Vaccine-preventable diseases have resurged despite decades of successful mitigation, due in part to changing vaccine recommendations. Listen to experts Paul G. Auwaerter, MD, MBA, FIDSA, FACP, and Camille Nelson Kotton, MD, FIDSA, FAST, to explore current events in vaccines and their implications on patient vaccine uncertainty, with expert discussion of learner-submitted questions.
Vaccine-preventable diseases have resurged despite decades of successful mitigation, due in part to changing vaccine recommendations. Featuring audio from a live webinar with experts Paul G. Auwaerter, MD, MBA, FIDSA, FACP, and Camille Nelson Kotton, MD, FIDSA, FAST, this podcast explores current events in vaccines and their implications on patient vaccine uncertainty, with expert discussion of learner-submitted questions. For more, and to download the accompanying slides, visit our program page. Topics covered include:
Presenters:
Paul G. Auwaerter, MD, MBA
Sherrilyn and Ken Fisher Professor of Medicine
Divisions of Infectious Diseases and General Internal Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Camille Nelson Kotton, MD, FIDSA, FAST
Clinical Director, Transplant and Immunocompromised Host Infectious Diseases
Infectious Diseases Division
Massachusetts General Hospital
Associate Professor, Harvard Medical School
Boston, Massachusetts
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This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Current Events in Vaccines: Implications for Vaccine Confidence and Clinical Practice
Dr. Paul Auwaerter (Johns Hopkins University): Thank you for joining us this afternoon or this morning, depending where you'll be. Dr. Kotton and myself hope this will be informative to you.
2025-2026 Was One of the Most Consequential Years for Vaccines in Decades
We decided to start off with some outbreaks, many of which you've probably been following in the news. And I have to say, when I was an infectious diseases fellow over 30 years ago, I studied measles virus virology and translational studies to try to improve vaccines for global use. At the time, measles was soon eliminated from the United States, and I really didn't think we would be facing issues now. But measles is the canary in the mine.
The reason I say that is it's the most contagious of infectious diseases, such that the dependency on people being immunized is critical for prevention. You've no doubt heard of the concept of herd or population immunity. And so when levels fall below 95% and measles is introduced, we will see perhaps ongoing cases that don't sort of cease as outbreaks had in the past. And this is no doubt due to a number of factors related to vaccine hesitancy.
Our topic today and other challenges that have especially been amplified from some of the socio political forces that are the consequence of the COVID pandemic.
2026 US Measles Outbreaks
So importantly, I think we're on the cusp of no longer being known as a country that has eliminated measles and the Pan American Health Organization is going to vote this coming fall on whether we still qualify. And I have to say, I think this is in danger. You can see already through half of the year, we've outstripped the number of cases from last year regarding measles. And this is mainly afflicting younger children. But you can see also a substantial number of adults, most of whom are unimmunized.
We know that over 16 states are reporting immunization rates in school children less than 90%. And I think these are some of the critical factors that will probably see. It's very difficult to now eliminate or help staunch outbreaks. And this is true for a number of other vaccine preventable illnesses. And you may have seen measles in your practice, but if not, I think we all have to be prepared.
Another routine immunization that I think many of us highly recommend for everyone, but especially people at risk and seniors, is influenza. Last year was the worst influenza season in 25 years in terms of medical visits. This is something that was attributed mostly to the more virulent H3N2 subtype. And there wasn't great match, honestly, with the vaccine last year. But importantly, you can see the potential for this particular respiratory infection to wreak havoc.
And recently, a example of where a change in vaccine practices led to consequences, some of you may have been familiar with a change with our military where there is no longer standard influenza immunization for people entering the military. And there was an outbreak of influenza amongst Air Force recruits in Texas. And unfortunately, one of the recruits died of influenza, which shows that even completely healthy people are at risk. Which is why, until there is still a recommendation to immunize everyone over six months.
Other Vaccine-Preventable Disease Signals: Mumps, Pertussis
Other outbreaks. Although mumps, you can see here only 117 cases. I have a feeling this is something that will again leap to the headlines in short order as a number of people that are not being immunized for measles are also not being immunized for mumps. Pertussis is another vaccine preventable illness here, which, you know, is famous for causing severe infections in infants and children with a whooping cough.
