On Thursday, a Centers for Disease Control and Prevention advisory panel voted to recommend limiting the combination measles, mumps, rubella, varicella vaccine, and on Friday the panel will vote on Covid vaccine recommendations, as well as whether or not to continue recommending the hepatitis B vaccine for infants within 24 hours of birth.
It was the most substantive meeting since Robert F. Kennedy Jr. had broken his promise to senators made during his confirmation hearing, and totally reconstituted the vaccine advisory panel, Advisory Committee on Immunization Practices, or ACIP, firing everyone on the panel in one fell swoop and replacing them with a hodgepodge group of allies, almost all of whom were less qualified than the people who had been there before, and almost all of whom were more skeptical about the benefits of vaccination.
Since Kennedy took over the U.S. Department of Health and Human Services, there’s been a lot of worry about just where a longtime anti-vaxxer would take the country’s vaccine policy, and today was probably the clearest glimpse we’ve gotten yet.
So I wanted to talk through what we should take from that meeting with Dr. Paul Offit. He’s a pediatrician who specializes in infectious disease, a former member of ACIP and someone who took some nuanced positions on Covid vaccination during the pandemic, but has been pretty alarmed about the changes being put into place by Kennedy.
And a last note: We’re recording this on Thursday evening, just after the panel made their votes.
Paul, thank you for joining me.
Paul A. Offit: Thank you, David.
Wallace-Wells: The last time we spoke was a few months ago, when you sketched out a few different ways that R.F.K. Jr. and his team might do damage on vaccines. They could soften recommendations, leaving decisions a bit more in the hands of parents and doctors; they could withdraw recommendations, leaving insurance in an uncertain spot, and they could make it a lot easier for families to sue over claims of vaccine injury, potentially including autism.
You called that last one a kind of worst-case scenario, which could functionally destroy vaccine infrastructure in this country. After today’s vote by ACIP, where are we on that spectrum? How should we think about how bad it is and where we’re heading?
Offit: So I guess the issue that worried me the most today was the hepatitis B birth dose. Let me put this in perspective: Normally the way this works is there’s a question that’s raised. So: Is the hepatitis B birth dose necessary? Would it be safer or more effective if you gave it at 1 month of age or 2 months of age? And then what you do is you form a working group and you examine those issues. That wasn’t done. This was just a kind of hodgepodge of what people are thinking about without really having the kind of evidence to answer any of those questions.
So in 1982 we had a hepatitis B vaccine, and that was recommended for all children at birth if their mother was detected with the infection. Then in 1988 that was extended to include the birth dose for all children born to mothers who had hepatitis B, as well as people who were in a racial or ethnic background that put them at risk for hepatitis B. And what they found in those years is that there were still tens of thousands of children who got hepatitis B, 10,000 to 15,000 children less than 10 years of age who would get hepatitis B.
And they weren’t getting it from their mothers; they were getting it from relatively casual contact with people who had chronic hepatitis B. They were getting it from the fact that there are millions of people who have chronic hepatitis B in this country and they were coming in contact with them.
Wallace-Wells: So these days you hear a lot from folks who are skeptical of the hepatitis B vaccine, that this is a sexually transmitted disease, and maybe we should recommend it for others who are positive, but we don’t need to worry about exposure of infants because they’re not sexually active, of course. What you’re saying is this experience, which we had in the relatively recent past, shows pretty emphatically that there’s a large population who is still vulnerable to infection because it is not simply a sexually transmitted disease — it can be transmitted in all these other ways as well?
Offit: That’s right. Now, you’re especially vulnerable as an infant, so you want to make sure that those children are protected in that first year, and hence the birth dose. And with the birth dose, we’ve virtually eliminated hepatitis B virus in less-than-10-year-olds. I don’t understand why we’re having this discussion.
Wallace-Wells: Well, that’s actually what I was going to ask — we can see in some very clear way the benefits of this vaccination. Why has this vaccine in particular animated so much pushback among the cohort that we’re talking about, R.F.K. Jr. and his allies? Why do they seem so especially focused on hepatitis B as opposed to many of the other vaccines that American kids now get pretty routinely?
