Why We Shouldn’t Copy Other Countries' Vaccine Schedules
The United States isn’t Denmark. Or Japan. Or Germany.
The White House recently announced plans to align U.S. childhood vaccination recommendations with those of other countries. The rationale sounds sensible: Denmark recommends vaccines for 10 diseases, Japan for 14, Germany for 15, while the United States recommends them for 18. Why not match Denmark or Japan?
The answer is straightforward. The United States isn’t Denmark. Or Japan. Or Germany.
The United States doesn’t recommend routine vaccination for tuberculosis, typhoid, yellow fever, or malaria, while other countries do. Does that make our schedule deficient? No. It reflects our different disease burden.
Our health system, population, and health care system differ in ways that matter when we design vaccine policy. We can’t copy another nation’s approach and expect the same results. Vaccines are rigorously tested, proven safe, and recommended for a reason. Health is shaped by many things beyond medicine, including socioeconomic and environmental factors. Many of these factors are worse in the United States than in peer countries. Our average life expectancy is a low outlier compared to every other high-income country. Overall, the differences with most other high-income countries (referred to as OECD) are relatively minor (see table). Hepatitis B, discussed below, is one example. Others are hepatitis A, rotavirus, and meningitis, in which our vaccination program is universal, providing a safety net; chickenpox, where the US, as many other countries do, chooses to avoid millions of kids getting a preventable illness; RSV, where the US is leading with adoption of a recently developed vaccine; and influenza.
The United States recommends annual flu vaccination for children starting at six months. Many European countries don’t include flu shots in their childhood vaccine recommendations Why? European nations often have stronger primary care systems that can identify and target high-risk children. They have paid sick leave policies that help keep contagious parents and children home. Japan keeps people safe from flu through universal health coverage and population-wide health systems that the U.S. lacks.
Consider universal hepatitis B vaccination at birth, which the CDC’s vaccine advisory committee voted to end last week. I warned of and explained the danger of changing hepatitis B vaccination of newborns on September 30 of this year, and unfortunately dangerous change is exactly what the current administration has implemented. The White House fact sheet notes that the United States vaccinates newborns against hepatitis B at birth, while some countries only vaccinate infants of mothers who test positive for the infection.
But here’s what the comparison misses. Denmark has universal prenatal care and robust social services. Virtually every pregnant woman in Denmark receives consistent medical attention and testing for serious diseases that can be passed to their babies throughout their pregnancy, including hepatitis B. Japan has universal health insurance and one of the world’s lowest rates of maternal hepatitis B infection.
The United States doesn’t have these advantages. Many American women deliver babies without adequate prenatal care—about 1 in 4 pregnant women, according to a recent report. We can’t reliably identify every mother who carries hepatitis B or guarantee that every infant won’t be exposed to hepatitis B in the home, which accounts for a quarter of all infections. Indeed, we tried targeted vaccination in the 1980s—and it failed. Universal vaccination at birth reduced hepatitis B infections in children and young people by 99%, which I wrote about last week.
Here’s the data for birth dose. Delay of just a few days or weeks increases the risk that an infant will become infected by 400%.
That’s why we’ve vaccinated at birth since 1991. Yes, many children who receive the vaccine will never face exposure to hepatitis B. But we can’t know which ones have been or will be exposed. Universal vaccination creates a safety net for the children that our fragmented health system might otherwise miss.
This raises the paradox of successful vaccination policy. Vaccines work so well that people forget why we need them. Most parents today haven’t seen a child paralyzed by polio or brain-damaged by measles. When diseases disappear from our everyday lives, vaccines can appear unnecessary. Resistance to vaccines grows precisely because the need for them becomes less visible.
The United States recommends more vaccines than some peer nations because we face different challenges. We don’t have universal health coverage. We have higher rates of certain infectious diseases. We have less access to consistent, affordable healthcare. Our vaccine schedule reflects these realities.
Because we don’t have the same level of protections, we cast a wider net with vaccination. Vaccine recommendations are based on the population’s level of risk of exposure to disease and how that disease affects health. Cost-effectiveness matters too—the balance between vaccine costs and the costs of medical visits, hospitalizations, and missed work from disease. These calculations differ by country.
Research shows the benefit of following established U.S. vaccine recommendations. Among U.S. children born between 1994 and 2023, routine childhood vaccinations prevented approximately 508 million cases of illness, 32 million hospitalizations, and more than a million deaths. The economic value of vaccines is also enormous—vaccination programs in those 30 years will have saved $540 billion in direct costs (such as medical expenses) and $2.7 trillion in societal costs (such as the effects of missed work).
If we cut back the vaccine schedule to match Denmark’s or Japan’s, we won’t be a healthier country. We’ll simply lose protection for many of our children.
Vaccine policy should follow the evidence. Most importantly, our recommended vaccines have decades of evidence supporting their safety. Evidence-based decisions also need to include context. Before we scale back protections American children depend on, we should ask two basic questions: Where is the credible evidence to support these changes? And do we have the systems in place to keep kids safe without those vaccines?
Dr. Tom Frieden is author of The Formula for Better Health: How to Save Millions of Lives – Including Your Own.
The book draws on Frieden’s four decades leading life-saving programs in the U.S. and globally. Frieden led New York City’s control of multidrug-resistant tuberculosis, supported India’s efforts that prevented more than 3 million tuberculosis deaths, and led efforts that reduced smoking in NYC.
As Director of the CDC (2009-2017), he led the agency’s response that ended the Ebola epidemic. Dr. Frieden is President and CEO of Resolve to Save Lives, partnering locally and globally to find and scale solutions to the world’s deadliest health threats.
Named one of TIME’s 100 Most Influential People, he has published more than 300 scientific articles on improving health. His experience is, for the first time, translated into practical approaches for community and personal health in The Formula for Better Health.