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Parents used to be able to choose whether to have their young children get the measles-mumps-rubella (MMR) and the varicella (chickenpox) vaccines separately, or get the combined MMRV vaccine. That changed last month, when the CDC, citing the increased risk of febrile seizures, removed that option and formally recommended that all children under age 4 receive the vaccines in two separate shots.
But before the agency changed the recommendation, poor children were more likely to get the MMRV vaccine than children who were covered by private insurance, according to Dr. Monique Yohanan.
In an op-ed published this week in Deseret News, Yohanan, senior fellow for health policy at Independent Women, said the decision by the Centers for Disease Control and Prevention (CDC) to stop endorsing the MMRV vaccine exposes a tension in U.S. vaccine policy.
“What happens when protecting children and treating them fairly are in conflict?” Yohanan asked.
In an interview with The Defender, Yohanan said that as she listened to the members of the CDC’s Advisory Committee on Immunization Practices (ACIP) debate the change, she believed the key issue remained “unsaid.”
Critics of the change argued that eliminating the MMRV shot for young children raised “equity issues,” because it could make accessing the vaccines harder for some families.
“Frankly, from my perspective, you don’t go on and on about something being an equity issue without saying, ‘Well, actually, poor kids are the ones getting this shot. And we’re using it right now for administrative convenience for poor kids,’” Yohanan said.
‘Vaccine policy seemed to concentrate the seizure risk in poor kids’
Since the MMRV vaccine was first licensed in 2005, U.S. children have received vaccines against the four diseases in a two-dose series, with the first typically given at 12-15 months and the second at 4-6 years.
Yohanan noted that doctors have administered those doses differently: Children with private insurance have received two shots — the separate MMR and varicella vaccines — while children on Medicaid have received the combined MMRV shot.
Soon after the CDC launched the MMRV, studies revealed its increased seizure risk. As a result, the CDC recommended the combined shot as a second-line option, advising doctors to administer it only if parents requested it after discussing the risk.
Since then, about 15% of kids have typically received the combined shot.
“When the committee spoke about ‘access,’ they were saying the quiet part out loud — the kids who will be impacted by this change are poor kids because they are the ones who’ve been getting this shot,” Yohanan wrote in her op-ed.
She said it “defies credulity” that parents of low-income children on Medicaid would choose the combined shot after learning about the increased seizure risk.
Yohanan told The Defender that clinics participating in Medicaid or the Vaccines for Children Program — which covers vaccines for children whose families can’t afford them — find it easier to administer a single shot. She said families with limited incomes often struggle to reach appointments because of work schedules, transportation challenges and a shortage of available clinics.
“There are not a lot of providers who take Medicaid,” she said. “And so from an administrative convenience standpoint, it makes a lot of sense that at that kind of clinic, you’d be much more likely to give a kid a single shot if you can.”
“There is no world that I can imagine where, in a clinic with kids who have private insurance, the routine would be to give them the second-line treatment that would double the risk of seizures,“ she added.
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In her op-ed, Yonahan wrote:
“I grew up on Medicaid, and most of my family still depends on it. ‘Access issues’ are policy-speak for poor. It stings to know that there are public health leaders, however well-intentioned, who think that poor kids having more seizures than rich kids is a reasonable tradeoff for staying up to date with the schedule. No one says that directly, yet everyone sitting in the waiting room knows it.”
Yohanan said conversations about equity are meant to raise concerns about people who are left out. In this case, the vaccine policy seemed to concentrate the seizure risk in poor kids.
“I think that says something about how those doctors think about the parents of those kids. I don’t think it says good things about them,” he said.
By changing the recommendations, the CDC finally standardized the policy for the MMR and varicella vaccines for all children.
However, Yohanan wrote, that change is not enough. She said:
“If equity means anything, the agency owes the public more than a quiet revision of the schedule. It owes an explanation. How did a system built to protect children decide that it was OK for poor children to have twice the risk of febrile seizures in the name of administrative convenience? And why did it take nearly 20 years to acknowledge it?”
As debates about the CDC’s childhood immunization schedule enter mainstream conversation, more equity issues are coming to light.
Immigrant children who lack proper vaccination records sometimes receive double or triple the recommended number of vaccines because hospital protocols instruct staff to vaccinate children if no documentation exists.
The Vaccines for Children Program also subjects children enrolled in Medicaid to different treatment standards by requiring doctors to strictly follow the CDC schedule, limiting parents’ ability to delay or opt out of routine vaccinations.
Related articles in The Defender- Key Takeaways From Last Week’s Meeting of New CDC Vaccine Advisers
- CHD Funds Lawsuit Against CDC Over Program That Forces Pediatricians to Give COVID Vaccines to Kids on Medicaid
- Exclusive: Some Kids Getting Double or Triple Vaccinated, California Nurse Says
- CDC’s New Vaccine Advisers Vow to Study Cumulative Effect of Childhood Vaccine Schedule
