Many doctors agree with the Food and Drug Administration’s recent decision to remove the black box warnings on at least some forms of hormone therapy used to treat the symptoms of menopause. But in making the announcement, health officials misleadingly suggested that women could take the drugs for long-term benefits to the heart and brain. Menopausal hormone therapy is not currently recommended for those uses.

On Nov. 10, the FDA announced it would be removing the black box warnings for increased risk of cardiovascular disease, breast cancer and probable dementia on all hormone treatments for menopause. Such products include a variety of formulations of estrogen, often with another hormone, that work to alleviate symptoms such as hot flashes, night sweats and vaginal dryness, which can be severe in some women. 

The warnings were first applied in 2003, following the results of a large randomized controlled trial that was part of the Women’s Health Initiative. This study, funded by the National Institutes of Health to better understand how to prevent disease in older women, was widely misinterpreted as finding that risks of menopausal hormone therapy, or MHT, outweighed benefits for managing menopause symptoms. Use of MHT plummeted.

In the intervening years, it has become clear that certain forms of MHT, such as oral pills that act systemically, or throughout the body, do have some risks, but can be safely used to treat symptoms in most women without risk factors when started within 10 years of menopause. This is when symptoms are most likely anyway. Other forms of MHT, such as vaginal estrogen, pose little if any risk. Menopause is when a woman stops menstruating; a woman is considered postmenopausal once she has gone a year without a period.

Medical groups such as the American College of Obstetricians and Gynecologists have long recommended MHT after considering an individual’s risks and benefits and have petitioned the FDA to remove the black box warnings for low-dose vaginal estrogen. They do not, however, advocate the use of hormones for overall health when a woman does not have any symptoms, due to a lack of convincing evidence.

In making their black box announcement, FDA Commissioner Dr. Marty Makary and Health and Human Services Secretary Robert F. Kennedy Jr. misleadingly extolled the benefits of MHT in preventing cardiovascular disease and dementia.

“Hormone replacement therapy has been found to reduce the risks of cardiovascular disease and mortality by as much as 50%, Alzheimer’s disease by 35%,” Kennedy said near the beginning of the Nov. 10 press conference announcing the change.

“By a large body of evidence, there are now recognized to be profound long-term health benefits that few people, even physicians, know about,” Makary later said of hormone therapy, calling it “life-saving.”

“What are we doing not offering women this potentially powerful treatment? With few exceptions, there may be no other medication in the modern era that can improve the health outcomes of women on a population level than hormone replacement therapy,” he added.

Kennedy and Makary made similar claims in a variety of subsequent appearances, including Kennedy’s citation of the same figures in a Dec. 2 Cabinet meeting.

Experts told us their statements don’t reflect the full scientific literature on the topic.

“The totality of the data do not support a preventive benefit of hormone therapy for these diseases,” Dr. Nanette Santoro, a menopause researcher at the University of Colorado Anschutz, told us. “One must selectively pull out specific numbers from specific studies to come up with a miraculous reduction in risks.”

No guidelines, neither from ACOG, the Menopause Society, the International Menopause Society nor the Endocrine Society, she noted, recommend hormone therapy to prevent cardiovascular disease or dementia.

Makary and Kennedy also downplayed risks of systemic MHT, implying that breast cancer risks are not borne out by the data. This is misleading and does not tell the full story.

“They’ve systematically cherry-picked things that show benefit and that diminish risk,” Dr. Martha Hickey, a menopause clinician and researcher at the University of Melbourne, told us.

“Providers should always have a nuanced conversation about the risks and benefits of systemic hormone therapy with their patients. Each woman is different, and this conversation needs to be tailored to the needs and priorities of each woman,” Rebecca Thurston, a menopause researcher at the University of Pittsburgh who focuses on cardiovascular and neurocognitive health, told us. She emphasized that MHT is highly effective for hot flashes and night sweats and can also prevent menopause-associated bone density declines but is not recommended for the prevention of heart disease and dementia “based on the highest quality science.”

The FDA did not respond to a request for comment.

Cherry-Picked Dementia Benefits

In touting the benefits of MHT, Makary and Kennedy repeatedly claimed that hormone therapy has been found to lower the risk of Alzheimer’s disease by 35% and reduce cognitive decline by 64%. The numbers were also cited in an HHS fact sheet.

Both reflect findings in individual scientific studies, but they are cherry-picked and not representative of the overall literature.

Pauline Maki, a menopause and cognition researcher at the University of Illinois College of Medicine, explained in a series of social media posts that the 35% figure is “misleading and inaccurate in light of what we now understand.” It comes from a 1996 case control study of a single retirement community in Laguna Hills, California.

The study looked at how often women with an Alzheimer’s disease or dementia diagnosis on their death certificate had self-reported using hormone therapy, compared with those who did not have such diagnoses noted. It found that women with Alzheimer’s were less likely to have said they used hormones, with hormone use associated with a 35% lower risk of the disease.

While that might sound pretty good, Maki said, this doesn’t prove that it’s the hormones that made the difference, as other factors associated with hormone use could be driving the result instead.

There are also much larger and more recent case control studies that Makary and Kennedy did not mention. While the cited Laguna Hills study drew from a population of around 9,000 and involved fewer than 1,500 women who died 30 or more years ago, three population-wide case control studies have been published in the past six years, each with 60,000 or more participants.

“When you look at those studies, a very, very different result emerges,” Maki said in a video post. “Far from reducing the risk of Alzheimer’s disease, those studies found zero evidence for a reduction, and in fact, found an elevated risk.”

Maki said that women should not be concerned about increasing their dementia risk if they are using hormones to alleviate menopause symptoms. “But if you use it for primary prevention, particularly long term, there’s no evidence of benefit,” and there could be potential harm, she said.

The second study Kennedy and Makary have cited is a 2005 Danish follow-up study of 343 women who had previously been in a randomized controlled trial and had received hormone therapy or placebo years earlier. Researchers administered a cognitive screening test and found that while there was no difference in the average scores among those who ever took hormones versus those who never did, the subset of women who took hormone therapy for two to three years had a 64% lower risk of testing positive for cognitive impairment.

Maki told us that the study had a better design in terms of exposure to hormone therapy, but was “weak in its measure of cognitive impairment and is weak methodologically as only a subset of women in the original study participated in this follow-up.” She said it was odd to highlight either this paper or the Laguna Hills paper given all the other studies that have been conducted on the subject over the past 20 years.

When randomized controlled studies have been done, they have failed to find that hormone therapy has cognitive benefits in recently postmenopausal women. Four such trials have found no effects — good or bad — on cognition.

