What Could Trump Really Do to Vaccines?

Members of anti-vaccine fringe groups have taken Robert F. Kennedy Jr.’s recent meeting with President-elect Donald Trump as a sign that his promise to “Drain the Swamp” will extend to the country’s immunization policy-makers.

But it is unclear just how much sway Trump could have over childhood vaccinations. There are no federal laws mandating vaccinations. The task of regulating public health generally falls to the states, and immunization requirements are no different. All 50 states require school-aged children be immunized. Every state includes an exemption for medical reasons, and most others—excluding California, Mississippi, and West Virginia—allow parents to opt out based on religious or philosophical beliefs.

While the federal government—and thus the president—has little say in who must be vaccinated, it has considerable power over policy, much of which is set at the Centers for Disease Control and Prevention, an agency that will be led by an as-of-yet unknown Donald Trump appointee.

Trump’s pick will be charged with developing the vaccination schedule, which states rely on for their school requirement laws. The president-elect has made it clear he objects to the agency’s current recommendations, tweeting in 2014, “I’m not against vaccinations for your children, I’m against them in 1 massive dose. Spread them out over a period of time & autism will drop!”

After vaccines are licensed and approved by the Food and Drug Administration, the Advisory Committee on Immunization Practices (ACIP), a CDC panel of medical and public health experts, studies the research and data to make decisions about when and in what amounts those vaccines should be administered.

According to Kennedy, a hero of the anti-vaccine movement, Trump extended him an invitation to chair a committee on “vaccine safety and scientific integrity” during their meeting this week. The Trump camp later said in a statement that the president-elect was merely “exploring the possibility of forming a committee on Autism.” Public health experts reached by The Daily Beast expressed concern that the incoming president is talking about forming committees that already exist and work well.

“NO need for new gov’t commission. Current scientific evidence is solid!” the American Academy of Pediatrics tweeted in response to Tuesday’s meeting, along with a link to a statement that read in part, “Vaccines are safe. Vaccines are effective. Vaccines save lives.”

“We’ve already got the National Vaccine Advisory Committee, the Advisory Committee on Immunization Practices within the Department of Health and Human Services (HHS), and the Interagency Autism Coordinating Committee that coordinates the efforts of HHS agencies,” said Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and a contributor to The Daily Beast.

“I suspect Trump doesn’t know it,” Offit said. “Or he thinks [the existing committees] are part of a massive conspiracy to hide the truth.”

Both are fair guesses. In 2014, Trump tweeted, “I am being proven right about massive vaccinations—the doctors lied. Save our children & their future.” And his new friend Kennedy certainly sees a plot in the current committees. The environmentalist-cum-conspiracy theorist has compared health officials on these boards to Nazi concentration camp guards, and widespread vaccinations to the Holocaust.

Another issue lies in the power—or lack thereof—of the recommending committee, said Dr. Mark Sawyer, professor of clinical pediatrics at University of California San Diego School of Medicine and a pediatric infectious disease specialist who has served on the CDC’s Advisory Committee on Immunization Practices.

“The recommendations are not binding,” Dr. Sawyer said. “The head of the CDC ultimately decides whether to accept them. The president could ignore them and do the opposite. That’s the concern.”

In theory, Trump could choose an anti-vaccine activist like Kennedy or the discredited physician who started the movement, Andrew Wakefield, to lead the CDC. The agency’s directorship is usually a less political appointment than other top government positions. But Trump has defied logic with a number of other picks so far: He’s chosen a fossil fuel industry ally and climate change denialist to head the Environmental Protection Agency; a billionaire creationist and school vouchers advocate as the secretary of education; and a secretary for health and human services who belongs to an organization that opposes mandatory vaccinations and promotes the pseudoscientific idea that vaccines cause autism.

In addition to developing guidelines, the federal government also buys and distributes vaccines, mostly for children. In response to a measles outbreak that killed hundreds of poor, unvaccinated children in the early ’90s, Congress established the Vaccines for Children (VFC) Program, which purchases vaccines at a discount and distributes them to states to inoculate poor children.

“If you cut back funding for that program, you could do a lot of damage,” Offit said.

For Dr. L.J Tan, former director of medicine and public health at the American Medical Association and chief strategy officer for the Immunization Action Coalition (IAC), a group that promotes immunization education, the most endangered program under a Trump presidency is the one that funds our immunization infrastructure. Known as “Section 317,” the CDC-administered federal program pays for vaccines, epidemiology, science, surveillance, the management of outbreaks, and more.

A recent report from the Department of Health and Human Services’ National Vaccine Advisory Committee called Section 317 “the backbone of the U.S. immunization program.” Congress funded the discretionary program with $610 million in 2016 but is under no obligation to do the same next year.

“We’re very worried about a hawkish incoming Congress that will say, ‘That’s $600 million we can take off the table,’” said Dr. Tan, who is also a voting member of the National Vaccine Advisory Committee.

“We already have certain members of Congress who are vaccine hesitant,” he said. “Now we have a president who appears to be vaccine hesitant—though I hold out hope—but you put all this together and add it to Republicans who want to show the people who put them into power that they’re serious about cutting the deficit… it’s a perfect confluence of events.”

Trump’s transition team did not respond to a request for comment on his vaccination policy.

The public health experts agreed that a real danger lies in Trump’s possible legitimization of fringe conspiracy theories that have the potential to influence the beliefs and decisions of individual parents, ultimately affecting the number of children who are vaccinated.

Less than 2 percent of parents of kindergartners in the U.S. sought exemptions from vaccinations in 2014, according the the CDC, though certain pockets of unvaccinated children are still a cause for concern.

Dr. Rodney Willoughby, a professor at the Medical College of Wisconsin and a member of the committee on infectious diseases at the AAP, told The New York Times in 2011 that false alarms on vaccines sounded by politicians and celebrities have historically had a negative impact on vaccination rates for up to four years, leading to the resurgence of easily preventable diseases like measles.

“My concern is that fringe groups should not dictate agendas,” said Dr. Walter Orenstein, a professor at Emory University’s School of Medicine and former director of the U.S. Immunization Program from 1988 to 2004. “Trump has heard from people from fringe groups. I hope that once he is in office, that members of the medical and scientific community will be able to prevail with him on the issues.”

There is no indication that Trump has met with a reputable organization on vaccines. But with the science on their side, child safety advocates are hopeful.

“Vaccines have always had bipartisan support for as long as I can remember: both sides of the aisle, every administration, all the way to Eisenhower,” said Amy Pisani, the executive director of Every Child By Two, a vaccine education organization founded by former first lady Rosalynn Carter and former Arkansas first lady Betty Bumpers.

“If President-elect Trump has been presented with this alternative viewpoint, I feel like he’ll have the same ‘Aha’ moment when he sees the science and learns about the incredibly successful vaccine structure we already have in place. These are staffed with highly qualified people who have families and children themselves and want it to work and be safe. Once [Trump] realizes that, we’ll be fine,” Pisani said.

For now, she is waiting.

“We are trying very hard to find someone on Trump’s team who would speak to us,” Pisani said. “They haven’t said, ‘No’ yet, we just haven’t found the right person.”