What Role Should States Play in Providing Access to Vaccines?

Ashish Jha: 00:00:00

Hey everybody. Ashish Jha here in Providence, Rhode Island on a sunny afternoon, and we are back with a moment in health, the podcast where we talk about one data point, discuss one study, and then answer a question. And today I'm going to go ahead and get started by talking about the data point, which is 21% one in five. What is that number? Where does it come from? It comes from a recent paper, trends in county level, MMR, vaccination coverage in children in the United States, published June 2 of 2025 by some colleagues from Hopkins, and 21% is the proportion of counties in the US, based on their data, that have measles vaccination rates of at least 95% or above. Now if you're a frequent listener to this podcast, you know that we have talked about measles vaccines and the importance of keeping it at 95% keeping vaccination rates at 95% that's how you ensure that if you introduce a case of measles in that county, it will not spread, because of the very high level of population immunity. It's such an incredibly contagious virus that once you drop below 95% there is a risk of the virus starting to circulate. And once you get below 90% that risk goes substantially higher. And from the same paper, we can calculate that about half the counties in America now have measles vaccination rates below 90% which is a real problem. One last point on this. The real issue here is a couple of things. One is, kids under the age of 12 months generally have not gotten a measles gotten a measles vaccine because they just aren't generally eligible yet. And so if you have a low vaccination County, those kids could end up getting could end up getting infected and quite sick. And then you have immunocompromised kids, kids who might have cancer immunodeficiencies, they are not eligible to get the measles vaccine. They can't get it actually, and they rely on everybody else around them being vaccinated. And once county level vaccination rates really fall, what you're

Ashish Jha: 00:02:10

going to see is not just healthy kids getting back, getting infected, but immunocompromised kids getting potentially infected and very, very sick. So the number is 21% that's the proportion of counties in America that are at 95% vaccination rates or higher.

Ashish Jha: 00:02:34

Okay, now moving on to one study, and the study of this week that I want to talk about comes from the June 2025 issue of the lancet planetary health. It's one of the lancet journals, and the study is called air pollution and fetal brain morphological development, a prospective cohort study. So let's talk a little bit about what the study does, what it does show, doesn't show, and I want to use it to talk a little bit about air pollution as a broader problem. So the study looks at about 1000 people living in Barcelona, Spain, follows them over time. It's a prospective cohort study, and basically finds that pregnant women based on the amount of exposure they had to air pollutants, specifically nitrous oxide and black carbon. The higher the exposure, the more they could see changes in fetal brain morphology, changes that would be concerning for neural development. Now it's a small study. About 700 women or 700 people ended up in this study, and so it's, as I said, it's a small study. They see these morphologic changes and taken in isolation, we're not exactly sure what these neurologic changes mean, certainly concerning, but unto itself, not definitive data that air pollution is causing neural development problems. But if you take a step back and look at the broader issue, there have been lots of other studies that show that air pollution can be harmful for fetal development. They can certainly be harmful for kids and cognitive development, and it gets at the broader issue of air pollution in general, who UNICEF, others, estimate that between seven and 8 million people a year die from air pollution. This makes it, in some ways, the number one risk factor for death. In the world, there are about 70 million people who die every year. So about 10 to 11% of all deaths can be attributed to air pollution. That's a massive number, and largely, I think, underappreciated by most people, especially in the particularly in the public health community. We

Ashish Jha: 00:04:38

often think about other risk factors, which are, of course, very important. But it turns out air pollution globally is a major killer. Now, the way people die from air pollution is, of course, you have these effects on neural development that we're talking about here, but the way people die is, air pollution leads to more cardiovascular disease, more heart attacks and strokes. Leads to more cancers. And so we don't. Tend to attribute it to air pollution directly. If somebody comes in with a stroke and dies, we think of that as a stroke death, not an air pollution death, but we know stroke rates go up substantially when there's more air pollution around. So this study really adds to the literature by helping us understand that not only is air pollution bad for kids, causing asthma, adults causing heart attacks and strokes, prolonged exposure, causing cancer. But even in fetal development, we can start seeing some of the negative effects of air pollution, and that means that we really have to do a lot more work to bring air pollution down, largely by burning less carbon. A lot of the pollutants come from coal fired power plants, other kinds of plants that burn a lot of carbon. But of course, there are other pollutions, like nitrous oxide, sulfur dioxide and other things as well that can be quite harmful. So that's your study of the week, air pollution and fetal brain morphologic development, a prospective cohort study from the June issue of Lancet planetary health.

Ashish Jha: 00:06:10

All right. And now to the one question. And for the one question of the week, I have my friend, colleague, Scott Rivkees, former Surgeon General of the great state of Florida, with Surgeon General from 2019 through 2021 through the summer the fall of 2021 and is now a professor here at the Brown School of Public Health. Scott, welcome to the podcast. Thank you for having me happy to be here. Excellent. All right, so, Mike, one question for you really comes from what we're seeing in Washington with at HHS, with ACIP, the Advisory Committee on Immunization Practices. So here's the question, assuming the federal government makes it harder for people to access vaccines for free, what do you think the role of states should be?

