Health secretary Robert F. Kennedy Jr. and his lieutenants have sent multiple signals in recent weeks that they envisage a world in which far fewer people are urged to get Covid-19 shots each fall. It is a vision that they seem likely to try to realize.
But others have actually started that process.
The Advisory Committee on Immunization Practices, the expert panel that has up until now guided the nation’s vaccination policy — a group Kennedy distrusts and dismisses as conflicted — is already talking about changing policy in ways that would lead to far fewer people being urged to get Covid boosters later this year.
The ACIP advises the Centers for Disease Control and Prevention on which immunizations should be recommended for which people, studying vaccines both when they are newly approved and over time, to see if safety concerns or changing patterns of disease warrant altering the recommendations for a product’s use.
If the committee meets as scheduled in late June — a meeting in February was delayed by weeks by officials in the Department of Health and Human Services — members are likely to be asked to vote to replace the current universal Covid vaccination recommendation with a more targeted one. Instead of shots being recommended every year for anyone 6 months and older, they would be recommended only for people considered to be at highest risk from Covid infections.
The precise form of the proposed recommendation has not yet been made public. But at the ACIP’s last meeting in mid-April, a presentation by a member of a subcommittee that works on Covid vaccines suggested that group will likely recommend annual shots for adults 65 and older, some younger adults with medical conditions that increase their risk of severe illness from Covid infection, including pregnant people, possibly health care workers, and some very young children.
Other people would likely be told they could get a shot if they wanted one, but would not be actively urged to get a Covid booster every year.
Three-quarters of the members of the Covid vaccines work group favored this approach, Lakshmi Panagiotakopoulos, who works in the CDC division focused on coronaviruses and other respiratory viruses division and who serves as co-lead of the subcommittee, said at the April ACIP meeting.
If proposed, the recommendation or recommendations would have to be approved by the entire committee, and then be signed off on by the CDC director, once one is confirmed. (Nominee Susan Monarez has not yet begun her Senate approval process.)
The times when the CDC director hasn’t accepted a recommendation from the ACIP can be counted on the fingers of one hand, with several fingers to spare. But top health officials in the Trump administration have regularly bucked convention, and it is currently unclear if the Food and Drug Administration will even approve updated Covid shots for the fall.
Moving to a risk-based policy for Covid vaccine use would be much more in keeping with the way most of the rest of the world handles Covid vaccination at this point, said Ben Cowling, chair of epidemiology at Hong Kong University.
“I think the priority should be those who are really at highest risk of ending up in hospital with Covid. Those groups should be the highest priority for Covid vaccination,” Cowling told STAT in an interview.
For the first few years after Covid emerged, when fewer people had immunity to the SARS-CoV-2 virus and the risk of severe illness existed across a broader range of age groups, a so-called universal vaccination recommendation made sense, Cowling said. But at this point the immunological landscape has changed.
For the past couple of years, Covid hospitalizations and deaths have mainly occurred in people over age 65, he noted. “Very few children, very few young adults, healthy young adults end up in hospital,” he added. “Of course they may get Covid, but it’s very unusual for them to end up in hospital because of getting Covid.”
Studies the CDC conducted looking for antibodies to SARS-2 in the blood of blood donors aged 16 and older have found that the overwhelming majority of Americans have some defenses against the virus now, acquired by infection, vaccination, or a combination of the two.
“I think [a universal recommendation] was a good decision in 2021, 2022, but I think the situation has changed now,” said Cowling. “There’s a lot more natural immunity about.”
The World Health Organization has recommended targeted use of Covid vaccines for several years, said Stanley Perlman, a coronavirus expert from the University of Iowa who serves on the WHO’s technical advisory group on Covid-19 vaccine composition. (Perlman is also a consultant to the ACIP’s Covid vaccine work group.)
“The WHO has felt this for a couple of years already, that vaccinating people who are 19 or whatever it is — 17, 18 — to 50 is unnecessary,” he said.
The United Kingdom, Canada, and Australia have already moved to this type of approach. In all three countries, older adults — 75 or 80 years old and older — can get a Covid shot every six months, an option open to Americans 65 and older. One shot a year is recommended for those aged 65 to 74 in the U.K. and Australia and for those 65 to 79 in Canada. None of these countries pushes adults under the age of 65 to get vaccinated, unless they are immunocompromised or have medical conditions that put them at risk of serious illness if infected.
For other demographic groups, like healthy children, for instance, this trio of countries and the WHO either do not recommend vaccination or say vaccination “may” occur once a year.
Figuring out who qualifies as a high-risk adult likely won’t be easy, if the discussion at the ACIP’s April meeting is any indication. Panagiotakopoulos, the work group co-lead, said 74% of adults 18 years of age and older have at least one medical condition that puts them into a higher risk category.
“This is what becomes tricky because … there’s plenty of obese 20-year-olds, and so they would be at a higher risk,” said Perlman. “On the other hand, there’s no evidence that we’re getting ICUs full of … obese children and [young] adults.”
Some members of the ACIP questioned whether such a change in policy would be hard to put in place, worrying that any attempt might discourage people who should be vaccinated from getting a shot.
Perlman sees the issue another way, arguing that focusing on the people who really need to be protected from the virus could increase vaccine uptake in those groups. “I’m not really keen on getting a 40-year-old healthy person vaccinated, but because that person is feeling this is ridiculous, he then discourages his mother, who’s 80 and has diabetes,” he said. “That’s bad.”
