Letter to the Honorable Alex Azar, Secretary of the Department of Health and Human Services, and Dr. Robert Redfield, Director of the Centers for Disease Control and Prevention - Amid COVID-19 & Ahead of Flu Season, Senator Hassan Joins Bipartisan Letter Calling on the Trump Administration to Ensure Americans Receive Critical Immunizations

Letter

Dear Secretary Azar and Dr. Redfield,
As is evident with COVID-19, vaccines are critical to preventing infectious disease outbreaks.
Since the COVID-19 pandemic, vaccine delivery has been severely disrupted worldwide,
1
creating severe risk for outbreaks of preventable infectious disease while also fighting COVID19. Amidst this pandemic, we appreciate the testimonies focused on immunization efforts that
Department of Health and Human Services (HHS) officials provided to the Senate Committee on
Health, Education, Labor, and Pensions on September 9th and 23rd. Given the importance of these
efforts, we urge the Administration--in close partnership with state and local governments--to
lower vaccine hesitancy and ensure all Americans continue receiving their necessary
immunizations to prevent additional illness and outbreaks.
Childhood vaccines are one of the most cost-effective and life-extending public health
interventions providing immunity to infectious and deadly diseases. In the last 20 years,
childhood vaccines have prevented more than 21 million hospitalizations, saving the U.S.
economy about $1.4 trillion in total societal costs.
2 For every $1.00 spent on childhood vaccines,
more than $10.20 is saved in direct costs.3 Federal programs such as the Center for Disease
Control (CDC)'s Section 317 and Vaccines For Children program (VFC) have successfully
expanded access to vaccines for different racial, income, and geographic groups by providing
immunizations at no cost to children who are enrolled in Medicaid, uninsured, or underinsured.
4
In March and April, the United States witnessed a steep decline in childhood immunizations.5
In
response, on August 20, HHS announced a new rule allowing state-licensed pharmacists to order
and administer vaccines to children ages 3-18 years old.6 While we are pleased to see HHS take
steps to address the decline in immunization rates, we ask that you consider steps to ensure
that this program does not indirectly reduce critically important well-child checkups for
children,7
possibly fragmenting care delivered in the pediatric medical home.
While declining child immunization rates have been closely monitored, immunizations for
adolescents and adults--particularly for older adults--are critical in reducing preventable illness
or death.8
In addition to the annual seasonal influenza vaccine, adults are encouraged to receive a
shingles vaccine and a pneumococcal polysaccharide vaccine upon turning 50 and 65 years old,
respectively.9 Additional vaccination coverage for diseases or infections, such as HPV, are
encouraged for adults who did not receive the vaccine in their adolescence. Unfortunately, not
enough U.S. adults receive their vaccines as recommended. For example, although 1 in 3 people
will develop shingles in their lifetime,10 few adults over 65 have been vaccinated for shingles. In
fact, only 23 percent of White Americans, and 9 percent of Black and Hispanic Americans
receive their adult immunizations as recommended.
11 Low adult immunization rates for vaccine preventable diseases cost the U.S. economy about $9 billion each year.
12
The CDC recommends all people over six months of age receive a seasonal influenza vaccine
each year.13 With flu season here, we are particularly concerned that all Americans, especially
young children and older adults, receive their seasonal influenza vaccine. Even before the
COVID-19 pandemic, adherence to the yearly influenza vaccination varies across state, age
group, and demographic information. In 2017, only 37 percent of adults adhered to the
recommendations, a 6-percentage point drop from 2016.14 The low vaccination rate for seasonal
influenza is alarming when considering that vaccination could prevent up to 810,000
hospitalizations and 61,000 deaths each year.
15 Children under five years are at high risk of
developing flu-related complications such as worsening of asthma or heart disease, pneumonia,
encephalopathy, or even death.16 In 2017 and 2018, 90 percent of Americans who died from
influenza were aged 65 years or older. Further, about 15 percent of older Americans hospitalized
due to influenza lost two or more basic self-care functions.17
Older adults residing in long-term care facilities are especially vulnerable. Close living quarters,
shared caregivers, and frequent outside visitors create conducive environments prone to rapid
influenza spread and transmission.18 Should our Nation's influenza immunization rates remain
low as the COVID-19 pandemic continues, we could see an unprecedented strain on our
healthcare resources and an inconceivable death toll. A high influenza disease rate will make it
difficult to distinguish between the two viruses, resulting in diagnostic uncertainty. This can lead
to mistreatment, coinfection, and confusion about how to respond to symptoms, further impeding
public health properly.
Low immunization rates across different communities will require different levels of support and
resources from the federal government. For example, Alaska has the lowest pediatric vaccination
rate in the United States at 74.2 percent for children 19-35 months.19 Additionally, Alaska
Natives comprise 18 percent of Alaska's population. Alaska Native communities face significant
