independent Medical Alliance, Medical Academy of Pediatrics and Special Needs, and Physicians for Informed Consent as non-voting liaison members (organizations that have expressed skepticism of vaccines).

   • Removes the American College of Obstetricians and Gynecologists (ACOG) as a liaison member.

   • Moves ACIP support from CDC's National Center for Immunization and Respiratory Diseases to the CDC Office of the Chief of Staff, which may signal greater political control over operations.

   Second, there was no Advisory Committee on Immunization Practices (ACIP) meeting this week as planned. This is due to the ongoing legal battle led by the American Academy of Pediatrics (AAP) against HHS. Notably, an ACIP meeting could have occurred if qualified members were selected or ex officio members were appointed, but that didn’t happen. Typically, the ACIP meets every June to discuss annual respiratory vaccines (e.g., influenza and COVID-19). This is one domino in a line that ensures access to vaccines and clear recommendations. What does this mean for those dominoes? Hopefully, not very much. To understand how the missing ACIP meeting impacts vaccine access and recommendations for fall respiratory vaccines, The Evidence Collective put together a quick explainer here and linked to a fantastic scenario planning table from the Common Health Coalition:

   The Evidence Collective

   No ACIP this week

   This week, ACIP was supposed to meet. But the legal battle led by the AAP (American Academy of Pediatrics) against HHS and RFK Jr. over the process for selecting members remains in limbo. The meeting has been officially canceled…

   Read more

   2 months ago · 2 likes · Katelyn Jetelina, Chelsea Cipriano, Jess Steier, DrPH, David Higgins, MD, MPH, and Dr. Emily Smith

   ---

4. Recent Webinars. I’ve given several public webinars recently that are recorded and free to watch. Topics include school immunization requirements (for NDSU), practical communication tools for addressing vaccine hesitancy (MaineHealth Grand Rounds), and navigating misinformation and evolving vaccine policy (National Press Foundation panel for journalists).

That’s it for this week.

Go USA Soccer!

-DH

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, and Bluesky.

This newsletter is free for everyone. However, if you want to support the work that goes into creating it, a paid subscription means a lot.

Subscribe now

Share

What if AI could have your difficult vaccine conversations for you? No more contentious interactions with a neighbor or frustration from addressing the same viral claim for the 100th time with a parent. The moment you felt disagreement brewing, you could pass it off to the AI agent. Would you take that offer?

I would not.

Hard conversations about topics like vaccines are a part of our infuriatingly beautiful human experience. And as AI advances, we will have to choose whether to continue leaning into those uncomfortable conversations or offload them to microchips, giving up a piece of our humanity in the process.

Subscribe now

I recently saw a newborn in my clinic. I know the family well and have cared for their other kids. So, I was confused when I couldn’t find a hepatitis B vaccine dose recorded in the nursery birth records.

“Did Sam get his hepatitis B vaccine in the hospital?” I asked.

The mother hesitated before replying, “We know you recommend vaccines, but we don’t want him to get any.”

I was genuinely surprised. I knew they had vaccinated their older children because I was the one who had vaccinated them. In fact, just several months ago, they had vaccinated one of their older children. They trusted me before, and now they don’t.

I felt confused, angry, and sad. I was sad at the possibility of their newborn not getting the protection I know could save their life. I was angry at social media, our health leaders, and everyone who profits from parents’ fear. And I was confused at the sudden reversal. It had already been a long day, I was frustrated, and it was harder than usual for me to respond with empathy.

You know who doesn’t get angry, sad, or frustrated? You know who has endless empathy (albeit completely simulated and deceptive)? AI. It’s also getting good— scary good.

Many people are skeptical of AI’s abilities to the point of delusion. In reality, AI is evolving faster than the fields of vaccine research and health communication research can keep up with. It’s not only becoming more adept at providing clear, accurate information, but it’s also quickly becoming good at mimicking emotional language and even demonstrating “empathy”.

Over the past several years, I have had conversations with AI where I pretended to be an anxious parent who is hesitant to vaccinate my child. Even a year ago, the dialogue was robotic, distant, and entirely unapproachable. It now explores my hesitancy with open-ended questions, affirms my concerns, supports my autonomy, and makes a recommendation, all while providing clear evidence. It’s like it read the communication textbook (it did), and it will only get better.

I could have responded to Sam’s family with, “Tell me why you don’t want to vaccinate, and I will systematically debunk claims you have heard with my expertise.” For many reasons, I didn’t say that. Honestly, this is where AI would beat me easily.

When it comes to specific knowledge, AI is more of an expert on vaccines than clinicians. Try it for yourself. Tell your favorite AI that you are worried about the amount of aluminum your kids are getting in vaccines and ask it to explain the risks and benefits. It will walk you through the evidence, distilled to digestible bites, and contextualize the information. Will it hallucinate a reference or get a piece of information wrong? Of course, but clinicians are also far from perfect in their knowledge, and clinicians or parents doing their own searching and research isn’t without risk.

But AI is doing more than just providing facts like an internet search engine on steroids; people are looking to it because they feel heard. Of course, it cannot really understand or empathize without experiencing what it means to be human. This “deceptive empathy” creates the illusion of connection and reassurance, tempting a shortcut around the hard work of real, lasting human connection.

Sam’s family had access to me, their pediatrician. They have health insurance coverage and were able to get a timely appointment.

People are also turning to AI because it is accessible and fills a gaping hole in our health systems. Finding timely, responsive, and affordable answers to common questions and concerns within our health systems is elusive for far too many people. If you are a parent with vaccine concerns who is fortunate to have a primary care provider for your child, you can schedule an appointment in 3 months, send a chart message and get a truncated, hurried response, or pull out your phone and get personalized answers from a seemingly super-genius expert within seconds.

At least 1 in 3 adults report using AI for health advice, and that is precisely why we must be talking about this. Simply dismissing AI the same way people should never look for health information on the “net” or “World Wide Web” (hello, 1990s) is not an option because people are using it. And there are serious potential harms to AI use for health advice, like inaccurate diagnoses, inconsistent information, or failure to recommend urgent evaluation, which need to be mitigated.

After taking a deep breath, I asked Sam’s family, “I’m curious: you trusted me when I recommended vaccines for your other kids; what made you change your mind now?”

His mom started crying and said they were feeling confused and overwhelmed. They didn’t know who or what to trust, and they had seen so many things that made them question. They felt lost.

At this point in the conversation, AI could have given them directions. It could have analyzed their questions, responded accurately, drawing from a much deeper pool of science and evidence than my brain has access to, and laced its response with deceptive empathy. It could probably do a better job of addressing the claims they had been exposed to, giving the facts, and reasoning with them than I could.

But would they have trusted it if it had recommended they vaccinate?

Ironically, medicine, science, and public health often mistake human beings for logic machines in health communication and decision-making. But that’s backward; that’s AI, not humans. Humans make decisions based on much more than logic: values, emotions, and experiences. If humans were logic machines, then a super-advanced AI would be the ultimate solution to vaccine communication.

I responded to Sam’s family, “I understand why you are feeling confused. There’s a lot of information out there. Ultimately, this is your decision to make, but just like your other children, I believe these vaccines are important, and I recommend he get them.”

At some point in every conversation about vaccines (or any health decision), there is an implicit ask for trust. Even if small, there is always a leap of faith. Medicine doesn’t deal in certainties; it deals in probabilities. No matter how strong the weight of the evidence is, at some point, I reach out my hand across a divide and ask a family to trust me. Not because I have the most knowledge or sound reasoning, but because I love my patients, have their best interests at heart, can empathize with their human experience, and have shown up for them, time and again, even when it’s hard. AI can’t say that.

I am assuming that the alternative to AI is an available, skilled, and empathetic clinician. As I have said, many families do not have convenient access to that, and as a society, we must work to decrease those barriers. AI can be upscaled to reach millions, whereas I can only talk with several dozen people each week. There is massive public health potential there that shouldn’t be ignored. Is AI better than a parent searching social media, asking a Facebook group, or asking neighbors? Probably. But reach isn’t the same as depth. I find myself disengaging more and more from social media as it is flooded with AI content (mostly slop). I crave embodied human interactions. The human slop on social media is not good, but at least it is human.

Sam is now fully up to date on his vaccines.

Not every story ends this way, but this one did. I cannot help but think that an AI, without the relationship and trust, could ever have walked with the family to get to that point. Even if it could have, I wouldn’t have wanted it to because I am also more human for having leaned into the hard conversation. And in the process, I gave them one of the most beautiful and important gifts one person can give another: my attention, time, and care. If our communication is reduced to only agreeable, information-sharing pleasantries, we become no different than the AI tools themselves.

We have agency with this decision. Abdicating our responsibility to engage with each other on difficult topics means giving up part of what makes us human, and I, for one, will choose to keep engaging.

-David

Note: As with any piece on AI, this post probably won’t age well. I hope it’s wrong. I hope it’s challenged. I hope you disagree. And I hope we have difficult conversations about it. Because that means it’s human.

*The name and specifics of the patient and family I cared for in this article were altered to protect their privacy.

**AI was not used in the creation of this writing.

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the Colorado outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

This is the first in a series of conversations about what the next era of vaccine governance could look like. I’ll be talking with clinicians, scientists, policymakers, leaders, and parents: the full range of people who shape and live with vaccine policy in the U.S. Hopefully, some conversations will confirm things that many readers already believe, and others will challenge them. That’s the point. You can read more about why I launched this series [here].

When I wrote the introduction to this series, I said that rebuilding vaccine governance can only take place between two truths: the systems we had were imperfect, and abandoning them entirely is dangerous. Finding people who are genuinely doing that building, not just defending what was or completely tearing it down, is the whole purpose of these conversations.

Dr. Alister Martin was first in line.

In the face of federal changes over the past 18 months, states and local jurisdictions have had to fill the void as best they can. Martin is the Commissioner of the New York City Department of Health and Mental Hygiene. He oversees a city of 8.5 million people that functions, in many ways, as a national stress test for public health. He is also an emergency medicine physician, a former White House advisor, and the founder of national initiatives to connect patients to resources and civic power they already have.

I wanted to start this series with someone who is not theorizing about what rebuilding should look like from a distance, but is managing public health crises and the effects of a breakdown in federal vaccine governance in his community right now. When I told him I wanted to have this conversation, he said something that struck me: “This is only the beginning.” We already had something in common: building something better in the future doesn’t mean having the silver bullet, and anyone hoping to find an answer by the end of a single conversation, meeting, or conference is fooling themselves.

That’s the spirit I’m trying to bring to this series.

The full interview is below, but three ideas from our conversation have really stayed with me.

First, he emphasized that the urgency to rebuild is not hypothetical. The Hep B birth dose, which is administered in the hospital and is one of the first signals of a problem, is already declining in NYC. This is consistent with national trends in eroding vaccine confidence and declining vaccination rates.

Second, he proposes a governance model in which rigorous, independent science is at the top, connected to deep community engagement at the bottom. I’m genuinely torn on this framing: is this model still too top-down, with community engagement just a better delivery mechanism for expert consensus? Or is the risk the opposite, that we democratize vaccine governance in ways that undermine expertise? Many people working on this problem agree that vaccine governance shouldn’t be entirely top-down. But the devil is in the details of how horizontal it can really be, and that tension is one I expect to return to throughout this series.

Third, and most importantly for me: Martin argues that service has to be the message. Public health cannot ask for trust before it has earned it, and it earns it by solving the problems people actually have right now. His version of the question is simple: “Why are you going to take my recommendation about vaccines when I wasn’t there to help you with the things that you said were a major challenge in your life?” I find this one of his most compelling observations, and it is underrecognized in public health right now.

While trust and community are at the center of any answer, the harder question is: how do you earn trust at scale, across communities with genuinely different needs and worldviews, fast enough to matter? Is it even possible?

What follows is our conversation, lightly edited for length and clarity.

The Conversation

David Higgins: Alister Martin, thank you for taking the time for this conversation.

Alister Martin: Thank you. This is the first conversation of many.

You have an unusual career that spans emergency medicine, public health programs at a national scale, federal and state government, the White House, and now as NYC Health Commissioner. What brought you to this work?

It starts with my mom. Growing up, my mom was a nurse in a program called Nurse-Family Partnership, which is one of the most evidence-based and effective public health interventions that we know in terms of doing prenatal interventions and maternal education.

