For decades, physicians have relied on evidence-based guidelines for preventive health measures. The recent changes to the Advisory Committee for Immunization Practices (ACIP) indicates that the CDC vaccination recommendations will now be opinion-based guidelines. The Committee has been completely reconstituted with all-new members who share United States Secretary of Health and Human Services Robert F. Kennedy Jr.’s vaccine skepticism. Initial indications are that the Committee will not be incorporating results of randomized controlled vaccine trials but rather will be starting from a premise that vaccinations are inherently harmful. As a result, future ACIP recommendations and CDC guidelines that then adopt the ACIP recommendations will likely look very different than current recommendations and guidelines with elimination of some recommended vaccines altogether and elimination of certain patient populations to receive other vaccines.
Until now, most physician professional organizations have adopted the ACIP recommendations (and thus the CDC guidelines) for use in clinical practice. Consequently, hospitals and physicians have incorporated the ACIP recommended vaccination schedule into their electronic medical records to trigger alerts and reminders to practitioners about which of their patients are due for various vaccinations. With the impending divergence between the ACIP vaccination recommendations and vaccination guidelines from physician professional organizations, it will be necessary for hospitals and doctors to decide which of these different vaccination guidelines to incorporate into their own clinical practice.
Clinical practice guidelines often use medical jargon and can be confusing for laypeople to understand. Thus, most Americans rely on their own physician’s recommendations when it comes to screening tests, vaccinations, and other preventive health measures. This will be especially true if the public loses trust in the Federal government’s guidelines when those guidelines come under fire from public health authorities and medical professional organizations. When asked “Who do you trust?”, most Americans will say that they primarily trust their own physician.
What are the U.S. physician professional organizations saying?
The good news is that for children, the American Academy of Pediatrics (AAP) publishes its own recommended vaccination schedule and the 2025 AAP vaccination schedule can be found here. Historically, the AAP recommendations mirrored the federal government’s recommendations. However, as of June 24, 2025, the AAP no longer endorses the vaccination schedule published by the CDC. The AAP determined that the newly constituted Advisory Committee for Immunization Practices was aiming to sow distrust in immunizations.
For adults, things are a bit more complicated and thus far, no one professional organization has taken responsibility to develop its own vaccination guideline. Historically, the American College of Physicians has endorsed the ACIP’s vaccination recommendations. Because the American College of Physicians is the largest professional organization of internal medicine physicians, it has been regarded as the adult equivalent of the American Academy of Pediatrics. The American College of Physicians has expressed concern about the membership of the new ACIP and the likelihood of the ACIP eliminating some vaccinations from the federal government’s vaccination guideline. However, to date, the American College of Physician has yet to indicate whether it will develop its own vaccination guideline or endorse some other organization’s guidelines.
The American College of Obstetrics and Gynecology provides recommendations for vaccinations that should be given to pregnant women. One of the first changes to the ACIP’s vaccination schedule was to drop the recommendation that pregnant women should receive a COVID vaccination. The American College of Obstetrics and Gynecology strongly objected to this decision based on published scientific studies that found that pregnant women who developed COVID were more likely to suffer preterm delivery, fetal death, maternal respiratory failure, and maternal death than women who do not develop COVID during pregnancy. Currently, the American College of Obstetrics and Gynecology recommends that pregnant women be vaccinated against influenza, pertussis (Tdap), COVID, and respiratory syncytial virus (RSV). Given the College’s public criticism of the new ACIP, it is likely that its vaccination recommendations will diverge from the ACIP’s vaccination schedule.
The American Academy of Family Physicians represents physicians who practice family medicine. Family medicine practice includes both children and adults. In addition, many family physicians also care for pregnant women. For this reason, the American Academy of Family Physicians is in a unique position to represent the constituency of all of the other three previously mentioned professional organizations. In the past, the American Academy of Family Physicians has endorsed the ACIP’s vaccination schedule. However, the president of the Academy has publicly criticized the vaccine skepticism expressed by Robert F. Kennedy, Jr. and it is likely that the Academy will not endorse the ACIP’s recommendations in the future.