inequity in health care and health status compared to other U.S. populations. According to initial
data collected by the local health department, Alaska saw a 48 percent decrease in total vaccines
administered (both pediatric and adult) in April 2020 compared to April 2019. In May and June
2020, the State of Alaska continued to see a 12 to 15 percent decrease compared to the 2019
vaccination rates. The federal government needs to direct its efforts toward geographic and racial
communities that have historically shown low rates of immunization.
While the federal government must ensure Americans are receiving their immunizations now, we
must look forward to the key to ending this pandemic: a COVID-19 vaccine. Vaccines are only
effective in preventing outbreaks if enough people are immunized, achieving herd immunity.
However, a recent Gallup poll found that if the federal government offered free, FDA-approved
COVID-19 vaccines today, 35 percent of Americans would not agree to be vaccinated. Despite
communities of color being disproportionately affected by COVID-19, this rate was even higher
for non-white Americans, at 41 percent. In rural areas, the rate was 44 percent.20 Although the
largest COVID-19 outbreaks have occurred in metropolitan areas, certain factors make people
living in rural communities vulnerable to severe illness or death from COVID-19, such as being
more likely to smoke cigarettes, have high blood pressure, or be obese.21 The high level of
hesitancy among Americans for a COVID-19 vaccine is alarming and must be carefully
addressed to achieve herd immunity.
As Americans are recommended to receive their seasonal influenza vaccine by the end of
October,22 we urge that the Administration carefully monitor the rate at which these vaccines are
administered to avoid a dual outbreak of COVID-19 and seasonal influenza. With that said, we
request that the Administration answer the following questions related to the handling of existing
immunizations and vaccine hesitancy no later than October 23, 2020:
1. How is the Administration and the CDC working with the states to increase childhood
and adult routine vaccination rates?
a. Do Section 317 and VFC program have adequate funds to address these decreases
in vaccination rates and to address issues posed by vaccine hesitancy?
b. What is the Administration doing to ensure vulnerable populations, including
American Indians / Alaska Natives, communities of color, and those with
disabilities have access to routine vaccinations during COVID-19?
2. How is the Administration tracking immunization rates of all age groups (i.e., young
children, adolescents, adults, and older adults)?
a. How is the Administration responding to reported dips in adolescent
immunizations?
b. What is the Administration doing to ensure that adults continue to receive their
immunizations?
3. What is the Administration's plan for ensuring that Americans receive their seasonal
influenza vaccine before the CDC's recommended timeframe of late October?
a. What is the Administration's plan for ensuring nursing homes and long-term care
facilities are vaccinated against seasonal influenza early to avoid additional
causalities?
b. What is the Administration's plan for ensuring that children under the age of 5 are
vaccinated against seasonal influenza, including the completion of a 2-dose series
for younger children receiving the flu vaccine for the first time?
4. What is the Administration's plan for responding to potential coinfection of COVID-19
and seasonal influenza?
a. How does the CDC plan to prepare providers and the public with resources to
distinguish symptoms of seasonal influenza from COVID-19?
5. What action has HHS taken to work with pharmacies and pediatricians since announcing
its rule on state-licensed pharmacists administering vaccines on August 20th?
a. How will HHS ensure that pharmacists communicate with a child's pediatrician
and state immunization registry once they receive an immunization, guaranteeing
accurate reporting and adhesion to a child's recommended vaccination schedule?
b. Will pharmacists be working with federal programs such as VFC or Section 317
in the procurement and Administration of these vaccines?
c. How will the vaccines under this rule be paid for?
d. How will HHS monitor effects of the rule on utilization of well-child services?
e. How will HHS monitor the impact on existing disparities in immunization rates?
f. How will the Administration continually evaluate this policy to ensure that it
sunsets with the conclusion of the Public Health Emergency?
6. What is the Administration doing to combat vaccine hesitancy and related
misinformation for routine immunizations? For a future COVID-19 vaccine?
a. How are you assessing the root causes of why many Americans are experiencing
vaccine hesitancy for COVID-19?
b. How will the Administration educate Americans on immunizations to
strengthening our country's awareness, understanding, and trust in vaccines?
c. What awareness campaigns are you running or planning to establish trust in
Americans for a COVID-19 vaccine?
d. Given that the COVID-19 vaccine is likely to be less than 100 percent efficacious,
what percentage of the population do you estimate needs to be vaccinated to
achieve herd immunity?
We appreciate your work to address the COVID-19 pandemic and ensure that Americans
continue to receive their vaccines. Thank you for your time in reading this letter and to respond
to it as promptly as you reasonably can.

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