One randomized controlled trial — the WHI Memory Study — found that at 18 years of follow-up, women were 26% less likely to die of dementia if they had taken one type of an oral estrogen-only therapy. These women had all had hysterectomies, allowing them to take systemic estrogen without progesterone. (In women with intact uteruses, progesterone or a synthetic form called progestin needs to be added because estrogen on its own can increase the risk of uterine cancer.)

But the absolute benefit was very small, and the authors said the result should be interpreted with “particular caution.” The same trial found earlier that a combined estrogen and progestin therapy more than doubled the risk of probable dementia in postmenopausal women 65 years and older.

Some scientists have hypothesized that the timing of MHT matters, such that hormone therapy might benefit the brain if given early in the menopause transition or before disease sets in — and then shift to being neutral or harmful later. But as the Menopause Society’s 2022 position statement on MHT explains, the concept has not “been definitively supported” in randomized controlled trials.

Based on “good and consistent scientific evidence” — the highest graded recommendations — the society concluded that “[i]n the absence of more definitive findings, hormone therapy is not recommended at any age to prevent or treat a decline in cognitive function or dementia.”

Possible Cardiovascular Benefits in Some Women Uncertain

Makary and Kennedy have frequently claimed that hormone therapy dramatically cuts the risk of heart disease, casting it as a clear and definitive finding.

While there is some evidence of a cardiovascular benefit when MHT is started within 10 years of menopause or before the age of 60, this remains a hypothesis that has not yet been confirmed in trials.

“Until we have that next trial that would answer these questions, we can’t make these very large sweeping claims,” Dr. Chrisandra Shufelt, a women’s health internist at the Mayo Clinic in Florida who has studied the impact of hormones on cardiovascular disease, told us.

Both health officials have specifically said that hormone therapy slashes cardiovascular disease risk by 50%. HHS has used the same statistic in its press release and fact sheet.

The study often cited for this, however, is a 1991 review that specified that those findings pertained to oral estrogen-only hormone therapy — the kind given to women without uteruses — and needed to be confirmed in a randomized controlled trial.

Indeed, the review predates findings from the 2002 and 2004 WHI studies, which were specifically done to test whether hormone therapy actually did prevent cardiovascular disease in primarily healthy postmenopausal women.

“There’s observational data and there’s lots of it,” Marcia Stefanick, a WHI investigator and chronic disease prevention researcher at Stanford University, told us, noting that’s why the WHI study was done in the first place. “We know that the women who are using menopausal hormones were very different from the women who weren’t,” she explained, adding that they were “less obese, less likely to smoke, more physically active, more highly educated, less likely to eat high fat diets and have salt in their diet.”

At the time, hormones were commonly prescribed for prevention and were recommended by medical societies for that purpose.

“What piqued our interest in the late 80s and early 90s was that hormone therapy was increasingly being used for other indications — that is, prevention of cardiovascular disease in particular,” Dr. Jacques Rossouw, the project officer for the study from its inception until his retirement in 2014, told us. He emphasized that he was speaking to us in his personal capacity and not on behalf of the WHI investigators nor his former employer, the NIH.

Surprising many, when the WHI study testing MHT with oral estrogen and progestin was stopped after five years in 2002, it did not identify cardioprotective effects — and in fact the medications appeared to increase risk for the group as a whole. Nor did the oral estrogen-only part of the study find heart benefits when it halted in 2004. (A separate trial known as HERS similarly found no cardiovascular benefit with MHT in women with existing coronary disease, with an increased risk of blood clots, contrary to earlier observational studies.)

When later stratified by age, and after longer follow-up, the WHI results suggested that the cardiovascular risks of hormone therapy are generally lower in younger women closer to menopause and higher in older women starting therapy 10 years or more after menopause. These risks dissipated over time, and were more evident in women taking combined therapy. For younger women 50 through 59 years of age taking estrogen alone after 13 years of follow-up, the study pointed to a reduced risk of heart attack and coronary heart disease.

“If you look at the estrogen and progestin trial, there’s no benefit for younger women at any point for anything,” Stefanick noted. “It’s only in the estrogen-only trial, and those are women who had a hysterectomy.”

In trying to understand why the observational studies diverged from the trial data, these subanalyses, combined with other studies, including in monkeys, led to the so-called “timing hypothesis.” It proposes that estrogen has beneficial effects on the heart if given early and before plaques have formed in arteries, but is neutral or can be harmful later in life when women have established plaques.

As several guidelines document, there is wide agreement that timing affects the cardiovascular risk of hormone therapy — and that oral MHT is safe in most younger postmenopausal women who have bothersome symptoms. But there is far less agreement that this means MHT is preventing cardiovascular events in these women and that hormones should be given for the purpose of preventing heart disease.

Yet another WHI subanalysis published this year found that among the subset of younger women with moderate or severe hot flashes and night sweats in the trials, both estrogen-alone and combined MHT reduced symptoms without changing atherosclerotic cardiovascular disease risk. But for postmenopausal women age 70 and older with these symptoms, that risk was increased in both cases.

The WHI studies tested just one dosage of a particular oral estrogen and progestin, and it is unclear if the results apply to other dosages, types or modes of delivery. While Makary and others have emphasized that newer products may have reduced risk, by the same token, it hasn’t been shown that they would necessarily show any cardiovascular disease benefit.

“Most of us do believe it’s safer, but being safe is not the same as being beneficial,” Stefanick said, speaking of transdermal estrogen, a systemic product that is widely considered safer for the heart than oral formulations since it bypasses the liver. She added that she was not aware of any evidence of transdermal formulations showing heart disease benefits.

Makary has also referenced a 48% decline in fatal heart attacks with MHT, pointing in the press conference to a review published in Circulation. The 2023 review, which Shufelt co-wrote, was describing a subgroup finding in a 2015 Cochrane systematic review. It notably did not back the use of hormones to prevent heart attacks, and stated that it is “appropriate that no medical societies” recommend MHT for that purpose.

While the overall finding of the Cochrane review was that MHT did not protect against mortality or cardiovascular disease, when broken down by timing of therapy, a subanalysis found there was a 30% risk reduction of death from any cause and a 48% reduced risk of coronary heart disease (defined as cardiovascular deaths and nonfatal heart attacks) in women starting hormone therapy less than 10 years after menopause. 

These results were largely driven by the three largest trials, Shufelt told us, and were only possible because the analysis pooled results from studies using different types of MHT, including both oral estrogen alone and combined therapy. One of the included trials is a 2012 Danish study of around 1,000 participants that was not blinded and did not use a placebo. The Cochrane review itself notes that if the Danish study is not included, the findings would not be statistically significant (see table 3). Moreover, the review found an increased risk of blood clots in veins in the younger subgroup — a fact Makary and Kennedy never mention.