My early experience was that public health is deeply personal and happens in communities. It’s direct. It’s solving someone’s real problem. That’s what I saw growing up. But I also heard my mom’s stories of navigating systems that quite frankly seemed almost set up for the recipients to fail at accessing the resources they needed. Many of her patients were young immigrant moms, just like she was once. My mom was a Haitian immigrant who came to New York City when she was a teenager.

She taught me a lesson: when you are connected to someone’s problem, you have a responsibility to help them solve it. And I never forgot that, and I took that with me as an emergency room physician. You know just as well as I do, that we are often faced as doctors with challenging scenarios where the patient in front of us needs so much more than the walls and apparatus of healthcare can deliver. After a while, I had to make a decision: am I just going to complain about how bad healthcare is, or am I going to try and get in the ring and do something about it? And my life has been wrestling with that question: for patients who our healthcare system fails, there has to be a better way. And I think public health is a better way.

What does vaccine governance—how guidance is developed, regulated, and implemented—look like from where you sit right now?

Well, let me just be honest: I’m tremendously concerned about where we are right now. What we’re seeing from the federal government is a systematic attempt to weaken trust in public health writ large, and specifically in vaccine guidance. These efforts have sown confusion and chaos, making it really challenging for individual New Yorkers to have the information they need to decide what they want to do about vaccines. And we’re seeing it already in our own data.

We’re already seeing a decrease in uptake of the Hep B birth dose. You can make an argument that maybe complete vaccine uptake isn’t happening because people are not following up because their lives are busy, or because parents are working multiple jobs. But the Hep B birth dose, that one should happen immediately after birth. I can’t draw a complete link between the rhetoric we’re hearing in DC and these numbers. But I have to tell you that it’s certainly not helping.

What can’t New York City live without from vaccine governance at the federal level? What do you need?

I think the future of what this looks like is the following. From the top-down, we need to have the science be rigorous, be independent, be clear enough that clinicians, insurers, schools, parents, and departments know what the standard is. That’s what we need at the top. But in the past, that’s all we relied on. What we also need is the bottom-up. Those recommendations from the top are only useful when the community trusts the messenger and can access them. So, you have to do both of these things at the same time.

In the past, we relied solely on the federal government for top-down messages. It’s possible that those days when we rely on the federal government are over. Because what we know from the last 10 years is that, even before this administration, trust in public health was declining. So this administration is making things more challenging, but the problems started before this administration. The piece we have to add is the bottom-up component.

What does that look like?

In every single community where we’re trying to get these messages out, we have to be methodical about several things: who are the best messengers to deliver these messages? — Are they community health workers? Are they navigators? Are they imams? Are they rabbis? And then, where do we meet people to deliver those messages? That is the work of public health now. It ends up looking a lot more like public engagement because, when you build a public engagement campaign, it really needs to reflect the specific context of the population. We’ve expected that one-size-fits-all messaging can get most of the work done. We have to shift away from that idea.

What do you do with the top-down if it’s not the federal government anymore?

Well, look at what you’re seeing from us. In New York City, we adopted the American Academy of Pediatrics guidelines. For adult vaccines, the gap left by the federal government is still open, though other professional bodies are working to fill it.

A share of Americans expressed some support for the current direction of federal vaccine policy. How do you engage with people who actually might find what is happening right now appealing — people who have a very different view than maybe you and I do sitting here?

It comes down to trust. You can only move at the speed of trust in public health. And I think what you’re seeing is a reflection of two things happening. That segment of the population no longer trusts the traditional approach to public health. They just don’t. And then there’s a group that agrees with them and says: hey, look, those public health folks have burned us once. And so, ‘here’s what we should do instead’.

It’s less about every person in that group doing hard-hitting research and trying to figure out if the evidence makes sense. It’s more about: are you speaking my language? And my language is: I’m hurt. I got let down by institutions. And now I’m looking for another way.

And let me be clear: everything I just said is what I’m seeing with the Make America Healthy Again (MAHA) movement. They are saying, ‘official public health and traditional institutions have not given you the full answer. They’ve let you down. Come this way instead.’ But I think there’s a third way between the traditional public health model and what MAHA’s doing. And the way I think about it is: to be trusted, you need to be trustworthy. You need to be worthy of someone’s trust. And how are you worthy of someone’s trust? You have to help them with their needs.

If I’ve never seen you on my block, and all of a sudden you drop into my neighborhood, and you say ‘you need to wear a mask’, and ‘you need to take this vaccine’, people will say ‘who are you? Where have you been? I’ve been hungry for the last two weeks. I don’t know if I’m gonna ever see a primary care doctor, because the waiting list is three years long. I don’t have a place to live. You haven’t been helping me solve these challenges, so why do you then get a seat to help me decide what I’m gonna do?’

So the direction we’re exploring here at the health department is: how can the service be the message? How can we serve people and address their material needs, solve their real problems, and let that be the message that builds trust?

And the last thing I’ll say on this: this isn’t anything new. This is how public health started. Public health emerged because people were getting sick from contaminated street wastewater, which was dangerous. Public health began by going out to clean up the mess. Literally. And so I think we need to get more involved in people’s lives in this way — through what we’re calling direct action public health.

You said better community engagement enhances trust, and part of that is listening. What does genuine listening look like, and how do you feed the listening back into the decisions you’re making?

The way I’ve been thinking about it is this: let’s make sure we take care of all the standard health interventions — the vegetables — but also make sure we’re addressing the person’s top-of-mind problem right now.

Here’s one example of what it looks like in practice: partnering with managed care organizations to deliver large amounts of free food directly to communities through neighborhood health action centers and clinics. We run a network of three action centers and 11 public health clinics that deliver healthcare services, and address the social determinants of health by helping people enroll in SNAP, Medicaid, and tax assistance programs.

But you can’t start the conversation there. You start with food. If people are hungry and facing food insecurity, that is what brings them in the door. Let’s address that immediate need first. Then, in the wake of that interaction, once trust has been built and that need has been met, we can start talking about the other things. Is your Medicaid coverage stable? Can we help you enroll in SNAP? Are your child’s vaccines up to date? How else can we help? The listening should come after we help solve the person’s current problem, because that’s how you build the trust to get them to share what’s actually going on.

The second thing: you need to incorporate their perspective in the creation of the new intervention. We’re currently building a whole series of interventions to keep people on their Medicaid coverage ahead of the January 1, 2027, HR1 start date. I might come up with some pretty good ideas, and my chief of staff might too. But none of them, when the rubber meets the road, are probably as good as someone who’s actually lived this challenge. They’re gonna have ideas far better than ours. You’ve got to incorporate folks into the decision-making, into the building of the intervention.

You have said affordability is obviously a public health priority, but it’s also a path to rebuilding trust. Walk me through that argument, specifically about vaccines.

I think this is a direct line, and I think we’ve been talking about it the whole time, but I’ll be even more explicit. Number one: You cannot have a conversation in this country around affordability without talking about health. Number two: when we look at what really makes people sick in this city and in this country, it’s poverty. My patients, your patients, many of them are making decisions every single day between putting more food in the fridge and paying their copay. Do they take a day off from work to see their primary care doctor, knowing that if they do, it might mean they lose their job?

We’re putting people in an impossibly challenging position, which is literally bankrupting many New Yorkers and Americans. And to date, public health has not really made itself part of the affordability conversation. It needs to be. It needs to be at the center of the conversation.

Some of the things we’re going after are these four. The first: Medicaid coverage, doing everything we can to help people cut through the bureaucratic red tape and keep their Medicaid status. The second is benefit enrollment. We’ve calculated that there are millions upon millions of dollars in this city alone that people leave on the table because they’re not enrolling in cash assistance benefits: SNAP, Lifeline, tax credits. We as a health department see hundreds of thousands of people a year, either in our clinics or action centers or vital records shops. Why aren’t we helping people enroll in these programs? The third is medical debt. Medical debt is the number one driver of personal bankruptcy. We’ve already erased about $135 million of medical debt, helping thousands of New Yorkers, and I think we could do a lot more. And then the fourth is eviction: helping people who are facing eviction connect to legal counsel and help them keep their homes.

Here’s how it all links back to vaccines. It’s all the same conversation. If we don’t help you with these types of things around affordability, the things that are the thorns in your side right now, why are you going to take my recommendation about vaccines when I wasn’t there to help you with the thing that you said was a major challenge in your life? It comes back, for me personally, to that story I told you at the beginning: once you’re connected to someone’s problems, you have a responsibility to help solve them. And I think public health has that same dynamic.

Dr. Alister Martin is the Commissioner of the New York City Department of Health and Mental Hygiene. This conversation has been lightly edited for length and clarity.

The Next Era of Vaccine Governance series is being done in collaboration with The Evidence Collective.

If this conversation resonated with you, I would love to hear your reaction in the comments. I want this to be an open conversation. And please share; these conversations are only useful if they travel.

Thanks, as always, for being part of this community.

-David

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

It reads like something from today, but it was written in 1896, printed on postcards, and mailed across Britain by the National Anti-Vaccination League.

Here are examples of the originals.

Researchers have documented common manipulation tactics, such as cherry-picked data, fake experts, conspiracy theories, emotional appeals, and the exploitation of scientific uncertainty. When I speak about vaccine communication with health professionals, I frequently get questions implying these techniques are new.

But the tactics were all there 130 years ago, long before social media. This playbook is not new.

So, if the tactics are identical, then what has actually changed?

Two things. The first is obvious: the size, scale, and speed at which messages can spread. A postcard in 1896 may have reached dozens of neighborhoods and towns over the course of weeks. A social media post reaches the world in seconds, amplified by an algorithm optimized for outrage, and with no accountability. The information ecosystem today is completely different.

However, the second change is the one I keep thinking about, and I don’t think it gets enough attention.

In his book Bowling Alone, Robert Putnam discusses the quiet collapse of America’s community life: we are joining fewer civic organizations, knowing fewer neighbors, and attending fewer community gatherings. We have lost what Putnam called social capital—the value of collective social networks that serve one another and build trust.

That erosion matters for how health misinformation influences people today. For over a century, misleading claims existed alongside shared institutions that could buffer against extreme messaging. The local church, newspaper, and doctor. Rotary clubs, PTAs, and neighborhood associations. These institutions were far from perfect. They often reflected the biases of their time and were frequently exclusionary toward marginalized communities. Yet, for those within them, they functioned as a collective anchor.

Today, many of those institutions still exist, but people no longer show up. Church congregations have declined over recent decades. Local newspapers have closed or been bought out by non-local actors. Civic organizations are dwindling. And physicians—still the most trusted source of vaccine information in survey after survey—are seeing patients for shorter visits, often lack long-term therapeutic relationships, and have increasingly limited availability.

Instead of community forming around where we live, work, worship, or play, new substitutes for community are increasingly shaped by partisan political identification or social media algorithms.

I want to acknowledge that many past community institutions were often gated and built on exclusion. However, the breakdown of those structures hasn't necessarily led to a more inclusive shared reality. Instead, we traded the old institutions, with all their flaws, for new, digital communities that thrive on fragmentation rather than community-building.

The tactics of the Anti-Vaccination League were potent enough in that era to shape policy and influence large groups of people. Today, those same tactics travel to millions instantly, and the institutions that once provided a buffer have eroded.

As early as 1896, the Anti-Vaccination League recognized the need for community work. The postcards were more than just propaganda; they came with an invitation to belong. That combination is part of what gave the movement its staying power. And it continues today, only now with tools that scale to millions instantly and far fewer competing sources of trust to push back.

The uncomfortable truth is that the anti-vaccination movement has figured out that people need to belong to something. They aren’t just selling people on their set of “facts”; they are calling people into a community. The health and science world often misses this reality. Many believe that people have weighed the evidence on both sides and accepted an alternative set of facts. The reality is, they have decided to accept an invitation to join a community that welcomes them.

Evidence needs a community to give it weight. Around vaccines, that work is already happening in small ways.

Health care is a team effort, and trust lives not just with physicians but with the medical assistant who rooms the patient, the nurse who answers the portal message, the local pharmacist, family navigators, social workers, and the community health worker. My own work aims at improving how all these people communicate and build trust with families. Trusted voices in faith communities, schools, and neighborhoods still matter too. I was part of a recent science-and-faith gathering that filled me with hope about the possibility of working together on shared messaging. And the work has to extend online too, whether we like it or not, because that's where people are increasingly building community.

