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Downstream Effects of CDC Adopting ACIP Recommendations for COVID-19 and MMRV Vaccines Downstream Effects of CDC Adopting ACIP Recommendations Susan Kansagra, Andy Baker-White, Meredith Allen, Kimberly Martin, Ericka McGowan Learn about the downstream effects of CDC adopting ACIP recommendations for COVID-19 and MMRV vaccines, as states examine how their policies and laws intersect. On Oct. 6, CDC adopted the recommendations that the Advisory Committee on Immunization Practices (ACIP) made in September — specifically, individual-based decision-making for COVID-19 vaccine and separate measles, mumps, and rubella vaccine, and the varicella vaccine in toddlers. The adoption of these recommendations now sets in motion a cascade of other processes that influence access to vaccines. In addition, several states have begun to examine how their state level policy and laws intersect with ACIP recommendations given the delay in adoption and the uncertainty of the process going forward. COVID-19 Vaccine Recommendation CDC adopted the recommendation for shared clinical decision-making for the COVID-19 vaccine for those six months and older. The adoption of this ACIP recommendation has a ripple effect on coverage and access: It enables states to begin ordering COVID-19 vaccine under the Vaccines for Children program. It allows state Medicaid programs that link coverage to ACIP recommendations to cover the cost of the vaccine. It enables pharmacists to provide the COVID-19 vaccine under the federal PREP act declaration — as opposed to or in addition to state law, which varies by state. Many state health departments issued standing orders and executive orders to enable pharmacists to administer in the meantime. It requires health insurers to cover the cost of the vaccine, as the Affordable Care Act ties insurance coverage requirements to ACIP recommendations. Though, prior to the meeting, health insurers indicated they would do so anyway this year. MMRV Recommendation The CDC also adopted the recommendation for separate varicella (V) and measles, mumps, rubella (MMR) vaccines rather than the MMRV vaccine (combined measles, mumps, rubella, varicella) for children under four years. As background, current guidance allows either MMRV or MMR + V to be administered to children 12-47 months. However, because of a small but higher risk of febrile seizures for dose one, they are recommended to be administered separately (MMR + V), unless families express a preference for MMRV. Only about 15% of children currently receive MMRV for the first dose, and the general consensus is that this decision will result in some changes but not significantly impact access to vaccines: The adoption of this recommendation means that VFC will no longer cover MMRV for children under four, but it continues to cover separate MMR and V vaccines. Since many state Medicaid plans tie vaccine coverage to ACIP recommendations, coverage of MMRV by state Medicaid will vary depending on this language, though separate MMR and V vaccines would continue to be covered. Private insurers can choose to cover MMRV and will likely continue to in the short term but are not required to. They are required to cover separate MMR and V vaccines. How States Are Preparing for the Future As it stands now, ACIP recommendations, particularly for respiratory viral season, are not that different than prior years – with influenza, RSV, and the COVID-19 vaccine recommended (the latter with shared clinical decision making). However, the delayed and unpredictable process has led many states to examine how closely they are tied to ACIP in law, regulation, or practice. Over 600 statutes across U.S. states and territories reference ACIP — whether for pharmacist vaccine authority, school entry, health care worker or other requirements. States have considered a variety of actions to ensure they maintain access to vaccinations for their jurisdictions including: Passing or introducing legislation that allows the state health department to use ACIP guidance from previous years or recommendations from other bodies (e.g., medical provider organizations) in state law, as it relates to school entry, pharmacist authority, and others. Issuing standing orders and executive orders to enable pharmacists to administer vaccines in the absence of ACIP recommendations. Examining Medicaid state plan language to determine how to interpret requirements when ACIP is referenced and considering updates to that language (e.g., North Carolina). Issuing state requirements for insurers on vaccine coverage (e.g., Oregon, California, Hawaii). Examining use of state funds to purchase vaccines. Supplemental Resources Tracking State Actions on Vaccine Policy and Access by KFF Vaccine Resources by the Common Health Coalition States Take Action to “Immunize” Vaccine Access by Mandy Cohen, Julian Polaris, and Liz Dervan Vaccine Integrity Project — Fall Immunization Information by the Center for Infectious Disease Research and Policy Special Thanks - Blog - Downstream Effects of CDC Adopting ACIP Recommendations Padding Block - Large Related Content - Blog - Downstream Effects of CDC Adopting ACIP Recommendations article yes

Each year the U.S. battles seasonal influenza, leaving millions of people sick, hospitalized, or worse. As COVID-19 cases continue to rise, it is crucial for all eligible individuals to receive a flu vaccine to help reduce the likelihood of contracting both flu and COVID-19.