The authors of the Cochrane review said in a commentary that their analysis of younger participants “should be interpreted with caution due to its post hoc nature and is therefore not adequate to make recommendations for its use to prevent cardiovascular disease in this population.”

In addition to studies looking at health outcomes, there are two smaller randomized controlled trials that have assessed whether there might be cardiovascular benefits of MHT when given to younger postmenopausal women. A 2014 study using a lower dose of estrogen failed to find any beneficial effect on atherosclerosis progression after four years.

A 2016 trial of around 650 participants found that in women within six years of menopause, MHT did appear to stall the thickening of the carotid artery. However, there was no impact on two other secondary measures of coronary atherosclerosis.

Shufelt said that it is not clear that the observed slowing of artery thickening is indicative of a cardioprotective effect. Typically, the thickness is only concerning for preclinical heart disease if it reaches a certain level, and the women still had normal thicknesses, she said. She likened the study results to slightly lowering a person’s blood pressure from an already normal pressure. 

Shufelt said the studies were important because they showed that hormone therapy doesn’t increase risk in these populations, but “we’re not there yet to say that it prevents disease.”

Incomplete Information on Breast Cancer Risk

Kennedy and Makary both have emphasized that the WHI results were misinterpreted, and use of MHT subsequently fell. This narrative is broadly correct, but the officials misled on exactly how the study was misinterpreted, downplaying statistically significant findings on breast cancer risk.

The 2002 WHI study was “not statistically significant, but it triggered a media frenzy and led to the FDA applying unscientific black box warnings to all hormone replacement therapy products in 2003,” Kennedy said during the Nov. 10 press conference.

Makary also emphasized that the WHI breast cancer results were not statistically significant. “If we don’t have statistics, then we don’t have science,” he said.

Rossouw, the former WHI project officer, called this portrayal of breast cancer risk and WHI “just dead wrong.”

The WHI was stopped around three years early in 2002 after an independent board of researchers saw that breast cancer risk had reached a level that they had decided in advance would be unacceptable. Clinical trials are required to have such a board of safety monitors. The data also showed risks of blood clots and strokes, while failing, as we’ve said, to substantiate the idea that hormone therapy could prevent cardiovascular disease. The WHI researchers concluded that, given its overall balance of risks and benefits, MHT could not be recommended to prevent chronic disease and that it would not be ethical to continue the trial.

Rossouw was the first author of the 2002 WHI paper released in conjunction with the termination of the study. This is the publication Makary and Kennedy were referring to when they cited breast cancer results that were not statistically significant. But Rossouw explained that these data were preliminary. The women stopped their treatments under the study protocol after a median of 5.6 years. The researchers published their 2002 paper based on the 5.2 years of data available at the time. “There’s a lag,” he explained. “When you stop a trial early, there’s some data that are in process that you have not yet analyzed.”

The researchers were subsequently able to analyze the data collected in the final months of the trial. “When we did the full analysis and published those data, the breast cancer risk in the estrogen-progestin trial was statistically significant,” he said. The researchers wrote in a 2003 study that they had found a 24% increase in breast cancer cases in women who were randomly assigned to receive the combined hormonal therapy.

Furthermore, as the researchers continued to follow the women for years after the trial ended, they repeatedly found a statistically significant increased risk of breast cancer for combined MHT, both at 13 years and 20 years of follow-up. The WHI ultimately showed a decreased risk of breast cancer in women who took estrogen-only therapy.

The WHI investigators wrote in a Nov. 12 response to the FDA that “combination estrogen plus progestin increased the risk of breast cancer irrespective of age and this risk became more significant over time in the trial and with longer duration of follow-up.”

Some observational studies also have found an increased risk of breast cancer associated with use of MHT. One meta-analysis published in 2019 found that taking MHT was associated with increased risk of breast cancer even among people who took it between one and four years, with increasing risk the longer people took the therapy. 

Hickey called the evidence showing an increased risk for breast cancer from combined MHT “strong and consistent.” She added that it makes mechanistic sense that hormone therapy might have some impact on breast cancer. “I think with breast cancer, there’s a very strong biological mechanism by which menopausal hormone therapy increases the growth of existing breast cancers and possibly the initiation of new breast cancers,” she said. 

In general, practice guidelines support the use of MHT for troublesome menopausal symptoms while urging doctors to inform patients about possible risks and benefits.

“Women should be counseled about the risk of breast cancer with hormone therapy, putting the data into perspective, with risk similar to that of modifiable risk factors such as two daily alcoholic beverages, obesity, and low physical activity,” the Menopause Society advises doctors, for example.

“Hormone therapy does confer some risk, and so what we don’t want to do is overgeneralize or underestimate that risk, because it potentially could be harmful to some people,” Dr. Monica Christmas, director of the menopause program at University of Chicago Medicine and associate medical director of the Menopause Society, told us.

People who have already been diagnosed with breast cancer are typically recommended to avoid systemic MHT, according to the group’s guidelines, although it may be an option in specific cases. Vaginal estrogen, which is applied topically, is an option for those experiencing vaginal symptoms.

What some people arguably misinterpreted were the implications of the WHI results for treating menopausal symptoms.

The 2002 study notably did not say that the trial showed that the risks of MHT outweighed its benefits when used to treat troublesome hot flashes and night sweats that come with menopause. Investigators, including Rossouw, stated this at the time.

However, this nuance sometimes was lost as study authors, communications officers, journalists, doctors and the lay public interpreted and communicated the WHI results. Many left with the impression that the researchers had found that the risks of MHT outweighed the benefits in general, and not just for preventing chronic disease. In 2001-2002, nearly 39% of women between ages 52 and 65 used MHT. As of 2017-2020, fewer than 5% did. 

Makary also dismissed the WHI data by saying that it only applied to an older progestin. “Today, hormone therapy is available in formulations that do not appear to carry the same increased risk of blood clots or breast cancer that was seen in earlier studies,” he wrote in a Nov. 10 viewpoint published in the Journal of the American Medical Association. There is some support for this idea, but this conclusion is not certain.

The Menopause Society guidelines say that some “but not all” of the available data suggest a lower breast cancer risk from certain hormones compared with the type tested in the WHI study. There are no data from randomized trials to tease apart whether breast cancer risks vary by hormone type.

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For months, President Donald Trump or members of his administration have used federal data showing a large increase in employment for U.S.-born workers and a decrease in employment among foreign-born workers to claim that “all net job creation” in his second term has been for citizens. And for months, multiple economists and labor experts have said that officials should not do that because these specific figures are misleading.

The figures can mislead because the reported levels of native- and foreign-born workers are influenced by predetermined population estimates for 2025 that the Census Bureau calculated in 2024.

