As more hospitals nationally go to universal masking for patient care, we see the other side of an incoming problem: Only 19% of adults older than 18 years of age have received the latest vaccine against SARS-CoV-2, according to the Centers for Disease Control and Prevention (CDC).
“Not enough Americans are vaccinated,” the CDC reported.1 “As of Dec. 30, 2023, only 8% of children report having received the updated COVID-19 vaccine. Only 38% of adults age 65 years and older report having received this vaccine, which is concerning given that they are at higher risk of hospitalization from COVID-19.”
The CDC’s Advisory Committee on Immunization Practices recommends that everyone aged 6 months or older stay up to date with recommended COVID-19 vaccination. Widespread vaccine apathy in the face of resurgent COVID-19 and other respiratory pathogens is frustrating for infection preventionists and healthcare epidemiologists. Disinformation driven by an anti-vaccine movement that coalesced during the pandemic is seen as the primary driver.
“We can’t give up, but it’s a big problem,” says Pat Jackson, RN, MA, CIC, FAPIC, immediate past president of the Association for Professionals in Infection Control and Epidemiology (APIC).
“It is something we are talking about in orientation with our new APIC board members. How can we combat misinformation?” she says. “The anti-vaccine movement is very purposeful and strong. It is not just happenstance that people grab hold of some comments on social media. This is a movement that is well planned.”
Universal Masking
As this report was filed, hospitals in at least 15 states had reinstated universal masking policies for healthcare workers and incoming patients. Universal masking had been dropped at many facilities as the pandemic subsided and the CDC relaxed recommendations in 2022.
“It is something that should be considered based on what is happening in your community and your hospital, but I think we saw that universal masking was helpful during COVID,” Jackson says. “The downside of universal masking is that you don’t get enough interaction with the patient; they can’t see your face and it’s hard for the hearing impaired. But I think — based on what is happening in your area — it may be a wise decision in the winter months when we see all kinds of respiratory pathogens.”
With the end of the pandemic public health emergency declared May 11, 2023, many surveillance systems that could help determine local and community transmission have been discontinued.
In the absence of these data, look for upticks in healthcare-associated infections and respiratory illness in healthcare workers as a threshold for implementing universal masking, she recommended.
“[Universal masking] is very helpful if you are having issues within your hospital,” says Jackson, director of infection prevention at White Rock Medical Center in Dallas. “I think a lot of hospitals are either seeing that or they want to prevent that.”
The spike in COVID-19 infections is being driven by the emergence of the Omicron subvariant JN.1, which has become predominant and represented 62% of genomic testing as of Jan. 5, 2024.2 The current vaccine targets immunity to the Omicron subvariant XBB.1.5. Although the pandemic virus continues to mutate, the current monovalent vaccine still is protective — particularly for severe outcomes — against JN.1 and other COVID-19 subvariants.3
“COVID-19 hospitalizations increased 20.4% the week ending Dec. 30, 2023,” the CDC reported. “In that same period, deaths went up by 12.5%, with COVID-19 deaths accounting for 3.6% of total deaths in the United States.”
Still, COVID-19 infections now are causing severe disease less frequently than earlier in the pandemic. An informative detail is that wastewater surveillance, which captures both symptomatic and asymptomatic COVID-19 infections, shows a 27% increase over the same period last year.
“This change in the relationship between infection levels and illness severity is related to greater immune protection levels provided by vaccines, prior infection, or both,” the CDC explained.
Estimating that 97% of the population have natural or vaccine-induced antibodies against SARS-CoV-2, the CDC noted that “this immune protection can fade over time but tends to last longer for preventing severe disease than for preventing infections.”
JN.1 has mutations in the spike protein that make it more transmissible or immune-evasive, but there is no sign yet that it causes more serious illness than previous variants. Regardless, a rapidly spreading variant like JN.1 — the most prevalent variant worldwide — has an extended reach into populations at risk for serious outcomes.
Even mild infections can be transmitted to vulnerable patients, and there remains the threat of post-infection events, such as long COVID and a rare but serious complication in children: multisystem inflammatory syndrome in children (MIS-C).
“[MIS-C] usually occurs two to six weeks after a child is infected with SARS-CoV-2,” the CDC reports.4 “The child’s SARS-CoV-2 infection may be very mild or have no symptoms at all and may go unrecognized. The best way to prevent MIS-C is to protect against getting SARS-CoV-2 infection, including staying up to date with COVID-19 vaccines and other prevention actions.”
Vaccine Recommendation Scripts for Providers
Unless medically contraindicated, healthcare providers should offer influenza, COVID-19, and respiratory syncytial virus (RSV) immunizations to patients, the CDC recommended in a Dec. 14, 2023, health alert.5
The CDC provided examples of scripted messages healthcare providers can use depending on the reason patients give for remaining unvaccinated. For example, the CDC urged an empathetic but no-nonsense response when patients who are not otherwise contraindicated say, “I didn’t know vaccination was recommended for me.”