There is no silver bullet. But we won’t make progress unless we recognize that the work is about more than just correcting misleading claims; it's about rebuilding the connective tissue that makes communities more resilient before the next postcard arrives, in whatever form it takes.

I want to hear from you, and I’m curious what you’re seeing. Can you think of a time that a non-medical trusted voice in your community influenced your health decisions? Why did you listen to them?

Thanks, as always, for being part of this community.

-David

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

The rotavirus season is underway, with rising rates across the U.S. Rotavirus is a common cause of severe diarrhea and vomiting in infants and young children. Before vaccination, it caused up to 70,000 hospitalizations in the U.S. every year, mostly in children under five, due to rapid and severe dehydration. Since routine rotavirus vaccination began in 2006, hospitalizations have dropped by roughly 80%.

Media coverage has highlighted the seasonal rise in rotavirus infection. However, the scale of this season deserves context: the 8.1% positivity rate (as of April 24) has surpassed last year’s peak of 6.8%. But historical post-vaccine peaks have reached as high as 27%, with a median around 14%. Although wastewater monitoring data also show increased levels of the virus, we don’t have historical trends to compare with. It is not clear that this season is unprecedented.

Social media posts have blamed the current “surge” in rotavirus cases on vaccine hesitancy and refusal, with some directly claiming rotavirus is spiking primarily because parents aren't vaccinating. And media coverage implicitly points to hesitancy as the primary explanation for low rates. I understand the instinct to raise awareness about vaccine refusal. But the data don’t clearly show refusal is the primary driver of current trends, and that framing risks obscuring the less sensational but more likely reason for low rotavirus coverage: poor access and real barriers imposed by our fractured health system on families.

Rotavirus vaccination rates have declined in recent years, with national coverage at 74%. However, rotavirus vaccination coverage has always been lower than that of many other routine vaccines, long before RFK Jr. became Secretary of Health and Human Services, recent federal health policy shifts, or the COVID-19 pandemic. While coverage is down from a peak of 77% in 2018-2019, rates are similar to those in the mid-2010s, with a modest 1-3 percentage-point dip in recent years. The most recent national rotavirus coverage data cover children born in 2021–2022, so we don’t yet know what happened to vaccination rates in this season.

Here’s the nuance that isn’t being reported: Rotavirus vaccination coverage is much more susceptible to access and logistical barriers than that of many other vaccines because it is front-loaded and time-sensitive. Infants need to receive the first dose of the vaccine before 15 weeks and complete the entire series (2 or 3 doses, depending on the vaccine brand) by 8 months. There is no opportunity to “catch up” if they miss visits. If a child loses Medicaid coverage, can’t find a pediatrician, or isn’t able to get in on time, they can catch up on a measles vaccination months later, but not for rotavirus. Among children on Medicaid who start the series, some studies have found that only 1 in 2 complete it, and completion is higher with the 2-dose vaccine than with the 3-dose. That pattern cannot be explained by hesitancy alone, but it becomes clear once you account for logistical and timing constraints.

Compare rotavirus vaccine coverage with measles vaccine coverage (MMR) at 24 months of age, which has consistently been 15-18% higher.

What’s going on here? Is there significantly more hesitancy toward the rotavirus vaccine than the MMR vaccine? There isn't good evidence for it, and I don't see it in my clinic. The persistent gap in rotavirus coverage is a signal of access challenges, not attitudes.

This matters because the diagnosis determines the response. If I treat a disease I haven't properly diagnosed, the treatment won't help. Similarly, if the dominant narrative says vaccine refusal alone is driving low rotavirus coverage, we will invest in the wrong interventions. Media campaigns and myth-busting on social media will not help the family whose Medicaid lapsed between the 2- and 4-month visits, or the family that moved and can’t find a pediatrician who accepts new patients before the 8-month window closes.

If rotavirus vaccine coverage data for 2023–2025 arrive and the trend continues lower, the dominant narrative will likely be hesitancy. But what about the 4.6 million children who lost Medicaid during the unwinding, when projections suggested that nearly three-quarters of disenrolled children would still be eligible? What about the infants who aged out of the rotavirus window while their family was navigating a paperwork problem? They will show up as unvaccinated. They may be labeled vaccine-hesitant when they are not.

These barriers do not fall equally. Among the most recent national data, children living below the federal poverty line complete the rotavirus series at 61%, compared to 79% for those above it, an 18-percentage-point gap, compared to just 4 points for MMR in the same data. Children in rural areas complete the series at 71%, which is also significantly lower. And the rotavirus poverty gap has been widening in recent years. The structural factors that make a front-loaded, time-sensitive vaccine hardest to complete are concentrated in the communities already carrying the greatest burden of preventable disease.

Vaccine hesitancy is real and plays a role. A national survey of pediatricians found that parental deferral, general vaccine safety concerns, and doubts about whether the rotavirus vaccine is even necessary are genuine barriers. But misapplying it as the central problem only serves to protect the status quo. That refusal narrative shifts all the blame onto parents, instead of acknowledging the responsibility we all have to address systemic barriers that disproportionately affect the most vulnerable communities.

The goal is to make sure no child goes through what I did. In addition to improving confidence in vaccines, this means ensuring Medicaid continuity to prevent coverage gaps, protecting the Vaccines for Children program, improving access to primary care, enhancing reminder systems and standing orders at well-visit appointments, and integrating with WIC and home-visiting programs. It requires understanding why vaccination isn't happening, rather than assuming we already know.

A note on last week's POLITICO piece

Last week, I wrote about a misleading POLITICO poll that suggested vaccine skepticism and concerns about vaccine safety were now the norm in America. The rotavirus refusal narrative is a similar error in a different form.

I had a lot of engagement with last week’s piece. STAT news republished it, and I was a guest on several podcasts to discuss the dangers of this misstep. Since then, POLITICO changed the headline on the story to “Many Americans express doubt about vaccines, POLITICO Poll finds,” with a correction note stating, “An earlier version of this report's headline misstated the poll's findings on the number of Americans skeptical of vaccine safety due to an editing error.” I am glad they changed the headline; however, I still see the headline message spreading, and my concerns with the substance and potential harm of the poll remain.

If you want to hear more, you can listen to this week’s podcast (starting at 43 minutes) or BBC’s More or Less here. It’s only 9 minutes and is worth your time.

Thanks, as always, for being part of this community.

-David

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

Two years ago, I wrote in the New England Journal of Medicine that one of the greatest threats to childhood vaccination is the normalization of skepticism, even though it isn't actually the norm. When credible outlets, trusted voices, and social media algorithms inadvertently tell the public that most Americans doubt vaccines, some may start to wonder if they should, too. I watched that play out this week.

On Monday, Politico published a poll on vaccine attitudes titled, “More Americans doubt vaccine safety than trust it, POLITICO Poll finds,” followed by the subtitle, “Health Secretary Robert F. Kennedy Jr.’s views are commonplace across the land.” I consider Politico a reputable news outlet, so this headline stopped me in my tracks.

Within hours, other credible outlets ran headlines such as “Vaccine skepticism now the norm for many Americans.” I saw similar messages spread across social media and heard from others in my professional networks. And most notably, The Defender—the media outlet of Children's Health Defense, the anti-vaccine organization formerly led by RFK Jr. himself—ran the headline “Vaccine Skepticism in U.S. Is Widespread, Politico Poll Reveals.” A physician quoted in the piece claimed the findings showed that nearly half the country is "unsure about vaccine safety." And a Health and Human Services spokesperson added that "This survey makes it clear that Secretary Kennedy’s priorities resonate across party lines."

That’s a big claim. As I have written about before, these statements are not supported by the weight of evidence. Yes, as epidemiologist pointed out in an interview for the Politico piece, there is a large, movable middle, and it deserves serious attention from clinicians and communicators. But, does this poll support the idea that RFK Jr.’s views are now commonplace and vaccine skepticism is widespread?

Absolutely not.

A careful reading of the poll data tells a different story.

Subscribe now

To understand why, we need to look carefully at the specific survey question driving these headlines. In its article, Politico said, “Nearly half of U.S. adults surveyed last month signaled they think the science on vaccines remains up for debate and that it’s damaging to require people to receive them…” Other outlets ran with similar interpretations.

Here is the actual question from the poll:

“Which of the following comes closest to your view?: The science on vaccines is clear and it is damaging to question it | The facts on vaccines are still up for debate and it is damaging to enforce their uptake”

Read that question carefully and answer it honestly.

Did you notice the problem? You weren’t asked about one thing; you were asked about four different things simultaneously.

1. Is the science on vaccines clear?

2. Is it damaging to question vaccine science?

3. Are the facts on vaccines still up for debate?

4. Is it damaging to enforce vaccine uptake?

These are separate and independent beliefs all bundled into a binary choice. Survey methodologists call this a “double-barreled question.” This question has four barrels.

Think about how people might answer this.

• A pediatrician who believes the science is clear, but also that vigorous debate is essential to good science. Where do they land?

• A parent who thinks the evidence is clear and has vaccinated their children, but believes that “enforcing uptake” is government overreach, agrees with half of both options.

• A hesitant parent who has real questions about the childhood schedule, but still brings their kids in for every appointment and supports school vaccine requirements as a reasonable community protection, has nowhere to go either.

The survey question cannot distinguish these people. As a result, it is difficult to interpret and a misinterpretation to claim that half the country is now skeptical of vaccines.

To make this clear, let me explain how I would have responded. I believe the science on vaccines is clear, but I don’t think it is damaging to debate or question it when done in good faith. In fact, I believe it can be damaging not to debate or ask questions; that is what good scientists do. And is it “damaging to enforce vaccine uptake”? That depends on how it is enforced. Evidence shows that overly harsh enforcement can backfire on the ultimate goal of improving uptake. That would place me somewhere in the middle as well.

There are several findings worth considering carefully.

• When asked what best describes their view, only 10% of respondents chose the most skeptical position that “vaccine risks are significant, and enforcing vaccines is dangerous”. I hesitate to cite this finding, as the answer choice combines two different concepts—risk and enforcement—but even then, this seems inconsistent with the headline finding above.

• When asked if they support reducing the number of vaccines Americans receive, 40% of respondents supported this. This question has a similar framing problem. Nobody in the United States is forced to receive a vaccine, and the actual policy debate is about recommendations, not what Americans are compelled to accept. The wording subtly implies that vaccines are currently happening to people rather than being chosen. Even so, 40% is real and reflects something the medical and public health community needs to take seriously.

• When asked whether reducing vaccines is a core principle of the Make America Healthy Again (MAHA) movement, only 34% said yes. Even for people who identified with MAHA, vaccines don’t seem to be the animating issue. That challenges the idea that RFK Jr.’s views are commonplace across the land.

  ---

This poll should not be interpreted in isolation. Multiple surveys (1),(2),(3),(4),(5),(6) and research from the last several years show a slow erosion in confidence but remarkably resilient support for vaccines. A Reuters/Ipsos survey conducted in February found that 84% of Americans, including 81% of Republicans, said vaccines like those for Measles, Mumps, and Rubella (MMR) are safe for children. Seventy-four percent said the government should require children to be vaccinated to attend school. A February poll from the Partnership to Fight Infectious Disease found that 89% of Americans — including 82% of Republicans — said vaccines are essential for public health.

Notably, Republican pollsters Fabrizio and Ward, in a memo to the White House late last year, found strong bipartisan majorities supporting vaccines like MMR, Tdap, and hepatitis B — including more than three-quarters of Trump voters — and warned that efforts to limit vaccine access could backfire politically.

While there are genuine warning signs of eroding trust and confidence that deserve acknowledgment, the weight of the evidence says vaccine support remains the norm. But that reality is not immune to the stories we tell about it.

I understand more than most that Americans' feelings about vaccines are incredibly messy. I appreciate that polls such as this one attempt to tease out the nuance. And they are often all we have, since research on vaccine delivery has been cut and remains chronically underfunded.

But how this type of information is gathered and interpreted has significant consequences on people’s beliefs and attitudes, and mistakenly misframing vaccine skepticism as more widespread than it actually is can cause harm. It may change what clinicians say in the exam room, the decisions policymakers and leaders make, and ultimately become a self-fulfilling prophecy. If enough people hear a misleading message that most of their neighbors are skeptical about vaccines, some will start to doubt, too.

Unfortunately, this week's poll became the raw material for that normalization. I believe this poll was conducted and reported in good faith, but it does not show that RFK Jr.’s views on vaccines are now mainstream or that most Americans no longer trust vaccines.