In an August post on Substack, Jed Kolko, a senior fellow at the Peterson Institute for International Economics, wrote that “the apparent boom” in employment of workers born in America “is just a statistical artifact” attributable to the way the population and employment estimates are determined.

“If someone is reporting the increased native-born employment, they are ignoring warnings by the Census Bureau not to do that,” he told us in an interview.

But that’s exactly what Trump and administration officials have done repeatedly.

“Before I entered office, 100% of all new net jobs were going to migrant workers,” Trump said during Dec. 9 remarks in Mount Pocono, Pennsylvania, for example. “Think of that, 100% of new jobs were going to migrants. These are government numbers, by the way. These are not Trump numbers. These are government numbers because they say, ‘Well, did Trump come up with these numbers?’ No, I didn’t … Migrant workers and illegal aliens got 100%. But since I took office, 100% of all net job creation has gone to American citizens.”

He then repeated a version of the claim about net job growth for only U.S. citizens in his prime-time address to the nation on Dec. 17.

Data from the Bureau of Labor Statistics — touted in a Dec. 16 post on the White House website — do show that this year native-born employment increased by almost 2.7 million from January to November. On the other hand, employment for foreign-born individuals decreased by 972,000 in that period.

Trump is wrong to use foreign-born employment to mean “migrant workers and illegal aliens.” BLS says the foreign-born category includes “legally-admitted immigrants,” some of whom may have since become citizens, “refugees, temporary residents such as students and temporary workers, and undocumented immigrants.”

In addition, during Joe Biden’s presidency, the data show an increase of 7.5 million in native-born employment, more than the 6.5 million increase in foreign-born employment.

BLS publishes this employment data, which is based in part on its Current Population Survey, or CPS, a monthly survey of 60,000 households conducted by the Census Bureau for BLS. But the figures shouldn’t be used to make such comparisons, some experts have said.

Misleading Employment Levels

One of those experts, Kolko, who is also a former undersecretary for economic affairs at the Department of Commerce during the Biden administration, explained the reasons why the data are questionable in his August post. He said that Trump administration officials and others who had pointed to the BLS data to claim that there had been a massive increase in native-born employment were guilty of committing a “multiple-count data felony.” 

At the time, the official figures showed that native-born employment was up 2.5 million through Trump’s first six months back in office. 

“The statistical agencies explicitly warn that these data” from the CPS “are not suitable for sizing and trending the foreign-born and native-born populations,” Kolko said. He pointed to a September 2024 working paper by Census Bureau staff that said the bureau, because of the survey’s small sample size, “routinely cautions against using the CPS to estimate the size and the geographic distribution of the foreign-born population when other data are available.”

“In fact,” Kolko wrote, “the apparent boom in native-born employment is just a statistical artifact, arising from arcane rules about how the data are constructed and population levels are determined.”

Those arcane rules, he told us in an interview, involve the household survey and predetermined population estimates for 2025 that the Census Bureau calculated in 2024. Those “population controls,” as he referred to them, significantly influence the reported totals for native- and foreign-born workers.

“The way the CPS works, the foreign-born and native-born population add up to a predetermined forecast that was made last year,” he said by phone. “So, a big decline in the reported foreign-born population” based on the survey “is going to be offset by a reported increase in the native-born population.”

As an extreme example, Kolko wrote in August that if the entire foreign-born population vanished from the U.S., the CPS would automatically report that the native-born population increased by millions of people to equal the predetermined estimate of the total population. 

People work in a restaurant in New York City on Dec. 16. Photo by Spencer Platt/Getty Images.

And when the estimated native-born population increases, so does the estimated number of U.S.-born workers, as Ben Zipperer, senior economist for the left-leaning Economic Policy Institute, explained in a September article.

Dean Baker, the founder and senior economist for the Center for Economic and Policy Research, another left of center group, said in a Dec. 1 analysis that there are “three obvious reasons why the CPS would show fewer foreign-born workers” in 2025. 

One reason, he wrote, “is that some number of immigrants have actually left the country,” either leaving on their own or being deported. Another reason is that more immigrants, even ones in the country legally, may be reluctant and not respond to the survey. Finally, “immigrants may not answer the survey accurately,” meaning that some foreign-born residents may say they were born in the U.S. when they were not, he said.

Baker noted that BLS data show that while the reported foreign-born population 16 and older has declined since last year, the native-born population has increased by more than 5 million — a figure that he suggested is not believable. That is how the Trump administration gets “the explosion in employment for the native-born they are boasting about,” he said.

Kolko also said the reported increase in the native-born population is not realistic. 

“The rate of immigration is slower this year, and it’s possible that the foreign-born population has declined,” he told us. “Immigration policy can cause the foreign-born population to grow faster or more slowly than forecast. But, in contrast, the native-born population typically grows at a predictable rate, because that’s based on fertility rates, the age distribution and mortality rates. So, aside from something like a pandemic, the native-born population typically doesn’t grow faster or slower than expected.”

“That’s why it is not plausible for the native-born population to jump the way it was reported in the CPS, and the way the CPS is constructed explains why we see this increase,” Kolko said.  

Notably, data from a different monthly BLS survey of businesses, called the Current Employment Statistics, or CES, show that total U.S. employment increased by just 499,000 workers, on net, from January to November. That’s more than 1 million fewer net jobs added than the estimated increase of almost 1.7 million according to the CPS, which is the only survey of the two that breaks down native-born and foreign-born employment.

“We might expect a difference, since these are from different surveys (native/foreign from the CPS, total jobs from CES), but a difference of 1 million jobs in just 10 months is pretty big!” Jeremy Horpedahl, an associate professor of economics at the University of Central Arkansas, wrote in a Dec. 17 blog post.

We reached out to the White House about Trump’s claims, but didn’t receive a response.

Check Unemployment Rates

Rather than employment levels, Kolko told us to look at the reported unemployment rates, as he also suggested in his August piece.

“The unemployment rate is the best information the CPS offers about the native born and the foreign born. Ignore the levels of population and employment: they mislead,” he wrote.

David J. Bier, director of immigration studies at the libertarian Cato Institute, also told us to focus on the unemployment rate, because he said that is what the CPS was really designed to determine.

“The survey is meant not to establish how many people are in the United States, or how many people are in any subcategory. It’s meant to figure out what the people in the United States are doing,” he said. “Are they working? Are they not? Are they retired? Are they in school? That’s what the survey is supposed to do, and it’s supposed to look at the rate at which these things are happening. … That’s where the survey data is useful.”

