Comments from Richard Besser, MD, on Vaccination Classification Recommendations
The Robert Wood Johnson Foundation (RWJF) is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work alongside communities, practitioners, researchers, nonprofit organizations, and public institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.
The U.S. Department of Health and Human Services (HHS) has requested information on the categories used in federal vaccine recommendations and the potential expansion of vaccines classified under “shared clinical decision-making” (SCDM).1 My comments responding to this request are grounded in my current role as president and CEO of RWJF and the perspectives and expertise of RWJF grantees, who include healthcare providers, researchers, and patients. They are also informed by the more than 30 years I spent practicing pediatrics, when I relied extensively on vaccine recommendations from the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) to protect and improve the health of my patients and provide sound counsel to their parents.
Vaccines are one of the greatest achievements in science, public health, and modern medicine.2 Pediatric vaccines have saved millions of lives, prevented millions of illnesses and hospitalizations, and saved trillions of dollars while reducing disparities in health outcomes. Among U.S. children born between 1994 and 2023, routine childhood vaccinations prevented approximately 508 million cases of illness, 32 million hospitalizations, and over 1.1 million deaths.3
Given the critical importance of vaccines to people’s health, I appreciate the opportunity to provide public comment on potential changes to vaccine policy. HHS has requested information about “whether the categories currently used in Federal vaccine recommendations [routine (universal), risk-based, and SCDM] are adequate.” The answer is simple: Yes. The Administration has not offered a single valid medical, scientific, or safety reason to change them. Further, I strongly urge HHS to drop its proposed changes to the recommended childhood vaccination schedule, restore the science-driven and transparent process for reviewing vaccine evidence and developing recommendations that worked so well for decades, and publicly affirm the value of routine vaccination, especially for children.
The changes being pushed by the Administration will create more confusion and further reduce vaccine access and trust. In fact, that appears to be the point. The result would be increased preventable illness and death and worsening disparities for low-income people, racial and ethnic minorities, and people living in rural areas. All this would come on top of the devastating measles outbreaks of the past two years that have sickened thousands, hospitalized several hundred, and killed several people. We can and must do better as a nation. Now is the moment for HHS to demonstrate honesty, accountability, and science-driven leadership.
I. CDC vaccine recommendations should be based on the best available science and rigorous, transparent decisionmaking.
1. Restore the central role of an expert, independent Advisory Committee on Immunization Practices (ACIP) in making vaccine recommendations.
HHS requested public comment about what factors it should consider when making vaccine recommendations.
That should start with restoring the proper role of ACIP, which has historically been comprised of independent members with expertise in vaccinology, immunology, infectious diseases, children’s health, adult health, and public health. They reviewed evidence and made vaccine recommendations based on the best available science and with full public transparency. Physicians and patients alike trusted and followed those recommendations.
Based on decades of experience, ACIP used sound scientific frameworks to inform their vaccine reviews and subsequent recommendations. These included the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for evidence reviews and the Evidence to Recommendation (EtR) model for translating reviews into guidance in ways that clearly explained why recommendations were being made.4 ACIP working groups reviewed the available data extensively and presented it to the full committee for discussion and consideration. Meetings were open to the public. Agendas included opportunities for oral and written comments from interested parties. Any votes on vaccine recommendations were transmitted to the director of the CDC for review and published in CDC’s Morbidity and Mortality Weekly Report (MMWR) if approved by the director. These rigorous and transparent processes are core elements of earning and maintaining public trust in CDC’s vaccine recommendations.
2. Repudiate and reverse harmful vaccine policy recommendations from the past 20 months.
HHS has veered drastically from a science-driven, transparent approach to vaccine policy. In its place is an antivaccine ideology causing confusion through obfuscation, lies, and rogue decisions. In less than two years, the department has taken a series of actions that will cause irreparable harm to millions, including the most vulnerable communities.5
- In May 2025, HHS Secretary Robert F. Kennedy, Jr. announced via a social media post that the agency no longer recommended COVID-19 vaccination for children and pregnant women.6
- In June 2025, Secretary Kennedy fired all 17 members of ACIP and went on to name several replacements who hold his anti-vaccine beliefs.7
- In August 2025, Secretary Kennedy canceled nearly $500 million in federal research grants to further study mRNA, the technology that led to COVID-19 vaccines that President Trump supported through “Operation Warp Speed” during the pandemic and which would have left us better prepared for whatever the next infectious threat might be.8
- In November 2025, the CDC was forced to change its website to suggest a causal link between vaccines and autism, though no such link exists.9
- In January 2026, Secretary Kennedy announced a major, unilateral overhaul of the childhood vaccine schedule, lowering the number of recommended vaccines from 17 to 11 while circumventing ACIP altogether.10 Secretary Kennedy did not release new evidence to justify any of these changes.11 A federal judge later ruled that these changes were unlawful. That ruling also stayed the appointment of the new ACIP members and set aside the votes they had taken.