Offit: Because it’s a birth dose, they call it the gateway vaccine to vaccine hesitancy. That’s the way it’s described, and you can understand it to some extent. I mean, your child has just been born, and now you’re injecting them with a biological agent that many people don’t understand, so you can see the hesitancy. And so I think that’s why those who are concerned about vaccines — skeptical, and arguably cynical, about vaccines — target the hepatitis B birth dose. I just think they’ve raised a question that has already been answered in the data showing that we’ve virtually eliminated this disease in children.
Wallace-Wells: Just from the way that they spoke about that today and in the past, it’s not as though they’re coming with new information, new research, new perspective. It’s kind of the same old talking points. The line you mentioned earlier that this is the gateway drug — it’s like on some intuitive level, it makes sense that they would open with an assault on this vaccine, not because there’s a clear sign of population-scale damage. In fact, quite the opposite. But just because it’s the one vaccine that’s organized so much of their thinking in the past.
Offit: That’s exactly right. And Robert Malone, who’s now one of the voting members of the ACIP and a self-proclaimed anti-vaccine activist — he doesn’t think the term should be used pejoratively — but he said, when asked the question, “Why are we looking at this?” he said, “Because parents are concerned.”
But see, I think in many ways it’s a communication issue. People don’t understand. They don’t understand what that biological agent is, what the hepatitis B vaccine is. I think many have the false notion that this is only meant to protect against a disease encountered by people who were either born to a mother with hepatitis or who might later become an intravenous drug user or a sex worker, which just isn’t the case.
Wallace-Wells: I saw one of the slides that was presented also showing a declining exposure to hepatitis B in the American population, but of course, that is in part a function of the widespread vaccination of the population. But it does suggest one of the dynamics undergirding this cultural phenomenon more generally, which is that we used to live among many more infectious diseases.
Through vaccination, we’ve defeated many diseases — pushed them back, or at least to the margins of our lives in America. And now some portion of us looks at that landscape and thinks: Do we really need to worry about a child getting exposed to hepatitis B? If we’ve cut the circulation of the disease that much, you could say the same thing for many of these diseases.
It feels like on some level what we’re seeing is a kind of cultural immune amnesia. People talk about immune amnesia in the biological sense, but here we’re experiencing it socially. We’ve forgotten what it’s like to confront some of these diseases head-on, and now we have the luxury of thinking they don’t represent a meaningful risk to children.
Offit: You’re right. I think vaccines have largely been a victim of their own success. What amazes me is that I’m a child of the 1950s, so I had measles, I had mumps, I had rubella, German measles, varicella — I had all those diseases. And I certainly remember polio — as my parents certainly did.
And it’s not just that we largely eliminated measles from this country in 2000. I think we eliminated the memory of measles, but that’s not the case with hepatitis B. There’s at least two million people out there that are infected with hepatitis B. Many don’t know it; it’s called the silent epidemic for that reason, and they’re highly contagious. This is a far more contagious disease than, say, H.I.V., because there’s such a huge amount of virus in the blood.
You have between 100 million to 10 billion infectious particles per milliliter of blood if you’re infected with hepatitis B. And that virus lives well on surfaces; it can live up to seven days on surfaces.
Wallace-Wells: And what do you expect is going to happen tomorrow? Can we just count on them changing the recommendation in some meaningful way? What do you think will happen? They didn’t get around to a vote today; they ran out of time.
Offit: I think I’m going to guess that they’re going to say that anybody who’s born to a mother who has hepatitis B needs to get a birth dose. And then, if you’re born to a mother who isn’t detected as having hepatitis B in that first trimester, that you can wait at least one month before you give that vaccine. I think they’ll do that in the name of restoring public trust, because that’s what R.F.K. Jr. constantly says: We need to restore the public trust. They’ll see this as an issue for parents, and they’ll think it helps restore trust.
I guess I don’t see it that way. I could be wrong, but the reason I don’t is that I lived through the 1999-2000 thimerosal issue. I was on the Advisory Committee on Immunization Practices between 1998 and 2003. At that time, we were adding more and more vaccines to the schedule, and some of those vaccines contained an ethylmercury-based preservative called thimerosal. That became a big issue.