I wish the headlines didn’t matter. But for people who see them, that is not the case. Parents and patients making decisions need accurate information about where their neighbors and our communities actually stand together, not a distorted picture that makes skepticism feel more normal than it is. The least we can do as clinicians, health professionals, and communicators is make sure the message we're sending them is accurate, because this norm is worth defending.

Share this if it was useful and spread the word.

And thanks, as always, for being part of this community.

-David

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

“So, what brought you into town?”

“I was speaking at a conference,” I said.

“What were you speaking about?”

“Um, vaccines and public health communication.”

“Oh, I used to believe in vaccines, but then I started doing some research, and I heard President Trump say…”

I don’t know if I visibly winced, but I was not excited about the direction this conversation suddenly took and very much wanted to go back to my book.

My reluctance to engage further in conversation was more than just a desire to be an introvert after a lot of conference extroverting; it was a small sign of something not discussed enough: conversation fatigue.

It wasn’t that I didn’t care about vaccines. At the moment, I was exhausted by the prospect of another emotionally heavy, values-laden conversation with a stranger when my tank was already running on empty. I suspect that I am not the only one who has had this experience.

Conversations with random strangers are one thing, but with patients, the stakes are higher. It’s both a heavy conversation and a strain on a therapeutic relationship with serious downstream consequences, including the potential for burnout and moral injury.

When I teach vaccine communication workshops to health professionals, I often get questions like, “Don’t you ever get tired of dealing with wild social media claims?”, “Does any of this actually work?”, or “Don’t you sometimes just want to scream in frustration?” Clinicians, nurses, and other professionals often approach me after talks to share their weariness and fatigue, cynicism, and feelings of defeat from repeatedly and often unsuccessfully addressing vaccine hesitancy.

This isn’t just anecdotal. Pediatricians who regularly engage with vaccine-hesitant parents report higher levels of burnout and decreased job satisfaction. Qualitative work describes clinicians' feelings of being discredited, frustrated, and professionally undermined by these repeated encounters.

Many of us are having the same heavy conversations over and over again, and we are up against an invisible opponent who has hours with patients before we even get five minutes. They aren’t occurring in a vacuum. The explosion of information available on smartphones and social media, the erosion of trust in expertise, and now federal health authorities introducing undue doubt mean we are facing unprecedented headwinds.

What accumulates when we start to question whether the conversation even makes a difference in the face of these headwinds is even more insidious than burnout. Many of us have experienced walking from one room, treating a child with a vaccine-preventable disease, into the next, where vaccination is refused. That gap between what we know can help and what we cannot deliver produces something deeper than burnout: moral injury. This can lead to profound anger, guilt, and ultimately a loss of trust within the therapeutic relationship.

When clinicians are carrying this level of strain, it shapes the conversations patients and parents experience and the care they receive. Vaccine conversation fatigue, burnout, and moral injury can distort how we see the people we are talking to.

Many people might be tempted to blame parents for these challenges, but they aren’t adversaries. They are also fatigued by conflicting and confusing information and, in some cases, by poor communication from people in science and medicine.

Vaccine-hesitant parents have shared their experiences with me of feeling dismissed, ridiculed, or shamed by a health professional. Just look at the comments section of any “pro-vaccine” post. Every time I post something “pro-vaccine”, I get at least one response that paints vaccine-hesitant parents as the enemy. People are watching and listening, and how we show up in public always feeds a narrative.

I can’t help but wonder how many of these negative interactions happened because providers felt the way I did on the plane—tank already empty and frustrated—resulting in communication that lacks empathy and partnership. And I can’t help but wonder how many times I have been that provider.

Here is what I have learned, and what I keep reminding myself.

The first move is to reframe the job. The goal is not to win the conversation; it’s to show up as a trusted expert navigator. Not every encounter or conversation will result in a patient saying “yes”. Many will end with a “let me think about it,” and that is a win. Sometimes the win is as simple as having a respectful conversation. Partial progress is still progress, so learn to recognize that. You may have planted a seed that you will never see sprout.

Set limits on where and when you engage. You do not have to respond to every negative claim you hear, every social media comment, every holiday dinner disagreement, or every flight seatmate. Choosing your moments wisely is critical for sustainability.

Name what you are carrying and do not attempt to carry it alone. Sharing your experiences with colleagues, friends, or someone you trust interrupts the buildup that can lead from conversation fatigue to burnout. The burden for addressing vaccine hesitancy does not fall on you alone; it falls on the collective “us”, other clinicians, nurses, community health workers, public health professionals, scientists, community leaders, etc. Everyone has a share of the responsibility in improving health.

Learn to communicate more effectively. Research shows that learning effective communication skills not only improves outcomes but also boosts confidence and self-efficacy. Evidence-based conversation frameworks, empathetic language, and engaging questions can be taught, and I have seen how valuable and empowering it can be to learn these skills.

Finally, and for many, the hardest part: separate your identity from the outcome. A parent declining vaccines or a neighbor not changing their views is not a referendum on your skill, credibility, or worth. You can give the best communication in the world and still hear a resounding “no”. Recognize that most of the outcome is outside your immediate control.

I ended up having a conversation with my seatmate. They didn’t change their mind or show any signs of shifting their views. But before we went our separate ways, they did thank me for talking with them. Maybe all I did was demonstrate that people with widely differing views can have a respectful, thoughtful conversation. I will take that as a win.

Thanks, as always, for being part of this community.

-David

Quick Programming Note:

The response to my interview series, The Next Era of Vaccine Governance, has been incredible. I have several interviews lined up and a long list of people who want their voices heard, and I want to honor that. Over the coming months, some will appear here as individual or group interview summary posts, others may find their way to a podcast, and some to other venues. This is clearly meeting a need, and I’m grateful for it. Please reach out if you have ideas or if you are interested in collaborating on this work.

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

"There is a method to how these decisions historically have been made — a method scientific in nature and codified into law through procedural requirements. Unfortunately, the Government has disregarded those methods and thereby undermined the integrity of its actions."

That’s from this week’s federal court ruling in AAP v. Kennedy, which held that the government cannot unilaterally change national vaccine policy by bypassing the country's scientific and procedural processes.

The court issued three stays:

1. It blocked the January 2026 guidance, which altered the childhood immunization schedule.

2. It halted the reconstitution of the ACIP, which included 13 Kennedy-appointed members.

3. It prevents any further use of votes made by those ACIP members

In summary, the court’s action reinstates the pre–June 2025 federal vaccine schedule, providing immediate guidance as further legal challenges proceed.

The judge opened his ruling by quoting Carl Sagan: science is “far from a perfect instrument of knowledge,” but it is still “the best we have.” He then drew a direct parallel to law: “Procedure is to law what scientific method is to science.“ The government bypassed both, and that’s why it lost.*

This is a big win for vaccine access, provider confidence, and our communities. And it is worth celebrating.

But make no mistake, this legal victory is not the end of the story.

Reality Check

My phone lit up after the decision was released. Colleagues across the country were ecstatically sharing the news about the ruling.

But another message brought me back to reality.

Friends with a new baby texted asking what this means for their child’s vaccines. What schedule should they follow? The “old CDC schedule”? The “new CDC” one? The AAP schedule? Is the AAP schedule the same as the “old CDC” schedule? Is the “old CDC schedule” out of date? I told them I recommend the AAP schedule, which pediatricians like me have continued to use throughout this chaotic time.

Like many parents, they have spent the last year watching vaccine guidance flip, then flip it back, then flip it again. New ACIP members in June. A thimerosal vote in summer. A hepatitis B decision in December. A new CDC schedule in January. The AAP published its schedule days later. In the exam room, pediatricians like myself have been telling parents one thing while the government says another. And now a legal ruling has entered the conversation.

The ruling restores some clarity, for now. But it can’t undo a year of confusion that’s already inside people’s heads. As of today, the CDC website still shows Kennedy’s revised schedule, not the pre-June 2025 guidance the ruling reinstated. For a clinician or parent trying to figure out what to do right now, that’s not a minor detail. And I don’t expect parents who were already skeptical to suddenly become more interested in vaccinating solely because of this decision. The ruling is a legal win. It is not a trust win, yet.

In some media coverage—particularly in right-leaning outlets—the ruling was framed primarily as a political story about a “Biden-appointed judge,” rather than a decision about vaccine policy, scientific rigor, and process. For those readers, this week’s ruling was a story about judicial overreach. That gap is part of the problem, and it doesn’t close with any court ruling.

Yes, this is a win. But it is far from over.

The government will undoubtedly appeal. Secretary Kennedy’s team has already said they “look forward to this judge’s decision being overturned.” It would not be surprising to see an appeal filed within days.

Even if the stay holds, what a procedurally compliant ACIP would look like under this administration remains unclear. Whether HHS finds creative ways to reconstitute a committee that appears legitimate on paper is an open question.

At the same time, freezing federal vaccine recommendations in early 2025 presents new risks. Decisions on next season’s respiratory vaccines, such as RSV, flu, and COVID, will need to be made soon. Without a lawful ACIP, the process for those recommendations is now uncertain.

There are also immediate gaps the ruling leaves unresolved. One product that protects infants against RSV (clesrovimab) may no longer be available at no cost to families who need it through VFC, because the Kennedy-appointed ACIP authorized its inclusion.

And the stayed ACIP members don’t disappear. They have large platforms, active social media presences, and no shortage of venues to keep amplifying the same claims that got their votes paused. If anything, expect them to frame this as censorship.

This lawsuit and ruling matter. As Richard Hughes, IV, the lead counsel for the AAP, put it in a commentary, “Not to litigate is to accept that this ‘new normal’ is valid.” However, this case cannot be expected to restore public trust or provide clarity on its own. That work is much harder and will not happen from the top down.

So, what can those of us in public health and pediatrics do in response?

Talk to your patients and communities. Don't wait for them to come to you confused or hear a spun narrative somewhere else. A court ruling won't rebuild trust the way a trusted voice can.

Watch the appeal and be ready to respond. When the appeal comes, and it will, be ready to explain what this ruling actually said, and what it didn't.

Support state and community-level vaccine access efforts. I’ve been asked whether this week’s ruling makes these efforts less important. The opposite is true. A federal stay is not a permanent fix, and state legislation that codifies vaccine access and protects immunization infrastructure is a hedge against exactly the kind of reversal that may be coming. Those efforts are more important now, not less.

Keep doing the communication work. The misinformation infrastructure is still running. The exam room, your community, or your platform, all of it counts.

Professional societies have stepped up admirably when federal guidance failed. As they continue to take the lead, transparent and public deliberation will be essential to maintaining the trust that makes their guidance so credible.

Bottom line: This legal victory is a step in the right direction, but the hard work of securing vaccine access, confidence, and public trust is only becoming more critical.

Thanks, as always, for being part of this community.

-David

*Disclaimer: I am definitely not a lawyer. For the best legal analysis on this case, I point you to an excellent explainer by at Skeptical Raptor.

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

The twice-a-year ritual of changing our clocks stole an hour of sleep this week, but it’s still been a busy one. Instead of an essay, I am sharing five things I have been working on, most of which dropped this week: an update on The Next Era of Vaccine Governance series, articles on school vaccine requirements and clinic vaccine dismissal practices, a prebunk for the upcoming ACIP meeting, and a podcast I co-hosted on the myth that won’t die that pediatricians make big profits on vaccines.

1. Engagement with “The Next Era of Vaccine Governance.”

The response to my post about The Next Era of Vaccine Governance was more than I expected. Many of you filled out the survey or reached out with comments and ideas.

Across those responses, a few themes stood out. Readers said the biggest unanswered questions about vaccine policy center on transparency, such as how decisions are made, who influences them, and how evidence is weighed. Many also emphasized the need for broader participation in policy conversations. And several noted that strengthening trust will require clearer communication about the data and processes that guide vaccine recommendations.

When I share this feedback with leaders, I often hear a similar response: “We are already doing these things!” That always makes me pause. If people don’t know these things are happening or aren’t hearing about it clearly, are they actually helping to build trust? As I said in the original essay, we can debate the accuracy of people’s perceptions endlessly, but legitimacy and trust do not depend only on technical correctness; they also depend on whether people can see, understand, and feel that institutions are responsive to their concerns.