- In August 2026, the White House issued an executive order recommending fewer routine child vaccinations, increasing the number of vaccines categorized as SCDM, and proposing to break up the measles, mumps, and rubella (MMR) vaccine into three separate shots, for which no formulations are readily available in the U.S. and which would inevitably lead to reduced and delayed protection against these serious illnesses.12
II. Changing vaccine recommendation categories would likely cause confusion, undermine vaccine access and uptake, and worsen health outcomes.
In the RFI, HHS asks whether the vaccine recommendation categories “routine,” “risk-based,” and “shared clinical decision-making” should be modified, expanded, or overhauled completely. These categories all serve useful purposes, but only when utilized properly. HHS’ attempts to reclassify routine vaccinations under SCDM absent any new evidence or safety signals would be particularly harmful to people’s health.
1. Routine vaccination should be the standard when evidence indicates a benefit for all individuals in a defined age or population group with limited harm.
A routine recommendation for vaccines advises vaccination for everyone in a defined age or population group for whom the vaccine is safe and effective. It is the category under which the overwhelming majority of vaccinations are administered because of their clear and convincing benefits demonstrated through careful reviews conducted by ACIP. Routine vaccinations reach the highest number of children because they are the standard of care during pediatric medical visits. Providers offer routine vaccinations to every eligible patient unless there is a medical reason not to do so.13 Research shows that this “presumptive approach”—where a provider informs a parent or caregiver that shots are due for the child, and endorses providing those shots—is the strongest driver of vaccine acceptance.14 Clear communication and messaging, along with trust in healthcare providers, strongly impacts parents’ decision to vaccinate their children.15 Nearly 90% of Americans with children under 18 report they always or sometimes vaccinate their children based on doctor recommendations.16
All vaccination, including routine vaccination, includes communication between the healthcare provider and the patient or caregiver about the benefits and risks of each vaccine. This is typically done through a combination of written materials and dialogue. In the case of routine vaccination, the provider also typically states that he or she recommends the vaccine because it has been shown to be of significant benefit to an age or population group. Together, these make up the informed consent process that underlies the practice of medicine.17
As a pediatrician, nothing I did had a greater impact on the future health of my patients than ensuring they were vaccinated fully and on time. That is why I welcomed and encouraged conversations about vaccines. Patients and caregivers have the right to ask questions. Providers, in turn, have a responsibility to listen and address questions in a thoughtful, empathetic manner. These exchanges happen in exam rooms across the country every day. In my role as a healthcare provider, it gave me the opportunity to share information with families that could save their children’s lives. It engendered trust and a shared commitment to the health of their children.
This is why communications about vaccine benefits and risks should be based on good science, follow a standard protocol, and be flexible to accommodate individual needs. They should not be a “backdoor” for requiring providers to address unverified or false information about vaccine risks or to engage in unnecessarily complicated or time-consuming processes. Communications about vaccines with patients and their caregivers should also leverage the expertise of other members of the healthcare team, like nurses and medical assistants; electronic medical records including patient portals; and the time before and during clinical visits.
Routine vaccinations have done wonders for the health of children nationwide. For example, following the CDC’s recommendation for routine pediatric use in 1991, Hepatitis B vaccination rates among children ages 19 to 35 months rose from 16% in 1993 to 90% in 2000.18 Hepatitis B immunization among children aged 13 to 15 years also experienced dramatic gains, rising from near zero to 67%.19 The increases in Hepatitis B immunization rates led to substantial reductions of new Hepatitis B cases, particularly for children.20 This is important since Hepatitis B infections during childhood dramatically increase the risk of liver cancer in adults. CDC estimates that routine childhood immunization against Hepatitis B prevented over 6 million illnesses, 900,000 hospitalizations, and 90,000 deaths among children born in the U.S. between 1994 and 2023.21 Similarly, rotavirus immunization increased from 44% to 59% between 2009 and 2010, after being added to the routine pediatric schedule in 2006. By 2020, pediatric rotavirus immunization had reached 77%.22 CDC estimates that routine childhood immunization against rotavirus prevented over 30 million illnesses, 800,000 hospitalizations, and 400 deaths among children born in the U.S. between 2007 and 2023.23
2. Unnecessarily classifying vaccines as non-routine reduces uptake.
SCDM should be reserved for the narrow set of vaccines for which the evidence does not support a general recommendation for any defined group, leaving the decision to be made on an individual basis between clinician and patient. SCDM is meant for clinical situations in which the evidence permits more than one reasonable course of action—situations of genuine equipoise.