“Make a strong recommendation, like ‘You are due for your flu and COVID-19 vaccines today. I’ve gotten these vaccines myself and recommend them for you, too,’” the CDC states in the health alert.
Regarding those who cite vaccine safety concerns, the CDC recommends giving patients accurate and up-to-date information about vaccine benefits and safety.
An example given as a scripted message is: “Flu, COVID-19, and RSV vaccinations are safe and are the most effective way to keep your family healthy this fall and winter respiratory season. Side effects tend to be mild and temporary; serious adverse events are rare. For example, you may experience a sore arm or low-grade fever.”6
Prevention Paradox
Another issue that complicates vaccination uptake is a bit of a paradox. As effective vaccines drive viruses such as measles to near eradication, people become complacent and start skipping the immunizations necessary to maintain this herd immunity.
“Vaccines are one of the greatest discoveries of our lifetimes, but they are a victim of their own success [and face] a powerful anti-vaccine lobby with politicians behind it,” Jackson said. “It is an issue that is of great concern to APIC because we know that vaccines are [critical] to combat infectious diseases. With COVID, we know that people who are vaccinated are less likely to have really severe illness.”
This protective effect extends to long COVID, the protracted misery of a broad panoply of symptoms that can linger indefinitely after initial infection. This could be become a persuasive point for vaccination, since there is emerging evidence that the risk of long COVID is diminished considerably for those immunized before initial infection. (See “Vaccination Can Prevent or Lessen Long COVID.”)
But while science advances it remains under attack. A combination of disinformation and pandemic fatigue has people dodging and questioning other vaccines. Moreover, this is not an aberration that inevitably will revert to some semblance of normality. Indeed, the public acceptance of vaccines may become a longstanding problem, said William Schaffner, MD, a professor of preventive medicine at Vanderbilt University.
“The result is not a foregone conclusion,” he says. “We are going to have to work on this within our own healthcare community as well as in the [public] to restore trust in vaccination. We need to convince people that vaccination is not only in their personal best interest, but in the best interest of everyone around them. These are, after all, communicable diseases. I think we have some difficult years ahead because of this vaccine fatigue, COVID fatigue — as well as this political overlay that has now become very prominent regarding vaccinations. We can hope for the best, but that is not going to do it. We are going to have to really work on this at the grassroots level.”
Refusing COVID-19 vaccination during the pandemic became a kind of perverse badge of courage, with tens of thousands dying needlessly because they were manipulated and convinced that vaccines were the real problem. (See Hospital Infection Control & Prevention, August 2023.)
Michael Osterholm, PhD, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, spoke to this issue in a recent podcast.
“We live in a world today where alternative facts are common,” he said.7 “The authority figures and those who were trusted in the past to provide us with information that could help save our family members from serious illness, hospitalizations, and deaths are not appreciated or respected. In all my 50 years in public health I’ve never, ever experienced anything like this. What has been well understood, well appreciated — time-honored vaccine programs that have saved so many lives — are now being challenged as somehow being the work of the devil.”
Healthcare Workers
Even healthcare workers can fall under the sway. There are some lagging indicator data that show that many healthcare workers are reluctant to stay current on COVID-19 vaccinations. While vaccination requirements for healthcare workers vary by facility, health municipality, and state law, CDC data from the 2022-2023 flu season are not particularly encouraging.
“Up-to-date COVID-19 vaccination coverage was 17.2% among healthcare personnel (HCP) working at acute care hospitals and 22.8% among those working at nursing homes,” the CDC reported.8 “Influenza vaccination coverage was 81% among HCP at acute care hospitals and 47.1% among those working at nursing homes.”5
This CDC analysis describes influenza and up-to-date COVID-19 vaccination coverage among healthcare workers working in acute care hospitals and nursing homes during the 2022-2023 influenza season (Oct. 1, 2022-March 31, 2023). Healthcare facilities report vaccination of employees for influenza and COVID-19 to the CDC’s National Healthcare Safety Network (NHSN).
“During the 2022-2023 influenza season, fewer than one-quarter of HCP working in acute care hospitals and nursing homes were up to date with recommended COVID-19 vaccination, and fewer than one-half of HCP working in nursing homes had received influenza vaccine,” the CDC reported.
There clearly was a pandemic effect. During the 2017-2018 and 2018-2019 flu seasons, vaccination coverage among HCP in acute care hospitals was 88.6% and 90%, respectively.
“The current findings suggest that factors associated with low vaccination coverage might have been exacerbated by the COVID-19 pandemic and compounded by emerging concerns such as vaccine fatigue and other as yet unidentified factors,” the CDC reported.
Many hospital systems dropped COVID-19 mandates for healthcare workers when the Public Health Emergency was lifted on May 8, 2023. The Centers for Medicare and Medicaid Services announced it would not enforce its SARS-CoV-2 immunization requirement for healthcare workers June 5, 2023, until Aug. 4, 2023. They officially rescinded the mandate on Aug. 5, 2023. APIC and other infectious disease groups have called for facilities to continue to mandate flu and COVID-19 vaccines for healthcare workers, warning that some states are moving to ban such policies.