Now, we live on this planet, and we’re all exposed to methylmercury, which has a half-life of about 50 days. We all have some mercury in what we drink. Ethylmercury, by contrast, has a much shorter half-life and is eliminated from the body much more quickly. If you look at children’s bloodstreams after receiving thimerosal-containing vaccines, you can’t detect any meaningful increase in the mercury burden beyond what we already carry from simply living on this planet.
There are about nine studies showing you’re at no greater risk of any neurodevelopmental problem if you got a thimerosal-containing vaccine than if you didn’t. My feeling at the time, as an ACIP member, was to vote no when the issue came up: Should we insist pharmaceutical companies move from multi-dose vials to single-dose vials? Here’s why. Preservatives were needed in multi-dose vials because, when you puncture a vial multiple times, you can inadvertently introduce bacteria. Then the child who gets the eighth, ninth or tenth dose might be inoculated with a contaminated vaccine, leading to abscesses, cellulitis, sepsis or even death. That’s why mercury-containing preservatives were added to vaccines in the 1930s, and they essentially eliminated that risk.
So the amount of mercury in those vaccines was trivial — or arguably undetectable. But it didn’t sound good. It’s not like there was a National Center for the Appreciation of Heavy Metals standing up in defense of mercury. I actually had to testify in front of a congressional hearing where one of the congressmen stood up and said: When it comes to mercury, I have zero tolerance. Well, if you’ve got zero tolerance for mercury, you’d have to move to another planet, because on this planet, there’s mercury.
Wallace-Wells: But pulling back from that particular history to talk a little bit about where we are and where we’re going more generally, we are in a place where there is declining trust in vaccines, and I often think that is somewhat overhyped. We’re talking about declines on the margins, but they are epidemiologically meaningful because they’re pulling the rates of coverage below herd immunity. That means there can be more outbreaks.
That was happening before the pandemic, but it picked up during the pandemic. So on some level it’s intuitive to think that we should do something to restore public trust in these programs and these vaccines.
And yet when I hear figures like the members of this panel, up to and including R.F.K. Jr. — not to mention many other people who are that skeptical in one way or another — it doesn’t inspire any kind of confidence in me, and what it sounds like they’re saying is whether or not there are any questions about these tools, we have to change our recommendations. We have to change our messaging, not because there’s any real risk, but because there’s some imagined risk or exaggerated sense of risk in a certain subset of the population.
Now, maybe for those 3 or 5 or 8 percent of parents, that will feel like this is some kind of concession, but what about for the 90 percent of parents who are still getting their kids all the vaccines that are recommended and have been doing so without much protest or pushback for many years?
Offit: No, that’s exactly right.
And the only reason I brought up that thimerosal story was that it was couched in the same way this is being couched. Which is that we need to be openhearted and open-minded to the parents’ concerns, which is that we should take thimerosal out of vaccines. But that certainly didn’t make vaccines safer.
It only made them, frankly, more expensive in the developing world. Because now you’re only at single-dose valves — much less available. And that hurt children, I think, by doing it that way. Because we elevated this theoretical risk above a real risk, and the result was the opposite.
People were saying: Wait, why was this ever in there? Now they’re taking it out in a precipitous manner. It must have been harmful. So we gave birth to an anti-vaccine movement. It was the opposite of what we had expected. And I feel the same way, and I think you’re alluding to this here.
Why can’t we just explain better why we’re doing what we’re doing? So that people can understand the need for a dose, rather than saying: OK, let’s just loosen up, because then it looks like it was really never that important to begin with.
And I think what you do when you say that — and we’ll see how people vote on this on Friday — is that you’re only going to lessen the degree to which people get the vaccine because they’re thinking: Yeah, it really wasn’t that important to begin with.
Wallace-Wells: And the panel did give a one vote on the M.M.R.V. vaccine. Can you walk us through what that vote said and what it means for coverage for measles, mumps, rubella and varicella, which is chickenpox?