Historically, SCDM or risk-based designations for vaccines tend to result in lower uptake, which is why they are used only in narrow circumstances where the available evidence justifies it. For example, a recent CDC analysis found that only 12% of eligible adolescents received the meningococcal B vaccine under SCDM, while 61% of the same group received the meningococcal A vaccine, which carries a routine recommendation.24 ACIP recommended the meningococcal B vaccine as SCDM after carefully analyzing all the available evidence pointing to the rarity of the disease, lack of evidence for herd immunity, and rapidly waning immunity.25 Data also confirms adults aged 27 to 45, for whom the HPV vaccine is classified as SCDM, have a significantly lower vaccine uptake (16%) compared to adolescents (62%), for whom that vaccination is routine.26 As with the meningococcal B vaccine, ACIP recommended the HPV vaccine under SCDM for adults 27 to 45 because the evidence indicated that the benefits are minimal given past exposure to the virus.27
By contrast, this administration is attempting to apply the SCDM classification to routine vaccines without any evidence warranting such a change. Last year, for example, the CDC took the unprecedented action of downgrading the routine birth-dose hepatitis B vaccination recommendation, despite overwhelming evidence of its safety and effectiveness and conclusive evidence that such a change would harm children.28 Hepatitis B is one of the most contagious and serious illnesses a young child can experience. Prevention at birth is essential: when infants are infected at or around birth, 90% develop chronic, lifelong infection, and 25% will die from cirrhosis or liver cancer.29
Providers report several concerns with unwarranted SCDM.30 As the American Academy of Pediatrics (AAP) underscored in its legal challenge to recent changes to ACIP, downgrading vaccines from routine to SCDM unnecessarily disrupts care delivery, shortens discussions of other medical issues, fosters distrust of medical professionals, and reduces access to care.31 Vaccination disparities by race, ethnicity, and socioeconomic status are already well documented. Unwarranted expansion of SCDM would only exacerbate such unequal outcomes.32
SCDM status also limits pharmacy access to vaccines. Roughly 70% of all COVID-19 booster shots were administered at pharmacies by the final year of the pandemic, and pharmacies remain the most common setting for flu and COVID-19 shots.33 Pharmacists in all 50 states, the District of Columbia, Puerto Rico, and U.S. territories are licensed to administer vaccines, but state regulations often limit which vaccines pharmacists can administer, at what ages, and whether patients must have a prescription.34 Many state laws restrict pharmacists from administering vaccines that carry the SCDM designation.35 Even where pharmacists may be authorized to administer vaccines subject to SCDM, they may be hesitant to do so because they do not have complete access to patient records and must rely on patient attestation of relevant risk factors. SCDM may also raise legal liability concerns.36
Classifying or downgrading vaccines to SCDM when there is no reason to do so, or adding new categories beyond “routine,” creates uncertainty for parents, more health risks for children, and potential legal barriers for providers. Parents look to their child’s providers for clear vaccine messaging. But HHS’ extreme misuse of the SCDM designation is setting a dangerous new precedent, forcing providers to abandon the “presumptive approach” and giving parents and caregivers an unfounded impression of clinical uncertainty about vaccines that are safe and effective.
3. Unnecessarily classifying vaccines as non-routine creates access barriers and fosters mistrust and hesitancy.
Downgrading routine vaccines to SCDM or risk-based may also have consequences for vaccine access. Vaccines recommended for SCDM continue to be covered by Medicare, Medicaid, and most private health insurance plans. However, patients, pharmacists, and other vaccine providers often mistakenly believe that absent a prescription or other documentation from a clinician, coverage of the vaccine in question will be denied. For example, a recent survey indicated that confusion persists among patients regarding which providers can participate in SCDM, with only half of respondents identifying registered nurses and only a third identifying pharmacists as capable participants.37
HHS’ drastic and unjustified changes to the childhood vaccine schedule in January 2026 sowed additional chaos into an already fraught vaccine policy environment. Providers were left to determine whether to follow the new guidelines or the previous evidence-based recommendations. Provider organizations and states were left to develop their own vaccine recommendations with suspect guidance from the federal government, and states had to figure out how best to set or modify school vaccine requirements. Most importantly, parents and caregivers were left with more questions about what to do for their children and whether their insurance or federal programs would cover the costs of vaccination. Such uncertainty fuels public mistrust and adversely impacts take-up.38, 39
As a result, a growing number of states have decided to disregard federal vaccine recommendations and rely instead on recommendations from medical groups like the AAP, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians.40 This is a necessary response yet such fragmentation may have its own consequences. Geography should not determine which families have access to evidence-based vaccine recommendations and which do not. It would be far preferable if the federal government were again a reliable, trusted, single source for all states. Unless and until that happens, I worry that vaccination rates will continue to decline, while exemption rates and cases of vaccine-preventable disease will continue to increase sharply.41
4. Informed consent is required irrespective of the vaccine classification and is therefore irrelevant to the vaccine schedule analysis.
