Are conditional vaccine recommendations the future?

Autonomy is an important part of medical practice, but sometimes more choice can lead to more confusion.

Primary care physicians must keep track of a multitude of vaccinations for both children and adults, and they rely on agencies tasked with assessing the efficacy and cost of vaccine to make recommendations on their use.

This job, however, is becoming more and more difficult, and even leading experts question whether recommendations in the future will stick around for the long run.

In an editorial published in the Journal of the American Medical Association in January 2019, Nancy M. Bennett, MD, MS, professor of medicine and public health sciences, director of the Center for Community Health and Prevention, co-director of the Clinical and Translational Science Institute at the University of Rochester School of Medicine and Dentistry, said that when the CDC’s Advisory Committee on Immunization Practices (ACIP) was established, there were six vaccines recommended for children-and now there are three times that.

As the number of available vaccines increase, and data on costs and efficacy grows, Bennett-who has served on ACIP for seven years, the last three as chair-said recommendations will be more fluid, and it will be increasingly up to physicians to use their own clinical judgment when it comes to how to use them.

This may be a problem, though, with some clinicians already unhappy with recommendations that are far from concrete.

For example, a 2018 report in Academic Pediatrics, concluded that category B recommendations from ACIP-like the one issued for serogroup B meningococcal vaccines in 2015-often create confusion for providers and patients. Using the meningococcal B recommendation for the study, researchers found that only 24% of providers could correctly define a category B vaccination, and roughly half didn’t know the private and public payer coverage rates for category B vaccines. Nearly 60% of providers stated that they would have trouble explaining a category B vaccine recommendation to patients, and 22% felt that ACIP should not be making category B recommendations at all.

However, about 40% favored category B recommendations because of the autonomy it provided to clinicians for individual decision-making.

Bennett said moving forward, ACIP recommendations cannot be permanent if they are to reflect the real-world safety and value of vaccines. Preferential recommendations will also become more common, Bennett predicted, as well as increasing consideration of the long-term risks and benefits for licensed vaccines.

Vaccines against major diseases like smallpox and polio have already been developed and widely used, and going forward Bennett said more vaccines will target less severe and less common diseases. Precision medicine will lead to vaccines with very narrow indications, she explained, and this specificity will make it more and more difficult for ACIP to make permanent recommendations.

The goal of editorial was to reiterate the fact that clinicians will have to increasingly rely on their own judgment, but also trust in the data provided by agencies like ACIP.

“My primary point was to remind clinicians of and help them understand the thoughtful and careful process of making recommendations for vaccine use in the United States,” Bennett told Medical Economics. “My hope was that reviewing this process, and also pointing out some of the new challenges, would reassure them that our recommendations are sound and that they do try to incorporate clinical feasibility.”

Bennett would not comment on whether ACIP can or should make administration decision-making more clear for clinicians, but said ACIP does err more toward standard recommendations when possible.

“The ACIP prefers standard, universal recommendations over shared decision making recommendations, but the data do not always support universal, age-based recommendations,” Bennett said. “It is often difficult to weigh the societal benefits versus individual benefits.”

She said she hopes the editorial will help clinicians better understand ACIP’s process, and the changing nature of vaccines. She said it is also important for clinicians to take responsibility for their knowledge about these vaccines

“My intention was to call attention to the careful, deliberative process of the ACIP, highlighting the value of independent, public health assessment of the value of vaccines. I also wanted to highlight the ways in which the committee is changing in response to changes in the policy environment and in vaccine technology,” Bennett said. “I believe that understanding this process is beneficial for patients, clinicians, insurers, and other policy makers.”