The Covid-19 vaccines were hailed as a miracle upon their arrival. They were delivered earlier than anyone thought possible and proved to be extremely effective in preventing hospitalizations and deaths. More than 80 percent of all Americans, and more than 90 percent of adults, have received at least one dose of the vaccine, a remarkable breakthrough in a country where less than half of people get a flu shot each year.
But so far this year, only 7 percent of adults have received a dose of the new formulation of the vaccine that became available in September, compared with 28 percent who have gotten the flu shot.
This raises a question that would have seemed unthinkable three years ago: What if we create a miracle vaccine and no one wants it?
Ever since that first injection, public interest in subsequent Covid-19 vaccines has steadily declined. Less than 70 percent of the US has completed their initial two-dose series of vaccines. Less than 20 percent of the country received the bivalent booster vaccine last year.
Experts say the public’s lack of interest in the latest Covid footage is likely a combination of poor messaging from the authorities, waning fear of a virus that was completely unknown three years ago, and the political polarization of the pandemic itself. But whatever the reasons, that vaccine ambivalence remains a health threat.
Older people and very young babies are still more likely than the rest of the population to be hospitalized with Covid-19. Vaccination rates fell for the former group, who were also the most likely to die of infection, and for the latter they were never strong; 95 percent of children under the age of 4 are unvaccinated. About half of the elderly hospitalized for Covid-19 these days have never received the vaccine, experts say, confirming that the unvaccinated are still much more severely affected by the virus.
Infectious disease experts saw 2023 as a key year for the country’s recovery from the pandemic. It would test whether the US health care system can mount a robust response to the winter cold and flu season, particularly through a successful vaccination campaign. The dismal start to that campaign could pose a tough question to the public health community: If Americans no longer care about getting vaccinated against Covid-19, what do we do now?
Why Americans Aren’t Getting Vaccines Against Covid-19
Part of the story is simply human nature. Covid-19 arrived in 2020 behaving strangely (with so much asymptomatic transmission) and causing deadly casualties (the first iteration of the virus was significantly more virulent than the flu). Much of the economy was shut down and people were confined to their homes. It was a scary time and vaccines offered hope for a future where you would not only be less likely to get seriously ill, but life could return to normal. When the vaccines went to hospitals, pharmacies and vaccination clinics in December 2020, Americans were eager to get them.
But three years and multiple new vaccine formulations later, the novelty has worn off.
Americans are not so worried about Covid-19 now. About two-thirds of American adults said they are not worried about getting seriously ill from Covid-19 in a September poll by the health policy think tank KFF. That figure was about the same for flu and RSV, suggesting that Americans have come to view the new coronavirus as a similar health risk to other cold-weather illnesses that have been circulating for a long time.
People are no longer afraid of this virus, Paul Offitt, director of the Center for Vaccine Education at the Children’s Hospital of Philadelphia, told me.
As evidence, he recounted riding the subway with 100 screaming football fans without masks headed to the Eagles-Cowboys game. No one in that subway car was wearing a mask, he said. We are close to winter, and this is in theory a winter virus.
Knowledge is one part of that change in attitudes. Another is political polarization: Republicans, both rank and file and their political leaders, are increasingly hostile to Covid-19 vaccines, with a general skepticism of government mandates spilling over into conspiracy theories and disinformation. (Offit marveled at that turn of events: These vaccines are the most amazing medical and scientific achievement of his life and the Trump administration’s greatest achievement. And yet.)
Only 25 percent of Republicans said in a September KFF poll that they would get the latest version of the Covid-19 vaccine this fall or winter. Another 40 percent of the party said they had received an earlier dose but would not get the new vaccine, and 36 percent said they had not been vaccinated at all. By comparison, 45 percent of independents said they would get another chance, and 69 percent of Democrats said they would. While the reality doesn’t exactly match those answers, the gap between Republicans and others shows that partisanship drives attitudes about vaccines.
It’s become part of one’s identity that they’re not someone who specifically gets Covid vaccines, said Dr. Klein Gounder, a senior fellow at KFF and editor-in-chief for public health at KFF Health News. That can spill over to vaccines, but it starts with Covid.
There are troubling signs of a general resurgence of vaccine skepticism: 3 percent of American schoolchildren reported being vaccine exempt for the upcoming school year, the highest proportion on record, according to the CDC. Ten states have exemption rates above 5 percent; just two three years ago.