On Aug. 11, 2021, CDC updated its guidance on COVID-19 vaccination for pregnant or breastfeeding individuals. We’ve answered seven common questions about the new guidance and what it means for state and territorial health officials as they push to vaccinate more Americans.

Learn how ASTHO's Foundations in Case Investigation/Contact Tracing training helps deepen understanding of outbreak response strategies.

The Public Health Response to Hantavirus: Key Actions, Perspectives, and Takeaways Public Health Response to Hantavirus: Key Takeaways Ericka McGowan, Sidnie Christian, Margaret Nilz Learn about the hantavirus outbreak from the MV Hondius and the ongoing public health response — including the important work of state and local health departments. On May 2, the World Health Organization (WHO) received notification of an international hantavirus cluster linked to passengers aboard the MV Hondius cruise ship, following reports of severe acute respiratory illness. Subsequent laboratory testing confirmed infection with the Andes strain of hantavirus, a rare zoonotic virus associated with hantavirus pulmonary syndrome. The event drew international public health attention because of the distinct challenges posed by the cruise ship setting, the need for multi-country coordination as exposed passengers returned home, and the involvement of the Andes virus — which can be transmitted person to person unlike other strains of hantavirus. In response, WHO and U.S. health authorities initiated contact tracing and surveillance to monitor for additional cases. Despite international attention, the risk to the public is low at this time. However, it remains crucial for state and territorial health officials to stay up to date on this developing threat, which serves as an important reminder that public health preparedness is more critical than ever. What Is Hantavirus? Hantaviruses belong to the family Hantaviridae within the order Bunyavirales and are primarily spread through contact with infected rodents (i.e., via exposure to their urine, droppings, saliva, or contaminated surfaces). Various strains exist globally, including the Sin Nombre virus, predominant in North America, and the Andes virus, predominant in South America. In humans, clinical signs are non-specific, including fever, fatigue, muscle aches, headache, and gastrointestinal symptoms. In severe cases, infection may progress to hantavirus pulmonary syndrome, with rapid onset of cough, shortness of breath, and fluid accumulation in the lungs. The recent cases raised concerns as the cruise ship setting likely facilitated exposure among passengers and crew. Additionally, the expedition's international nature meant potential exposure across multiple countries, with passengers disembarking before confirmation that illnesses on board were due to Andes virus — thus requiring coordinated surveillance, contact tracing, and risk communication among national health agencies. The particularly long incubation period of the Andes virus, 4-42 days after exposure, further complicates monitoring. MV Hondius Hantavirus Outbreak: Key Insights Timeline In early April, the MV Hondius ship departed Argentina. On April 11, the first case died on board, and a close contact died shortly after. On April 28, a passenger experienced onset of symptoms, later presenting with pneumonia, and died on May 2. On May 2, the United Kingdom reported a cluster of passengers with severe respiratory illness to WHO. At the time of reporting, 147 passengers and crew were on board while 34 passengers had disembarked. On May 2, PCR testing confirmed hantavirus infection of a probable case. On May 10, the MV Hondius was permitted to dock and let passengers disembark in the Canary Islands off the coast of Spain. Passengers were then transported to their home countries via non-commercial means. On May 11, U.S. passengers arrived at the National Quarantine Unit (NQU) in Nebraska for evaluation and monitoring. WHO and CDC continue to provide updates as the situation evolves. Risk to the Public While the risk to the public remains low, it is important for public health authorities to assess and monitor contacts closely during the 42-day period for symptoms, as deterioration can occur quickly. Monitoring and assessment are collaborative efforts supported by CDC and led by state and local health departments. CDC released interim risk assessment guidance to support health departments in managing people with potential exposure related to the MV Hondius. It provides definitions of high- and low-risk contacts, recommended care, monitoring, and guidance to reduce the risk of transmission and exposure. A Coordinated Public Health Response This outbreak punctuates the importance of international and federal agencies, state and local health departments, laboratories, health care systems, and specialized treatment centers working together to manage emerging threats. Shared guidance and regulations were necessary to help standardize monitoring and response efforts. WHO coordinated with 10 countries to ensure timely information sharing, response, repatriation, and contact tracing. Domestically, the U.S. Department