One other thing that became clear to me is that this effort will require collaboration. Colleagues at The Evidence Collective will be helping to facilitate the interviews and conversations for this series. And I need you! Your responses and engagement are shaping what comes next, so thank you.

2. School vaccination requirements: five questions with honest answers.

and I wrote a piece for her newsletter () this week, walking through five questions readers are asking about school vaccine requirements: Do they work? Should vaccinated parents worry? What’s happening in other countries? How should I talk to people who disagree?

The thing I found myself reflecting on most was this: requirements do more than help improve vaccination rates. School requirements are reminders and nudges that prompt families to seek preventive care, creating a moment of connection that might not otherwise occur. When families come in for school-required vaccines, they also receive screenings for chronic diseases, vision and hearing checks, and many other services that help keep them healthy.

It is an opportunity for clinicians to catch problems that might otherwise be missed. I have countless stories of this happening with my patients, where a school vaccine visit led to catching growth delay, prediabetes, or vision problems, all of which would not have been caught as quickly.

Here’s the other thing in the broader policy picture that is more complicated than either side tends to acknowledge. Most Americans still support school vaccination requirements, across partisan lines. In fact, several polls found that congressional candidates from any party who are critical of school vaccination requirements could lose significant support. Despite this, more than 200 vaccine-related bills have been introduced in state legislatures, and that gap between public opinion and legislative activity is worth watching closely.

Your Local Epidemiologist

Top 5 questions about school vaccination requirements

The most effective vaccine program in American history doesn’t require a single new drug, clinical trial, or breakthrough. It requires a form for school enrollment…

Read more

6 months ago · 165 likes · 6 comments · Katelyn Jetelina and David Higgins, MD, MPH

3. Podcast: Do pediatricians get rich on vaccines? (hint: no)

This episode of the podcast, which I co-hosted with , features two incredible pediatricians: Dr. Sara Goza (nearly 40 years in practice in Fayetteville, Georgia) and Dr. Sian Jones-Jobst (20 years in Lincoln, Nebraska).

A claim has been circulating for years and was recently amplified at the highest levels of the federal government: that pediatricians make big profits from vaccinating children and that their recommendations are financially motivated. spent six months investigating this: analyzing commercial reimbursement data across all 50 states, reviewing state Medicaid fee schedules, and interviewing pediatricians. What we found was that the opposite is true. Pharma does not pay pediatricians to vaccinate, pediatricians aren’t getting rich off vaccines, and many practices lose money on every dose administered.

But what struck me most about this conversation wasn’t the economics. It was that pediatricians like Dr. Goza — who did spinal taps in her office for years before vaccines became available — aren’t just being told their medicine is wrong, they’re being told their motivations are corrupt. That’s a fundamentally different and more damaging kind of attack.

4. The Evidence Collective launches with a prebunk for the March ACIP meeting.

I’m a contributor to The Evidence Collective (TEC), a network of multidisciplinary scientists and clinicians who are also science communicators, collaborating to deliver clear, evidence-based information that breaks echo chambers with empathy and speed. One way we do this is through TEC briefs. These briefs translate complex public health developments into clear, practical insights, ready before you need them.

This week, TEC launched its Substack.

This has been in the works for a while, and I am excited to see it go live!

The Evidence Collective

Public health is moving fast. We help trusted voices keep up and communicate evidence-based information with confidence.

By The YLE Admin Team

The launch piece is a prebunk for the upcoming ACIP meeting on March 18–19. If you’re not sure why this meeting matters or how to communicate about it effectively, this is a good place to start. It walks through the most likely COVID-specific claims that may surface, with the evidence you need to evaluate them clearly.

The March ACIP meeting is expected to focus on COVID vaccine safety and related topics. It’s also likely to include a discussion and potential vote on how the ACIP makes vaccine recommendations. That process question matters more than you may think. The ACIP uses specific frameworks to systematically and transparently review the certainty and strength of the evidence, then translate it into recommendations. Changing these may be more than a bureaucratic tweak; it could affect whether national vaccine recommendations remain grounded in rigorous evidence review and transparent decision-making.

5. Should pediatric clinics dismiss families who don't vaccinate?

Finally, this piece, co-authored with , and , dropped a few weeks ago and tackles a common question that doesn’t get enough honest dialogue: pediatric clinic vaccine dismissal policies.

This is a challenging topic, which I have come full circle on. I have practiced in clinics that dismissed families who refused vaccines, and in practices that chose not to. Over time, I have come to believe that preserving the relationship is usually the better path. Not dismissing families over vaccine decisions gives me the best opportunity to protect that child’s health over time. But I also understand why thoughtful colleagues, motivated by a duty to protect medically vulnerable patients, may reach different conclusions.

Unbiased Science

"Looking for a Pediatrician Who Doesn’t Push Vaccines”

If you spend any time in parenting groups on Facebook, you’ve seen the posts…

Read more

6 months ago · 119 likes · 21 comments · Jess Steier, DrPH, David Higgins, MD, MPH, and Elana Pearl BenJoseph, MD, MPH

A final note: An opportunity to support Community Immunity

I have been thinking about this for a while, and wanted to share my thinking.

This newsletter has always been free, and it will stay free. Everything I write will remain available to all subscribers. But I’m adding a paid option for readers who want to support this work more directly.

Writing Community Immunity takes time and effort. I do this work on my own time. If this newsletter has been helpful to you, a paid subscription is a simple way to say thank you and support the work. And if the free version is what works for you, that’s genuinely enough. The community and conversation are what matter.

Subscribe now

Thanks, as always, for being part of this community.

-David

Community Immunity is written by Dr. David Higgins, MD, MPH, a practicing pediatrician and public health physician whose work focuses on vaccine delivery, health policy, and communication. This newsletter is where he writes about vaccines, public health, and community. When he’s not seeing patients or writing, he’s coaching youth soccer or exploring the outdoors with his family. Find him on LinkedIn, Instagram, Substack Notes, and Bluesky.

This newsletter is free for everyone. If you want to support the work that goes into it, a paid subscription means a lot.

Subscribe now

Share Community Immunity

It’s January 2029. A new president takes office.

One of their first acts is to replace the Secretary of Health and Human Services, who quickly reshapes senior leadership across the health administration. At the CDC, all members of the Advisory Committee on Immunization Practices (ACIP) are replaced with the roster from four years earlier, minus a few who’ve moved on. And vaccine schedules are immediately returned to their pre-2025 recommendations.

The public health and medical world exhales. Order restored.

But how might people — parents, grandparents, educators, business owners, policymakers — interpret those moves? As a correction? A restoration of “science”? Or as a fresh wave of political and ideological overreach?

If it feels difficult to imagine why millions of Americans might view this “restoration” as reassuring, that discomfort is worth sitting with. This is the uncomfortable truth: our vaccine infrastructure requires thoughtful reform to better meet the evolving needs of the patients, families, and communities it serves.

The U.S. immunization system has delivered profound population health benefits over decades. Yet recent disruptions have exposed vulnerabilities in its resilience and its perceived legitimacy.

The next era of vaccine governance — how guidance is developed, regulated, and implemented — is emerging now. What emerges may rhyme with the systems we knew, but it cannot, and should not, be identical to them. If we, as health leaders, are serious about building trustworthy and accountable institutions, we cannot simply restore what once was.

Distrust was a Pre-Existing Condition

A few months ago, I sat with a parent I had known for years in my exam room. She had vaccinated her older children, but as we talked about vaccines, she paused and said, almost apologetically, “I know I vaccinated my other kids, but I don’t know if I trust vaccines for my baby.”

What struck me was that her concern didn’t stem from a specific misleading claim, a study, or a feared side effect. Instead, it reflected a quiet loss of confidence she struggled to explain fully. She couldn’t quite name when that trust had eroded, only that it had.

Conversations like this are becoming more common. They remind me that concerns about vaccines are rarely just about vaccines themselves, but about whether guidance — and the system from which it was borne — still feels worthy of parents’ confidence.

It would be easy to view these exam-room conversations as isolated events. Taken together, however, they point to something broader: a slow, uneven erosion of confidence in the people and systems that shape vaccine guidance.

Vaccine governance has fractured. A recent analysis from and colleagues captured the landscape well: a whirlwind of lawsuits, schedule changes, and states charting their own course on vaccine policy.

But we must be honest about one thing: the foundation of trust in vaccine governance had already shown cracks long before 2025.

KFF polling shows that public trust in the CDC to provide reliable vaccine information fell sharply during the pandemic, dropping from 85% in early 2020 to 63% by late 2023.

That decline reflected a pronounced partisan divide, with Republican trust falling dramatically during the early pandemic years while Democratic trust remained relatively stable. By mid-2025, those dynamics began to shift again as political alignments around federal health leadership evolved.

This loss of trust during the pandemic did not occur in a vacuum. Moments of tension between vaccine governance and public trust have surfaced repeatedly across modern vaccine history – from the 1976 swine flu campaign and Guillain–Barré concerns, to whole-cell pertussis debates in the 1970s and 80s, the thimerosal precaution of the late 1990s, the Wakefield MMR–autism controversy, value-laden HPV vaccine debates in the 2000s, and communication hurdles during the 2009 H1N1 pandemic. These episodes unfolded alongside a broader erosion of confidence in public institutions over recent decades, shaping expectations about how science communicates uncertainty and how institutions respond to it.

By the time COVID-19 arrived, many Americans were already carrying lingering questions about federal vaccine governance.

The “4 in 10” Reality

Another reality to sit with: Although a majority disapprove, nearly 4 in 10 Americans approve of the way RFK Jr. is handling his job as HHS Secretary, including his handling of vaccine policy.

That is hardly fringe support. For millions of people, recent disruptions are interpreted less as attacks on science and more as a form of long-awaited accountability. They see institutions that they felt stopped listening to and serving them years ago being forced to answer.

We can debate the accuracy of their perceptions endlessly. But in democratic institutions, legitimacy rests as much on perceptions, transparency, and responsiveness to people’s needs as on technical correctness. Distrust did not begin in 2025, and it won’t vanish with an executive order in 2029.

The Reality of Our Information Age

As health leaders, we also have to stop acting like we are still living in a world with three TV networks and a local paper. We are contending with a hyper-fragmented information age, and we are about to find out what happens when A.I. pours gasoline on the fire.

Some of the decline in trust reflects orchestrated disinformation and activism spreading rapidly in this information age. But “misinformation” cannot be our only explanation.

This era is not only destabilizing but also deeply empowering. Knowledge once mediated primarily through institutions and professionals is now widely accessible, allowing people to explore health information, engage in policy discussions, and participate more actively in decisions about medical care.

I see this in my own clinical practice. Parents who once relied heavily on clinicians for information now arrive after extensive online searches, and some reference A.I.-generated summaries. We must also recognize that people are navigating an abundant yet uneven information environment, and that access to knowledge does not always translate into confidence in interpreting or applying it.

Increasingly, parents aren’t looking for a single authoritative voice. They’re looking for someone they trust to help them navigate the chaos.

Instead of only pointing out misleading claims or lies, which can feel like an endless game of Whack-A-Mole, we need to build something that actually gives the public a reason to trust.

We Aren’t Going Back

The next thing to wrestle with is this: We aren’t going back. Reversibility is not the same as reconstruction. You can replace a committee and reverse guidance overnight, but you cannot “reset” public confidence that easily.

Attempting to force an overnight 1:1 restoration of the 2024 status quo risks perpetuating a polarizing whiplash. The instinct to restore is understandable. For many leaders and organizations, it reflects a desire for stability, institutional preservation, and a return to systems that felt stable and predictable.

But if every administration feels justified in purging vaccine advisory bodies to install only voices aligned with it and has the authority to do so, vaccine governance becomes inherently unstable. Vaccine policy requires continuity and predictability. From R&D through manufacturing, delivery, and uptake, the time horizon for vaccines spans decades. We are already seeing manufacturers hesitate to invest in new trials, which is a concerning signal for the future of preventable disease.

Many organizations, health leaders, and advocates are understandably focused on maintaining the existing vaccine ecosystem. In a recent commentary in the American Journal of Public Health, I described the collaborative efforts underway to protect access and confidence as federal governance falters. But preserving what we have cannot be the only strategy. While we focus on stabilization and harm reduction, we cannot forget what comes next.

The question is not how we get back to 2019 or 2024, but how to build a system that better meets people’s needs and protects the health of our communities for 2029, 2033, and beyond.