Scott Rivkees: 00:06:57

Well, states have a very important role. You know, public health and health care is really the domain of the states, but I can answer the question a little differently in terms of what I see as the lens coming down the road. I think the effects of this change can really be devastating on public health in this country. You know, in the past, policy, vaccination policy, healthcare policy really was based upon scientific evidence the role of the medical community. And now what really seeing is that really honestly being torn down. We're gonna have a situation where some policy is being replaced by political views. And since public health vaccination policies really have a very important role in the States, I think we could be in a situation where political bodies, political leaders in different states, are going to be dictating what this policy is. And so you could actually have 50 states with 15 different policies. So we're going to be in a really confusing situation, potentially a tower of Babel of vaccine recommendations vaccine coverage to the detriment of children and adults.

Ashish Jha: 00:08:11

Okay, so let me just drill down a bit more on this. So if you have, let's say, lack of clear guidance and lack of credible recommendations coming down from the federal government. What can states do to address this issue?

Scott Rivkees: 00:08:24

Yeah, so you know. So first, there are a couple of different ways to approach this. So in terms of federal funding, influence how certain policies take place. So for example, the vaccine for children program, this is a great program that provides vaccines for certain covered immunizations to the states, and then the states will distribute this to healthcare providers. So if the VCF program goes away and or certain elements of it will, then it's going to be up to the states. How are they going to backfill those vaccines for

Ashish Jha: 00:09:02

children. And presumably those are vaccines mostly going to poor kids, kids on Medicaid, kids on s Chip, I assume, yeah. So couldn't the state just like, mandate that their Medicaid program just cover those vaccines?

Scott Rivkees: 00:09:15

States certainly can do that. Yeah, the V you know, first in the United States, this great country of ours, about half the children in the United States are either on Medicaid or on the CHIP program. So about half the kids get their vaccines through this program. Then also the other children get it through commercial insurance, where what's covered there also is influenced by the states. So the States certainly could say that we're going to provide a certain pool of funds so that these children get covered. But other states this may not happen. So again, you're going to end in the situation where there can be state to state variability in what's covered by Medicaid, and then what they require also being covered by commercial insurance.

Ashish Jha: 00:10:00

Yeah. And last part of this question is, it seems to me, as unfortunate as that would be, is that better than a federal government that isn't requiring or recommend not requiring isn't recommending anything? I mean, it feels to me like at least it gives states some autonomy, some ability to step in and fill the void. Do you see that as at least a silver lining in this situation? Or how do you see that?

Scott Rivkees: 00:10:27

Yes and no, you know. So first of all, you know, in terms of what children have received for vaccines, you know there are a lot of vaccine preventable diseases out there. At the present time, there's been standard guidance for states in the medical community to follow which protects all children. So some states may develop new policies that are different than the federal government. Some following different medical organizations, and states are going to look to different individuals for different kinds of guidance. So you could really have a state having different policies in children being vaccinated based upon what borders they live within. So again, so some states may follow standard policies. Other states may not. Yeah.

Ashish Jha: 00:11:13

So it seems to me like the bottom line here is we are in for a lot more heterogeneity, a lot more state to state variation, and the benefit of having had a advisory committee that was rooted in science that gave standard guidance across the entire country, or maybe on the verge of losing that

Scott Rivkees: 00:11:39

exactly, You know, another thing too. There's something even more insidious than this. We are completely eroding the trust of the public. Yeah, where are families going to go to for advice? And I think, you know, one of the extreme examples of what happens when vaccines become politicized is the term red COVID, which was coined by David Leonhard in the New York Times. You know, in the beginning part of the pandemic, Republican governors, Democratic governors, they all lined up behind vaccines, and then we saw a divergence. So it got to the point where two years into the pandemic, the biggest risk factor, whether you died for COVID Wasn't your age, it was who you voted for in the previous administration. And my fear is this, is that we're going to see policies varying from state to state, and we're going to have, you know, children in one state protected against measles, another state protected against whooping cough, and other states not

Ashish Jha: 00:12:37

Yeah. Well, let me just wrap up by saying I My hope is that the history of immunizations in this country has not been partisan. I always remind people that West Virginia still has the highest rate of vaccination among school aged kids, and Mississippi is up there, and so is Massachusetts, reminding people that this has never been a red issue or a blue issue. Whatever happens next. I pray, pray, pray that we can keep it a nonpartisan issue. Scott, thank you for everything you've done during the pandemic. Thanks for your leadership here at the school, and thanks for coming by

Scott Rivkees: 00:13:11

today. Thank you so much.

Ashish Jha: 00:13:19

All right. So there you have it another episode of a moment in health where we talked about one data point, 21% the proportion of counties where kids are adequately protected against measles through high vaccination rates. We talked about one study air pollution and fetal brain development, a cohort study from Barcelona that tracked pregnant women and tracked both exposure to air pollution and morphologic differences we could see in the brain development on ultrasound and really as a part of a broader issue about how air pollution is very, very bad. We generally don't tend to pay enough attention to it, and it's something that we need to all continue to work on. And then the one question was my friend and colleague, Scott rivkees. I asked him, given what the federal government seems to be doing, on track to be doing on vaccines, what can states do? And what you heard from Scott was that states can actually do quite a bit, and that, I think is good and is important, but also a real concern about the patchwork we're going to get, where in some states they're going to recommend measles, other states are going to recommend mumps or rubella, but not measles or polio. It's a bit of a mess. And this is why I think it's really important at this moment for our medical societies, the American Academy of Pediatrics, the American College of Physicians, others, American College of Obstetrics, to step up and give very clear recommendations that I think all states should follow more on that in the in the coming weeks, but it is going to be a tumultuous time for vaccines, and you got a sense of that listening to Scott Rivkees. So thanks again for listening and. I'll be back next week with another moment in health. You.