Complicated vaccine guidelines are slowing adult immunization rates

A new report from the Global Healthy Living Foundation (GHLF) raises concerns that confusing vaccine recommendations are discouraging adult immunization — especially in underserved communities and in pharmacies, where most vaccines are now administered.

The report, “Enhancing Adult Vaccine Uptake: Challenges in Shared Clinical Decision Making and Risk-Based Recommendations,” examines how two Centers for Disease Control and Prevention (CDC) policy tools — shared clinical decision making (SCDM) and risk-based recommendations — may be contributing to lower vaccine uptake and widening health disparities.

“Our goal with this report is not to dismiss the intent behind SCDM and risk-based guidance, but to examine how these approaches work in real-world clinical settings,” said Robert Popovian, PharmD, MS, founder of Conquest Advisors, chief science policy officer at GHLF, and author of the report.

“Unfortunately, the data show that these policies can create unintended barriers to immunization, particularly when providers lack full access to patient histories or are burdened by unclear reimbursement protocols,” he said. “When policies lack clarity, the burden falls on providers and patients to navigate a confusing system — often with serious consequences.”

Vaccine uptake on the decline

The report cites CDC and peer-reviewed studies showing that SCDM guidance has been associated with lower vaccination rates. For example, after the CDC adopted SCDM for the PCV13 pneumococcal vaccine in 2019, uptake among Medicare beneficiaries fell from more than 70% to less than 60%, including among vulnerable subgroups and immunocompromised patients.

Similarly, a 2022 CDC analysis found that only 11.9% of eligible adolescents received the MenB vaccine under SCDM, while 60.8% of the same group received the MenACWY vaccine, which carries a routine recommendation.

The Hepatitis B vaccine — once governed by a risk-based recommendation — was revised in 2022 after “suboptimal uptake of the Hepatitis B vaccine, specifically among minority patients,” the report states. The CDC now recommends that physicians offer the vaccine to all patients 60 and older, regardless of risk factors.

Implementation problems in practice

The report detailed how real-world clinical settings — particularly pharmacies — struggle to apply complex CDC criteria. According to the report, “providers may hesitate to vaccinate based on a patient’s attestation without supporting clinical records,” and may face legal and professional risks by doing so.

“Health care providers, particularly in non-specialist or high-volume settings, may find it challenging to assess all patients for risk factors primarily due to time constraints,” the report states. It also notes that “insurers often require documented clinical evidence to approve payment for vaccines given based on risk factors.”

In pharmacy settings — where nearly 90% of adult vaccinations are now administered — these issues are magnified. “Not all physician practices will have Medicare Part D billing capability,” the report notes, and many physicians worry that health plans will “question their clinical judgment and potentially deny reimbursement.”

Calls for policy reform

GHLF’s recommendations include shifting more vaccines from SCDM or risk-based categories into routine guidelines, especially for older adults and those with chronic conditions. The report also calls for better alignment between the CDC’s Advisory Committee on Immunization Practices (ACIP) and the Food and Drug Administration (FDA) to ensure vaccine guidance is clear and consistent.

“ACIP must reassess the clinical risk criteria to ensure that pharmacists can effectively apply them without undermining their clinical judgment,” the report states.

“These findings reflect a consistent and concerning pattern,” Popovian said. “When vaccine policy becomes overly complex or misaligned across agencies, it places undue pressure on frontline health care providers and leads to confusion for patients.”

The full report can be found here.