Offit: Right. These vaccines are given twice. Once at 12 to 15 months of age, and then given again at 4 to 6 years of age. It’s important to note that at 12 to 15 months of age, which is an age where children are more susceptible to febrile seizures, which, although they don’t have any sort of long-term consequences, are certainly hard to watch ——
Wallace-Wells: On that, just for a brief second, I want to be really clear about this. This is one of the things that gives people some real pause about this. There is a low risk of a febrile seizure, which has, as you said, no long-term side effects. So there is something that is vivid and scary, but has no measurable impact on the long-term health of the child.
So not to say that we shouldn’t feel the animal feelings that we feel when we see someone having a seizure; that’s all completely natural, and as a parent would be terrifying. But from the perspective of public health policy, we are saying that that event, even when it happens, which itself is quite rare, has no meaningful consequence for the child going forward.
Offit: That’s exactly right. I think people hear the word “seizure” and they think epilepsy, and that this is now the gateway to having epilepsy. But none of that’s true.
There’s no change in neurodevelopmental outcome or attention deficit disorder, hyperactivity disorder, et cetera. But of course it’s hard to watch. For example, our hospital gives Measles, Mumps, Rubella and Varicella separately as the first dose, and then gives M.M.R.V. as the second dose. That’s what we do in the four to six year range. Your risk of having a febrile seizure is increased by viral infections, or by anything that causes fever, including vaccines. It is not common, but certainly, one can argue that for parents, they may say, well, you know, I understand it’s a small increased risk, but I also understand that there’s no long-term side effects, and I’d rather my child get two shots rather than four.
I think what the vote did today — because they basically said that they didn’t recommend the M.M.R.V. vaccine for the 12-to-15-month-old group — is that they may eliminate the parents’ choice.
Wallace-Wells: Looking at the presentations that were made today, the conversations that you watched today, that I watched today, what does it make you think about where we’re heading, putting aside for a moment M.M.R.V. and hepatitis B? Just in general, how did these proceedings make you think about which way the wind is blowing here?
Is it possible to look at hepatitis B and M.M.R.V. and say: Well, they’re kind of tinkering around the margins and these aren’t the recommendations I would make, but they’re not going to be all that consequential or catastrophic? Or should we be thinking that we’re heading for some more significant and more damaging changes in the months and years ahead?
Offit: We should be thinking that we’re heading for more damaging changes in the months ahead.
Wallace-Wells: So tell that story. Where are we headed?
Offit: So right now I agree; I think we’re sort of tinkering at the margins. I think in the June meeting, the ACIP voted against the use of thimerosal-containing flu vaccines. That was an anti-science vote. Today also, the M.M.R. versus M.M.R. plus V., I think that may have some problems down the line in terms of availability for those vaccines through the Vaccine for Children Program. We’ll see. But again, that’s not a monumental decision.
Hepatitis B — you’re starting to get there, because now if you really say, OK, you can wait a month or more, knowing that there can be false negative tests, knowing that a lot of people don’t get tested, this was a safeguard. This meant you were jumping with a net and now we’ll have to see how that plays out.
Then what happens is we move down the line, knowing we have a secretary of health and human services who is a virulent anti-vaccine activist and science denialist, who will do everything he can to make vaccines less available, less affordable and more feared. He means it. He believes — as he said — that we have simply substituted chronic diseases for infectious diseases, and he wants to do everything he can. As he said, God has put him on this earth to eliminate infectious or chronic diseases in children, and I think he sees vaccines as one of those causes.
He could make it so that the Advisory Committee on Immunization Practices doesn’t vote through the Vaccine for Children Program to approve certain vaccines. He says: I don’t think they’ve been tested enough. I don’t think they did placebo controlled trials. I don’t think they did gold standard science. I think the people that published studies were in the pocket of industry — which is what he says all the time. And then you’ll see a gradual erosion of the Vaccine for Children Program, or if you really want to end vaccine manufacture in this country, go after the Vaccine Injury Compensation Program, which was created in the mid-1980s to prevent frivolous civil litigation and keep companies from making vaccines.