But adults often are very protracted, prolonged, and severe coughing, sometimes called the 100 day cough and the number of cases in 2024 where 43,000 and last year, nearly 28,000, including 16 attributable deaths. Which again, I think the routine tetanus diphtheria, acellular pertussis vaccine is something that has gotten heightened awareness around pregnant women and others. But for the general population often is not routinely reinforced on an every 10 year basis.
Other Vaccine-Preventable Disease Signals: Meningococcal Disease
Meningococcal disease, a potentially lethal disorder had the highest number of cases last year, particularly with serogroup Y, which particularly came out in certain areas such as New York, California, Virginia, and Chicago. Unlike just adolescents and infants who are usually at highest risk, there are some other groups that were affected specifically 60% of these cases were among Black Americans and had heightened case numbers in people who were living with HIV and those who are undomiciled.
Vaccine Hesitancy Turns Susceptibility Into Outbreaks
So you can see there are a large number of these outbreaks. I think we are seeing more and more something very different, although we've always had issues with occasional measles, occasional mumps outbreaks, but nothing that seems to be conspiring to occur so frequently against so many. And this probably reflects the decline in the confidence of getting vaccines routinely for a number of factors.
Also, people that are living in localized clusters who are often have lower immunization rates than perhaps the general population in counties or states, along with for measles importation from overseas or just seasonal factors. And then, you know, the outbreak, of course, leads to spread. And what happens is the sense of not getting vaccines within a social group is often necessary a pretext for these outbreaks that are now happening.
Vaccine Recommendations
So vaccine recommendations. There have been changes in the past year, and I'm not sure we've seen the consequences of those yet. But I think it's important to just review a bit what's happened.
Changes in Current Federal HHS/CDC Vaccine Recommendations
Probably the most significant has been a change articulated by our Department of Health and Human Services and the White House and CDC for a change in so-called core childhood vaccine recommendations. Which were largely taken from the small country of Denmark, as opposed to the rather large and heterogeneous population with often different health care practices and health care access that we have in the United States.
version 7/2/2025 CDC/ACIP Child and Adolescent Immunization Schedule: ≤ 18 Yr of Age
What I've generally been recommending to my colleagues and using for recommendations are very much what I would call the older but established and, well, evidence based recommendations that have been published just last summer before these changes. I won't go over these in detail, but I believe many in our field stand by these recommendations very strongly and include a number of professional societies like the American College of Physicians, the American Family Practice Association, Academy of Pediatrics and Obstetricians and Gynecologists.
Comparison of 2025 and Current CDC Childhood/Adolescent Vaccine Recommendation
So from 2025, in terms of when those vaccines were recommended against diseases, that's declined by six. In terms of vaccines that have a routine or regular recommendation that's declined by six, with others shifting to so-called shared clinical decision making or those in a higher risk group. And then others have different changes that have some other bases, which we don't have time to address today.
COVID-19 Adult Vaccination 2025 vs 2026
Now, if we shift to adults, the primary change over the last year has been a shift in COVID immunizations, which are still available, still paid for by insurance and targeted to highest risk groups. But it's no longer a universal recommendation or a strong recommendation that you can make if you follow these new guidelines, as opposed to the 2025 guidelines. And there's more of an emphasis at discussing with your patient their risks, their prior infection history, exposure, and patient preference. So it's really moved from what we would say is a universal recommendation, which is what we still have for influenza technically from the CDC to one that is this shared decision-making that Dr. Kotton will speak about a bit more.
Resources to Consult for Vaccine Recommendation and Info
Key Points
And so in closing, I think we all have identified through both news organizations or own professional societies and journals that vaccine preventable diseases have definitely had a resurgence, which was true in beginning before the pandemic, but is especially getting more steam - head of steam now, and that we don't know the consequences of these changes in federal vaccine recommendations. However, I think many of us in our infectious disease realm stand by the earlier 2025 recommendations, which I would strongly recommend. And what will happen in terms of vaccine uptake, how all of us in the health care profession work with these recommendations and help answer questions and can we sort of help reverse or slow this decline in confidence of vaccines and prevention of diseases will be absolutely key?
