As respiratory virus season draws near, no federal health official has signed off on recommendations for this year's updated COVID-19 vaccines, leaving the federal vaccination schedule without an update and access to the shots in limbo for some low-income children. According to reporting by Stat news earlier this week, two immunization program experts—who spoke on the condition of anonymity to avoid reprisal from the Trump administration—said that because there is no sign-off, states are not yet able to order COVID-19 shots for children who receive vaccines through the Vaccines for Children (VFC) program. The federal program provides vaccines to children who are Medicaid-eligible and under- or uninsured, which includes around half of all children in the US. Typically, federal vaccination recommendations come about after a panel of expert advisors for the Centers for Disease Control and Prevention—the Advisory Committee on Immunization Practices (ACIP)—publicly reviews vaccine data and votes on recommendations for use. Then, the CDC director decides whether to adopt those recommendations. While directors don't always adopt ACIP's recommendations, they usually do—and often on the same day as the ACIP vote. After that, the recommendation becomes part of federal vaccine guidance, and insurance companies and federal programs are required to cover the recommended shots. Of course, the CDC is currently without a director to sign off on ACIP recommendations. Health and Human Services Secretary and anti-vaccine activist Robert F. Kennedy Jr dramatically ousted Susan Monarez from the role just weeks after her Senate confirmation. In testimony to the Senate afterward, Monarez said she was fired because she refused Kennedy's directive to blindly adopt vaccine recommendations. Without a director, the sign-off would fall to either Kennedy or the current acting director, Jim O’Neill, who is Kennedy's deputy health secretary. But, so far, nearly two weeks after an ACIP vote, there has still been no sign-off, or a determination. Surprise, delay The current ACIP—composed of vaccine skeptics hand-selected by Kennedy—made their recommendation September 19 after a chaotic meeting. In a surprise to health experts who feared more restricted access, Kennedy's ACIP unanimously voted for a COVID-19 vaccine recommendation that is more permissive than restrictions added by Kennedy's Food and Drug Administration.