We went from 18 companies that made vaccines in 1980 to four by the end of the decade because they were driven out by litigation. That Vaccine Injury Compensation Program stops the bleeding, and I think he wants to reopen that wound. And when, at that second confirmation hearing, he was asked by Elizabeth Warren: You promise me that you won’t reconfigure the Vaccine Injury Compensation Program to financially benefit yourself and your personal injury lawyer friends? He said: No, I’m not going to stop pursuing pharmaceutical companies.
He loves this, and I think that’s where he’s at. At some point, Congress or the president of this country are going to have to stand up for the health of America’s children and realize they can still have their MAHA movement — because there were a lot of things in the MAHA movement that are likable — and not have an anti-vaccine agenda at the center of it.
Wallace-Wells: What you’re saying now — and I think is really important — is that there is this big, looming risk about the Vaccine Injury Compensation Program. And the real threat there, as I understand it, is that in this upcoming report about autism, if it becomes the position of Kennedy and H.H.S. — meaning the C.D.C., et cetera — that vaccines are contributing in a meaningful way to the autism epidemic in this country, that will truly open up a can of worms for the entire vaccine infrastructure and make it very, very hard for us to preserve anything like the systems we’ve had in place over the previous decades.
What do you expect that report to say? How worried should we be about it? How consequential do you think that report will be?
Offit: It’s hard to know. It used to be that we made policy decisions based on solid, reproducible, robust scientific studies. That’s not true anymore. Where the anti-vaccine activists like Robert F. Kennedy Jr. were shouting from the sidelines for a couple of decades, now they’re making policy based on their fixed, immutable, science-resistant beliefs.
He has said that autism is preventable, which goes against, frankly, all the evidence to date. There’s not a single cause for autism, but certainly there are a number of factors that predispose one to autism. One is paternal age. The second, to a lesser extent, is maternal age.
It’s certainly known that there are certain infections during pregnancy that increase the risk, like cytomegalovirus infection or rubella infection. There are certain drugs you can take, like valproic acid, which is an anti-seizure medicine that increases your risk of autism.
There are certain maternal health issues, like obesity and diabetes, that increase your risk of autism. So what those all point to is one thing, which is you’re probably born with autism. And so the notion that it’s preventable, meaning that there’s something you’re being exposed to after birth that’s causing you to have autism, is probably wrong on its face.
But I fear he’s going to hold up some bogus paper because that’s what he does, and then he makes a decision based on that. And will it be the birth dose of hepatitis B? Will it be aluminum adjuvants in vaccines? You just don’t know because everything that used to matter in this world regarding science dictating policy doesn’t matter anymore.
We have a secretary of health and human services as well as an Advisory Committee on Immunization Practices that supports him. We’ve lost all guardrails here.
Wallace-Wells: I want to close by talking about something that you mentioned a few minutes ago, which is to say one could imagine moving forward and taking some inspiration from MAHA in a scientifically rigorous, public-health-oriented way. I want to ask what that would look like for you.
What are the good questions to ask about the vaccine schedule as it exists today? What are the open questions? What should researchers worrying about this bundle of concerns be focused on?
What would be a reasonable, laudable version of MAHA, and they’re taking on vaccines, but they’re doing so in a responsible way?
Offit: I’d like to divide up something in one way, which is I think that the Make America Healthy Again movement has a lot of features in it that are excellent.
I do think we are generally more overweight and obese in this country than other developed world countries. I think that ultraprocessed foods play a role in that. It’s not simply that. I think there are also socioeconomic factors and behavioral factors that are part of that, but that is part of it.
I think we do overmedicate our children. I think that’s all true. When I talk to people in the MAHA group — there’s a podcaster named Brinda Adhikari who has a podcast called “Why Should I Trust You?”
She has MAHA people on, she has public health people on, and the MAHA people aren’t necessarily anti-vaccine. That’s not necessarily part of their movement. That’s R.F.K. Jr. It’s certainly some part of their movement. There are a lot of MAHA people that don’t like getting diverted with this anti-vaccine story.
But I think some people are watching the C.D.C. getting torn limb from limb and liking it because of what happened during the Covid pandemic. So how do we get the trust back? In terms of vaccines, I think we need to explain ourselves better. I think we assume that because vaccines have been so remarkably successful at making us live longer, better lives — we live longer than we did 100 years ago in large part because of vaccines and sanitation — and we take that for granted.