Communicating With People Who Are Vaccine Hesitant
So now I'd like to turn it over to my well informed colleague, Dr. Kotton, who also has a special perspective because of course she was involved in earlier guidance for the vaccine recommendations. Camille.
Dr. Camille Nelson Kotton (Harvard Medical School): Great. Thanks very much, Paul. So excellent presentation. I will now take over and talk about communicating with people who are vaccine hesitant. And I think this is one of the more challenging things that we are doing these days in the clinic setting.
The Vaccine Hesitancy Continuum
All right. So vaccine hesitancy is really a continuum. And I think many of you are experiencing this in the clinical setting. I will say it's sort of starts maybe where people are refusing all vaccines and are with conviction. They really are sure that vaccines are not for them. And in general, this is a relatively new phenomenon, not entirely new.
Vaccine hesitancy has actually been around for a couple of hundred years. But this sort of more extreme vaccine hesitancy is new in its strength and breadth, I think. So refusing all vaccines with conviction, and then there's sort of the refuse all vaccines, but a little bit less sure. And that's where I actually generally find that I can gain some traction with people and start discussions. And sometimes it's not the first time I meet with them or the second, but often you can sort of lay some groundwork.
And then there's sort of the accept some vaccines, delay some vaccines, refuse some vaccines. And that's always interesting to me that people can actually feel that they have the full medical depth of medical, strong medical knowledge to be able to pick and choose. And then there's the more passive acceptance where they accept all, but they're really not sure, but their healthcare provider told them what was a good idea. And so they just kind of say yes.
And then we have the active demand. I call these the sort of active vaccinators or the vaccinees where they are actively seeking vaccination. They were sort of at the head of the line when COVID vaccines or RSV vaccines became available. And yes, so they are strongly in support of vaccines. And I don't know that I've seen anything quite like this in medicine in general until now if we think about things like prophylaxis against pneumocystis in immunocompromised or things like that, there's never really this extreme school of thought going on. So it's, I think, something new for many of us.
CDC SHARE Framework: An Approach to Vaccine Conversations
So the CDC has developed this share framework, and as a member of the Advisory Committee on Immunization Practice from 2020 through 2024, I interacted with people who had developed this framework, and I found this very helpful in thinking about my approach to vaccine conversations. So the first is, number one, share reasons why a vaccine is right for a specific individual.
And I often say I'm concerned about your health and I don't want you to develop vaccine preventable illness X or Y and sort of, you know, initiate that the reasons why we believe that the vaccine is indicated. I will also highlight positive experience with the vaccines either what I have seen in patients. And people often find this very interesting where I say, "Wow, it's been a dramatic change in people who are vaccinated versus unvaccinated."
As an example, we previously were not giving until several years ago when national policy changed. We weren't giving shingles vaccine to our transplant recipients. And now we give it to everyone and wow, we've really seen disease go away. And when I talk about that, people are like, "Oh yeah, I - I think I want that. I don't want shingles.
And when I talk about my clinical experience and then I'm no longer seeing zoster encephalitis with brain damage, which I would see a couple of times a year in immunocompromised patients, but the vaccines basically wiped that out. And so when I talk about that, people have a lot of good buy in. There's also highlighting the personal experience, and you may or may not feel comfortable sharing personal experience. I do say to patients, I vaccinate all my loved ones. I make sure that my parents are vaccinated, that my children are well-vaccinated, and I myself get the vaccines and all of my colleagues in infectious disease who are Harvard Medical School professors, we all get these vaccines.
I think there's a lot to be said about us doing it ourselves. And then when we give it to our loved ones, I can see that there's - can be some change in how they're thinking about things. So either highlight the professional experience or perhaps the personal experience. And then I usually say, "But tell me what you're thinking about or what your concerns are," or, you know, depending on how they're looking.
Yesterday a woman looked like she was on the verge of tears in clinic and I said, "Just tell me more about it. Just tell me what you're thinking and feeling and what your worries are." And I think you know, this is a really special moment and it's a good time for actually patient clinician bonding, where they really feel seen and heard. Remind patients that vaccines protect them and their loved ones from disease and complications, and then explain the potential costs and hazards of getting the vaccine so that they do understand that you've thought about safety. That could be something that you put up on the wall in clinic, or that you have the, you know, you have somewhere as a reminder for the various steps.