The most recent BLS data show that the unemployment rate for the native-born population has not improved; it was 4.3% in November, the same as it was in January. Meanwhile, the unemployment rate for the foreign-born population was 4.4% last month, down from 4.6% at the beginning of the year.

Bier said the unemployment rate is a more reliable statistic because it’s not dependent on the number of people in the country.

“It’s really dependent on the number of people surveyed. And if you survey enough people, you’re going to get pretty close to the actual distribution of what those people are doing,” he said.

Kolko told us that the BLS only publishes the native-born and foreign-born employment levels to be transparent about the data that underlie the calculation of the unemployment rate. But the rates ultimately are not affected by the population controls in the CPS, he said, “so it is fine to look at the native-born unemployment rate and the foreign-born unemployment rate.”

In a Dec. 17 post on X, Kolko again advised the public: “Do not look at native-born LEVELS of anything — employment, unemployment, labor force, or population. These stats may be official but they are meaningless.”

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President Donald Trump and former Secretary of Transportation Pete Buttigieg have sparred over the condition of the air traffic control system, which is complex and carries a history of planned upgrades and overhauls that stretches back decades.

Trump has promised since he took office to update the system and, in December, awarded a contract with an initial $12.5 billion payment to Peraton to deliver on the Brand New Air Traffic Control System plan that he announced in May.

A plane flies by he air traffic control tower at Reagan National Airport on Feb. 03, 2025 in Arlington, Virginia days after a midair collision killed 67 people. Photo by Kayla Bartkowski via Getty Images.

As he has touted his plan, Trump has also cast blame on the Biden administration for letting the system deteriorate. For example, the president referred to Buttigieg on Nov. 10, saying, “he spent billions of dollars trying to patch together our air traffic control system, which was a conglomeration of all different systems in all different cities. He spent — they had hundreds of companies working on it and they were spending billions of dollars. And when they turned it on, it didn’t work, it didn’t even work a little bit. That’s why you had a helicopter crashing into an airplane.”

Trump has made some version of this claim multiple times this year.

Buttigieg responded on Nov. 10 that the president’s claim was “false and confusing” and that the Biden administration had begun “a long-term communications fix that is still underway that he is now passing off as his idea.”

Neither one of their claims is quite right.

It’s true that the Trump administration has devoted more funding to upgrading the system than the Biden administration did, but experts also told us that much of Trump’s plan is an extension of a project that began in 2003 and continued under Biden.

We’ll explain what the state of the air traffic control system is and what each administration proposed to do about it.

As for Trump’s suggestion that Biden-era projects were responsible for the midair collision between a U.S. Army helicopter and a passenger plane on Jan. 29, that’s not supported by the National Transportation Safety Board investigation so far. The investigation is still ongoing, but the initial report published on March 7 cited a yearslong problem with helicopters and planes being too close to each other. “Existing separation distances between helicopter traffic operating on Route 4 and aircraft landing on runway 33 are insufficient and pose an intolerable risk to aviation safety by increasing the chances of a midair collision,” the report said.

The U.S. System

The U.S. air traffic control system is comprised of more than 400 towers across the country that shuttle millions of passengers to and from the nation’s airports every day.

“This is an incredibly complex system,” Lance Sherry, director of the Center for Air Transportation Systems Research at the College of Engineering and Computing at George Mason University, told us in a phone interview.

“You can’t turn this off and start over,” he said of updating the system. “You’ve got to change the tires while it’s going 100 miles per hour on the highway.”

The system is a network that broadly involves communications from the ground to aircraft in the sky — which requires each airline to equip planes with compatible technology — and management of air traffic flow. Communications and navigation are done by both radio and satellite-based technology.

“[M]odernization has long been plagued by delays, cost overruns and under-delivery of promised benefits,” John Strong, a professor at the College of William & Mary who serves on the National Academy of Sciences Committee on air traffic control, told us.

He gave an overview of efforts starting in 1984, when IBM led the implementation of the Advanced Automation System, which had originally been proposed to cost $2.5 billion but ended up costing more than twice that when it was restructured and largely cancelled 10 years later without having been completed.

Then, in 2003, the Federal Aviation Administration began what Strong called “[t]he most ambitious recent project” — the Next Generation Air Transportation System, or NextGen. Among its many components was the goal of shifting from radar-based to satellite-based technology by 2025. “This included important applications in approach control to airports (for example, curved merging approaches rather than stacking up in a line in the sky) and moving from towers using paper flight data strips to electronic ones,” Strong said. “The technologies were rolled out to a limited number of airports.”

A September report by the Department of Transportation’s Office of Inspector General said that the FAA had spent about $15 billion by the end of 2024 to deliver “new capabilities and benefits,” but ultimately fell short, concluding that “FAA’s efforts have not delivered the vision of a transformed and modernized air traffic system.”

“So the FAA has a long history of problems that extended from the George W. Bush administration, through Obama, Trump I, and Biden,” Strong said.

But technology, alone, is only one part of the picture, Sherry said. “The way to improve the system is to better manage the flow,” he said.

The flow of air traffic can be managed by changing the number or direction of runways at an airport or by adjusting the flight paths into the airport.

“For sure, you don’t want the sector controller using an old system, but, at the end of the day, that’s not where the bottlenecks are,” Sherry said, the bottlenecks are in the flow.

There are other factors, too, such as staffing shortages. While the number of flights has increased by about 10% over the last decade, the number of air traffic controllers has decreased by about 6%, according to a December report from the Government Accountability Office.

What Trump Has Proposed

As we said, in May, the Trump administration issued a proposal “to build a brand new, state-of-the-art air traffic control system that will be the envy of the world,” according to a press release. The initial contract for that project was awarded in December to Peraton, a security and technology company.

The One Big Beautiful Bill Act that passed in July provided $12.5 billion for the project, which Secretary of Transportation Sean Duffy said is expected to total $31.5 billion and be finished by the end of 2028.

But experts have characterized the plan as more of an extension of NextGen than a completely unique plan to overhaul the air traffic control system.

“FAA will continue to deploy NextGen systems beyond 2025 and other key capabilities beyond 2030,” the GAO said in its September report reviewing its oversight of the NextGen program. “Furthermore, the Secretary of Transportation recently announced a $31.5 billion plan for FAA to build the Brand New Air Traffic Control System, a state-of-the-art system that will replace core infrastructure including automation, communication, surveillance, and facilities. These plans include accelerating deployment of several key NextGen programs to be complete by 2028.”

A list of projects for the initial contract issued by the FAA on Dec. 4 shows technology and hardware upgrades, such as new radios, some updated radar systems, and additional weather-related systems.

“Everything listed there is some equipment located at some facility in the air traffic control system,” Sherry said. “It’s not to say those things aren’t necessary, but it’s a bottom up approach — it looks like a list of things people have wanted.”