But while that increase is worrisome, it’s clear, as Gaunder noted, that Covid is a special case for Americans. Last season’s flu vaccination rates were in line with pre-pandemic rates: lower than you’d like (57 percent for children, 46 percent for adults), but historically unremarkable. Flu vaccinations this year are in line with last year’s pace, according to the CDC.
People had already become accustomed to the annual flu vaccination campaign before the pandemic, and they seem to be sticking to old habits for the most part. So why do so many seem so immune to the public health community’s plea to simultaneously vaccinate against Covid-19?
Another factor may be that Americans are accustomed to such public health messages after years of living in public health emergencies.
In part, vaccines are a victim of their own success. Initial clinical trials reported incredible results not only in stopping severe disease (a primary public health goal), but in stopping any disease. Crazy headlines may have led the public to expect never to get sick, and public health messages have failed to break through with a reality check that even though you still feel sick, you’re much less likely to end up in hospital and should be counted as a victory. When reality did not meet expectations, the seeds of doubt and mistrust were sown.
For later recordings, Gounder said the public health message itself, which generally encourages everyone to get another Covid-19 vaccine, may be part of the problem. People are now more familiar with the virus and that means many have a general idea of how it works. They may know, for example, that age and chronic health conditions are the best predictors of risk of serious illness or death from infection.
Other countries, such as the United Kingdom, have targeted their recommendations at people over 65 and people at increased risk because of their health, as well as people who live with and care for those at-risk people.
Instead, the United States has so far erred on the side of simplicity with its vaccine messaging and recommendations: Another vaccine is recommended for everyone over 6 months of age. Experts admit there is an argument for that strategy. But as Covid-19 has become a more well-known disease and people understand it better, there may be a better case for a more nuanced approach.
At this point, people are likely to have survived their own infection and have first-hand experience with Covid-19. The initial vaccination campaign was crucial because people had no immunity to Covid-19 in the first place; the population was naive. But the reality of public health has changed three years later: most people are either vaccinated or infected or both.
So when official vaccine guidelines remain largely unchanged, and messages sent by public health authorities do not acknowledge the various risks or that people possess certain immunity, they may end up being ignored.
I understand some of the skepticism, Gounder said. When you tell everyone you’re in danger, try it, it doesn’t match your reality.
What the future may hold for Covid-19 vaccines
There are short-term steps the US could take to boost uptake of the Covid-19 vaccine, especially for the most vulnerable. Additional funding for nursing homes to maintain vaccination campaigns, for example: Only 17 percent of nursing home residents are up to date on their vaccines. Experts also stressed the importance of communicating to people that the very young can become seriously ill with Covid-19; even if they don’t die, health complications can be serious. Gounder said they would like to see the messaging begin with a greater focus on pregnant women, who can pass on some immunity to their unborn child.
But a bigger question arises when only 10 percent of the American population shows great urgency about getting a Covid-19 vaccine: How are we going to keep doing it?
Pfizer said in September that it expects one in four Americans to receive the latest injection. Although there is still time, current vaccination rates are far from that goal. It is an open question how the for-profit pharmaceutical manufacturers who make these vaccines will respond to what the market is telling them.
Gounder said it’s hard to imagine completely stopping Covid-19 vaccinations. Public health support for immunizing the elderly is strong. But drugmakers may scale back their production, especially if government recommendations become more targeted.
The federal government is pouring a lot of money into pharmaceuticals’ quest for a universal Covid vaccine, but until those efforts bear fruit (if they ever do), there may be less interest in producing new vaccine formulations after the download for this new season’s shot was so weak
The known unknowns for the future, which could spur another round of investment and interest in updated Covid-19 vaccines, are biological. The virus has evolved and will continue to evolve and could, in theory, reach a point where current vaccines are ineffective.
The second question mark is within us. The reason many people still enjoy protection from serious illness is that our body’s T-cells are familiar with the virus and can activate when they detect it. They may not be able to stop the infection completely (that’s the role of antibodies, which disappear more quickly), but they can suppress the virus before a person gets too sick.
What we don’t know today is how long the memory of our T cells will last and how durable that immunity really is. The only way to find out is to let more time pass.
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