A vaccination malaise that has beset much of the public appears to have extended to healthcare workers as well. In addition to citing an abysmal COVID-19 vaccination rate of 17% for healthcare workers during the 2022-2023 flu season, the Centers for Disease Control and Prevention (CDC) pointed to a “lack of provider recommendation” as one of four key reasons patients are skipping immunizations, with the others being concerns about serious side effects, the occurrence of minor side effects, and a lack of time or forgetfulness.
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.1
“Immunizations can prevent hospitalization and death associated with these respiratory diseases,” the CDC emphasized. “Immunizations are especially important for people at increased risk for severe disease, including infants, older adults, pregnant [women], and people with certain underlying medical conditions.”
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 recommended in the health alert.
To those who cite vaccine avoidance due to safety concerns, the CDC recommended 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.”2
Rejecting the Science
Avoiding immunizations is not a new phenomenon, but it is particularly tragic in a respiratory season marked by a triumph of science: the availability of three vaccines against a trio of viruses that cause immense suffering and death annually.
“In the past four weeks, hospitalizations among all age groups increased by 200% for influenza, 51% for COVID-19, and 60% for RSV,” the CDC reported.
The link to the unvaccinated appears direct, as uptake of all three vaccines is low. “Vaccination coverage for the seasonal 2023-2024 influenza vaccine is low in all age groups compared with the same period of the 2022-2023 season,” the CDC stated.
As of Dec. 2, 2023, only 16% of those aged 60 years or older reported receiving an RSV vaccine. Although it also is a threat to pediatric patients, RSV carries a significant risk of mortality in the elderly. Vaccination coverage for the updated 2023-2024 COVID-19 vaccine remains low.
“As of Dec. 2, 2023, the percent of the population reporting receipt of this vaccine was 7.7% in children six months to 17 years (including 2.8% in children six months to four years), 17.2% in adults ≥18 years (including 36% in adults ≥65 years), and 9.6% in pregnant [women],” the CDC reported.
In addition, multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection is on the rise. “COVID-19 vaccination can reduce the chance of MIS-C and post-COVID conditions,” the CDC advised. The U.S. Census Bureau estimated that 9.5% of the 134 million adults who have been infected with SARS-CoV-2 were experiencing long COVID symptoms in October 2023.3
With COVID-19 vaccines recommended for several years now, it is hard to ascribe patients avoiding immunization to a lack of provider urgency and messaging. With the SARS-CoV-2 shots targeted early and often for disinformation, we now see low uptake on other recommended vaccines due to this strange mix of political dogma, apathy, and fear.
Beyond the immediate concerns, there has been some kind of paradigm shift where vaccines are viewed by too many as more dangerous than the evils they prevent. Yet vaccines have probably saved more lives than antibiotics, which few would refuse to take for a bacterial infection. 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.
Michael Osterholm, PhD, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, spoke about this issue in a recent podcast.4
“We live in a world today where alternative facts are common,” Osterholm said. “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.”
While vaccination requirements for healthcare workers vary by facility, health municipality, and state law, CDC data from the 2022-2023 flu season are not encouraging.
This CDC analysis describes influenza and up-to-date COVID-19 vaccination coverage among healthcare personnel (HCP) working in acute care hospitals and nursing homes during the 2022-2023 influenza season (Oct. 1, 2022 to March 31, 2023). Healthcare facilities report vaccination of HCP against influenza and COVID-19 to CDC’s National Healthcare Safety Network (NHSN).
“Influenza vaccination coverage was 81% among HCP at acute care hospitals and 47.1% among those working at nursing homes,” the CDC reported.5 “Up-to-date COVID-19 vaccination coverage was 17.2% among HCP working at acute care hospitals and 22.8% among those working at nursing homes.”
For the record, the CDC’s Advisory Committee on Immunization Practices recommends that healthcare workers receive an annual influenza vaccine and that everyone aged 6 months or older stay up to date with recommended COVID-19 vaccination. The CDC estimates that 21,000 people died of influenza and 640,000 were hospitalized during the 2022-2023 flu season.6 A lot of SARS-CoV-2 surveillance systems have shut down, but the pandemic virus remains simmering and has begun an uptick apparently driven by the new predominant omicron subvariant, JN.1. As of Dec. 23, 2023, the CDC reported a 17% increase in hospitalizations and a 10% increase in deaths from the prior week.7
“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 the recommended COVID-19 vaccination, and fewer than one-half of HCP working in nursing homes had received influenza vaccine,” the CDC reported.
There was a pandemic effect, as 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.
COVID-19 is not gone, and it is not seasonal, Osterholm said, citing increasing cases in the summer months for New Zealand. Anecdotally, some hospitals have returned to universal masking for patient-facing healthcare workers.
Few would argue that a return to widespread public masking is a non-starter, and some healthcare facilities could struggle to return to personal protective equipment (PPE) policies that were relaxed last year.
“Healthcare facilities have relaxed masking requirements to align with individual risk assessment,” Osterholm said. “I imagine hospitals and nursing homes will struggle to implement new mandates if they attempt to. This is a stark reality of our current situation: weak recommendations and severe pandemic burnout [are] happening at the same time.”
Moreover, this is not an aberration that will inevitably revert to some semblance of normality. Indeed, the acceptance of vaccines may become a longstanding problem, says William Schaffner, MD, a professor of preventive medicine at Vanderbilt University.
“The result is not a foregone conclusion,” Schaffner notes. “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.”
REFERENCES
- 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. Dec. 14, 2023.
- Centers for Disease Control and Prevention. Conversation guide for healthcare providers: Talking with patients about how to protect against fall and winter respiratory viruses. Dec. 14, 2022.
- Centers for Disease Control and Prevention National Center for Health Statistics. Long COVID Household Pulse Survey, 2022-2023. Last reviewed Nov. 8, 2023.
- Center for Infectious Disease Research and Policy. Osterholm update, Episode 147: JN.1, hospital capacity, and vaccine uptake. Dec. 28, 2023.
- 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.
- Centers for Disease Control and Prevention. Preliminary estimated influenza illnesses, medical visits, hospitalizations, and deaths in the United States — 2022–2023 influenza season. Last reviewed Nov. 22, 2023.
- Centers for Disease Control and Prevention. COVID Data Tracker. Posted Jan. 8, 2024.
A vaccination malaise that has beset much of the public appears to have extended to healthcare workers as well. In addition to citing an abysmal COVID-19 vaccination rate of 17% for healthcare workers during the 2022-2023 flu season, the Centers for Disease Control and Prevention pointed to a “lack of provider recommendation” as one of four key reasons patients are skipping immunizations, with the others being concerns about serious side effects, the occurrence of minor side effects, and a lack of time or forgetfulness.
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