Throughout the RFI, HHS erroneously conflates informed consent with SCDM, arguing that additional uses of SCDM are necessary to facilitate conversations between providers and patients about vaccines. HHS, however, ignores the fact that all vaccines require the patient’s, or the patient’s parent’s, informed consent—regardless of the vaccine’s recommendation category. No provider can administer a vaccine without informed consent as we described above.
Instead, HHS is attempting to unnecessarily broaden SCDM with the effect of forcing providers to convey a lack of clarity about vaccine efficacy and safety when clear and compelling evidence demonstrates otherwise. Misusing SCDM in this way would cause greater confusion and uncertainty among patients. In short, HHS is attempting to establish a system to get patients to say “no” to vaccination. That is medically and morally wrong.
5. The vaccine classification system does not create any vaccine mandates.
In Section 1.D. of the RFI, HHS seems to imply that there is confusion about whether federal vaccine recommendations are mandates. The CDC does not mandate a single vaccine, routine or otherwise. School-based vaccination requirements are developed at the state level, not federal. All 50 states have such requirements, which are often based on ACIP/CDC recommendations. These requirements ensure that children and teachers are safe in their classrooms, particularly individuals who have medical conditions that may preclude or reduce the effectiveness of vaccination. As always, parents retain the choice about whether and when to vaccinate their children.
III. Changing vaccine recommendations or vaccine recommendation categories could compromise equal opportunities for health
Health equity means ensuring that everyone has a fair and just opportunity to be as healthy as possible. Any future regulatory or administrative changes to our nation’s vaccination system must consider how proposed shifts could limit vaccine access or might disproportionately harm communities already facing significant barriers to health.
1. The Administration’s proposal for breaking up combination vaccines into single-disease vaccines would disproportionately harm low-income families, those living in medically underserved areas, and racial and ethnic minorities.
The White House’s Executive Order on immunization practices, released on August 10, 2026, calls for the combined measles, mumps, rubella (MMR) vaccine to be administered in three separate, single-disease injections.43 Separate MMR shots are not available in the U.S. and would likely take several years to develop and license. Even if that effort was successful, the cost to families would be significant. It would be especially harmful for children in low-income families, those living in rural and other medically underserved areas, and those from racial and ethnic communities who continue to experience discrimination in the healthcare system.
Parents and other caregivers would need to take additional time off work, arrange transportation, or secure childcare for other children to take their child to the additional medical appointments for single-disease vaccines. With limited access44, 45 to paid time off, many low-income families—especially low-income families of color—would face income loss or possibly even job loss. Healthcare providers—particularly those in medically underserved areas already coping with high demand—may struggle to accommodate extra vaccine appointments. In addition, 100 million Americans do not have a usual source of primary care and millions are at risk of losing Medicaid coverage because of the One Big Beautiful Bill Act, underscoring how unprepared our healthcare system is for major disruptions to vaccine policy.46
Breaking up the MMR vaccine would also increase the likelihood of missed or delayed doses, extending the amount of time that a child is unprotected from vaccine-preventable diseases. Whereas combined vaccines increase timely vaccine completion and reduce undervaccinated time among children, unnecessary vaccine “spacing” produces the opposite effect.47
In 2000, measles was declared eliminated in the United States. Yet our country has now experienced more measles cases in the past 20 months than the previous 25 years combined, with more being added each week.48 An expected result of dividing the MMR vaccine into three separate vaccinations would be even more children unprotected from measles and continued spread of this disease around the country.
2. Reduced vaccine access and uptake harms people with compromised immune systems and newborns with immature immune systems.
High vaccination rates in a given community are vitally important to protecting people whose immune systems are compromised, including people with cancer, HIV, and autoimmune conditions. Approximately 6.6% of the U.S. population (or roughly one in fifteen people) is immunocompromised and cannot receive certain vaccines or mount a sufficient immune response to them.49 Some of these individuals are unable to receive vaccinations, while some vaccines may be less effective for others.50 It is also important to protecting children who are too young to be vaccinated, especially newborns, as well as children who may have been vaccinated but for whom it provided inadequate protection. High vaccination rates accordingly benefit society as a whole, protecting the most vulnerable members of the community and providing an essential step toward the eradication of vaccine-preventable diseases.