I think we are a victim of our own success. It amazed me, we had a child come in with measles to our hospital last year, and many doctors came up to me and said, “I’ve never seen a case of measles before.” Which shocked me. I just never thought of that. So it’s not only that parents aren’t compelled by these infectious diseases; I think young doctors are less compelled because they didn’t grow up with them.
Wallace-Wells: The way that I see the politics of this moment is a little different than you. I agree that Kennedy has the marriage between anti-vaccine feeling and anti-public-health feeling and a behavioral, individualistic approach to these questions.
And all of that came together because of the pandemic in a big way, whereas they might have been somewhat separated before. But I also look back on the experience of the pandemic and I think, as you do, some mistakes were made around vaccine recommendations and guidance. I would like to go back and tweak some of those policies and positions.
But I think much more damage was done by the people who are sowing doubt and distrust throughout, about much bigger questions, like, was this even a disease worth worrying about? Are these people even dying of Covid or are they dying of vaccination? And I see on some level that Kennedy’s arrival at H.H.S. is a perfect illustration of this, which is to say there are a lot of Americans who felt let down, but how many Americans out there want no more vaccines? How many Americans out there, whether we overpromised that the Covid vaccine was going to deliver long-lasting, sterilizing immunity — we did overpromise that; we probably shouldn’t have because we probably should have known better — but nevertheless, those promises were made, and yet, how many Americans does that lead to think we need to throw all the bums out? Burn the institutions down, completely change the standards?
I just find myself thinking that the number of people who have that attitude toward all of these questions are much smaller and came to the pandemic with those commitments already, as Kennedy did. And the number of people who have grown a little bit more skeptical or a little bit more worried or a little bit more distrustful, they’re not in the hard-core camp of anti-vaxxers, and it shouldn’t be that hard to bring them back onto the side of trusting the authorities.
I don’t know that the Kennedy regime is going to appeal to them six months from now, two years from now in the same way that it might have appealed to them 18 months ago, when they were still reeling from the experience of Covid.
Offit: I completely agree with you, and I’m heartened by that. I think that there was a Trump-friendly pollster, and he did a poll looking at Republican and Democratic parents in terms of their attitudes about vaccines. This is exactly what you said: Most parents support vaccines. And it’s not partisan.
And I think that’s your question: How do we appeal to them? Because I think you’re right: Kennedy doesn’t represent most parents at all. He represents a small slice of parents who may have come into this pandemic that way and hardened their position, but he didn’t necessarily create their position.
Wallace-Wells: That’s the last question I wanted to ask you. There’s a dark timeline, which you walked us through a little bit, where some quite profound, fundamental damage could be done to America’s vaccination system and program. But there’s also a timeline that we may find ourselves in where some changes are made, maybe they’re not quite optimal, but they’re not catastrophic. It seems to me like that timeline is still in play.
If someone were to ask you: How can we try to keep the country on that brighter timeline as opposed to that darker timeline? What can we do as citizens, voters, Americans in social circles? What can we do to try to limit the blast radius of the Kennedy bomb and preserve as much of this infrastructure as we might hope to? Is there anything to do to direct the country toward the more palatable, less damaging path?
Offit: My sense is it’s a political problem. We have a president who has asked R.F.K. Jr. to be the secretary of health and human services, and he’s doing a terrible job. At no point has he ever stood up and said, “We need to make sure you vaccinate your children,” because that’s not who he is. So it’s a political problem, and I think it has a political solution. What was interesting about that poll is I know for a fact it was shown to a number of Republican senators on the Hill. And at that last committee meeting, the finance committee, when Senator Barrasso, Senator Tillis, Senator Cassidy, all three Republican senators, all went at R.F.K. Jr., they had seen that poll.
And so I just think that as things start to continue to erode, it would be nice if parents write letters to their congressmen, because when I’ve talked to people in Congress, they all say that if we get thousands of letters about one issue, that impresses us. So I do think eventually people will stand up. There’s an old expression, which is if everybody shows a little courage, no one needs to be a hero. Maybe that’ll happen.