Now Is Not the Time to Undo Adolescent Vaccination Policies

At a time when routine vaccination rates have yet to recover from a pandemic-era dip and vaccine confidence is more fragile than ever, the CDC’s Advisory Committee on Immunization Practices (ACIP) is considering rolling back certain vaccination recommendations.

Specifically, it is slated to consider elimination of the first dose of the meningococcal vaccine at ages 11-12, based on cost effectiveness rationale and because disease rates have declined over the long term. This stands to widen vaccine inequities not only for meningococcal vaccines, but also for an integrated set of recommendations for pre-teen vaccinations that include pertussis and HPV.

This could have devastating consequences for adolescent health. Now, in the face of rising outbreaks of meningococcal and other diseases, we need to strengthen — not weaken — our commitment to adolescent vaccination policies.

A Devastating Disease and a Vaccine to Prevent It

Meningococcal disease can be rapidly fatal and even with effective antibiotic therapy, 10-15% of those who contract it die. Among survivors, up to one in five endures long-term complications like neurological damage and loss of limbs. As a result of vaccine development and the implementation of the current meningococcal disease vaccine schedule, data suggests that the burden of meningococcal disease for serogroups C, W, and Y in this age group has decreased significantly, owing largely to vaccine success. (Serogroup A meningococcal disease is very rare in the U.S.)

The first dose of the meningococcal vaccine series for protection against serogroups A, C, W, and Y (MenACWY) has been crucial in preventing meningococcal outbreaks in adolescents, a high-risk period when students enter middle and high school where disease can spread rapidly. Today, 89% of adolescents ages 11-12 receive the MenACWY.

Incidence rates in vaccinated adolescents have plummeted 2- to 3-fold since the vaccine’s introduction. But invasive meningococcal disease, with its high case fatality rate, is still a profoundly serious threat to life and limb.

The Misguided Push for Cost-Savings

This longer-term reduction in incidence rates and the introduction of newer pentavalent vaccines that protect against five serogroups (MenABCWY) have raised questions about the ongoing role of early adolescent vaccination and the optimization overall of the meningococcal vaccination schedule. The resulting conversation has pointed toward the possible elimination of ACIP’s MenACWY recommendation for 11–12-year-olds.

However, I believe that the committee’s apparent consideration of cost-effectiveness and the lower incidence of disease as the primary determining factors could undermine widespread access to an essential means of prevention. Removing the 11-to-12-year-old dose may lead to an increase in susceptibility to invasive meningococcal disease during adolescence. Even if disease incidence has decreased in younger adolescents, the absence of routine immunization may allow for resurgence.

Policy Disruption and Politicization

States rely heavily on ACIP recommendations when setting their vaccination policies. More than two-thirds of states have laws requiring MenACWY vaccination for children entering seventh grade. Reversing federal recommendations could disrupt and weaken these policies without thoughtful consideration of the efforts made to adopt them in the first place.

The processes for adopting school immunization requirements are often lengthy and bureaucratic. My review of these policies, published this week in the journal Health Affairs, revealed that it took states an average of nearly a decade to adopt the current MenACWY vaccination requirements. Given the current political climate, weakening vaccination policies could encourage further opposition, as we have seen in states like Florida and Wisconsin.

An Avoidable Inequity

Without a formal recommendation and the reinforcement of state-level policies, it is uncertain whether healthcare providers will continue to recommend, offer, or stock the vaccine. This could worsen existing health disparities, as it places the burden on families to request a vaccine that might no longer seem necessary.

Additionally, without ACIP’s endorsement, private insurers may no longer cover the cost of the vaccine, and the vaccine could be excluded from the Vaccines for Children program, leaving it out of reach for the most underserved populations.

This potential policy shift also poses a broader risk to the adolescent “vaccination platform.” A reduction in one recommendation could lead to a decline in the uptake of other vaccines administered during the same visit, such as the HPV vaccine, which already faces significant challenges in reaching all adolescents — particularly those from minority and lower-income groups.

Public Health Principles and History Urge Caution

Public health decisions should be made with a population-wide, long-term view. If we accept an inevitable resurgence of vaccine-preventable diseases, we set a concerning precedent for other long-recommended vaccines.

Smallpox was the first and only disease ever eradicated in humans. But, of note, after its last U.S. outbreak in 1949, public health officials did not rush to end vaccination. They waited until the 1970s because suppression in the U.S. was critical until it was fully eradicated globally.

Despite polio’s elimination in the U.S. in 1994, polio vaccination is in its seventh decade. Continued vaccination efforts are essential to suppress and prevent the resurgence of even well-controlled disease threats, as evidenced when polio reemerged in the U.S. in 2022.

With meningococcal outbreaks on the rise — 143 cases and 17 deaths reported in the first 3 months of 2024 — the work is not done yet. In 2023, 422 cases of invasive meningococcal disease were reported in the U.S., mainly attributable to serogroup Y, marking the highest annual number of cases since 2014. Compounding the issue is the emergence of antibiotic-resistant strains.

Clearly, we still have a much longer way to go toward disease elimination. We are by no means “done” vaccinating adolescents against invasive meningococcal disease. Public health officials bear a responsibility to maintain viable, widespread, and equitable vaccination policies.

Richard Hughes IV, JD, MPH, is a partner with Epstein Becker Green in Washington, D.C. He teaches vaccines and preventive services law at The George Washington University Law School and served as vice president of Public Policy at Moderna during the COVID pandemic.