AAFP issues fall vaccine recommendations amid competing guidance

The American Academy of Family Physicians (AAFP) released its fall immunization recommendations Wednesday for COVID-19, influenza and respiratory syncytial virus (RSV).

The academy says it issued them in coordination with the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG) and the Infectious Diseases Society of America (IDSA) as part of the Vaccine Integrity Project.

More than one immunization schedule is in circulation. Federal childhood vaccine recommendations were narrowed in January and stayed by a federal judge in Boston in March, a case now on appeal, leaving the pre-June 2025 schedule as the operative federal one. AAFP published its own 2026 child, adolescent and adult schedules in March, and its childhood version aligns with AAP's.

"At a time when patients and physicians are navigating changing guidance, the AAFP is committed to providing clear, trusted recommendations based on the best available evidence," AAFP President Sarah C. Nosal, M.D., FAAFP, said in a statement accompanying the recommendations.

"Things are really confusing right now," Nosal told Medical Economics in an interview published in August.

AAP published its 2026-2027 influenza policy statement and technical report Aug. 10, and its COVID-19 and RSV policy statements and technical reports Wednesday, according to the academy's published timeline for the season. AAFP issued its influenza, COVID-19 and RSV recommendations together.

What the recommendations say

AAFP recommends annual influenza vaccination for everyone 6 months and older without a medical contraindication. Adults 65 and older should preferentially receive an enhanced influenza vaccine (high dose, adjuvanted, recombinant or mRNA) when one is available, though the academy says they should not delay vaccination to obtain one.

On COVID-19, the recommendation covers all adults 19 and older, with added weight for patients 65 and older, patients at increased risk of severe infection and patients who have never received a COVID-19 vaccine.

Adults 65 and older should receive a second dose of the updated vaccine six months after the first. AAFP recommends vaccination for all children 6 to 23 months and a risk-based single-dose approach for ages 2 to 18, which the academy says aligns with AAP's 2026 recommendation.

Vaccination is recommended in any trimester of pregnancy and during lactation, aligning with ACOG.

For RSV, AAFP says it supports CDC guidance recommending a one-time vaccine for adults 75 and older and for adults 50 to 74 at increased risk, and recommends RSV vaccination for immunocompromised adults and adolescents, aligning with IDSA.

Pregnant patients should receive the RSV vaccine at 32 to 36 weeks during the September-to-March window. Infants younger than 8 months without maternal protection should receive nirsevimab or clesrovimab, both long-acting monoclonal antibodies rather than vaccines. Infants and children 8 through 19 months at high risk of severe RSV disease entering a second season should receive nirsevimab.

Health care professionals should receive annual updated influenza and COVID-19 vaccination, the academy says, citing repeated occupational exposure and contact with patients at high risk of severe disease.

Coverage still keys off ACIP

Section 2713 of the Public Health Service Act, added by the Affordable Care Act, requires applicable health plans to cover ACIP immunization recommendations that the CDC director has adopted and that appear on CDC immunization schedules, without cost sharing.

The Vaccines for Children program works on the same hinge: CDC contracts for a vaccine only after ACIP passes a VFC resolution, an authority Congress gave the committee in 1993. A recommendation issued by AAFP, AAP, ACOG or IDSA triggers neither.

A Congressional Research Service report on the 2026 childhood schedule found that federal and state laws, including federal vaccine coverage requirements and state rules on vaccine administration, reference ACIP or CDC recommendations, and that the federal policy consequences of the January change remain unclear if it takes effect.

AHIP, in a statement updated in May, said member health plans will continue covering all ACIP-recommended immunizations with no cost sharing through the end of 2027.

That is a voluntary commitment from a trade association, not a coverage mandate, and it points back to the same ACIP recommendations the societies are working around.

The clinical decision support lands later

The American Immunization Registry Association is translating the influenza, RSV and COVID-19 recommendations into structured guidance for immunization information systems, electronic health records and other clinical systems, according to an implementation note posted alongside the recommendations on AMA's site.

