State leaders are going their own way in making vaccine policies this fall — which means your ability to get a COVID-19 shot may soon depend on where you live.
New York has declared a "statewide disaster emergency" to preserve access to COVID vaccines. Massachusetts is making insurers pay for vaccines recommended by the state and not solely those recommended by the Centers for Disease Control and Prevention. New Mexico is taking steps to ensure that pharmacists can continue to give out vaccines.
Some states are banding together to form regional health coalitions. Oregon, Washington, California and Hawaii have formed the West Coast Health Alliance to coordinate their vaccine recommendations. States in the Northeast are considering a public health collaboration.
The moves are in response to recent changes to long-established processes for crafting vaccine guidance at the federal level.
"We're seeing something happen that we're concerned [about], and we're not going to wait to see how it plays out," said Dennis Worsham, health secretary for the Washington State Department of Health, at a media briefing on September 3.
Those concerns include: staff and budget cuts at federal health agencies, the firing of prominent doctors from vaccine advisory committees, the firing of the new director of the Centers for Disease Control and Prevention and the resignation of top leaders from the agency, he said.
The tipping point came last week, Worsham said, when the Food and Drug Administration put limits on who's eligible for the fall COVID shot, restricting approval to people who are 65 or older or have other health problems that put them at risk. That means healthy adults and children who want to get the vaccine must now get a prescription outside federal recommendations.
"That's what kicked off the conversations with the three governors [in California, Oregon and Washington] about: how are we going to provide the most accurate information, based on science and evidence, for our states?" Worsham says.
Members will be reviewing data briefings and guidance from scientific and medical sources to make their own recommendations for the states they serve. If the federal government makes changes to its recommendations on childhood vaccines, for instance, "we will have to look and see if those changes were based on ideology and not science," Worsham says.
The creation of the alliance feels necessary to some public health practitioners.
"I'm sad that we're in a place where we have to do this," says Dr. Erica Pan, director and state public health officer at the California Department of Public Health. "Vaccines are one of the most important public health interventions in our lifetimes, after sanitation, and they have saved millions of lives. We want to make sure we continue to protect our communities."
Federal delays have consequences
The CDC's Advisory Committee on Immunization Practices — an influential vaccine advisory panel — has not yet weighed in on who should get COVID vaccines this fall.
Many states have vaccine laws that are tied to ACIP's recommendations. "That includes things like school entry requirements, guidelines for health care workers, whether pharmacists can provide COVID vaccinations," says Dr. Susan Kansagra, chief medical officer for the Association of State and Territorial Health Officials. "In the absence of that recommendation, things are defaulting to state laws."
While in prior years, the COVID vaccine was available to basically everyone, the restrictions from the FDA on this year's booster are affecting what pharmacies in some states can provide.
"For now, people who are under 65 seeking the COVID vaccine for the first time are reverting back to state laws," says Kyle Robb, director of state policy and advocacy at ASHP, a professional association for pharmacy professionals. "This is the first time since the COVID vaccine has been available that there's any question whether pharmacists can prescribe the vaccine."
These circumstances have prompted Gina DeBlassie, the cabinet secretary for the New Mexico Department of Health, to issue a public health order to make COVID shots widely available at pharmacies across the state.
"New Mexico can't wait," she says. "The vaccines are anticipated to be received in the state this month. We're removing barriers and we want to ensure access."
While demand for COVID vaccines has been highest for those 65 and up, "we want to make it available for those that are in high risk populations or those that are caring for individuals that are in that high risk group," DeBlassie says.
Other sources of medical authority besides CDC
The CDC's ACIP is scheduled to meet later this month to review COVID vaccines. Even so, states have started diversifying their sources for vaccine information.
Health Secretary Robert F. Kennedy Jr. fired the former committee members in June and replaced them with new panelists, many of whom — like Kennedy — have a history of anti-vaccine activism.
"That had been an incredible body of people representing different areas of expertise," says Dr. Jeffrey Koplan, former CDC director and executive secretary for ACIP. "To have that abandoned and replaced by people who are not experts in the field is terrible. I characterize where we are now as a royal muddle."
For some state leaders, these changes have stoked "growing concerns about the credibility of this ACIP and what they may come out with," Kansagra says.
"We're not going to remove ACIP as one of the organizations that we reference, but we're going to include other medical professional organizations" such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, DeBlassie in New Mexico says.
The Vaccine Integrity Project, launched earlier this year from the University of Minnesota with the backing of some former top CDC officials, is another source of data-based information state health officials are tapping.
"What they've been doing is providing the most recent evidence and systematic reviews to see if there's anything that justifies new recommendations," says Pan in California. "We're closely monitoring their updates and have trust and appreciation for what they've put together."
Florida goes a different way
While states with Democratic governors have been zigging to protect vaccine access, the Republican state of Florida has zagged.
At a September 3 press conference, Florida surgeon general Dr. Joseph Ladapo called COVID vaccines "poison" and said requiring them echoes the institution of slavery. "Who am I as a man standing here now to tell you what you should put in your body?" he said. Ladapo announced that Florida would be working to end all vaccine mandates in the state.
Ladapo's office did not respond to an interview request from NPR.
"While there's always been some variation state-by-state in vaccine laws, what we're seeing now is an amplification because of the lack of a federal coordinating entity," Kansagra says.
Differences between states in the availability of COVID vaccines and whether they're recommended can be confusing for consumers.
"As we navigate this changing landscape, talk to your provider, get your information from a trusted source around vaccines, and make sure you understand where to go and what your insurance covers," Kansagra advises.
State health officials will be watching closely when the CDC's revamped vaccine advisory committee meets later this month to vote on recommendations for COVID, Hepatitis B, and some other vaccines.
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