The Infectious Diseases Society of America represents physicians who specialize in infectious disease. This includes both pediatric and adult infectious disease specialists. In the past, the Infectious Diseases Society of America has endorsed the CDC’s vaccination schedule. However, the president of the Society joined the presidents of the other four above mentioned professional organizations to criticize the recent wave of vaccine skepticism expressed by the leadership of the Department of Health and Human Services. To date, the Infectious Diseases Society of America has not stated which vaccination schedule it will endorse.
What about recommendations from outside the United States?
The World Health Organization makes comprehensive vaccination recommendations that are applicable to all countries. By necessity, many individual vaccinations only apply to certain regions of the world where the corresponding infectious diseases occur. For this reasons, the WHO makes recommendations for many vaccinations that are not applicable in the United States. For example, the WHO recommends BCG vaccination in countries where there is a high incidence of either tuberculosis or leprosy (i.e., not the United States). On his first day of presidency, Donald Trump withdrew from the WHO because of his opinion that the WHO mishandled the COVID epidemic. However, the WHO’s vaccination schedule recommendations are likely to be seen as less biased and more scientifically-based than the ACIP’s vaccination recommendations in the future. In other words, even though the U.S. has withdrawn from the WHO, the WHO vaccination recommendations will be more reliable than the U.S. government’s vaccination recommendations.
Because of its geographic proximity, Canada shares a similar infectious disease epidemiology to the United States. The National Advisory Committee on Immunizations makes recommendations to the Public Health Agency of Canada, similar to the ACIP’s relationship with the CDC in the United States. The result is the Canadian government’s vaccination schedule for adults and for children. Historically, Canada’s vaccination schedule has been very similar to the CDC’s vaccination schedule in the United States. As the U.S. vaccination schedule moves away from an evidence-based guideline towards an opinion-based guideline, U.S. physicians may choose to look to our northern neighbor for recommendations about vaccinations that have not been tainted by misinformation.
Other developed countries, such as Australia, the United Kingdom, and France, create their own vaccination schedules. However, specific bacterial and viral infections that are common in these countries are not always common in the U.S. Conversely, infectious diseases common in the U.S. are not always common in other countries. For this reason, there are often very appropriate differences in the recommended vaccination schedules between the U.S. and other developed countries. For example, Japanese Encephalitis is common in Japan but rare in the U.S., resulting in vaccination against Japanese Encephalitis appearing in the recommended vaccination schedule in Japan but not in the United States.
So, what should physicians and hospitals do now?
One thing is certain, if the CDC adopts recommendations from the ACIP that diverge from guidelines from U.S. physician professional organizations, then it will cause confusion and mistrust by the American public. From the layperson’s vantage point, if the CDC’s guideline differ from the American Academy of Pediatrics’ guideline, then one of them has to be right and the other wrong. When in doubt, most patients will turn to their own doctors and their own hospitals for guidance. Therefore, it is incumbent on us to decide whose vaccination schedule we are going to adopt in our clinical practices and incorporate into our electronic medical records.
I used to loathe our hospital’s clinical practice guidelines. We would appoint a group of physicians, pharmacists, nurses, etc. to develop a specific clinical practice guideline for the management of one medical condition. That work group would search the medical literature and spend hours of time that could have been used to take care of patients to instead create a guideline document that usually ended up nearly identical to similar guidelines produced by physician professional organizations. Once loaded onto the hospital’s internet site, the hospital would track the number of views each guideline had every year – frequently fewer than 20 views/year despite having thousand of doctors and nurses on staff. The reason that the hospital’s clinical practice guidelines were not looked at is that most practitioners used on-line resources such as UpToDate to guide them in the management of specific medical conditions – not the hospital’s own clinical practice guidelines. But when it comes to future recommended vaccination schedules, a hospital-created clinical practice guideline may be more important than ever before.