The existing equipment has some limitations — some of it is old and unreliable, he said. “So, all of that needs to be upgraded. And that’s what’s been released by the FAA. But it would be nice to take this opportunity to update the principles, not just the technology,” Sherry said.

Strong told us something similar. “What is being promoted now [is] quite a step change and well beyond the incrementalism in recent years. That said, I think it mainly is modernization of facilities and equipment, but not a fundamental rethinking of how the ATC system might operate, how it should be governed, operated, and funded,” he said. “I do think the current Trump admin proposal will be a major improvement – if it can be completed on time and on budget. But both the timeline and past experience makes me withhold judgment at this point.”

The Brand New Air Traffic Control System, or BNACTS, is going to finish off what NextGen never got to do, Sherry said.

For example, as described in the GAO report, the NextGen plan had envisioned installing a tool that would help to more efficiently move planes between gates and runways called a Terminal Flight Data Manager program, or TFDM, at 89 airports. The first one was deployed in 2025, but the plan reduced the total number of airports to 49 and delayed the rollout for those airports to 2030.

“However, as part of the Brand New Air Traffic Control System, FAA now plans to deploy TFDM to all 89 planned sites,” the report said, and, indeed, the TFDM system is included in the BNACTS plan.

“It’s an extension of NextGen,” Sherry concluded of BNACTS.

What Biden/Buttigieg Did

The 2021 Infrastructure Investment and Jobs Act provided $5 billion specifically for air traffic control improvements — $1 billion per year for five years.

Of the funding for air traffic control, $3 billion was spent by the end of fiscal year 2024, Strong said. About a third of that was spent on tower replacements and upgrades, largely in secondary places, such as Grand Junction, Colorado; Missoula, Montana; Wheeling, West Virginia.

“The remaining $1.9b was allocated across updating power and communications systems (such as the one at Newark and Philadelphia which caused all the problems in 2024 and earlier this year), navigation/weather/tracking equipment, tower approach and departure facilities, long range radar and enroute flight centers,” Strong said.

Another $284 million was used to fund a surge in controller hiring to begin to address the shortfall in the number of controllers, Strong said. “This was an important down payment on staffing shortages.”

Katie Thomson, who served as deputy administrator for the FAA during the Biden administration, noted the $5 billion included in the Infrastructure Investment and Jobs Act, too, when we asked her about the competing claims from Trump and Buttigieg.

She also noted a 15-year contract that was given to Verizon in 2023 to provide faster and more secure communications called the FAA Enterprise Network Services Program, or FENS, and the budget proposal for fiscal year 2025 for facility replacement and modernization, or FRRM, that would have spent $9 billion over five years to replace some facilities and modernize radar systems, although Congress didn’t allocate those funds during the Biden administration.

“The current efforts to build a ‘Brand New Air Traffic Control System’ are derivative of the FENS contract and the FRRM proposal – both initiated by the Biden Administration,” Thomson told us in an email.

We reached out to Buttigieg to ask what he was referring to when he said that Trump was “passing off as his idea” a Biden era plan, but we didn’t hear back.

“My assessment is that the failure of [air traffic control] modernization predates the Biden administration,” Strong said. “However, the funding during the Biden administration was mostly carrying on with plans that were inadequate in both scope and funding. The Infrastructure bill provided very little funding for [air traffic control] (in relative terms) and much of it was to deal with immediate problems (staffing, equipment breakdowns, etc.)”

Copper Wire

One of Trump’s frequently repeated claims is about the use of copper wire, as compared to fiber optic cable, for air traffic communications systems.

For example, Trump said while visiting Qatar in May, “They wasted billions of dollars on trying to hook up air systems to copper and they tried to hook up copper to glass.”

The White House didn’t respond to specific questions about several of the president’s claims, but a spokesperson did point to the highly publicized issue at the Newark Liberty International Airport this spring, when there were at least three outages of air traffic communications equipment for up to 90 seconds. Some lawmakers said outages were due to a “fried” copper wire.

“The FAA has multiple communications systems including copper wire and fiber, as well as some wireless,” Strong told us, and those systems are patched into one another.

Sherry considers references to copper wire as a euphemism for old infrastructure, like a landline phone. Part of the NextGen plan was to upgrade air traffic control systems to optical cable, which has better speed, accuracy and reliability, he said.

We asked the FAA how much of the older wire had been replaced across the system, but we didn’t get a response.

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Echoing a longstanding anti-vaccine trope, President Donald Trump falsely claimed that the American vaccine schedule “long required” babies to get “far more” vaccines than are given in “any other” country, and he directed health officials to better “align” practices with those of other countries. The recommended schedule in the U.S. is quite similar to that of other high-income nations, and it isn’t a federal mandate.

Moreover, there are important country-specific differences, such as health care systems, that can explain why vaccine schedules differ around the world. There is no evidence that the existing U.S. vaccine schedule is harmful to children.

Trump’s directive came in a Dec. 5 memo, which told the director of the Centers for Disease Control and Prevention to “review best practices from peer, developed countries” and consider updating the childhood vaccine schedule to “align” it with countries that give fewer vaccinations.

Indeed, multiple news outlets have recently reported that the Department of Health and Human Services is considering changing the U.S. vaccine schedule to match or nearly match that of Denmark, which recommends vaccination against an unusually low number of diseases. Some outlets reported that a canceled Dec. 19 press conference was set to announce this news. (An HHS spokesperson told reporters that the accounts about the topic of the press conference and planned changes were “pure speculation.”)

Explaining the rationale for his directive in a Dec. 5 post on Truth Social, Trump exaggerated the number of vaccines given to American babies.

“The American Childhood Vaccine Schedule long required 72 ‘jabs,’ for perfectly healthy babies, far more than any other Country in the World, and far more than is necessary,” Trump said in the post. In the past, he has incorrectly claimed that babies get “80 different vaccines” all at once.

It is difficult to give a single number for how many shots children receive in the U.S., but babies do not get 72 vaccines. As of early 2025, a child by age 2 was routinely recommended to get around 30 vaccine doses that protected against 15 diseases. Many of the doses are given in combination vaccines, however, so the number of shots given is typically lower. By age 18, the total number of doses could reach into the 70s, but only if including seasonal influenza and COVID-19 vaccines for every year. 

“Getting to an exact number is difficult, given the flexibility in how vaccine doses are administered, but by any measure, any number that reaches the 50s or 60s, let alone 70s, invariably includes annual influenza vaccines and COVID-19 vaccines from birth through age 18,” Jason Schwartz, a professor at the Yale School of Public Health with expertise in vaccine policy, told us.