3. Reducing vaccine uptake widens health inequities, including among people living in rural communities.
By making evidence-based vaccinations routine, we allow the benefits of these life-saving innovations to be universally disseminated, increasing health equity. By engaging in practices that reduce vaccine uptake, we throw that process into reverse. A recent and tragic example was described in studies conducted by our grantees and others, which documented how the rural-urban difference in excess deaths during the COVID-19 pandemic widened after vaccines were available. As the authors note, “Differences in vaccination rates across metro-nonmetro categories may be playing an increasingly important role in the rural mortality disadvantage observed in the second year of the pandemic.”51 As vaccine hesitancy increased mortality differences between rural and urban areas during the pandemic, we can expect similar episodes in the future if we take actions that discourage routine vaccinations. We are already witnessing some examples of this with the current measles outbreaks, which have disproportionately affected rural communities.52
IV. Conclusion
Healthcare in America is far from perfect, but our nation’s vaccination system has long been a point of pride. Scientists, researchers, medical providers, parents, caregivers, and families have all done their part for generations to protect millions of people from serious illness and disease. Thanks to vaccines, countless children have had the opportunity to grow up healthy and thrive.
As a physician, a parent, and a former HHS civil servant, I am deeply disappointed that the Department is moving to rapidly dismantle this highly successful system. I have seen firsthand how vaccines can transform lives for the better, and how a lack of access to vaccines can devastate entire families and communities. In 2025 and 2026, we have seen the consequences of reduced vaccination rates with communities in multiple states experiencing measles outbreaks that are getting worse by the day and have already claimed several lives.
I urge HHS to take one simple step: Stop. Stop targeting vaccines. Stop politicizing health. Stop giving diseases that belong in the history books the opportunity to come back.
And start doing what HHS is supposed to do: Protect people, prevent disease, and save lives.
[1] U. S. Dep’t of Health & Hum. Srvs., Request for Information: Categories Used in Federal Vaccine Recommendations and the Role of Shared Clinical Decision-Making, 91 Fed. Reg. 54724 (Aug. 24, 2026), https://www.federalregister.gov/documents/2026/08/24/2026-17250/request-for-information-categories-used-in-federal-vaccine-recommendations-and-the-role-of-shared.
[2] Ian K. Amanna & Mark K. Slifka, Successful Vaccines, 428 Curr Top Microbiol Immunol. 1 (2020), https://pubmed.ncbi.nlm.nih.gov/30046984/.
[3] Fangjun Zhou et al., Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program — United States, 1994–2023, 73 MMWR Morb Mortal Wkly Rep 682–685 (Aug. 8, 2024), http://dx.doi.org/10.15585/mmwr.mm7331a2.
[4] Ctrs. for Disease Control & Prevention, Updated Framework for Development of Evidence-Based Recommendations by the Advisory Committee on Immunization Practices, 67(45) MMWR Morb Mortal Wkly Rep. 1271–1272 (Nov 16, 2018), https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a4.htm?s_cid=mm6745a4_w.
[5] Richard Besser, MD, Robert Wood Johnson Foundation, This court case could decide the future of childhood vaccines, The Hill (Feb. 2, 2026), https://thehill.com/opinion/healthcare/5735590-court-challenges-vaccine-changes/.
[6] Ctr. for Infectious Disease Rsch. & Pol’y, Federal Vaccine Action Timeline, https://vaxintegrity.cidrap.umn.edu/federal-vaccine-action-timeline (last visited Sept. 15, 2026).
[7] Id.
[8] U. S. Dep’t of Health & Hum. Srvs., Press Release, HHS Winds Down mRNA Vaccine Development under BARDA (Aug. 5, 2025), https://www.hhs.gov/press-room/hhs-winds-down-mrna-development-under-barda.html.
[9] Rob Stein & Pien Huang, The CDC Revives Debunked Link Between Childhood Vaccine and Autism, NPR (Nov. 20, 2025), https://www.npr.org/sections/shots-health-news/2025/11/20/nx-s1-5615040/cdc-rfk-childhood-vaccines-autism.
[10] Ctrs. for Disease Control & Prevention, Press Release, CDC Acts on Presidential Memorandum to Update Childhood Immunization Schedule CDC Acts on Presidential Memorandum to Update Childhood Immunization Schedule (Jan. 5, 2026), https://www.cdc.gov/media/releases/2026/2026-cdc-acts-on-presidential-memorandum-to-update-childhood-immunization-schedule.html.
[11] Kelly Whitener & Hannah Green, HHS Announces Changes to Recommended Vaccine Schedule for Children, Ctr. for Child. & Fam. (Jan. 15, 2026), https://ccf.georgetown.edu/2026/01/15/hhs-announces-changes-to-recommended-vaccine-schedule-for-children/.