Shared Clinical Decision-making: Possible Outcomes
Now shared clinical decision making is something that was developed long ago by the Center for Disease Control. In that, it was only intended to be used when we didn't have enough information to make a robust recommendation on vaccines. So a good example of this is the very first year that the respiratory syncytial virus, RSV vaccines, were available, we did not necessarily have robust data, and we wanted to make a slightly more gentle recommendation where we talked about shared clinical decision making and where people discuss risks versus benefits.
Now, this has sort of taken over in the modern era where people think that this is better than a universal recommendation, but it's actually not.
And the thought was that this would allow vaccination to be focused on those most likely to benefit. However, those things don't really wash out. And what happens is we miss the opportunity to vaccinate a lot of people who did not realize that it would be beneficial for them.
So from a public health perspective, we end up having a lot of practice variation. We have less consistent vaccine recommendations. Nobody really knows what's going on. I suspect many people here are confused about current vaccine recommendations. And there is lower vaccine uptake. There's reduced herd immunity and there's overall a greater risk of outbreaks. So it actually does not work out in clinical practice. So it was intended for one thing is now being used for another. And broad shifts from routine recommendations can actually reduce vaccine coverage.
Shared Clinical Decision-making: In Practice
And so we really need to be careful about this. We actually generally when we know a vaccine is safe and effective and recommended for public health purposes, you know, things like influenza vaccine for all children over a certain age and all adults. That's because influenza vaccine saves lives. That's an easy one. And it's not intended to be shared clinical decision making. It's in the same way that I don't usually ask people, do you feel like wearing your seatbelt today? Do you like your seatbelt? People look at me like I have nine heads when I ask if they wear their seatbelt, almost everybody says to me, "Of course I wear my seatbelt." We don't do shared clinical decision making about seatbelts. Vaccine should be similar, and so we actually are seeing lower vaccine uptake because of these softer recommendations.
Highlighting the Benefits of Vaccination
So it's important to highlight the benefits of vaccination. And one thing we've learned from influenza, COVID-19, respiratory syncytial virus, pneumococcal, other vaccines, it's that there are these other huge side effects that can really enhance outcomes.
There was a recent VA study where they looked at COVID-19 people who were basically in the Veterans Administration hospital system, people who are either COVID-19 vaccinated or not. And those who were COVID-19 vaccinated had lower risk of hospitalization, lower risk of death, lower risk of severe disease. They actually didn't have a significant change in the overall rates of infection. And so I think all of us are like, yeah, sooner or later I get COVID, infection, whatever. But I think all of us want to avoid severe disease, hospitalization, and death. So I think that's an important when people hear like lower risk of death, oh yeah, I buy into that.
And then there are generally cardiovascular protective effects of many of the vaccines. So if someone has heart disease and they're worried about their heart, one of the best, most proactive things they can do besides, you know, taking blood pressure medicines and statins is actually to be well-vaccinated. And we've seen that with numerous vaccines. Similarly, we do see lower risk of dementia with multiple vaccines.
There have been numerous reports this year that with shingles vaccines, people have a lower risk of dementia. And when I talk about dementia, people are like, "Oh, I don't want dementia. I don't want death, I don't want dementia, I don't want hospitalization." So I get a lot of buy in for those topics. Also protection of kidney function. And, you know, in the early part of the COVID-19 pandemic or in bad years of influenza, we put a lot of people on dialysis. Some have regained in function. Unfortunately, many of the people that I see going for kidney transplant now tell me that they were fine until they got severe COVID and that put them on dialysis.
And they say to me, "I really wish I could have been better vaccinated. I don't know why I didn't take the vaccine. Now I'm on dialysis." So protection of kidney function is one of the benefits of vaccination as well. So many, many things that if you don't want to engage directly on the topic of infection prevention, because that may be a bit of a agitating situation. You could think about the collateral benefits of vaccination as well.