That guidance is expected by mid-September. The note encourages organizations to reference those resources before independently developing their own technical logic for the new recommendations.

What a dose costs the practice

"You are absolutely correct that family docs are still giving vaccines, but they are expensive, and the most common concern is reimbursement rates," Nosal said in the August interview. The majority of vaccines children receive are administered in a primary care family physician's office, she said, and the vaccines most likely to be stocked there are childhood and influenza vaccines.

Practices buy doses before they administer them.

"Those large networks have a lot more capital and are able to have in-house pharmacies and large stocks of vaccines, which has limited the ability of the most important place to have vaccines, which is your primary care doctor's office," Nosal said.

Counseling codes exist; payment does not

Three CPT codes for immunization counseling on days when no vaccine is administered, 90482 through 90484, took effect Jan. 1, 2026.

"In the sense that we can capture the work we're doing, both through documentation and the use of CPT codes, unfortunately, those codes are not yet reimbursable by CMS, and most private payers also are not paying for those codes," Nosal said in August.

"We continue to do advocacy work. We have the codes existing. It is making sure that we can actually be paid for the work and time we're spending on keeping our patients in America healthy," she said.

What a referral to the pharmacy costs

"When patients go to a pharmacy, pharmacies often will not vaccinate infants or children, so that opportunity may be lost fully," Nosal said. Not all states require that vaccines administered to adults be entered into a registry, she said.

"So patients run the risk of not knowing they've been vaccinated, missing or receiving a wrong dose or additional dose, not getting a dose at all or not being able to reconcile some vaccines at one location and vaccines at another location," Nosal said.

The evidence behind the recommendations

The Vaccine Integrity Project, based at the University of Minnesota's Center for Infectious Disease Research and Policy, identified 299 eligible studies across three reviews of influenza, COVID-19 and RSV immunization, published primarily between August 2025 and June 2026.

The reviews ran in JAMA and were provided to the societies to inform their recommendations.

Updated COVID-19 vaccination was 53% effective against hospitalization among adults 65 and older during the 2025-2026 season, according to the review. Vaccination was associated with a 76% reduction in COVID-19-related emergency department visits among children 9 months through 4 years.

An analysis of VISION Network data found influenza vaccination provided 31% protection against influenza-associated hospitalization in older adults.

Across eight influenza seasons, vaccine effectiveness against laboratory-confirmed influenza-associated death among children and adolescents was 80%.

RSV vaccination among adults 60 and older was 69% to 83% effective against RSV-related hospitalization in single-season estimates.

Nirsevimab effectiveness in infants ranged from 63.6% to 93% against RSV-related hospitalization within 6 to 12 months, varying with the timing of the dose. Comparative studies identified no new safety signals for any of the three immunizations.

A cohort study of U.S. veterans put vaccine effectiveness against RSV-related hospitalization at 81.1% over the first six months after vaccination and 48.5% at 12 to 18 months. AAFP recommends a one-time RSV vaccine. The review's authors write that the potential for waning effectiveness among older adults in a second season warrants continued attention, and that additional evidence may require future guidance.

The review identified no eligible studies reporting on the effectiveness of clesrovimab, one of the two monoclonal antibodies AAFP lists for infants younger than 8 months.

A trial published in July, after the review's search window closed, reported comparable adverse events between infants given clesrovimab and those given palivizumab, an older product.

CDC estimated that influenza was associated with 390,000 to 800,000 hospitalizations during the 2025-2026 season. Its preliminary estimates for RSV over the same season put the burden at 2.8 million to 5.8 million outpatient visits, 170,000 to 340,000 hospitalizations and 9,900 to 25,000 deaths.

The four societies' recommendations, along with a consolidated printable reference, are posted on AMA's site, and AAFP's schedules and shared clinical decision-making guides are on its own.

"We've partnered with other major medical organizations and the Vaccine Integrity Project to make sure that we have the most up-to-date and accurate vaccine recommendations, so that's definitely where I would direct you as a physician," Nosal said.