How ACIP Moves From Evidence to Vaccine Recommendations

This page describes ACIP's recommendation process as updated in 2018.

The Advisory Committee on Immunization Practices (ACIP) is a federal advisory committee that advises the CDC Director and the Secretary of Health and Human Services on using vaccines and related products to control vaccine-preventable diseases in the U.S. civilian population. Work groups gather and analyze the science and present options. Recommendations approved by a majority of ACIP's voting members go to the CDC Director, and those the Director approves are published in MMWR, becoming CDC guidance on the date of publication. ACIP harmonizes its schedules as far as possible with those of medical organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians and the American College of Nurse-Midwives.

From GRADE to Evidence to Recommendation

In 2010 ACIP adopted GRADE (Grading of Recommendations Assessment, Development and Evaluation), a method for building evidence-based recommendations. Since then, GRADE evidence profiles — assessments of how certain the evidence is about each benefit and harm — have been central to its work.

But certainty of evidence is not the only thing panels weigh. They also consider how the people affected value the outcomes, health economics and practical implementation. Over the following years GRADE added Evidence to Decision, or Evidence to Recommendation (EtR), frameworks to structure that step from evidence to decision and to make the influence of those other factors visible.

ACIP followed these developments and built its own modified EtR framework, adopted unanimously at its February 2018 meeting. National Immunization Technical Advisory Groups in other countries and the World Health Organization's Strategic Advisory Group of Experts on Immunization had adopted similar frameworks. ACIP's Evidence-Based Recommendations Work Group — CDC staff, current and former ACIP members, outside methodologists and GRADE Working Group representatives — develops and reviews the framework.

What changes

New or substantially revised ACIP vaccine recommendations use the EtR framework to show the committee's deliberations and judgments. Each recommendation falls into one of three categories:

1. ACIP recommends vaccination for everyone in an age group or for a group at higher risk of the disease;
2. ACIP does not recommend the vaccine;
3. the recommendation relies on clinicians' judgment in individual patient conversations about whether vaccination is right for a particular person.

ACIP may also decline to make a recommendation, for example when more information is needed.

Spelling out these factors and the judgments behind them is meant to make ACIP's recommendations more transparent, consistent and clearly communicated to health care providers, partner organizations and the public. More about GRADE is on CDC's ACIP pages.

Sources

• Lee G, Carr W; ACIP Evidence-Based Recommendations Work Group. "Updated Framework for Development of Evidence-Based Recommendations by the Advisory Committee on Immunization Practices." MMWR 2018;67(45).