of State, Health and Human Services Administration of Strategic Preparedness and Response (ASPR), and CDC coordinated to form the domestic hantavirus taskforce. Together, the agencies have managed: U.S. passenger transport and repatriation. International coordination and communications. Access to health care and treatment structure. Quarantine and preparedness assets. Disease surveillance. Epidemiologic support. Risk assessment. Public communication. Coordination with state and local public health departments. This response highlights the expertise, logistics, and coordination required to manage high-consequence public health threats. Specialized Response Systems Responses to high-consequence infectious diseases (HCID) often require specialized infrastructure beyond routine health care. During events like this Hantavirus cluster, quarantine facilities, treatment centers, and coordinated health care networks help safely manage potentially exposed travelers while supporting health care system readiness. Together, these specialized preparedness systems help ensure that patients can be safely evaluated and treated while minimizing disruption to broader health care operations during HCID emergencies: The NQU at the University of Nebraska Medical Center and the Global Center for Health Security is a key component of this infrastructure. This unit is specifically designed to support quarantine and individuals exposed to HCIDs. U.S. passengers returning from the cruise ship were transported to Nebraska for assessment and monitoring, including one asymptomatic passenger who was admitted to the Medical Center’s Biocontainment Unit for further evaluation but has since been cleared to return back to the NQU. Regional Emerging Special Pathogen Treatment Centers (RESPTCs) serve as specialized hubs within the National Special Pathogen System. ASPR funds 13 RESPTCs in the United States to support management of care related to high consequence pathogens. The system is designed to distribute specialized care, offset operational burden, and maintain national surge capacity during complex infectious disease responses. ASPR’s Hospital Preparedness Program provided additional preparedness aid. This program supports health care coalitions and strengthens coordination among hospitals, emergency management agencies, public health departments, and health care partners. By advancing planning, training, exercises, and regional coordination, it helps health care systems maintain surge capacity and preparedness for complex emergencies. The Laboratory Response Network, which supports responses to biological threats, emerging infectious diseases, and other public health emergencies, plays a role in public health responses by supporting epidemiologic investigations and providing timely laboratory information to guide monitoring and response activities. In response to this Hantavirus cluster, the Association of Public Health Laboratories activated its Incident Command System to help support a coordinated laboratory response to the Andes virus. The Role of State and Local Health Departments State, territorial, and local public health agencies play a central role in infectious disease responses, especially when exposed travelers cross jurisdictional boundaries. For this response, agencies coordinated contact tracing, symptom monitoring, health care communication and preparation, laboratory coordination, and public risk communication. State and Territorial State and territorial health agencies serve as the primary lead for investigating and managing public health emergencies within their jurisdictions. In addition to coordinating with federal partners, health care systems, and laboratories, state and territorial health agencies may exercise legal authorities (i.e., isolation and quarantine) when necessary to help contain infectious disease threats. Their role helps translate national guidance into coordinated, jurisdiction-specific response activities. Local Local health departments also play a multifaceted role in outbreak response through community-level coordination, health care access, communication, and follow-up for potentially exposed individuals. In some states, local health departments also have the authority related to quarantine and isolation to prevent spread of public health threats. Local health departments help connect public health agencies, health care, emergency management partners, and community organizations to facilitate operational coordination and timely information sharing. Support from the Public Health Emergency Preparedness Cooperative Agreement Many of these preparedness and response capabilities are supported by the Public Health Emergency Preparedness cooperative agreement, which has helped health departments across the country strengthen their ability to respond to infectious disease outbreaks, natural disasters, and other public health emergencies since 2002. It supports surveillance capacity, emergency coordination, epidemiology staffing, and risk communication capabilities while helping jurisdictions build flexible and adaptable preparedness systems before emergencies occur. Events like this recent Hantavirus