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The Centers for Disease Control and Prevention's (CDC's) vaccine advisory committee voted on Thursday to rescind an earlier recommendation that allowed parents to choose how to immunise their children against measles, mumps, rubella and varicella (MMRV). However, a childhood vaccination programme within the CDC may still be able to provide and cover the single-shot MMRV vaccine after a subsequent vote from the Advisory Committee on Immunization Practices (ACIP) muddied the water.The meeting — boycotted by the American Academy of Pediatrics, which has broken ranks with the CDC over COVID-19 recommendations and sued Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. — is the second since Kennedy fired all former ACIP members and handpicked 12 new appointees; five were added to the roster just days earlier (see – Physician Views Results: Docs sound off on ACIP's controversial makeover — and it isn't pretty).It also follows the ouster of former CDC director Susan Monarez, who testified before the Senate Committee on Health, Education, Labor and Pensions on Wednesday that Kennedy was seeking to reshape the childhood immunisation schedule this month.One shot or twoThe outcome of Thursday's meeting will likely affect how the different measles vaccines are covered by health insurance.Two vaccine options are approved by the FDA: Merck & Co.'s ProQuad MMRV vaccine is designed to provide protection against all four diseases in a single shot, or parents can opt to have their child receive two separate shots, typically given at the same time, with one immunising against MMR and the second against varicella (MMR+V).Under the US childhood immunisation schedule, children receive their first dose of either MMRV or MMR+V between the ages of 12 months and 15 months, and a second dose between the ages of 4 and 6 years old. After concerns emerged in the 2000s that the MMRV vaccine was associated with a higher risk of febrile seizures, ACIP reviewed the safety data on both options. In 2009, ACIP recommended that both vaccines could be given to children, but with a preference for the MMR+V shots as the first dose, and the MMRV vaccine as the second dose. Providers were instructed to discuss the benefits and risks of both vaccination options with parents and caretakers, who were still able to ask for their child's first dose to be the MMRV vaccine, if preferred. According to data presented by the CDC at Thursday's meeting, about 85% of children receive the two-shot MMR+V vaccines, and 15% receive the MMRV vaccine.CDC scientists also shared data demonstrating that the risk of febrile seizure after the first dose of the MMR+V vaccine is about 1 in every 3000 to 4000 doses, while the risk increases two-fold if the MMRV vaccine is given as the first dose. No increased risk was found regarding the second dose. ACIP voted 8-3 to no longer recommend the MMRV vaccine for children under age 4, with one abstention.However, the committee members also voted 8-1, with three abstentions, not to change coverage for the MMRV vaccine under the CDC's Vaccines For Children (VFC) programme — which provides vaccines to children whose parents or guardians may not be able to afford them — though several expressed confusion about what the vote meant and how it would affect childhood vaccinations and insurance coverage.'Déjà vu' discussionThroughout Thursday's meeting, several ACIP members questioned the long-term effects of febrile seizures, including Vicky Pebsworth, Evelyn Griffin and Retsef Levi. They rationalised their objection to the MMRV vaccine as concern over a lack of years of follow-up data that prove the shot is safe. "If we assume that the benefit is long term, I think we also need to consider the fact that some of the adverse impacts could also be long term," Levi said.However, fellow ACIP member Cody Meissner pushed back on that idea, noting that febrile seizures are common in children under five and "pretty well defined," adding that "the vast majority of febrile seizures do not occur in association with vaccines."Similar to how he, at the last ACIP meeting, pointed out that the safety of thimerosal in vaccines had already been addressed, Meissner said the MMRV discussion "is really déjà vu for me because we had extensive discussions on this very topic 15 years ago.""As a paediatrician for more than 30 years, we're so familiar with febrile seizures. And I think most paediatricians would say that the prognosis is excellent," he added.Meissner said he supports the current ACIP recommendations, which allow parents to choose which vaccine they prefer, and voted against restricting the first dose to just the MMR+V vaccine. ACIP member Joseph Hibbeln, who also cast a no vote, characterised the debate as determining which poses a greater risk: "febrile seizures, which may or may not have long-term consequences — likely not — as compared to falling below a 95%, 90% coverage rate for herd immunity." He described the consequences of losing herd immunity as "devastating — pregnant women losing their babies, newborns dying and having congenital rubella syndromes." "If we make a major change…I think we have to have a darn good reason as to why we're making that change," Hibbeln added. Insurance impactsSeveral ACIP liaisons, including representatives of medical and infectious disease organisations, brought up their own concerns with changing the MMRV vaccine recommendation — and criticised what they perceived as a lack of comprehensive information in the CDC's presentation. "You're not looking at all of the aspects of how we evaluate vaccine implementation. You're looking at very small data points and misrepresenting how it works in the real world and how we take care of our patients,"  said Jason Goldman, president of the American College of Physicians. "So no, this was not a thoroughly vetted discussion. I want to see how we implement it, how it's accepted by the population, what's the feasibility, what's the equity, what are the harms and benefits. You have not considered all of those aspects in this presentation."Robert Hopkins, medical director of the National Foundation for Infectious Diseases, also pointed out a lack of consideration for issues around equity or "the implications of these decisions for our patients and for the practising physicians who are carrying out these actions."Goldman further decried that a recommendation against the MMRV vaccine gives "license to insurance companies and the [VFC] programme not to cover this vaccine… you are taking away the choice of parents to have informed consent and discussion with their physician on what they want to do for the health and benefit of their children."The implication that children could lose insurance coverage for vaccines is what seemed to have swayed the ACIP's second vote, which allows VFC to continue covering the MMRV shot. Before the vote, Pebsworth asked for clarification on whether the MMRV vaccine could still be given if the group voted against it, and seemed unaware that a recommendation from ACIP would impact insurance coverage. ACIP Chair Martin Kulldorff clarified that "our vote does have consequences sometimes on insurance coverage."Representatives from VFC and the Centers for Medicare & Medicaid Services confirmed that recommending against the MMRV vaccine would have coverage implications. "So that implies that the parents' choice, unless they want to pay for it themselves…is taken away," Hibbeln said. Faced with that knowledge, all members except Kulldorff either abstained or voted to allow VFC to continue covering the MMRV vaccine.