“A number of state legislatures, my own included, have passed laws that prohibit mandates,” Schaffner said. “Although influenza vaccine mandates may still be in place, the previous COVID mandates have been rescinded in many jurisdictions. Of course, this reflects the unfortunate political swirl that still surrounds COVID vaccination.”
FDA Reiterates Vaccine Safety
In the latest example of this politicalization, Joseph Ladapo, MD, PhD, surgeon general of Florida, called for a halt to messenger ribonucleic acid (mRNA) vaccinations for COVID-19 because of the possibility that residual deoxyribonucleic acid (DNA) fragments could adversely affect recipients.
“DNA integration poses a unique and elevated risk to human health and to the integrity of the human genome, including the risk that DNA integrated into sperm or egg gametes could be passed onto offspring of mRNA COVID-19 vaccine recipients,” Lapado said in a statement.9 “If the risks of DNA integration have not been assessed for mRNA COVID-19 vaccines, these vaccines are not appropriate for use in human beings.”
Ladapo previously had outlined this concern in communication to the Food and Drug Administration (FDA), which reemphasized vaccine safety and dismissed the DNA issue in a letter to the surgeon general. “We would like to make clear that, based on a thorough assessment of the entire manufacturing process, FDA is confident in the quality, safety, and effectiveness of the COVID-19 vaccines,” the FDA stated.10 “The agency’s benefit-risk assessment and ongoing safety surveillance demonstrate that the benefits of their use outweigh their risks. Additionally, with over a billion doses of the mRNA vaccines administered, no safety concerns related to residual DNA have been identified.”
The FDA underscored the severity of such claims in reemphasizing its oversight role in ensuring vaccine safety in the United States.
“The challenge we continue to face is the ongoing proliferation of misinformation and disinformation about these vaccines, which results in vaccine hesitancy that lowers vaccine uptake,” the FDA stated. “Given the dramatic reduction in the risk of death, hospitalization, and serious illness afforded by the vaccines, lower uptake is contributing to the continued death and serious illness toll of COVID-19.”
REFERENCES
- Centers for Disease Control and Prevention. COVID-19 activity increases as prevalence of JN.1 variant continues to rise. Published Jan. 5, 2024. https://www.cdc.gov/respiratory-viruses/whats-new/JN.1-update-2024-01-05.html#
- Centers for Disease Control and Prevention. COVID Data Tracker. Updated Dec. 30, 2023. https://covid.cdc.gov/covid-data-tracker/#datatracker-home
- Tartof SY, Slezak JM, Frankland TB, et al. BNT162b2 XBB1.5-adapted vaccine and COVID-19 hospital admissions and ambulatory visits in US adults. medRxiv 2023; doi: https://doi.org/10.1101/2023.12.24.23300512. [Preprint].
- Centers for Disease Control and Prevention. For parents: Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Last reviewed Jan. 3, 2023. https://www.cdc.gov/mis/mis-c.html#
- Centers for Disease Control and Prevention. Urgent need to increase immunization coverage for influenza, COVID-19, and RSV and use of authorized/approved therapeutics in the setting of increased respiratory disease activity during the 2023-2024 winter season. CDC Health Alert Network. Published Dec. 14, 2023. https://emergency.cdc.gov/han/2023/han00503.asp#
- Centers for Disease Control and Prevention. Conversation guide for healthcare providers: Talking with patients about how to protect against fall and winter respiratory viruses. https://www.cdc.gov/respiratory-viruses/tools-resources/downloads/HCP-conversation-guide-508.pdf
- Center for Infectious Disease Research & Policy. Osterholm Update, Episode 147: JN.1, hospital capacity, & vaccine uptake. Published Dec. 28, 2023. https://www.cidrap.umn.edu/covid-19/episode-147-jn1-hospital-capacity-vaccine-uptake
- Bell J, Meng L, Barbre K, et al. Influenza and up-to-date COVID-19 vaccination coverage among health care personnel — National Healthcare Safety Network, United States, 2022-23 influenza season. MMWR Morb Mortal Wkly Rep 2023;72:1237-1243.
- Florida Department of Health. Florida state surgeon general calls for halt in the use of COVID-19 mRNA vaccines. Published Jan. 3, 2024. https://www.floridahealth.gov/newsroom/2024/01/20240103-halt-use-covid19-mrna-vaccines.pr.html
- U.S. Food and Drug Administration. Response to Joseph A. Ladapo, MD, PhD. Published Dec. 14, 2023. https://www.fda.gov/media/174875/download
As more hospitals nationally go to universal masking for patient care, we see the other side of an incoming problem: Only 19% of adults older than 18 years of age have received the latest vaccine against SARS-CoV-2, according to the Centers for Disease Control and Prevention.
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