The Trump management has made its largest imprint on the U.S. childhood vaccine schedule to date. Among the changes, the government schedule demotes shots once universally recommended into a designation called “shared clinical decision making.” The shift affects vaccines that protect against diseases such as hepatitis A, rotavirus and the flu.
It may not sound like a big change, just a suggestion to have a conversation with a doctor. But “shared clinical decision making” has a specific meaning in terms of vaccines, implying that the benefit and risk calculation isn’t clear-cut, even though that isn’t the case with the shots classified. The change adds to the confusion and doubt that the current administration has injected into vaccine policy in the United States.
“This is really uncharted territory,” says Jake Scott, an infectious diseases physician at Stanford University’s school of Medicine.“Moving these vaccines to shared decision making doesn’t reflect scientific uncertainty, but it manufactures it.”
The changes, which the administration announced January 5, did not follow the long-standing protocol for considering updates to the U.S. childhood vaccination schedule. The traditional process of lengthy scientific review culminates in recommendations made by the Advisory Committee on Immunization Practices. Without using that intentional open process,“it’s really challenging to have confidence in any of the proposed changes,” says pediatric infectious diseases physician Lori Handy,associate director of the Vaccine Education Center at Children’s Hospital of Philadelphia.
No new evidence was presented to back the reduction in universally recommended vaccines.These changes “are not made in the best interest of children because more children will inevitably get sick,” Handy says.
Although the administration claims that the changes place the United States in consensus among peer nations’ vaccine schedules,“vaccine policy isn’t one-size-fits-all,” Scott says.“It has to account for how health care actually gets delivered in a given country,” including who has access, what the infrastructure looks like and where the gaps are, along with epidemiological differences between countries.
Shared clinical decision making
The administration has reclassified vaccines which protect against hepatitis A, hepatitis B, meningococcal disease, rotavirus, influenza and COVID-19 from universally recommended to shared clinical decision making. That category is inappropriate for those vaccines, Scott says. It’s for situations in which “individual factors meaningfully shift the risk-benefit calculation” and the benefit to the population is uncertain. Handy says that the category covers circumstances in which medical and social risk factors “are so nuanced that it is challenging to make a clear routine recommendation.”
Such as, in 2019, the ACIP recommended shared clinical decision making for adults ages 27 to 45 when considering the human papillomavirus, or HPV, vaccine. The HPV shot is universally recommended for preteens as it’s most effective at preventing HPV-related cancers before exposure to the virus. Many adults have probably already encountered the virus. But an unvaccinated adult who has tested negative for HPV and is entering a new sexual relationship could have risk of a new exposure. In that case, an HPV vaccine would be protective.
Shared clinical decision making is meant for occasions “where the risk-benefit calculation is close enough that individual factors could tip it either way,” Scott says. “But that’s not the case for any of these vaccines” that have been reclassified on the childhood immunization schedule.
“Every vaccine moved to shared decision making has been through rigorous evaluation,” he says. “for every single one, the benefits have been shown to outweigh the risks.” And the evidence supports a worldwide recommendation.
Hear’s a closer look at several of the diseases for which the vaccines have been moved into shared clinical decision making.
Hepatitis A
Hepatitis A is a highly contagious virus that spreads person-to-person or by consuming contaminated foods or drinks. “We know that our food supply is at risk for hepatitis A outbreaks,” Handy says. Having a shared decision making conversation about the risks of acquiring hepatitis A is basically asking someone if they are going to eat, she says. “That’s just not a practical conversation to have.”
Hepatitis A causes liver disease that usually resolves but can lead to liver failure. Cases of hepatitis A have dropped substantially with the introduction of vaccination. In 1999, the shot was recommended to children living in states with the highest rate of new cases, and then recommended across the country in 2006. Children have routinely received a two-dose series between 12 and 23 months of age.