The CDC recommends, but doesn’t require, vaccines on the schedule, which influences what insurance policies and federal vaccination programs will cover. Vaccine mandates for school or day-care attendance are set by states, and there are exemptions.

Trump’s claim is similar to one made in a Food and Drug Administration presentation given earlier on Dec. 5 during the CDC’s Advisory Committee on Immunization Practices’ meeting. Dr. Tracy Beth Høeg, the new chief of the FDA’s drug division and ex-officio ACIP member for the agency, said that as of early 2025, the U.S. was “really an international outlier in giving 72 doses of vaccines.” She contrasted the total with those of four other countries, including Denmark. Høeg’s counting choices, however, served to inflate U.S. numbers while minimizing those of other nations.

Since June, when HHS Secretary Robert F. Kennedy Jr. dismissed all the committee members and installed new ones, ACIP has departed from its normal evidence-based processes and weakened some vaccine recommendations.

Exaggerations notwithstanding, these claims assume that recommending more vaccines for children is a bad thing. In fact, vaccines were added over time to the U.S schedule through an evidence-based process, with the goal of protecting children against more diseases. And even as the schedule has grown, the total number of antigens — the proteins or sugars in vaccines that stimulate an immune response — remains lower today than a century ago.

“More vaccines is actually a good thing,” Dr. Sean O’Leary, a pediatric infectious diseases specialist at the University of Colorado Anschutz, told us, adding that vaccines on the schedule are studied for safety and effectiveness and “the actual number is not an issue.” O’Leary is chair of the American Academy of Pediatrics Committee on Infectious Diseases. The AAP is a nonprofit membership group representing pediatricians. This year, for the first time in decades, the AAP issued different vaccine recommendations than the CDC.

Comparisons Obscure Schedule Similarities

Høeg and Trump are not alone in giving high estimates of U.S. childhood vaccine totals. This is a common strategy long used by anti-vaccine advocates to imply that the U.S. vaccine schedule has grown at an alarming pace.

It is challenging to come up with a single number of vaccines universally recommended in each country, as children can get protection against the same diseases using different combinations of vaccines. The reality, however, is that countries’ vaccine schedules are fairly similar, which becomes more apparent when looking at the number of diseases targeted.

“The core set of diseases for which vaccines are used is very similar across high income countries,” Dr. Andrew Pollard, a pediatrician and director of the Oxford Vaccine Group at the University of Oxford, told us. “However, there is some variation based on differences in disease burden and the way in which the health system works.” For example, he said, some countries place more emphasis on cost-effectiveness than others.

As of early 2025, the U.S. had universal recommendations targeting 17 diseases in childhood and adolescence, including the 15 targeted in early childhood plus meningococcal and human papillomavirus vaccines recommended at older ages. Again, there is some ambiguity in counting how many diseases a vaccine schedule targets and in deciding which nations are “peer, developed countries.” But looking at data on the 31 nations that are both members of the Organization for Economic Cooperation and Development and classified by the International Monetary Fund as “advanced economies,” 17 is just a few more diseases targeted than the median of 14, according to our analysis. (We did not count infant immunizations with antibody products that protect against respiratory syncytial virus, or RSV, in our totals, as these are not vaccines. Countries vary in whether they have adopted maternal vaccination, infant immunization or — as in the case of the U.S. — flexibility in choosing either.)

In recent months, the U.S. has walked back universal recommendations for hepatitis B and COVID-19 vaccination for children. That brings the current U.S. total down to 15.

Trump’s memo and Høeg’s presentation did include comparisons of the number of diseases targeted by Japan, Denmark, Germany and, in Høeg’s case, the U.K. But they did not place these countries in a larger context of high-income nations.

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“The U.S. has a robust set of vaccine recommendations, and that reflects the priority on using the tools that are available to prevent illness and death, particularly in children, but the differences between the U.S. and peer countries have been overstated,” Schwartz said.

“The real outlier in this conversation appears to be Denmark,” he added.

Denmark is one of just three OECD advanced economy nations to not universally recommend the hepatitis B vaccine. It is also in the minority in not recommending vaccines against rotavirus, meningococcal disease or chickenpox. The U.S., on the other hand, is one of the few high-income nations to recommend vaccination against hepatitis A or to continue recommending universal COVID-19 vaccination until recently.

Seasonal Vaccines Lead to High Dose Counts

There is some truth to the idea that the U.S. vaccine schedule recommends a relatively high number of doses. However, anti-vaccine advocates often justify dramatically high numbers of doses compared with other countries by using misleading methods of counting.

In reality, a person could complete the U.S. childhood and adolescent vaccine schedule as of early 2025 while receiving less than two dozen shots and oral vaccines, not including flu and COVID-19 vaccines.

Høeg acknowledged during her presentation that in arriving at a count of 72 doses, she had counted “the yearly influenza vaccine,” but she omitted context on other countries’ flu vaccine recommendations.

The U.S. does stand out somewhat in having a longstanding universal recommendation for seasonal flu shots, including for children age 6 months and older. The universal childhood flu vaccine recommendations were progressively adopted in the U.S. in the 2000s, expanding to cover kids up through age 18 before the 2008-2009 flu season.

However, the U.S. is not alone in recommending childhood flu vaccination. In Europe, for example, flu vaccination recommendations for children have become more common in recent years, according to a November 2025 report from the European Center for Disease Prevention and Control. During last year’s flu season, six of the 30 European countries analyzed had universal recommendations throughout childhood beginning at 6 months, and another 13 countries had universal recommendations for certain age groups. (The remaining countries — including Denmark and Germany — recommended the vaccines to children with certain risk factors.) In our analysis of OECD countries with advanced economies, 21 out of 31 nations recommended universal flu vaccination for at least some portion of childhood.

In her dose comparisons, Høeg did not highlight vaccine recommendations from any countries that universally recommend these annual vaccines throughout childhood. Examples of these countries include Austria, New Zealand and Canada.

In her dose count for the U.K., which she reported as 17, Høeg appeared to omit annual flu vaccines, which are recommended every year from age 2 until around age 15.

The conclusion that the U.S. vaccine schedule ever included 72 doses also relies on counting yearly COVID-19 vaccines through age 18. But this relies on a counterfactual scenario in which annual shots were recommended for kids over an entire childhood. In the end, the annual doses were universally recommended starting at age 6 months for just over three years.

The U.S. was relatively slow among nations to drop its universal recommendation for COVID-19 vaccination in children. But even before Kennedy reconstituted the CDC’s vaccine advisory committee, the group had been moving toward a risk- and age-based approach to COVID-19 vaccinations. 

