Kevin Ault, MD, on ACIP Implementation: Access, Coverage, and Pregnancy Counseling

This is part 2 of our conversation with Kevin A Ault, MD, vice president of the National Foundation for Infectious Diseases (NFID) and professor of obstetrics and gynecology at Western Michigan University Homer Stryker MD School of Medicine. Ault previously served on the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP), where he helped shape multiple recommendations concerning COVID-19 vaccines in adults, adolescents, and children. He was also an author of the 2023 adult, adolescent, and pediatric US immunization schedules and an author on the recent adult hepatitis B vaccination recommendations, which include guidance for maternal immunization and adult hepatitis B vaccination.

In this discussion, Ault turns from committee debate to implementation. He outlines why access and coverage may look different across pharmacies, payers, and states, and he describes the kinds of data that would best support future ACIP deliberations. He also returns to practical counseling in pregnancy, where maternal protection and newborn protection remain central.

On near-term access and coverage, Ault sees uneven terrain. “Part of these recommendations is there’s going to be fragmentation of the systems that are in place,” he said. “There’s going to be different pharmacy chains that interpret these differently, certainly in the short term. Probably in the long term it’ll settle out. There are going to be different states and jurisdictions that interpret things differently.” He pointed to Michigan as an example of state-level action: “Here in the state of Michigan, our chief medical executive issued a recommendation, and everybody that hasn’t had a prior dose of the current vaccine get it because that puts you at higher risk of disease. And that was based on the data that you saw at the ACIP meeting.”

The payer landscape adds another layer. “Problem with large states like Michigan is there might be 20 or 30 different payers besides the federal payers,” he noted. “There are probably different deviations on the different Medicaid payers. But there’s also multiple payers on the commercial side. So to figure out the policies of multiple different pharmacy chains and multiple payers really makes things very, very fragmented.” He acknowledged recent statements from private insurers about COVID-19 vaccine coverage, then added an important boundary. “You heard the insurance companies get together and say that they’re going to cover COVID vaccines. But the federal programs that you mentioned, VFC, Medicaid and Medicare, don’t really fall under that jurisdiction. So it’s fragmented is really the best word for what’s going to happen.”

Asked what evidence would most help future ACIP decisions on COVID-19, hepatitis B, and MMRV, Ault said the September meeting revisited a lot of known ground, particularly for MMRV. “There was a lot of good data that was presented at the ACIP meeting by the CDC staff. They were impressive as always, and thorough as always, despite the short timeframe they were working in. So I’m not sure we’re going to see any new data. The MMRV discussion was basically a rehash of a 2009 ACIP meeting that I was representing ACOG.” He added that MMRV is less central to his own specialty, but after reviewing coverage from that period he felt “all those points were covered then.”

For hepatitis B, he underscored durability and current effectiveness. “We already know that it works 99% of the time for childhood cases, adolescent cases, young adult cases. And so I’m not sure we’re going to do any better than that.” What he would like to see, however, are forward-looking models that translate uptake into disease burden over time. “There was an article in the Journal of the American Medical Association a few months ago… that modeled what changes in vaccination uptake would do to disease prevalence. And you could certainly do that for hepatitis B,” he said. “Honestly, you may not see that much of a short-term change because there’s such great protection for a few decades after vaccination. It might be 10 or 20 years before you see a shift in the epidemiology of hepatitis B. Unfortunately, that shift would be young people getting liver failure and liver cancer and liver transplants, which we certainly don’t want to return to.”

Ault also emphasized adhering to ACIP’s evidence-to-recommendation framework and fully considering values and preferences. “One of the problems with the presentations was there’s a framework called evidence to recommendations, and one of the members said we’re going to change the recommendations because people don’t trust vaccines anymore. That would fall in the framework under values, and there might be data about that,” he said. “Recommendations are not made in a vacuum. There are seven or eight things that should and could be considered, and I think that got glossed over quite a bit.” He noted public comments from liaison members representing the American College of Physicians and the American Medical Association who urged a return to the usual process. “We should pay attention to the liaisons when they say that,” he added.

The conversation closed on counseling during pregnancy. Ault framed the message in terms that resonate most with patients. “COVID was one of the leading causes of maternal death in 2022, and deaths, maternal ICU admissions and hospital visits were largely confined to the unvaccinated population,” he said. “If a patient wanted to know my personal experience of COVID during pregnancy, it was nasty. It’s no fun to go to the medical intensive care unit and round on an intubated pregnant patient. I’ve had that experience both with influenza and with COVID, and I would like to not have that experience anymore. The best way to get to that point would be to vaccinate pregnant women.”

He added that protection of the newborn is a powerful motivator across multiple pathogens. “If you tell somebody who’s pregnant, protecting your newborn is one of the things that they value the highest about RSV and pertussis and COVID and flu,” he said. “RSV is common enough that most people know what it is. When we were doing studies of RSV vaccines during pregnancy, women who had prior pregnancies were like, yes, I want to avoid RSV. I want to be in your research trial.” For hepatitis B, he noted that success can create amnesia. “Hepatitis B vaccine has been so wildly successful that you have to go back to the last century to get stories about hepatitis B,” he said, recounting a medical student who had never heard of the disease. “That is probably a good thing,” he added, “and a reminder to keep doing the basics that work.”

ACIP Meeting Recap: September 18–19

• COVID-19 Vaccination: ACIP kept vaccination for people 6 months and older under shared clinical decision making, emphasizing individualized counseling on age, prior infection, immunosuppression, and comorbidities. Prescriptions are not required.
• MMRV in Pediatrics: To reduce febrile seizure risk, ACIP recommended separate MMR and varicella doses before age 4, rather than the combined MMRV product.
• Hepatitis B: The committee tabled a proposal to delay the newborn birth dose to 30 days, leaving the current schedule unchanged, while reaffirming universal HBV testing in pregnancy.

ACIP members also urged CDC to provide clearer, plain-language informed-consent materials and called for more transparent posting of vote language with consistent use of the evidence-to-recommendation framework.

Clinically, the playbook remains stable: continue COVID-19 vaccination via shared decision making for higher-risk patients, maintain HBV birth-dose practices and universal prenatal testing, and use separate MMR and varicella doses before age 4. Coverage through VFC, Medicare/Medicaid, and commercial plans is expected to continue without new prescription requirements.