Memorable Messaging Tools
Some things that are useful analogy to analogies to make messaging more memorable and concrete. Personally, I love the seatbelt analogy. I've used it many, I think thousands of times at this point. But for most people, I say, "Do you wear a seatbelt in the car?" And most people say like, "Absolutely, I can't believe you'd even ask me that question." But vaccines are really the same easy, low hanging fruit, you know, well-tolerated, excellent side effect profile, same as seatbelts.
The majority of people benefit by wearing a seatbelt. Okay, good. And so I find vaccines are sort of like a seatbelt. No promises. You may get infection, but overall, you're less likely to die in a car crash if you're wearing a seatbelt and you're less likely to have severe hospitalization, severe disease hospitalization or death. So very similar analogy. I find the seatbelt one super helpful.
Another one would be the flight simulator which is basically vaccines train your body in the same way that if you're doing a flight simulator, like the way a pilot might train, train, train on a flight simulator for, say a bad landing or they're prepared, vaccines prepare your immune system to see disease. And so just like a flight simulator, just like that training, vaccines train the immune system to see disease and to fight disease. And so that's what you want. You want a pilot who's done the flight simulator like a gazillion times, so they know all about every possible bad situation and have worked through it before you're on the airplane, same as your immune system.
You want your body to have gone through training before they see that in infection. Or you could also think that it's a bit like a software update. Like a lot of people say, "Yeah, I had three COVID vaccines back in 2021." I'm like, "That's great." None of those are effective anymore. It's kind of like, you know if you have a computer from, you know, 1998 yeah, like you got a computer. It's probably not working well. And so we do software updates. We need vaccine updates. That's why we need a flu shot every year, COVID- 19, at least vaccine at least every year, every six months for people who are over the age of 65 or immunocompromised. But it is important to stay up to date on your software, and stay up to date on your vaccines.
Question and Answer Session
Dr. Auwaerter: Well, Dr. Kotton, I thought those were super analogies and metaphors or whatever you'd like to call them, I think they're very useful for our practices. So yeah, please play some questions. And I think we have one that we could probably just kick off with. And thank you for Miriam. The question was what to answer a patients who are concerned about RNA vaccines. I think this is a certainly common topic. And I first want to just understand if it's COVID or the RNA vaccines itself.
But the easiest answer, honestly, to just get people across the line would be to talk about a protein subunit vaccine. So just to let them know that there's really a different technology that's really very similar to others that they've already received. But sometimes I also want to try to educate a little bit about RNA and both their concerns. And if I have time, try to answer those as well. But Camille, I was wondering what your thoughts were about that in your population.
Dr. Kotton: Yeah, I do think that that's a really useful recommendation. I also talk about the safety of mRNA vaccines. There's so much legend out there, you know, that it's going to go into your chromosomes or all kinds of things that are not actually scientifically plausible or possible and are actually just bluntly not true.
Some people I can talk about that and then other people I can't, but for people that are still interested, they just want to hear my perspective. There was actually a wonderful review that just came out on mRNA vaccines, but it talked about how severe adverse events are very, very rare. Close to like one in 1,000,000, one in 200,000.
I just talk about how I feel they're safe. I personally have had a bunch of mRNA vaccines. And I had no reaction. And I tell patients that and actually, you know what they they're like, yeah, I want one of those. I'm going out to get one of those.
For mRNA vaccines, there will be an influenza mRNA vaccine that I believe will be available this fall. And it's actually really robust protection for those of you that want some really good influenza protection better than what we usually get. I would actually consider that vaccine for yourselves, and if you're interested for yourself, talk to your patients about it.
The next one is what if you use the seatbelt analogy and the patient gets offended or upset that you compared the two? That's from Leah Ventura. Thank you for that question. Yes. Okay. So one thing that happens in clinic is sometimes the patient says, "Yeah, I never wear a seatbelt." And I will just admit that I almost don't know where to go with that. I thank you for laughing, Paul. I think usually the look on I try to, you know, hold it in, but that's a - that's a hard one.