Hospitals should create vaccination schedule work groups now. The best people to have on these work groups are both adult and pediatric infectious disease specialists. For smaller hospitals that do not have pediatric and/or adult infectious disease specialists on staff, possibilities include partnering with referral tertiary care hospitals to adopt their guidelines or incorporating medical staff members from OB-GYN, internal medicine, pediatrics, and family medicine who have expertise in infection prevention to create the hospital’s own vaccination guideline. Alternatively, hospitals may choose to adopt vaccination guidelines from specific physician professional organizations (for example, the vaccination schedule created by the American Academy of Pediatrics). These hospital-created vaccination guidelines should be clearly communicated to the entire medical staff, including the reasons for the guideline and where the guideline can be found on-line. The recommended vaccination schedule should then be incorporated into the hospital’s electronic medical record so that practitioners get alerts for patients needing specific recommended vaccinations.
Physicians in outpatient practices affiliated with hospitals or that use a hospital’s electronic medical record can simply adopt that hospital’s vaccination guideline. Independent physician groups that do not utilize a specific hospital’s electronic medical record will need to decide whether to adopt guidelines from one of their local hospitals, adopt guidelines from physician professional organizations, or create their own vaccination schedule.
But don’t forget the legal risks
One of the important dangers of the ACIP eliminating certain vaccines from the CDC vaccination schedule is the potential for medical malpractice lawsuits if patients receive an unrecommended vaccination and then have an adverse event (whether actually related to the vaccine or not). For example, last week, the ACIP recommended that Americans not receive vaccines that contain thimerosal, a preservative used in multi-dose vials of vaccines. The reason is that some ACIP members believe that thimerosal causes autism. The relationship between autism and thimerosal has been debunked by well-conducted scientific studies but is still held by many ardent vaccine skeptics. The incidence of autism is 3.1% of American children. This means that if 100 pregnant women receive a thimerosal-containing influenza vaccination, 3 of these women will have a child with autism by chance alone (unrelated to thimerosal). These 3 women could believe they have a basis for suing the physician who ordered their flu shot and their plaintiff attorney could use the U.S. government’s position that thimerosal-containing vaccines cause autism as the foundation for a malpractice lawsuit.
This could be particularly risky for physicians who practice in states that have not enacted malpractice legal reforms. These states have considerably higher medical malpractice insurance premiums than other states. For example, the average malpractice premiums for obstetricians in Los Angeles, California (a state with malpractice reform) is $49,804/year. But if that obstetrician moves to Miami, Florida (a state without malpractice reform), his or her premium will increase to $243,988/year. Thus, the obstetrician in Florida is far more likely to get sued when one of his patients gives birth to an autistic child than the obstetrician in California. For this reason, physicians (particularly in non-malpractice reform states) should make their reasons clear for adopting vaccination schedules that differ from ACIP recommendations. This could be done using vaccination consent forms or vaccination handouts to patients.
And lastly, a short story…
Several years ago, we had a hospitalist who was a vaccine skeptic and believe that thimerosal causes autism. She was pregnant during flu season and I recommended that she get an influenza vaccine. She refused and developed influenza when she was in her eighth month of pregnancy. Because of her influenza infection, she delivered prematurely and her baby ended up in the neonatal intensive care unit after sustaining an intracranial hemorrhage. The child spent weeks in the hospital and had permanent brain damage.
The reason thimerosal has been targeted by anti-vaxxers is that it contains about 50% by weight of mercury. Thus, a thimerosal-containing vaccine has about 25 micrograms of mercury. To put this in perspective, that is about the amount of mercury in a half of a 5-ounce can of albacore tuna. Despite the fervor of anti-vaxxer’s beliefs about thimerosal, scientific studies have shown that there is no link between thimerosal-containing vaccines and autism.
Thimerosal is currently only used as a preservative in multi-dose vials of influenza vaccines. Most flu shots in the U.S. are given by single-dose units that do not contain thimerosal. In our hospitalist’s zeal to avoid thimerosal, she ended up with a child with brain damage resulting from influenza infection.
History will not look kindly on the current administration’s approach to vaccinations to prevent infection. At best, it will be viewed as a temporary but tragic period when misinformation reigned. At worst, it will be a laughing stock of future generations. As physicians, we must do what is best for our patients, even if that differs from opinions espoused by U.S. Secretary of Health and Human Services Robert F. Kennedy, Jr.
July 1, 2025