Moving from Reaction to Reconstruction

Much of our collective energy has been devoted to responding to crises. That work is necessary, but it cannot be the endpoint. Operating only in crisis mode is exhausting. I want to invest more energy in helping create what comes next — to call the public into something better rather than only pointing to what is broken.

Building a better system of vaccine governance is messy. It won’t be fixed overnight, and it cannot be solved by simply returning to the old ways or walking away from the people and institutions that have protected us for generations. It requires imagination. We need people who can hold two truths at once:

1. The systems we had were imperfect.

2. Abandoning them entirely is dangerous.

Between those two truths is where building must take place.

From my own experience with that parent in the exam room, I know this: she wasn’t asking for certainty or more science facts. She was asking whether the people and systems behind the recommendation still deserved her trust and for someone to be a guide to her through the chaos.

Subscribe now

Launching a New Conversation

Over the coming months, I am launching a new series of interviews to explore what the next era of vaccine governance could look like. I’ll be talking to clinicians on the front lines of the “trust gap”, parents trying to do what’s best for their children as they navigate these systems, business leaders at the forefront of business and public health, scientists and policymakers imagining better models, and community leaders working outside traditional public health spaces.

Together, we will examine how policy is developed, who gets a seat at the table, and what “legitimacy” actually looks like in a polarized society. Some ideas may be structural; others, cultural. Some may feel uncomfortable, but all begin with the recognition that restoration alone is not enough.

Across conversations with clinicians, researchers, policymakers, and community leaders, several themes have emerged as potential starting points:

• Codifying advisory bodies so their structure cannot be reshaped overnight

• Safeguarding programs like VFC so families’ access does not hinge on rapidly shifting recommendations.

• Building more formal public input and dialogue into vaccine decision-making.

• Creating clearer pathways for professional, state, and community input to federal guidance.

• Requiring plain-language explanations of how recommendations were made, including areas of uncertainty or disagreement.

• Establishing guardrails to protect coverage and provider stability during transitions.

• Setting clear timelines for evaluating new vaccines to prevent decisions from stalling in ambiguity.

• Investing in trust infrastructure: sustained community dialogue, clinician communication training, and local engagement between crises

These are just starting points that require deeper thinking and broader input. And I certainly don’t have a monopoly on ideas; many people are far more qualified than I am to imagine what durable vaccine governance could become.

The next chapter of vaccine policy is already being written. Whether it earns trust will depend on whether we shape it intentionally or inherit it by default.

A Final Note

As I build this series, I want to make sure it addresses the most pressing questions on your mind. You can comment below, or for some anonymity, I’ve put together a brief, 3-question survey to help guide these upcoming conversations. I value your perspective!

Start Survey

Thanks, as always, for being part of this community. Special thanks to and for their thoughtful insights and review of this piece.

-David

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Leave a comment

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.

On its face, this is a routine update. The recommendations remain largely consistent with prior AAP guidance and continue to reflect decades of evidence, safety monitoring, and real-world pediatric care in the United States. And the AAP has been publishing childhood vaccine recommendations since the 1930s.

But this year, the schedule arrives in a very different environment.

The AAP recommendations now differ significantly from the recently issued CDC schedule, after nearly 30 years of alignment. Where the CDC has departed from longstanding evidence and established review processes, the AAP has chosen to continue recommending vaccines based on disease risk, safety data, and how pediatric care is actually delivered in this country.

The schedule is endorsed by twelve major medical and health care organizations representing more than one million clinicians across pediatrics, family medicine, obstetrics, infectious diseases, nursing, pharmacy, and public health. That endorsement reflects a broad consensus among the health professionals who care for children across the United States.

The release of this schedule and broad endorsement by the medical field are critical, but what comes next in exam rooms is even more challenging.

Subscribe now

Now comes the harder part

Hundreds of thousands of child health professionals across the United States are now tasked with explaining the value of these vaccine recommendations to parents who are navigating not just misinformation from fringe actors, but also conflicting guidance from federal health agencies.

Parents are walking into visits with more questions than usual. Some are confused. Some have heard that recommendations have changed. Some are unsure which guidance to trust. Most are simply trying to do the right thing for their child in a moment that feels noisy and unsettled.

If clinicians ever struggled to empathize with parents’ concerns, that should come more easily now. Families are trying to make sense of an environment shaped by anti-vaccine influencers and, increasingly, by actions and rhetoric from within the federal government that inflate vaccine risks, obscure benefits, and undermine confidence in the systems designed to monitor safety. Their pediatrician is saying one thing. Federal health authorities are saying something else. Confusion and concern are not only understandable but also expected.

In a moment like this, families are less concerned with policy disputes than with knowing whom they can trust to guide them through decisions about their child’s health.

What Families Need

What families are not asking for is a lecture on advisory committees or a comparison of schedules between countries. What they want is what they have always wanted from their child’s clinician: clear recommendations, honest explanations, and reassurance that the advice they are receiving is grounded in their child’s best interest.

That starts the same way it always has: naming what a child is due for and making a strong, confident recommendation. Clinicians should avoid preemptively explaining controversies or policy disputes; instead, they should anchor the conversation in the child in front of them.

When questions come up, empathy comes first. Parents are encountering headlines, social media posts, and conflicting messages that would make anyone pause. Acknowledging that confusion and partnering with families builds trust. These conversations do not require defending every policy decision. Short, clear explanations focused on why a vaccine is recommended, how it protects their child, and why you recommend it for all of your patients are often enough.

Importantly, not every visit needs to turn into a discussion of changes in national policy. In fact, most won’t involve that at all. If parents do not raise such questions, clinicians do not need to introduce new concerns. When parents do ask, the goal is not to litigate institutional disagreements, but to re-center the conversation on their child’s health, reaffirm your recommendation, and respond directly to what they are worried about.

What has not changed is just as important as what has. Most parents still choose to vaccinate. Vaccines remain one of the most effective tools we have to keep children healthy and thriving. Trust still lives in the exam room, and pediatricians remain the most trusted source of vaccine information for families.

At its core, the role of the clinician has not changed. Families need a trusted navigator in a confusing moment. Someone who knows their child and their family. Someone who can offer expert, evidence-based guidance that they cannot get anywhere else, and reassurance rooted in a relationship. Pediatricians and child health clinicians have walked families through far more complex and emotionally charged decisions than this. That is why families trust them.

Thanks, as always, for being part of this community.

-David

Leave a comment

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.

Last week, MedPage Today published a piece I wrote titled “Parents Are Confused. I’m Worried for My Pediatric Patients.” I wrote it after a recent series of conversations in clinic that felt meaningfully different from the questions I usually hear about vaccines.

These conversations weren’t driven by misinformation. The parents were disoriented.

One parent summed it up well with this question: “What vaccines are recommended now? I’m so confused.”

I’ve heard some version of that question several times this week, including from families who previously made confident, routine decisions to vaccinate.

That confusion is the predictable outcome of an overnight rewriting of the U.S. childhood vaccine schedule, justified as an effort to “restore” or “rebuild” trust.

This rationale deserves far more scrutiny than it has received.

The argument appears to go like this: the United States is a negative “outlier” compared to peer nations; routine childhood vaccination is facing a crisis of trust; and recommending fewer routine vaccines will lead parents to trust clinicians more.

As someone who studies vaccine delivery and communication, and who sits with families every day, I can say plainly: each of those assumptions is backwards.

This week, I want to examine the assumption underlying all of them: that the U.S. being an outlier in childhood vaccination is inherently a problem.

Almost no one is framing the possibility that the U.S. is an outlier because it was a leader in preventing childhood disease.

Is Being an “Outlier” a Problem?

One of the most common justifications for the schedule overhaul is that the U.S. was an “outlier” compared to peer nations, often citing countries like Denmark.

Many responses have focused on whether that claim is even accurate, noting correctly that the U.S. schedule is not dramatically different from those of many peer countries and that Denmark is itself an outlier.

While these points matter, they skip over the more revealing assumption embedded in the argument: being an outlier is evidence of a problem.

Being ahead of peer nations in preventing life-threatening disease, using one of humanity’s greatest achievements, is only a liability if you assume routine vaccination is a problem and we should do less of it. That conclusion is being treated as self-evident without ever being defended.

The U.S. has been an outlier in plenty of other domains where “different from peers” is rarely invoked as a warning sign. We have been an outlier in landing humans on the moon, building the internet, and sequencing the human genome. In none of these cases is outlier status taken as evidence that we should pull back to align with peer nations.

Difference, on its own, tells us nothing about whether a policy is good or bad. What matters is evidence of harm, risk, or unintended consequences that outweigh the benefits.

And this is where the justification falls apart.

We’ve been offered no new evidence that broader protection against vaccine-preventable diseases has become a liability rather than a strength. Instead, the vaccine schedule is being rewritten as if that conclusion were already established.

I joined the ScienceVs podcast this week to talk through these issues, and one point I tried to make there was this:

The fact that we have vaccine coverage for more diseases is not evidence of a problem. That's backward. It's not a competition to see how few diseases we can prevent.

Why “Peer Nation” Comparisons Fall Short

Setting aside the unexamined assumption that more vaccines are inherently problematic, the fact that another high-income country does not routinely recommend vaccines reflects different policy trade-offs, not a lack of evidence.

Vaccine schedules are shaped by national context, including disease epidemiology, health-system capacity, financing, equity, and the reliability of follow-up care. Those factors matter enormously.

Denmark has a smaller population, far less inequality, and universal health coverage. In that setting, policymakers can reasonably assume timely access to care, consistent follow-up, and fewer structural barriers. The U.S. operates under very different conditions.

Here, the childhood vaccine schedule must compensate for gaps in access, delayed diagnosis, inconsistent follow-up, and wide variation in healthcare delivery. It functions, in part, as a proactive clinical safety net, one designed to protect children despite those system-level weaknesses.

That difference is often overlooked.

I recently spoke with a pediatrician who practiced for many years in Denmark before moving to the U.S. He had many positive things to say about the Danish healthcare system, much of which we should aspire to replicate. Yet he viewed Denmark’s more limited vaccine schedule as a weakness, not a strength, particularly given how well the U.S. program has prevented disease across a far more complex system.

Calling the U.S. schedule an “outlier” was never evidence that it was wrong. In many cases, it meant we were setting the pace.

In fact, peer nations often move toward the U.S. over time. The United Kingdom’s recent adoption of routine varicella (aka chickenpox) vaccination is one example. And even Denmark recently added the RSV vaccine during pregnancy, following the U.S. lead.

Here’s the irony that isn’t being widely acknowledged: The U.S. is now becoming an outlier in the opposite direction, and we are narrowing protections while other countries expand them.

I’ve written more about how these country comparisons are misleading with here:

Unbiased Science

There’s Something Rotten In The United States

Special thanks to Dr. Kayleen Schreiber for leading this piece and developing our interactive data visualizations (she is not on Substack…

Read more

8 months ago · 173 likes · 17 comments · Jess Steier, DrPH, Unbiased Science, David Higgins, MD, MPH, Izzy Brandstetter Figueroa,MPH, and Elana Pearl BenJoseph, MD, MPH

Subscribe now

A Few More Things That Deserve Attention This Week

Another Development Is Unfolding Quietly, With Big Implications

While most attention has focused on the overhaul of the childhood vaccine schedule, something else is happening that has received almost no scrutiny.

As of today, The Hill has confirmed that at least 4 members of the Advisory Commission on Childhood Vaccines (ACCV) have been removed. This obscure commission advises HHS on the Vaccine Injury Compensation Program (VICP), the no-fault system Congress created to compensate rare vaccine injuries while protecting vaccine access and supply.

This matters because the ACCV sits at the legal and financial foundation of the U.S. vaccine system. It has also long been a target of anti-vaccine activists.

The commission advises the Secretary of HHS on what counts as a vaccine injury, which injuries are presumptively compensable, and how the Vaccine Injury Table is updated. Those decisions shape liability, compensation, and ultimately whether vaccines remain viable to produce and offer at scale.

Changes to the ACCV rarely draw headlines. But the replacement of members can profoundly alter how changes to the vaccine injury system are justified and whether the balance Congress struck in 1986 continues to hold.

Some reforms could meaningfully improve the Vaccine Injury Compensation Program. But, if responsible reform is truly the goal, these removals are difficult to square with that claim.