[12] Exec. Order 14420 (Aug. 10, 2026), https://www.whitehouse.gov/presidential-actions/2026/08/delivering-gold-standard-childhood-vaccine-recommendations-for-americans/.
[13] Ctrs. for Disease Control & Prevention, Healthcare Professionals: Child and Adolescent Immunization Schedule by Age (Oct. 7, 2025), https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html.
[14Jane Tuckerman, Jessica Kaufman, & Margie Danchin, Effective Approaches to Combat Vaccine Hesitancy, e243 Pediatr Infect Dis J. e243 (May 1, 2022), https://pmc.ncbi.nlm.nih.gov/articles/PMC8997018; Jason L. Schwartz, Revised Recommendations for Covid-19 Vaccines – U.S. Vaccination Policy Under Threat, 393 N Engl J Med 417–419, https://www.nejm.org/doi/full/10.1056/NEJMp2507766.
[15] Heather M.R. Ames, Claire Glenton, & Simon Lewin, Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence, 2(2) Cochrane Database Syst Rev. (Feb. 7, 2017), https://pmc.ncbi.nlm.nih.gov/articles/PMC5461870/.
[16] Partnership to Fight Infectious Disease, New Poll: Majority of Americans Support Keeping Vaccines Widely Available to Protect Children and Communities (Jan. 29, 2025), https://www.fightinfectiousdisease.org/post/new-poll-majority-of-americans-support-keeping-vaccines-widely-available-to-protect-children-and-co., https://www.fightinfectiousdisease.org/post/newpoll-majority-of-americans-support-keeping-vaccines-widely-available-to-protect-children-and-co.
[17] Child. Hosp. of Philadelphia, Vaccine Information Statements, https://www.chop.edu/vaccine-education-center/vaccine-information-statements-vis (last visited Sept. 15, 2026).
[18] Ctrs. for Disease Control & Prevention, Achievements in Public Health: Hepatitis B Vaccination --- United States, 1982—2002, 51(25) MMWR Morb Mortal Wkly Rep. 549–552, 563 (June 28, 2002), https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5125a3.htm.
[19] Id.
[20] Id.
[21] Fangjun Zhou et al., Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program—United States, 1994–2023, 73 Morbidity & Mortality Wkly. Rep. 682, 682–85 (2024), https://pmc.ncbi.nlm.nih.gov/articles/PMC11309373/.
[22] Ctrs. for Disease Control & Prevention, Vaccination Coverage by Age 24 Months Among Children Born in 2019 and 2020 — National Immunization Survey-Child, United States, 2020–2022 (Nov. 3, 2023), https://www.cdc.gov/mmwr/volumes/72/wr/mm7244a3.htm?s_cid=mm7244a3_w#T1_down.
[23] Fangjun Zhou et al., Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program—United States, 1994–2023, 73 Morbidity & Mortality Wkly. Rep. 682, 682–85 (2024), https://pmc.ncbi.nlm.nih.gov/articles/PMC11309373/.
[24] Robert Popovian, Enhancing Adult Vaccine Uptake – Challenges in Shared Clinical Decision Making and Risk Based Recommendations, Global Healthy Living Found. (Mar. 2025), https://ghlf.org/issues/vaccines/enhancing_adult_vaccine_uptake/.
[25] Ctrs. for Disease Control & Prevention, Shared Clinical Decision-Making: Meningococcal B Vaccination (Dec. 2024), https://www.cdc.gov/vaccines/media/pdfs/2025/03/2024-isd-job-aid-scdm-menb-508-remediated.pdf.
[26] Id.
[27] Ctrs. for Disease Control & Prevention, Evidence to Recommendations for HPV Vaccination of Adults, Ages 27 through 45 years, https://www.cdc.gov/acip/evidence-to-recommendations/HPV-adults-etr.html (last visited Sept. 10, 2026).
[28] See, e.g., Richard E. Besser & Starsky Wilson, Commentary, The Hepatitis B Vaccine Protects Our Most Vulnerable – Let's Keep It, U.S. News & World Report (Jan. 9, 2026), https://www.usnews.com/opinion/articles/2026-01-09/cdc-recommendation-hepatitis-b-vaccine.
[29] Jake Scott, Quiet Dismantling: How ‘Shared Decision-making’ Weakens Vaccine Policy and Harms Kids, University of Minnesota, Ctr. for Infectious Disease Rsch. & Pol’y (Jan. 6, 2026), https://www.cidrap.umn.edu/childhood-vaccines/cidrap-op-ed-quiet-dismantling-how-shared-decision-making-weakens-vaccine-policy.