The incidence of hepatitis A dropped from 12 cases per 100,000 in 1995 to 0.7 per 100,000 in 2022.People can accept the risks of children eating a variety of foods “because we know they’re protected” from vaccination,Handy says,“and that’s only something you can do before they experiance the risk.”
Hepatitis B
The necessity of providing protection before exposure is why the first dose of the hepatitis B vaccine had long been universally recommended at birth for newborns. These infants could be exposed during birth or soon after and are at especially high risk of developing chronic hepatitis B, a disease with no cure that damages the liver and increases the risk of liver cancer.
One in 4 children with chronic hepatitis B will die prematurely from complications of the disease. “All children are at risk of hepatitis B,” Handy says. The virus is very contagious “and we do not know who in the population has it.” But the universal birth dose recommendation was removed by the current administration in December.
Meningococcal disease
Outbreaks of meningococcal disease, caused by the bacteria Neisseria meningitidis, are unpredictable, and an infection can be deadly in just 48 hours. “It is such a devastating infection that we can prevent,” Handy says. Invasive meningococcal disease leads to meningitis, an inflammation of the membranes surrounding the brain and spinal cord, or sepsis, a blood infection.And the case fatality rate can be high, ranging from 4 to 20 percent in an analysis of 40 studies. Some 10 to 40 percent of survivors can be left with long-term impacts,including hearing loss and amputation.
Vaccination against meningococcal disease had been universally recommended for adolescents because this group is a key spreader of the bacteria. Any teen who gathers in close spaces with other teens,shares drinks,spends time in bars or dorms or other crowded settings is at risk,Handy says. So basically, all teens.
Influenza
For influenza, the question of what puts someone at risk isn’t complicated either: “Do you have contact with other people during the winter?” Handy says. “If yes, you deserve a flu vaccine.”
The administration’s redesignation of the flu vaccine to shared clinical decision making from a universal recommendation for children 6 months and older comes after one of the worst flu seasons for children,that of 2024–2025.There were more childhood deaths from influenza, 280, than in any nonpandemic flu year as recordkeeping began in 2004, researchers reported in september in Morbidity and Mortality weekly report. Data on vaccination status were available for 208 of those children: 89 percent were not fully immunized against the flu.
This season’s flu vaccine doesn’t match a late-breaking flu strain that is causing many cases. But it still provides children and adolescents 72 to 75 percent effectiveness against emergency department visits and hospital admission, researchers reported in November in Eurosurveillance. The analysis looked at data from the fall of 2025 in England. In the United States, there have been nine pediatric flu deaths reported so far this season, as of january 5.
Rotavirus
For U.S. children, rotavirus used to be the top cause of severe acute gastroenteritis, an infection of the gastrointestinal tract that leads to vomiting, diarrhea, dehydration and frequently enough hospitalization.
As vaccination was universally recommended in 2006, hospitalizations for the illness have fallen substantially. In the prevaccine era,the hospitalization rate for gastroenteritis was 76 per 10,000 in children under 5. By 2012, it had dropped to 34 per 10,000. Without routine vaccination, there will be an increase in rotavirus infections, Handy says. “We will end up seeing more children getting hospitalized for dehydration and vomiting who really don’t need to experience that.”
What parents and providers can do
With the administration backtracking on decades of robust vaccine policy, parents and providers can look to the American Academy of Pediatrics childhood vaccine schedule, with which the Centers for Disease Control and Prevention schedule used to be in alignment.“Clinicians can 100 percent continue to follow the schedule as laid out by the AAP,” Handy says.
Scott says: “When the federal government and pediatricians disagree, I would say trust the pediatricians.”
The science that supported the universal recommendation of these vaccines last month “is the same science that exists today,” he says. But now that the administration has recategorized the approach to these shots, Scott would advise parents to be proactive, to be sure to ask their providers during pediatric appointments if their child is up to date on vaccines. “Unfortunately, there is going to be more burden placed on parents now.” That burden should fall on public health institutions like the CDC, “but those institutions are failing, and so parents do have to fill in the gap.”