One of the members who was removed is a close colleague. I can say without hesitation that they are one of the most thoughtful, compassionate, and principled pediatricians I know. They bring care, balance, and seriousness to difficult questions, and if the aim is meaningful, good-faith reform of the VICP, they are precisely the kind of person you would want at the table.

These are precisely the kinds of procedural moves that can reshape a system before most people realize it is happening. And the risks to vaccine access and to families’ ability to choose vaccination in the U.S. are real.

I wrote more about these risks with the ACCV and VICP last month with colleagues from and here:

Unbiased Science

The Quiet Commission That Could Break the Vaccine System

There are almost endless levers RFK Jr can pull to impact your access to vaccines. From spreading falsehoods on social media to federal vaccine policy bodies like the ACIP (Advisory Committee on Immunization Practices). But there is one lever being positioned in the background, and it’s likely one you’ve never heard of but has profound implications, eve…

Read more

8 months ago · 93 likes · 32 comments · Jess Steier, DrPH, David Higgins, MD, MPH, and Katelyn Jetelina

Influenza Update

One final note on influenza.

This has been a particularly severe flu season. While local data in Colorado suggest we may be past the most recent peak, substantial influenza is still circulating in the community, and I continue to see it regularly in my patients.

Two points are especially important to emphasize.

First, it is not too late to get vaccinated. Earlier vaccination is ideal, but protection still matters now. The best time to get a flu vaccine was earlier in the season; the second-best time is today.

Second, the vaccine works. Early laboratory data sparked rumors that this year’s flu vaccine is ineffective against the predominant circulating strain, H3N2 subclade K. Those claims may have been overstated. While no flu vaccine is perfect, and effectiveness estimates are often not clear until well after the season ends, the available evidence shows the vaccine produces antibodies that recognize this circulating strain and provide meaningful protection, especially against severe disease.

Finally, as I said to NPR this week, weakening influenza vaccine recommendations in the middle of a severe flu season is irresponsible and dangerous. I continue to recommend influenza vaccination for all my patients.

Share

Leave a comment

Thanks, as always, for being part of this community.

-David

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.

Subscribe now

It’s 2027.

The Smith family is just trying to get through the week.

They have two kids, one in kindergarten and one still a toddler. Like most families, their days are a blur of school and work drop-offs, meetings squeezed between pickups, a landlord coming by to fix the sink, afterschool activities, and roughly 5,000 emails and to-dos they’ll never quite catch up on.

Tucked into this carefully choreographed chaos is a routine visit to the pediatrician, where vaccines come up, as they always do.

“So… are these still recommended or not?”

The Smiths had seen headlines and heard just enough over the past year to feel uneasy.

The pediatrician is clear, calm, and reassuring. “These vaccines are really important, and I still recommend them.”

“But we read the CDC says some of these aren’t recommended for everyone now?” Mr. Smith says.

The pediatrician doesn’t hesitate. “What’s changed is how the federal government is labeling the recommendations, not the evidence behind them. The decision is ultimately yours. I’m happy to talk through the risks and benefits with you, like I always have. I recommend the American Academy of Pediatrics schedule because it’s developed around what’s best for children’s health.”

The Smiths were still unsure, “We are just so confused. With everything we’ve heard, we’d like to wait and think about it.”

The Smiths left the appointment planning to “circle back.”

They aren’t refusing vaccines. They aren’t anti-science. In fact, they had always chosen to vaccinate their kids. They’re overwhelmed, and a year of conflicting messages has shaken their confidence just enough to pause

The following week, a neighbor claims that the CDC now says vaccines may cause autism and that we give too many vaccines. The Smiths don’t really trust their neighbor for medical advice, but it raises questions they can’t quite shake.

So they do what most parents do. They go online.

They try to read about vaccines and the diseases they prevent, but science and biology aren’t their background. They run into words like seroconversion, anamnestic response, and pharmacovigilance. It feels like a foreign language.

They read that the CDC wants parents to make their own “individual decisions” about vaccines. Yet, its own website offers little clarity about how to make an informed decision, or even whether vaccines are still important and safe.

In frustration, Mrs. Smith throws up her hands. “They want this to be our decision now,” she says, “but we aren’t vaccine experts. How are we supposed to know what’s best?”

They think back to what their pediatrician said. They trust her. So they decided to move forward with vaccination.

That evening, after bedtime, they sit down to figure out the next steps.

The first stop is the insurance portal.

The language is vague. Some vaccines are listed as “routine.” Others aren’t. One note says “coverage subject to clinical determination.” Another says “prior authorization may apply.” They can’t risk paying out of pocket if they aren’t covered; they don’t have the money.

They call the pediatrician’s office the next morning. The nurse is kind, but honest. “Ever since the CDC shifted its recommendations, we’re still sorting through all these changes,” she says. “We recommended the AAP schedule, but we’re getting questions from insurers, families, and even public health. Insurance covered vaccines last year, but there is a lot of confusion this year with new plans. I will have to look into this. Honestly, we haven’t even been able to stock every vaccine option. It’s been a lot.”

A week later, daycare calls.

There’s been a case of chickenpox in the kindergarten classroom.

The center isn’t closing, but children who aren’t fully protected are asked to stay home while records are reviewed. The state loosened childcare vaccine requirements last year following a shift in federal guidance. The Smiths scramble to confirm documentation. The immunization registry is backlogged, strained by months of changing guidance and workarounds.

Their younger child misses several days of daycare. It’s the second time this year; the first was during a pertussis outbreak at the same center. Mrs. Smith has no PTO left. Mr. Smith doesn’t get PTO and can’t afford to miss work. Tension builds. Childcare plans unravel. Now, even finishing routine vaccines means another appointment, more missed work, and continued uncertainty about insurance coverage. Everything feels harder than it used to be, for no clear reason.

A few days later, another issue comes up. Their older child is due for a flu shot.

In past years, this was easy. Sometimes it happened at the pediatrician’s office. At other times, they would use a pharmacy or a school-based clinic when schedules were tight.

Now they hesitate.

Is the flu shot still recommended? Does “shared clinical decision-making” require a separate visit first? Can the school vaccine clinic still give it? Will insurance pay for it?

They don’t know. And it doesn’t feel like anyone else does either.

At pickup, another parent says their clinic stopped offering some vaccines until guidance is clearer. Someone else was told to “check with their doctor first.” No one sounds anti-vaccine. Just confused.

None of this feels catastrophic on its own. It’s a series of small pauses: hesitation fueled by headlines, delayed appointments, fear of unexpected costs, routine vaccines now requiring extra justification, avoidable daycare exclusions, and clinics unsure what they’re allowed to offer.

A system that once made simple, safe prevention easy is now forcing families to second-guess and leading to delays.

The Smiths grow frustrated. They didn’t change their values. They still trust their pediatrician.

What changed was the clarity of the system around them. And that’s how vaccination slowly erodes, through friction, confusion, and small barriers that add up, for families just trying to get through the week and keep their kids healthy.

Subscribe now

The Policy Decision Behind the Confusion

The story of the Smiths begins to show why the actions taken by RFK Jr. and HHS this week to rewrite the U.S. vaccine schedule overnight matter.

An internal review was substituted for the transparent, public, deliberative process that has guided U.S. vaccine policy for decades. In fact, the role of the ACIP in vaccine recommendations is now unclear. There was no disease-burden modeling made public. No accounting for how many children might be harmed by lower coverage. There was no meaningful opportunity for clinicians, parents, independent experts, or the public to weigh in before recommendations that affect nearly every family in the country were altered.

That matters because ambiguity is not neutral. It shifts the burden onto families who never asked to become experts in immunology or vaccine policy. It also fails to create trust. It creates friction in systems that rely on clear and stable guidance.

If you want to understand why moving routine vaccines into “shared clinical decision-making” sounds benign but actually undermines the evidence, I’ve written more about that here:

And if you want a clear, evidence-based breakdown of the science and real-world impacts of this week’s decision, including potential implications, The Evidence Collective has published a detailed briefing here:

[TEC Briefing on the January 5 Vaccine Schedule Changes]

Parents should not be forced to become vaccine experts. And they need a system that makes prevention easy, clear, and reliable.

For families navigating this moment, the most important message remains simple: trust your pediatrician. Pediatricians are still recommending vaccines based on the best available evidence and what protects children’s health. They will continue showing up for parents with expertise, care, and empathy, even as the ground shifts beneath all of us.

Thanks, as always, for being part of this community.

-David

Leave a comment

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.

I was walking through a conference center earlier this year when I heard someone say this.

I looked around to see who the comment was directed at. It couldn’t be me. When I realized there was no one else nearby, I sheepishly mumbled a “thank you,” hoping the conversation would end there. It didn’t.

The well-meaning person, whom I didn’t know but who continued as if we’d been best friends for years, asked me several questions about being “an influencer.” Apparently, slipping in my AirPods and walking with purpose, after my extrovert tank had been running on empty for hours, was not the successful escape strategy I’d hoped for.

Each time they used the word influencer to describe me, I flinched, and a small piece of me died inside, prompting me to explain that I don’t sell anything, avoid sensational language, and have never aspired to have a brand.

They paused and said, “Okay, I won’t call you an influencer. But can I ask why you started doing so many public things like your substack?”

That question made me stop.

Why did I start writing this newsletter outside of obscure, paywalled academic journals? Why am I willing to pick up the phone when a reporter calls or write editorials? Why am I posting anything on social media at all?

This certainly isn’t my default setting. Until 2024, my social media presence consisted of an untouched Facebook account with a seven-year-old family photo and a decades-old MySpace account that I hadn’t logged into since college.

If I’m being honest, I’m much happier out of the spotlight. While I enjoy public speaking, after every talk I want to retreat to a cabin in the woods, read books, and fish for a few days to refill my introvert tank.

So why did I reluctantly step into the spotlight so often this year?

I don’t make money from this work, and it doesn’t meaningfully advance my academic or clinical career; it mostly opens me up to criticism and, at times, outright attacks. So why do it?

Because I’ve seen the harm that chaos, misinformation, and politicized messaging are doing to my patients, their families, and my community.

The places everyday people once depended on for trustworthy information are broken, yet parents, clinicians, journalists, and policymakers are still expected to make real decisions in real time, with real consequences.

Community Immunity began as an attempt to stand in that gap. To help people make sense of what was happening and to offer language that real people could use in clinics, newsrooms, classrooms, and kitchen-table conversations.

I also genuinely love the work of writing itself. I love words. There’s something grounding about taking a messy, complicated idea and slowly chipping away at it, like a stone, until the shape underneath becomes clear enough to share.

That craft felt even more necessary this year. Earlier in 2025, when it became clear that dangerous misinformation and misleading claims would be coming from our own federal health administration, I found myself in a slump. I asked a wise friend what we could do, if anything, in response. They said, “Protect the vulnerable and hold up truth for others to see.” That became my motto this year.

This work has clarified something important for me. Social media is not where debates are won. Comment sections are largely performative and dominated by the loudest, and often most obnoxious, voices. But quieter people are watching and trying to sort the real signal from the noise.

Posting reliable information lowers the friction for making good decisions. It prevents misinformation from being the only story available. That work is often invisible, but it matters.

For me, the most meaningful responses this year didn’t happen publicly. They came as emails, texts, or unexpected comments from people at conferences, who told me that something I wrote helped them think differently or communicate more clearly. That’s why I keep writing.

I need to be honest about what this work requires. Advocacy costs something, and sometimes it costs a lot. There’s real cognitive and emotional labor in constantly tracking misinformed policy shifts, misinformation cycles, and public fear, especially while practicing medicine, doing research, and raising a family. There were times when writing felt less like expression and more like responsibility.

And it turns out there are people who really dislike those who advocate for vaccines. I’ve been called names I hope my kids never see. I’ve received personal threats. And I understand that speaking publicly carries professional tradeoffs.

That doesn’t mean the work isn’t worth it. But it is expensive. And I’ve learned that being selective about what I respond to, and taking necessary breaks, is the only way this work remains sustainable.

I don’t know exactly what Community Immunity will look like next year. But I do know what I want it to continue being: a place for sensemaking. A place where evidence and empathy aren’t treated as opposites. A place that helps people stay oriented to science, to care, and to one another, even as the broader culture pulls us toward extremes.

So no, I’m definitely not an influencer.

But if this writing has positively influenced you, helped you feel better equipped in your own conversations, or sharpened your thinking, then it’s done what I hoped it would do.

Thank you for reading. And thank you for being part of the quieter, harder work of keeping our communities healthy.