[30] See, e.g., Laura A. van der Woude et al., Barriers to Implementing Shared Decision-Making in Postgraduate Medical Education: The Role of Disease-Centered Beliefs, 14(1) Perspect Med Educ. 436 (July 25, 2025), https://pmc.ncbi.nlm.nih.gov/articles/PMC12292059/.
[31] See Declaration of Dr. Suzanne Berman, AAP et al., v Kennedy, Exhibit B, Case No. cv-11916 (Mar. 3, 2026), https://litigationtracker.law.georgetown.edu/wp-content/uploads/2025/07/American-Academy-of-Pediatrics_2026.03.02_PLAINTIFFS-SUPPLEMENTAL-DECLARATIONS.pdf.
[32] Xiaoyang Lv et al., Socioeconomic Disparities in Childhood Vaccination Coverage in the United States: Evidence from a Post-COVID-19 Birth Cohort, 13 Vaccines 1256 (Dec. 2025), https://pmc.ncbi.nlm.nih.gov/articles/PMC12737472/; Stephanie Soucheray, Study shows vaccine uptake disparities among Black, White Americans, Ctr. for Infectious Disease Rsch. & Pol’y (Oct. 17, 2024), https://www.cidrap.umn.edu/influenza-vaccines/study-shows-vaccine-uptake-disparities-among-black-white-americans.
[33] Roua El Kalach et al., Federal Retail Pharmacy Program Contributions to Bivalent mRNA COVID-19 Vaccinations Across Sociodemographic Characteristics — United States, September 1, 2022–September 30, 2023, 73 MMWR Morb Mortal Wkly Rep 286 –290 (Apr. 4, 2024), https://www.cdc.gov/mmwr/volumes/73/wr/mm7313a2.htm; Ctrs. for Disease Control & Prevention, National and state-specific estimates of settings where adults received influenza, updated COVID-19, and RSV vaccinations, 2023-2024 respiratory virus season, https://archive.is/Wlz9v (last visited Aug. 31, 2026).
[34] Jill Rosenthal, 6 Ways States Can Protect Vaccine Access While the Trump Administration Dismantles the Federal System, Ctr. for Am. Progress (Nov. 20, 2025), https://www.americanprogress.org/article/6-ways-states-can-protect-vaccine-access-while-the-trump-administration-dismantles-the-federal-system/. Nat’l All. of State Pharmacy Ass’n, Pharmacist and Pharmacy Technician Vaccination Authority (Jan. 3, 2025), https://naspa.us/resource/2024-pharmacist-immunization-authority/.
[35] Spreeha Choudhury, Implications for Pharmacies Navigating Shared Clinical Decision-Making in Vaccination, Pharmacy Times (June 13, 2024), https://www.pharmacytimes.com/view/implications-for-pharmacies-navigating-shared-clinical-decision-making-in-vaccination.
[36] Austin Littrell, Complicated Vaccine Guidelines are Slowing Adult Immunization Rates, Medical Economics (Apr. 10, 2025), https://www.medicaleconomics.com/view/complicated-vaccine-guidelines-are-slowing-adult-immunization-rates.
[37] Annenberg Pub. Policy Ctr., CDC Urges ‘Shared Decision-Making’ on Some Childhood Vaccines; Many Unclear About What That Means (Jan. 5, 2026), https://www.annenbergpublicpolicycenter.org/cdc-urges-shared-decision-making-on-some-childhood-vaccines-many-unclear-about-what-that-means/.
[38] See, e.g., HHS, Press Release, HHS Takes Bold Steps to Restore Public Trust in Vaccines by Reconstituting ACIP (June 9, 2025), https://www.hhs.gov/press-room/hhs-restore-public-trust-vaccines-acip.html.
[39] See, e.g., Kaitlin Brumbaugh, Frances Gellert, & Ali H. Mokdad, Understanding Vaccine Hesitancy: Insights and Improvement Strategies Drawn from a Multi-Study Review, 13(10) Vaccines 1003 (Sept. 2025), https://pmc.ncbi.nlm.nih.gov/articles/PMC12567618/ (finding that “misinformation, safety concerns, and political decisions have contributed to declining vaccination rates, posing threats to public health). See also Oluwatosin Goje & Aanchal Kapoor, Meeting the challenge of vaccine hesitancy, 91(9) Cleveland Clinic J of Med. 550 (Sept. 2024), https://www.ccjm.org/content/91/9_suppl_1/S50 (concluding that due to the rise of misinformation, “legislation, policy interventions, research, innovation, and technology are needed to enhance vaccine uptake and ensure equitable access”).