This year, the AAP adopted recommendations similar to what the former advisory committee had been considering, urging kids under 2 to get vaccinated but backing away from a universal recommendation for all children. Under Kennedy, the CDC decided to recommend COVID-19 vaccination for all Americans 6 months and older under shared clinical decision-making. This means that people can discuss whether they need the vaccines with health care providers and get coverage for them if desired, but the vaccines are no longer universally advised.

Misleading Combination Vaccine Math

Another way anti-vaccine advocates inflate U.S. dose counts is by individually counting vaccines commonly given as a combination shot. The relative flexibility of the U.S. schedule and the availability of a variety of vaccines allows people to construct theoretical scenarios involving high numbers of doses.

In arriving at her count of 72 vaccine doses in the U.S. schedule, Høeg said on a slide in her ACIP presentation that she had counted vaccines against polio, hepatitis B, Haemophilus influenzae type b (Hib), and diphtheria, tetanus, and pertussis (DTaP) separately. These individual vaccines are available, but most babies get some doses in combination shots, experts told us. 

“It would be highly unusual, if not unheard of, for a child to receive each vaccine separately,” Dr. Michelle Fiscus, a pediatrician and chief medical officer of the Association of Immunization Managers, told us, referring to the combination vaccines.

Meanwhile, countries like Denmark and the U.K. have less flexible schedules that include specific combination shots. In calculating her low totals of 11 and 17 doses in these countries, respectively, Høeg appeared to count combination shots as only single doses, despite not always doing this in the U.S. tally.

She justified this by saying that “part of the difference” between the U.S. and other countries is that the U.S. can give individual vaccines, “whereas Europe tends to give combination vaccines in those circumstances.”

The FDA did not reply to a request for more information on how Høeg calculated her figures.

Decision-Making in Denmark

Trump’s directive to consider emulating vaccine schedules from other nations also glosses over major differences between countries that shape their recommendations. 

Countries are, of course, more likely to recommend vaccinations against diseases if they are common in the area. For example, the U.S. does not vaccinate routinely against “tuberculosis, typhoid, yellow fever, malaria, meningococcal disease (for infants), or dengue, while these are routinely recommended in other countries,” an AAP fact sheet said.

Leopold Nytoft Bergman, 10 years old, receives a vaccination against the coronavirus on Nov. 28, 2021, in Amagar, Denmark. Photo by Olafur Steinar Gestsson/Ritzau Scanpix/AFP via Getty Images.

Other factors include those related to a country’s health system, such as availability of specific vaccines or combination vaccines, the timing of routine health visits and cost-effectiveness analyses, the fact sheet said.

“We’re the most well resourced country in the world, and so sometimes we adopt things earlier, because some other countries are more cost-conscious,” O’Leary said. “But it’s not that they’re concerned about safety issues.”

In some cases, the difference between the U.S. and other countries is not in whether vaccination is recommended at all, but in whether it is recommended universally.

For example, as we have previously written, Denmark takes a risk-based approach to hepatitis B vaccination that relies on testing pregnant women for the disease and tracking at-risk babies. ACIP members cited policies in other countries to justify recently changing the U.S. approach to a risk-based one, despite objections from experts who said that the U.S. had an inferior rate of screening and follow-up.

“What we know, at least in the U.S., is that risk-based approaches don’t work,” O’Leary said. “That’s been shown over and over again.” These risk-based approaches might work better in countries with universal health care systems and electronic health records that track people across their entire course of life, he said.

Høeg did mention cost and other practical considerations as a factor on some slides, but she also held up Denmark’s evidence-based practices as an example while sharing safety concerns about vaccines.

Denmark has a “research culture where they really rely on randomized control trials, extensive documentation about the decision-making, about which vaccines they do and don’t recommend,” she said. But experts rejected the implication that the U.S. recommendations vary from those in Denmark due to differences in transparency and rigor of decision-making.

“Certainly in the U.S., we have decades of evidence of careful deliberation regarding how to use our vaccines optimally, very transparent advisory committee processes that have functioned for decades, the very active vaccine surveillance programs that have existed for decades designed to respond to rare adverse events,” Schwartz said.

“Their decision-making is not any higher quality than ours,” O’Leary said of Denmark. It is only recently, with the appointment of Kennedy and the new ACIP panel, that the vaccine decision-making process has departed from the “normal process that has been built over decades in the U.S.,” he added.

“We consider the vaccines that are used in the US but not in Denmark to be safe and effective,” Anders Hviid, who studies vaccination and epidemiology at the Statens Serum Institut in Denmark, told us in an email. “Every country is different, and every country’s national responsible authorities must make their own decisions based on a careful evaluation of national epidemiology, cost, logistics, ethics etc.”

Vaccine Schedule Does Not ‘Require’ Shots

Trump also was incorrect in claiming that the vaccine schedule “required” 72 shots for “babies.” There are no national vaccine mandates in the U.S., unlike in some other countries, including in Europe, although the U.S. does rely on school vaccine requirements that are set by states.

The vaccine schedule is made up of CDC recommendations on how vaccines should be used at the population level, guided by the recommendations of ACIP. “While the ACIP recommendations are closely watched, they’re influential, they’re important in how we think and talk about vaccines in the United States, nothing ACIP does directly connects to whether a vaccine is required for a particular child,” Schwartz said.

States set vaccine requirements children must meet to attend schools and licensed day care, he said. Discussions about these requirements “often begin with ACIP recommendations as a starting point for whether to consider a particular vaccine requirement, but those decisions by no means derive automatically from ACIP’s action,” he added.

For example, while a few states recommend yearly flu shots for young children in day care, states do not recommend annual flu shots for school-age children, even though these are on the vaccine schedule. No states currently require COVID-19 vaccines in schools.

“The U.S. has certainly featured vaccine requirements more prominently than many of our peer countries,” Schwartz said, referring to the state-level school requirements favored in the U.S. to reach high vaccination rates. But that “has been changing in recent years, precisely because of declining vaccination rates, in western Europe in particular,” he added. 

For example, Germany — highlighted as a peer nation by Trump and Høeg — in 2020 passed the Measles Protection Act, a national measles vaccine requirement for people being cared for in certain communal facilities, such as schools or day care, as well as those working in these and other facilities, such as hospitals. Since 2018, France has required childhood vaccination against a total of 11 diseases, an increase from a previous requirement for just the DTaP vaccine. The law is also enforced by barring children who have not met the requirements from attending schools or other settings where children gather.

One 2024 analysis of vaccination policy in Europe and the U.S. found that 12 out of 32 countries had at least one nationally required vaccine. A 2020 paper analyzing mandatory vaccination policies in Europe found that mandates were associated with a greater rate of people getting vaccinated and a lower rate of measles in countries that adopted them.

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