Two federal health agencies recently pared down the recommended populations they believe should receive a COVID-19 vaccine.
Left out of the new guidelines are healthy adults and children, who could now have trouble getting vaccinated at some Nebraska pharmacies.
A COVID-19 vaccine for individuals 65 or older and those with underlying health conditions is recommended by the Food and Drug Administration and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP). For adults and children older than 6 months, ACIP unanimously recommended that vaccination for COVID-19 be “based on shared clinical decision-making.”
Before the FDA’s change in August and ACIP’s vote in September, the vaccine had a blanket recommendation for individuals 6 months and older. According to the Nebraska Department of Health and Human Service’s census report, only about 17% of the state’s population is 65 or older.
Now, Douglas County Health Department Deputy Health Director Justin Frederick said a healthy Nebraskan’s ability to get a COVID-19 vaccine could vary between pharmacies.
“They may ask if you have an underlying medical condition, they may not,” Frederick said. “They may reserve those vaccines for adults over the age of 65, and if you're healthy, they may not give you one.”
Nebraska’s vaccine policies
The “shared clinical decision-making" piece of the ACIP’s new guidelines recommends healthy patients under 65 consult a doctor, nurse or pharmacist to determine if they need a vaccine.
Dr. Mark Rupp is a professor and interim chair of the Department of Internal Medicine at the University of Nebraska Medical Center. He said some people may not get vaccinated if they won’t -- or can’t -- contact a medical provider.
“Every time we have just a little bit of a barrier that's put into place, it makes it just that much harder for people to make up their minds and to seek out that vaccination that, in some instances, will keep them out of the hospital or keep them from dying,” Rupp said.
It’s common for states, local health departments and physicians’ associations to adopt the FDA and CDC vaccine recommendations. Some states even use them as direct guidance on who is legally allowed to administer certain vaccines.
Pharmacists in all 50 states can help with shared clinical decision-making. However, Rupp said Nebraska pharmacies typically have authority to give vaccines through a “collaborative practice agreement” with a medical provider, which potentially limits some pharmacies’ power to administer the vaccine.
“For instance, there are agreements that can be crafted to say, ‘if there is a vaccine that is recommended by the Advisory Committee for Immunization Practices of the CDC, then we grant the pharmacist full authority to give that vaccine,’” Rupp said. “So, if the ACIP changes their recommendations a little bit, suddenly the pharmacist hands are tied.”
Frederick added that people in rural areas could be disproportionately affected.
“This definitely adds barriers for folks, especially people in rural areas where access to doctors is limited and we have larger underserved communities where people don't have regular healthcare providers,” Frederick said.
Insurance coverage
Rupp said doctors can prescribe vaccines “off label” to people outside FDA recommended populations, but insurance may not cover them.
Insurance providers usually decide to provide coverage based on FDA- and CDC-recommended populations. However, most large insurance companies have agreed to continue covering the COVID-19 vaccine through 2026.
Frederick and Rupp said it’s best to double-check whether your provider will cover the vaccine.
The ACIP said benefit programs like Medicaid, Medicare and federal health insurance plans would continue to cover COVID-19 vaccines without a stated end date. The Vaccines for Children and Vaccines for Adult Programs -- which aim to cover underserved and uninsured populations -- will also continue to provide vaccines for free.
However, Frederick said the vaccines for those programs will not be distributed to local health agencies until the CDC director approves the new guidelines ACIP recommended.
“Unfortunately, both children and those that are underserved in our community -- we don't have vaccine to give them yet,” Frederick said. “We're very concerned about the delay in getting those recommendations approved so that we can get our allocation of vaccine.”
If Acting CDC Director Jim O’Neill approves the ACIP recommendations, the changes will be added to the CDC’s officially recommended immunization schedule.
Frederick said ACIP recommendations are usually approved within a couple of days. After two weeks, O’Neill still hasn’t signed off.
Vaccine hesitancy rises
O’Neill was appointed after U.S. Department of Health and Human Services’ Secretary Robert F. Kennedy Jr. fired the previous CDC Director in July. In June, Kennedy removed 17 members of the ACIP and replaced them. Many of Kennedy’s new appointees share his skepticism toward vaccines.
Rupp said there was little reason to change the COVID vaccine recommendations.
“There really hasn't been any change in the science or the research that would inform us to do anything differently than what we've been doing previously,” Rupp said.
Frederick said he believes there is a lot of misinformation surrounding vaccines and the consequences are real in Douglas County. According to the Douglas County Health Department’s latest Community Health Needs Assessment, parents have become more hesitant to vaccinate their children over the last 10 years.
“Back in 2015 it was about 5.2% of parents reporting some vaccine hesitancy, and that's grown to 13.1% in our survey from 2024,” Frederick said. “It's more than doubled, which is really deeply concerning, because vaccine remains one of our safest and most effective public health interventions to prevent the ongoing transmission of these childhood illnesses.”
Frederick said rare or mild vaccine side effects are often less dangerous than the diseases they prevent.
“We have short memories as a society, and we haven't seen the outcomes of a world that we live in that doesn't have vaccine,” Frederick said. “I'm a little bit worried that we're headed down a very dangerous road.”
Changes for children
Rupp is especially worried about children without immunity being exposed to the virus.
“Kids are going to do much better with vaccine priming their immune system rather than getting exposed and getting sick from the virus,” Rupp said.
Rupp said other organizations physicians get guidance from—like the American Academy of Pediatrics—have come out in favor of children and pregnant women being vaccinated. The ACIP did not vote on COVID vaccine recommendations for pregnant women and children during its September meetings, saying more safety and efficacy data was needed.
While a vote to pull the hepatitis B (HBV) vaccine recommendation for newborn babies was deferred, the ACIP voted to recommend that all pregnant women be screened for the virus.
Rupp said when children are not vaccinated early, they can contract HBV through fluids infected with the virus -- putting them at risk of chronic HBV that can last into adulthood. Since the CDC began recommending the vaccine for newborns in 1991, the number of HBV cases in the U.S. has dropped dramatically.
The ACIP also changed its recommendation on the combined measles, mumps, rubella and varicella (MMRV) vaccine. It said children under 4 years should receive separate MMR and varicella vaccines, citing a small increased risk of febrile seizures. Most American children already get the vaccines separately.
Amid all the changes, Rupp said he’s focusing on what’s best for his patients.
“From my standpoint, anybody who doesn't want to get sick from one of these respiratory viruses -- influenza or COVID-19 -- really should be getting vaccinated,” Rupp said. “The equation really hasn't changed, and the benefit from these vaccines quite clearly outweighs the potential risk.”
Frederick said there could be fewer healthy people eligible for COVID-19 boosters as the cold and flu season approaches.
“That could increase the risk of outbreaks if cases rise,” Frederick said. “I do think that the burden is shifting from federal campaigns, leading us to local providers and local health departments to communicate that risk and the benefits clearly to our communities.”