Usually people if they're a little offended that I even asked such like a silly question. I mean, really the answers are all over the place, so you never know. Right. I say, "Oh I, you know, didn't mean to offend. I'm actually surprised, but some people don't wear their seatbelts," and so like more like I'm on your side and that's usually not a problem. It hasn't been a problem for me. It is a bigger problem for me when they tell me they don't wear their seat belt. Paul, I don't know if you have anything to add there or if you-
Dr. Auwaerter: No, not really. I think you try to move on or just try to put it in a different context. But yeah, I think, you know, there are always going to people that, you know, look, the Medicare wellness exam that we some of us do, I do some primary care along with ID. So you know, the wellness exam that's embedded in there. So, you know, it's a yes/no kind of thing. And people say, "No, I might just ask why?" Because it might give some thinking into their risk benefit analysis as well.
But why don't we go on to this question, which is from William? How many people suffer from adverse reactions, severe ones, I should say, from vaccine administration per year. And of course, I don't know if we have super firm numbers, but I think if you look at the confirmed ones that sort of sort through legal rulings, generally, what I typically quote is the one in 1,000,000 kind of situation.
So out of every million shots, you know, of all-comers, there could be a serious adverse reaction. But if you look at sort of the serious illness, hospitalization, death, even in healthy people from influenza, as we talked about, I think that puts it into context. So the numbers are small. So I think that's important because I think when you have it, you're healthy and you're taking a shot. You feel like what could go wrong? Because I'm healthy, right? It's not like you're treating an illness.
So it is a different mindset, but I think it's a prevention issue and that's important along the lines of the same things that Camille had outlined in your examples. Camille, what's your sense when you were on the ACIP for those sorts of issues? I mean, obviously, safety is often on the forefront of people's minds because everyone's heard a story so and so got Guillain-Barre. You know, so and so's life was ruined by a vaccine. Of course, those stories are all over social media.
Dr. Kotton: Yes. Yes. Well, the risk is overall very low. I think somewhere in that one to 100,000 to one in 1,000,000, you know, if you look at the overall risk of a true severe adverse event like a well-documented one. Now it's amazing to me that since 2021, almost everything has resulted from a COVID vaccine. So I see patients who are like a young man with kind of male pattern baldness who unfortunately is just going bald, tells me it's from the COVID vaccine and like almost everything, and you're like, that's not really a thing. That's just not a thing, right?
But like almost everything happens from the COVID vaccine or some of my patients have actually stayed home with bacteremia and pyelonephritis. And they said, "Well, I got a COVID vaccine three months earlier, and I thought it was a fever from the COVID vaccine." So I try to like separate out because it's a sort of dangerous situation. I do try to tell them about the risk being low. That being said, a lot of people come to me and say, "I know three people who died from the COVID vaccine." That's a hard one because they don't have data.
They don't even know when the patient got a vaccine. They had a COVID vaccine and then died at some point later on. I struggle with that. I do just talk about overall data.
So Theodore Spiro says, "How do you handle patients with a prior vaccine reaction or complex allergy history?" One thing is that there's some really good guidance on the CDC website. So things like if somebody has a history of Guillain-Barre, can you give vaccines?
And the person I saw, I carefully asked a history. He said he'd had no vaccines before the Guillain-Barre. He just had plain and simple Guillain-Barre. And one of the things is the risk of Guillain-Barre from infection may outweigh the risk from vaccination. So if it's a high probability infection, things like COVID and influenza, that somebody's going to get those infections, it actually is probably better to be vaccinated than to be unvaccinated and run the risk of natural infection, which could also cause Guillain-Barre.
So I do talk to them about risk benefit when they're truly complex allergies, I partner with one of the allergists that I work with and will often talk about a plan talk about, you know, how to manage. And then I think what we mentioned before for people that feel that they are allergic to mRNA vaccines, there's still a more traditional vaccine platform.
Paul I turn it over to you.
Dr. Auwaerter: Oh, thanks. Well, I think we're nearing a close here and I want to say we're hoping that a lot of these discussion points are helpful for your practices.
Go Online for More Coverage of Vaccines!
Also please go online for more coverage of vaccines. You can download these slides and a case experience is also there as well.
Thank You for Attending
So I think on behalf of everyone, we really want to thank you for attending today. And hope you have a great day.