[40] See KFF, Reliance on Sources Other Than CDC/ACIP for State Childhood Vaccine Recommendations, https://www.kff.org/other-health/state-indicator/reliance-on-sources-other-than-cdc-acip-for-state-childhood-vaccine-recommendations/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (last visited Sept. 4, 2026); Victoria Willens, Assessing the Impact of Changes to Federal Vaccine Recommendations on State Immunization Policies, Johns Hopkins Int’l Vaccine Access Ctr. (Feb. 25, 2026), https://publichealth.jhu.edu/ivac/2026/assessing-the-impact-of-changes-to-federal-vaccine-recommendations-on-state-immunization-policies; Rob Stein, Medical groups offer vaccine guidance to fill federal vacuum, NPR (Sept. 2, 2026), https://www.npr.org/2026/09/02/nx-s1-5947884/covid-flu-rsv-vaccine-recommendations.
[41] Annenberg Pub. Policy Ctr., supra note 36.
[42] Paula Braveman et al., What is Health Equity?, Robert Wood Johnson Found. (May 1, 2017), https://www.rwjf.org/en/insights/our-research/2017/05/what-is-health-equity-.html.
[43] Exec. Order No. 14420, 91 Fed. Reg. 53173–53175 (Aug. 14, 2026), https://www.govinfo.gov/content/pkg/FR-2026-08-14/pdf/2026-16730.pdf.
[44] Elise Gould, Access to Paid Sick Leave Continues to Grow but Remains Highly Unequal by Geography and Wage Level, Econ. Pol’y Inst. (Oct. 7, 2025), https://www.epi.org/blog/access-to-paid-sick-leave-continues-to-grow-but-remains-highly-unequal-by-geography-and-wage-level/.
[45] Ann P. Bartel et al., Racial and Ethnic Disparities in Access to and Use of Paid Family and Medical Leave: Evidence from Four Nationally Representative Datasets, Monthly Lab. Rev. (Jan. 23, 2019), https://www.bls.gov/opub/mlr/2019/article/racial-and-ethnic-disparities-in-access-to-and-use-of-paid-family-and-medical-leave.htm.
[46] See Celli Horstman & Arnav Shah, The State of Rural Primary Care in the United States, Commonwealth Fund (Nov. 17, 2025), https://www.commonwealthfund.org/publications/issue-briefs/2025/nov/state-rural-primary-care-united-states; Elisabeth Rosenthal, The Shrinking Number of Primary Care Physicians is Reaching a Tipping Point, KFF Health News (Sept. 8, 2023), https://kffhealthnews.org/health-industry/lack-of-primary-care-tipping-point/.
[47] Samantha K. Kurosky, Keith L. Davis, & Girishanthy Krishnarajah, Effect of combination vaccines on completion and compliance of childhood vaccinations in the United States, 13 Hum Vaccin Immunother. 2494 (Sept. 2017), https://pmc.ncbi.nlm.nih.gov/articles/PMC5703402/. See also Gregory W. Daniel, Elizabeth Richardson, Heather Colvin, Vaccines and nervous parents: Why spacing out the vaccine schedule is not the answer, Brookings (Oct. 26, 2015), https://www.brookings.edu/articles/vaccines-and-nervous-parents-why-spacing-out-the-vaccine-schedule-is-not-the-answer/.
[48] Johns Hopkins School of Pub. Health, Tracking Measles Cases in the U.S. (Sept. 4, 2026), https://publichealth.jhu.edu/ivac/resources/us-measles-tracker. See also Ctrs. for Disease Control & Prevention, Measles Cases and Outbreaks (Sept. 11, 2026), https://www.cdc.gov/measles/data-research/index.html.
[49] Melissa L. Martinson & Jessica Lapham, Prevalence of Immunosuppression Among US Adults, 331 JAMA 880 (2024), https://pmc.ncbi.nlm.nih.gov/articles/PMC10870224/.
[50] Am. Cancer Soc’y, Vaccinations and Flu Shots for People with Cancer (Mar. 26, 2026), https://www.cancer.org/cancer/side-effects/infections/vaccination-during-cancer-treatment.html. See also Ctrs. for Disease Control & Prevention, People at Increased Risk for Severe Respiratory Illnesses (Aug. 18, 2025), https://www.cdc.gov/respiratory-viruses/risk-factors/index.html.
[51] Eugenio Paglino et al., Monthly Excess Mortality Across Counties in the United States During the COVID-19 Pandemic, March 2020 to February 2022, 9 Sci. Advances eadf9742 (2023), https://www.science.org/doi/10.1126/sciadv.adf9742.
[52] Erum Siddiqui et al., Measles Resurgence in Texas: A Public Health Wake-Up Call, 87 Annals Med. & Surgery 6937, 6937–39 (2025), https://pmc.ncbi.nlm.nih.gov/articles/PMC12577891/.
About the Robert Wood Johnson Foundation
RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work side-by-side with communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.