Thanks, as always, for being part of this community.

-David

Subscribe now

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky. (Not MySpace)

Two weeks ago, the Advisory Committee on Immunization Practices (ACIP) voted to change the childhood hepatitis B vaccine from a routine recommendation to a shared clinical decision-making (or so-called “individual based decision-making”) recommendation.

The committee now frames this as a decision for parents and clinicians to weigh benefits and risks on their own. On the face of it, that framing sounds reasonable and even reassuring.

So, why did 67 leading medical, health, and patient advocacy groups publicly oppose the move, and why have health leaders across the country sounded the alarm?

The answer is simple. A policy tool intended for narrow circumstances is being weaponized to manufacture uncertainty where none exists, allowing the ACIP to abdicate its responsibility to provide clear, evidence-based guidance and instead shift the burden of evidence interpretation onto clinicians and parents.

Subscribe now

What Shared Clinical Decision Making Means in Vaccine Policy

To understand why this matters, we need to be precise about what shared clinical decision-making (SCDM) is, and what it is not.

In vaccine policy, SCDM is not a communication style. It is a specific type of policy recommendation used when the evidence suggests a small, uncertain, or highly variable net benefit, such that a routine recommendation for the entire population is not warranted.

The ACIP began using SCDM in 2019, replacing older “permissive” or “Category B” language. Before this year, it had been used sparingly and only in limited circumstances, including adult HPV vaccination, meningococcal B vaccination for adolescents and young adults, hepatitis B vaccination for some older adults, and select pneumococcal recommendations.

SCDM designations have historically been reserved for rare cases where uncertainty is substantial enough that the committee cannot responsibly recommend a default course of action.

Policy Designation Is Not the Same as Bedside Decision Making

This is where much of the confusion and misdirection arises. There is a distinction between the application of SCDM as a vaccine policy designation and its use in clinical practice.

Shared decision-making in clinical practice is a collaborative, evidence-informed process that involves patients and clinicians working together to make healthcare decisions that align with values and goals. While definitions of clinical shared decision-making have evolved, it is most often understood as a tool for situations in which there is no single clearly superior option.

That distinction matters. The current committee is invoking the language of clinical shared decision-making in a context where uncertainty has been manufactured rather than demonstrated.

At the national vaccine policy level, SCDM has a very specific meaning. It signals uncertainty and suggests a small, unclear, or highly variable net benefit. Applying the SCDM label to routine vaccines that have strong, consistent evidence does not enhance patient-centered care or build trust. It creates the false impression that experts are divided on the best way to protect health when, in fact, they are not.

This framing also overlooks the influence of external actors on decision-making in the exam room. Much of the pressure to reframe routine vaccines as SCDM is not coming from patients or clinicians, but from distant actors who are far removed from clinical care. These voices use the language SCDM strategically, often stripped of context, to cast doubt on evidence and erode trust in expertise. Amplified through social media, they create the illusion of grassroots concern while fueling fear and confusion, even as they use misappropriated SCDM language to simultaneously imply that clinicians and parents should “figure it out” on their own.

Why “Individual-Based Decision Making” Is a Misleading Rebrand

In recent votes, the committee has intentionally shifted its language from “shared clinical decision-making” to “individual based decision-making.” That change is subtle, but not incidental. It wrongly implies that individualized conversations and informed consent were absent from the vaccine delivery process.

After changing COVID-19 vaccine recommendations from routine to individual based decision-making recommendations this year, acting CDC Director Jim O’Neill said, “Informed consent is back.”

But as I have written about before, informed consent is alive and well.

Unbiased Science

Informed Consent Is Alive and Well—Despite What You’ve Been Told

Acting CDC Director Jim O’Neill recently declared that “informed consent is back” for vaccines. This left us scratching our heads because informed consent never went anywhere. We can only assume that this reflects a misunderstanding of what informed consent is—and what it isn’t. But O’Neill isn’t the only one confused. Across social media, in public f…

Read more

9 months ago · 84 likes · 40 comments · Jess Steier, DrPH, David Higgins, MD, MPH, and Elana Pearl BenJoseph, MD, MPH

Patients have always had the right to receive information, ask questions, and decline vaccination. What informed consent does not require is neutrality when the evidence is clear, or giving equal weight to unequal evidence. A strong recommendation when the evidence is clear is not coercion or a mandate. It is a core ethical responsibility of medical professionals and can be given in the context of individualized, shared decision-making.

Yes, not all clinicians communicate effectively about vaccines, and not all consistently engage patients in respectful, individualized conversations when concerns arise. Many clinicians would also benefit from improved training in communication and responding to uncertainty. But that won’t be improved through a policy label. The solution to variable communication quality is investment in training and support, not the removal of clear, evidence-based guidance.

When Every Recommendation Becomes SCDM, Guidance Disappears

The ACIP exists to answer a core question for clinicians and public health professionals: “What does the best available evidence support, and how strongly should I recommend it?”

Under normal circumstances, that question is answered through clear, evidence-based recommendations. Today, many clinicians and public health leaders, including myself, no longer trust this committee to provide that guidance responsibly.

While less disruptive than eliminating recommendations altogether, SCDM is not neutral. It is still a form of guidance that shapes how vaccines are offered, discussed, reimbursed, and delivered. SCDM recommendations remain consequential policy choices with real downstream effects.

If routine vaccine recommendations are systematically converted to SCDM, the core question ACIP was created to answer goes unresolved. The vaccine schedule becomes a menu of options rather than expert guidance, and responsibility for interpreting the evidence shifts away from the advisory body charged with that task. While that shift may seem preferable to other alternatives given the committee’s current composition, it creates problems that will be difficult to undo.

In practice, SCDM recommendations outsource judgment to clinicians and families, many of whom lack the time, resources, or institutional support to independently evaluate complex vaccine evidence, especially in an information environment saturated with misinformation.

Who Pays the Price for Burden Shifting

This is the hidden cost of misusing SCDM vaccine policy recommendations.

Responsibility shifts away from expert bodies and onto individual clinicians and families. Clinicians are expected to review and synthesize vast scientific literature independently. Parents are asked to navigate complex risk-benefit calculations in an information environment saturated with misinformation.

Individuals with lower health literacy, limited access to trusted healthcare, and fewer resources are disproportionately affected. Far from promoting choice, this approach widens disparities.

Clinicians face real professional and legal risks when vaccine recommendations are muddled or inconsistently applied, a reality that has gone unaddressed during recent ACIP meetings. Pediatricians have been sued for failing to fully inform families about the consequences of vaccine-preventable diseases and for failing to offer recommended vaccines.

Here is the bottom line. A SCDM recommendation is a convenient way out for this committee. It shifts responsibility onto parents and clinicians, allowing the committee to avoid owning the consequences that come with making a complex public health decision. If these vaccines truly carried the concerns erroneously claimed during recent ACIP meetings, the committee would have reflected that with a vote not to recommend them. They have not done so because that would require real evidence, a transparent and rigorous review, and the willingness to stand behind such a consequential decision in the face of scrutiny from the overwhelming majority of the public who want vaccines and real experts. Leadership requires making clear decisions and accepting responsibility for their consequences. Shifting that responsibility onto others is not shared decision-making. It is a failure of leadership.

One Last Thing: ACCV Meeting Rescheduled for December 29 — Why This Matters

Before you go, one final development is worth flagging. A meeting of the Advisory Commission on Childhood Vaccines (ACCV) has been scheduled for December 29, 2025, according to a newly published Federal Register notice. The meeting was originally scheduled for this week and then moved to the narrow window between Christmas and New Year’s—a time when public attention, media scrutiny, and stakeholder participation are typically limited.

The ACCV is the federal advisory body charged with providing recommendations to the Secretary of Health and Human Services on the National Vaccine Injury Compensation Program (VICP), including proposed changes to the Vaccine Injury Table, which is a list of injuries presumed to be caused by vaccines for no-fault compensation. Any proposed changes to the Vaccine Injury Table must move through ACCV review as part of the federal rulemaking process.

It is worth remembering why the VICP and ACCV exist. They were created in the late 1980s to address two intertwined problems: ensuring that individuals who experience rare but real vaccine-related injuries are compensated fairly and efficiently, and protecting the nation’s vaccine supply from collapse under the weight of litigation, including claims not supported by evidence. The program was designed as a careful balance of supporting those injured while preserving broad access to vaccines by providing manufacturers and clinicians a stable, predictable liability environment.

That balance matters. If compensation and liability standards are broadened in ways that are not tethered to evidence, the VICP and vaccine infrastructure it supports risk becoming unsustainable. A compensation system that is overwhelmed by claims not causally linked to vaccines would ultimately undermine vaccine availability, affordability, and participation by providers and manufacturers.

To be clear, there are reasonable conversations to be had about improving the VICP. Many experts agree that the program could be faster, more transparent, more generous in certain cases, and more responsive to families navigating it. But those reforms must be evidence-based and carefully calibrated to preserve the program’s core purpose.

This upcoming ACCV meeting matters because the administration has signaled interest in revisiting the Vaccine Injury Table, and reporting has documented discussions about potentially expanding neurologic injury categories in ways that could allow children with autism diagnoses to qualify for compensation. As reported by Politico, advisers to Secretary Robert F. Kennedy Jr. have openly discussed efforts to “capture” autism cases within the VICP framework by broadening definitions, despite decades of evidence showing no causal link between vaccines and autism.

The health administration can either reform the VICP so it functions better for families who experience rare vaccine-related injuries, or approve changes that destabilize and ultimately break the program. It cannot do both.

The unusual timing of this meeting raises legitimate concerns about transparency and public oversight at a moment when changes to the vaccine compensation system could have serious downstream effects. As public focus remains fixed on the chaos surrounding ACIP and vaccine recommendations, consequential structural changes to the VICP may be moving forward with far less scrutiny.

This is something to watch carefully, as changes under the banner of reform could cause lasting damage to vaccine access, stability, and public trust.

Thanks, as always, for being part of this community.

-David

Leave a comment

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.

The two-day meeting of the ACIP—the advisory committee that informs the CDC on vaccine guidance—is over.

The meeting was a chaotic circus of unqualified and deeply misinformed presenters and participants. I am exhausted from trying to keep up with the sheer volume of inaccuracies, scientific distortions, and confidently delivered claims masquerading as expertise.

Throughout it all, one thought kept coming back to me: our kids deserve better.

They deserve real experts committed to transparent, rigorous, evidence-based policymaking—not policy-based evidence making, not performative theatrics, and not misinformed decisions that erode decades of progress in children’s health.

Between livestreaming the meeting and answering reporters’ questions, I sat with a parent in clinic who asked me, “Should I be worried about this?” They weren’t talking about hepatitis B. They were talking about the chaos.

In response, I’ll continue to show up and do the same thing I have for years: talking with parents who are anxious and confused, helping them make sense of the chaos, and partnering with them to help their children thrive. That work has never felt more important than now.

While the circus that is U.S. federal vaccine policy continues, pediatricians across the country will keep caring for kids and supporting families. We will show up in exam rooms, hospital nurseries, community clinics, and living rooms, offering evidence, empathy, and a steady hand. And we will continue to provide credible information with compassion, helping families make truly informed decisions.

And we won’t stay quiet while misguided policy and ideological theatre put children at risk. Our responsibility is—and has always been—to the health of children.

Do not come between a pediatrician and our patients’ health.

We are fiercely devoted to them.

Subscribe now

Rather than recapping the meeting, I would like to offer something more useful: a set of clear, evidence-based resources that I contributed to, which you can rely on as you process what happened and its implications.

• The Evidence Collective (TEC) has prepared this report to address many of the falsehoods that emerged from the meeting. It reflects an extraordinary effort by colleagues committed to protecting public health through clear, evidence-based information.

• I wrote a piece for The Conversation that describes the hepatitis B vaccines and potential implications.

• The American Academy of Pediatrics and 45 other organizations signed on to this statement, condemning the committee's actions.

• For those of you lucky enough to live here in Colorado (kidding—it’s terrible, don’t move here), I joined 9News to break down what this all means for our state and our efforts from Colorado Chooses Vaccines.

Thanks, as always, for being part of this community.

-David

Do you like this newsletter?

Community Immunity is free for everyone. If you find it valuable, please subscribe below and help spread the word!

Share Community Immunity

You can also follow me on LinkedIn, Instagram, Substack Notes, and Bluesky.