The National Vaccine Plan (NVP) is intended to be a comprehensive framework that guides national efforts of federal, state, local, multinational, and non-governmental partners to improve access to and increase uptake of vaccines, as well as continued development of new and improved vaccines. The 2020 NVP, currently being developed by the Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy, is intended to guide coordinated efforts for the next five years. The initial NVP was completed in 1994, and a new plan was published in 2010 that provided 10-year guidance for national vaccine efforts.

A recent Request for Information solicits stakeholder input on how the plan can be revised to strengthen and improve strategies to prevent infectious diseases through vaccination in the United States. The five overarching goals of the 2010 NVP (see exhibit 1) likewise represent foundational principles for the next generation of the plan. However, as noted in 2016, the mid-course review of the NVP, the immunization landscape has changed significantly. Given the changes of the past decade, the 2020 NVP should prioritize efforts to address new challenges and embrace current opportunities to advance immunization throughout the population.

Exhibit 1: Goals of the 2010 National Vaccine Plan

Develop new and improved vaccines: Prioritize development of new vaccines that target diseases of public health importance and support the research, development, and manufacturing of these products. Support research of novel and improved vaccine delivery methods. Enhance the vaccine safety system: Maintain and improve the United States’ robust vaccine safety infrastructure. Improve providers’ clinical practice when administering vaccines, as well as the timeliness of evaluation to address vaccine safety concerns. Support communications to enhance informed vaccine decision-making: Improve communication across stakeholders regarding important vaccine information and increase public awareness of the benefits and risks of vaccines. Ensure a stable supply of, access to, and better use of recommended vaccines in the United States: Maintain a consistent supply and delivery of vaccines. Reduce financial barriers to vaccination and improve surveillance of vaccine-preventable diseases (VPDs), as well as health insurance coverage for vaccines. Maintain a strong, evidence-based, and transparent process to develop and evaluate immunization recommendations. Increase global prevention of death and disease through safe and effective vaccination: Recognize the United States’ obligation to participate in global efforts to combat VPDs. Support the United States’ involvement in global health organizations such as the World Health Organization and GAVI, the Vaccine Alliance.

Source: Department of Health and Human Services. 2010 National Vaccine Plan.

Progress In the Past Decade

Advancements in vaccine policy, technology, and public health infrastructure have improved vaccine access, including through expanded scope of practice laws and enhanced ability to track vaccination status across delivery settings. These innovations continue to strengthen the nation’s capacity for disease prevention. Expansion of the adult vaccine platform featuring new vaccines for shingles and pneumococcal disease, and a robust vaccine development pipeline, including candidates for respiratory syncytial virus (RSV) and Clostridium difficile, offer promise for widening the array of vaccine-preventable illnesses. The Affordable Care Act (ACA) expanded first-dollar coverage of vaccines for Medicaid expansion populations, thus removing financial barriers to vaccination for millions of low-income Americans. Finally, increased recognition and investment in the value of health care data systems has led to significant improvement of immunization information systems (IIS). The use of IIS data to generate real-world evidence on vaccine uptake can enhance efforts to understand and improve vaccine access and delivery, by allowing us to identify gaps and better understand the impact of policy changes on the vaccine landscape.

Persistent Challenges

New and sustained challenges limit immunization across the life course. A culture of vaccine hesitancy threatens to undermine public health and the value of vaccines. This threat has been exemplified by recent measles outbreaks and has grown so extensively in the past decade that in 2019, the World Health Organization recognized vaccine hesitancy as one of the top 10 threats to global health. Social media and online platforms increasingly facilitate the spread of misinformation about vaccines and vaccine safety and thus amplify the threat to public health.

Despite the expansion of vaccine coverage under the ACA, coverage disparities persist. Notably, the ACA’s first-dollar coverage requirement for Medicaid expansion populations does not extend to traditional Medicaid beneficiaries, who comprise a much larger population, including pregnant women. Nor does the ACA requirement extend to Medicare beneficiaries, who remain subject to out-of-pocket costs for vaccines covered under Part D. Out-of-pocket costs for vaccines have been shown to limit uptake and thus reduce immunization rates. Moreover, the growing complexity of recommendations from the Advisory Committee on Immunization Practices continues to result in provider confusion that ultimately limits full implementation of evidence-based immunization strategies.

Looking Ahead To The 2020 National Vaccine Plan

The 2020 NVP represents an important opportunity to improve immunization rates throughout the population. The plan ought to prioritize efforts to address vaccine hesitancy, an approach notably absent from the 2010 NVP. For example, the plan could offer guidance on how to address the spread of misinformation, through strategies such as leveraging provider-parent encounters to advance informed decision making, building partnerships with social media platforms to mitigate vaccine falsehoods, and messaging the value of vaccines through targeted strategies across digital and print media platforms.

Immunization access barriers, both in the form of coverage disparities and provider implementation challenges, could receive greater attention. For instance, while access is currently incorporated into a broader goal, it could be elevated to its own goal separate from supply objectives and strategies. This separate goal could address the remaining and significant IIS gaps (for example, interoperability), practice costs associated with vaccination (particularly for adult providers), insufficient provider reimbursement, and disparities in scope of practice for non-physician immunizers, such as pharmacists, all of which affect patient access to vaccines. Including sub-goals and objectives that are specifically spelled out can help provide a national framework for accountability.

Besides providing a vehicle to address the nation’s major immunization challenges, the 2020 NVP can serve as a platform for communicating successes and highlighting factors contributing to success. For example, since introduction of the Human Papillomavirus (HPV) vaccine, the rate of HPV cancers and genital warts has fallen by 86 percent among teenage girls. Adult immunizations, such as those for pneumococcal disease, have saved thousands of lives and averted illness for tens of thousands of people.

Conclusion

While the ACA, an expanding vaccine pipeline, and increased recognition and use of data collected through IIS have all strengthened the vaccine ecosystem, barriers to access, a growing culture of vaccine hesitancy, and continued challenges with interoperability and use of data in vaccination programs all threaten to diminish these advancements. With so much progress needed, the nation has an opportunity through the 2020 NVP to address these challenges and set a course for national immunization success over the next five years. The development of the 2020 NVP provides an opportunity to enhance immunization activities at all levels (federal, state, and local) by ensuring the guiding framework reflects contemporary challenges and opportunities for optimizing vaccine uptake.

Authors’ Note

The authors regularly engage in paid advisory services rendered to biopharmaceutical companies, including vaccine manufacturers. The views expressed here are their own.