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Americans Have Been Slow to Get Boosted. What Could It Mean for Future Covid-19 Vaccines?

While the CDC now recommends three shots to protect against Covid-19 — and four for some individuals — people in the U.S. have lagged behind their counterparts in other large, high-income countries in getting boosted.



A CARE Clinic staff member administers a vaccine. (Photo courtesy of CARE clinic)

As Covid-19 becomes endemic, like the seasonal flu, people are likely to need additional vaccines to protect against the virus. But persuading Americans to get them may not be easy.  

People in the U.S. have lagged behind their counterparts in other large, high-income countries in getting boosted. That’s true despite clear evidence that protection from the vaccine wanes after several months—and that a booster dose provides added protection. While 65.9% of Americans are vaccinated against Covid-19, just 45.4% have received a booster shot. During the omicron surge, the United States surpassed other high-income nations in total deaths due to Covid-19. 

Misinformation was a significant reason many Americans didn’t get the initial Covid vaccine. But people passing up boosters have different reasons, according to Rashanna Lynch, the Chief Medical Officer at Ryan Health in New York City: “I think the hesitancy is not because of fear of the vaccine that we saw with the series, because if you’re due for a booster…you’ve already been vaccinated, you are not anti-Covid vaccine.” 

“You promised me two…Why are all these things changing?” 

It’s not necessarily a lack of information preventing people from getting boosted, according to Lynch, but perhaps, too much of it. 

“I think the Covid vaccine has been given the most publicity of any vaccine we’ve had in this country, so every single detail is put out every day and it’s a lot of information that’s constantly changing…It’s a lot of stuff for non-medical people to grasp and understand,” she said. While Ryan Health was “inundated with people wanting vaccines” at the beginning of the rollout, there’s been less demand for booster shots. “People are just confused about all the information that continues to change.” 

At AltaMed in Los Angeles, which serves low-income and uninsured individuals, many of whom are Spanish-speaking, Dr. Illan Shapiro says his patients are experiencing the same confusion. “’You promised me two and right now you’re adding another one and I’m hearing that I need a fourth one. Why is this happening? Why are all these things changing?’” he said he hears regularly from patients. Shapiro tells them that the booster is necessary “to actually remind your body, ‘Hey, wake up you need to produce more’” antibodies. 

Though the public health guidance is changing in response to changes in the virus, “we are all tired,” said Shapiro, “and every time they change a rule or add another rule, it’s actually very hard to accommodate.”  

Particularly for his patients. “Our community works day-to-day. They have two or three jobs. They do everything in public transportation…Every time we add another visit to a doctor or another visit to get a vaccine, they need to ask permission [from] their work, they need to make sure that they’re taking care of their kids, they need to make sure they have transportation.”  

AltaMed has been holding pop-up vaccine clinics at churches, schools, and other community spaces, in addition to providing the shots to patients at their routine visits. “We need to make sure we are creating opportunities…for our patients to be comfortable with us. To meet them where they are,” Shapiro said. 

For patients who want to make an appointment, AltaMed has patient navigators who speak Spanish and can help patients sign up online at their local pharmacy or help them book a visit at one of their clinics. Because of the increased vaccine supply, the clinic has more flexibility in when and how many patients they can administer the shot to in one day. Unlike at the beginning of the vaccine rollout, patients no longer face prolonged wait times for an appointment. 

“If you’re not there, there’s no paycheck” 

Despite the wide availability of vaccines, some patients still can’t manage to take time off work or spare a sick day, should they have side effects.  

Though some workplaces offer paid sick leave—California passed a bill mandating certain employers provide 40 hours of supplemental sick leave for Covid-19-related illness and vaccine appointments—many of Shapiro’s patients work jobs where “if you’re not there, there’s no paycheck.” They are farmworkers, servers, cooks, day laborers—jobs with few employee protections. Shapiro generally tells his patients that losing one day of work is tough, but it’s better than losing five to 10 days to a bout of Covid-19. 

According to Katie Irwin at Healing Hands Ministries in Dallas, Texas, work hasn’t necessarily prevented her patients from getting boosted. However, unlike with the first series, it hasn’t been a motivating force: “My sense is that there are a lot of people that got the vaccine because it was required. They wanted to keep their job and it wasn’t enough of a conflict for them to say, ‘It’s so important to me not to get it, that I’m going to quit my job.’”  

But now, since most workplaces don’t require their employees to get boosted, there’s less motivation to go in for another jab. “I just don’t think there was a compelling reason” for people to get boosted, said Irwin. “They just didn’t think it was that big of a deal.” 

“’I get it. There’re no microchips…I just want to wait.’” 

At AltaMed, Shapiro says his patients have expressed a similar lack of urgency. They tell him, “’I understand what you’re saying. I get it. There’re no microchips. It’s OK. We need it, but I just want to wait.’” But Shapiro is concerned, because immunity doesn’t kick in until two weeks after the shot, which means that every day patients wait, they’re leaving more time for the virus to spread. 

The reason people want to wait often comes back to mistrust, a theme that’s haunted public health officials since the beginning of the pandemic. “There’s a lot of just fear,” Shapiro said. That fear is concerning: “Covid is real and the fewer vaccinated people we have, the more people get sick.” 

This lack of trust could be a problem when and if additional vaccines are required to protect against Covid-19, which like all viruses, continues to mutate.  

To reduce hesitancy, Shapiro is working to inform his patients so they know when and why they need additional doses. “If the virus changes and the vaccines don’t work, yes, we need another one. If our body stops creating antibodies, yes, we need to have another one. If we are starting to see more cases, we need another one. If we are starting to see more complications or a higher mortality rate, yes, we need another one.” 

Though there are likely to be a “wave of questions” the next time a Covid vaccine is recommended, “I think it will be way easier next season,” said Shapiro. 

“It will probably be comparable with influenza…it will be part of the system.” 

Since the start of the pandemic, Direct Relief has shipped more than $3 billion in medical aid to 111 countries, including the U.S., and issued more than $130 million in funding to support the world’s health systems.

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