Enhance COVID-19 vaccine uptake through trust-building, addressing misinformation, and promoting coadministration with flu shots. Read full strategies.
COVID-19 remains the leading respiratory infectious disease responsible for hospitalizations and deaths regardless of age or comorbid status.[1,2] During the spring and summer months, COVID activity has been consistently high to very high based on the National Wastewater Surveillance System (NWSS).[3] In the summer of 2024, there were tens of thousands hospitalizations, and between 400-700 Americans died per week from COVID-19.[4,5] We are entering the fall and winter period where COVID and other respiratory illnesses peak.[6] Last season, there were more than 45,000 deaths due to COVID-19.[5]
There is also the risk of developing long COVID, even among young, healthy adults, defined by over 200 symptoms including respiratory issues, fatigue, and brain.[7,8] The risk of long COVID increases with each COVID-19 infection, regardless of severity.[9] Currently, approximately 5% of the US adult population have an active case of long COVID.[10]
Even with clear and simple recommendations, during the 2023/2024 season, only 22.5% of eligible adults and 14.9% of children (6 months through 17 years) reported receiving the most updated COVID-19 vaccine.[5,6] This occurred despite the vaccine demonstrating a high effectiveness against serious outcomes such as hospitalizations.[11] Data from December 15, 2020, to October 29, 2022 shows that unvaccinated adults were 5.3 times more likely to have severe/critical disease than fully vaccinated patients.[12] Staying up to date on vaccination is one of the most important ways to protect individuals against serious illness/death, as well as reduce the impact of COVID-19 on daily life, such as absences from work or school, canceled plans, and delayed events.[13] As for long COVID, several studies have shown that staying up to date with one’s COVID-19 vaccination can reduce the risk of long COVID.[14] This article reviews key lessons learned from the 2023-2024 season and provides potential strategies to address barriers to COVID-19 vaccine uptake.
COVID-19 vaccine approval, distribution, and delivery in the U.S. is highly regulated. The Vaccines and Related Biological Products Advisory Committee (VRBPAC) reviews vaccine safety and effectiveness data, advising the FDA on approval.[15] Once approved, the Advisory Committee on Immunization Practices (ACIP) recommends vaccine use, which becomes CDC policy. Vaccine manufacturers then collaborate with partners to support healthcare providers in delivering vaccines to the recommended recipients.[16]
COVID-19 morbidity and mortality remain significant regardless of age, supporting the CDC recommendation that all persons aged 6 months and older should receive the updated 2023–2024 COVID-19 vaccine.[17]
Risks of COVID-19 by Age Group
People of all ages are at risk of COVID-19 hospitalization. The cumulative COVID-19 hospitalization rates by age group are shown in Table 1. Across all age groups, low vaccination rates contributed to the risk of hospitalization.[18–20]
Table 1. COVID-19 Cumulative hospitalization rates by age through August 3, 2024[18]
| Age group | COVID-19 hospitalizations per 100,000 population |
| 0-4 years
6-< 12 months 1-4 years | 91.3
207.2 40.7 |
| 5-17 years
5-11 years 12-17 years | 12.9
11.3 14.6 |
| 18-49 years
18-29 years 30-39 years 40-49 years | 48.0
33.5 50.9 62.9 |
| 50-64 years | 136.1 |
| ≥ 65 years
65-74 years ≥ 75 years | 687.2
351.2 1178.0 |
Risk factors for Severe COVID-19 Outcomes
Certain groups continue to have a higher risk of severe COVID-19 outcomes.[21] These including infants, older adults, and people with underlying medical conditions or certain disabilities. Approximately 1 in 2 US adults have at least one comorbid condition that increases the risk of complications of COVID-19, and many of these have multiple comorbidities.[22] As the number of comorbidities increases, the risk of death, invasive mechanical ventilation and ICU admission also increases.[23] In the pediatric population, more than half of hospitalized children had no underlying medical conditions.[24]
Long COVID
Beyond hospitalizations and deaths, COVID-19 has also been associated with an increased risk of long COVID. As of June 24, 2024, an estimated 18.4% of US adults are experiencing long COVID.[25,26] Research indicates that the cognitive deficits associated with long COVID in hospitalized patients are comparable to aging 20 years.[27] The highest reported prevalence of long COVID was seen in people aged 40-49 years and in those who have had 3 or more infections.[25,28]
COVID-19 Burden vs. Influenza
During the 2023/2024 season, and as of August 10, 2024, COVID-19 continues to cause a more significant burden than influenza in the US.[29] COVID-19 hospitalization risk was higher than influenza in all age groups, particularly in older adults (≥ 65 years) where the number of COVID-19 related hospitalizations was five times of that seen with influenza.[24,29] Despite these statistics, the immunization rate for influenza as of May 11, 2024, for US adults (≥ 18 years) was more than double than with COVID-19 (48.5% vs 22.5%) and nearly four times the rate for those under 17 (53.9% vs 14.4%).[19,30,31]
The Continued Evolution of COVID-19
The SARS-CoV-2 virus continues to evolve, which could significantly affect the US healthcare system and contribute to hospitalizations in people with waning immunity.[32] Through the first half of 2024, the JN.1 variant became the dominant strain and was subsequently replaced by its descendants in the KP family throughout the summer. The updated COVID-19 mRNA vaccines were developed to closely target the variants that are currently circulating and causing the surge in COVID activity, including the KP.2 variant.[32,33]
2023/2024 Vaccine Uptake in Different Populations
Despite the ACIP recommendation to vaccinate all persons aged ≥6 months with the updated COVID-19 vaccine, the uptake of the 2023/2024 COVID-19 vaccine was suboptimal.[17,19,20] Across all ages, uptake was lower than the 2023/2024 influenza vaccine. COVID-19 vaccine uptake was also lower in all minority US adults (Asian, Black, Hispanic, multiple races, Pacific Islander, American Indian) compared to White, non-Hispanic US adults.[19,20,31]
The primary barriers to vaccination can be grouped into the following categories:
SARS-CoV-2 virus will likely remain endemic in the US and ongoing strategies will be required to protect the US population and achieve public health goals. The 2023/2024 season highlighted a need for adjustments in the delivery of COVID-19 vaccines; potential strategies are discussed below.
COVID-19 Vaccine Approval Process
In the 2023/2024 season, delays in COVID-19 vaccine approval, FDA licensure, and ACIP recommendations resulted in COVID vaccines for the 2023/24 season becoming available 6-8 weeks after flu vaccines were available.34 This year, the ACIP recommendations for the 2024/2025 COVID-19 vaccines were issued in June 2024 and FDA approval was received on August 22, 2024, with doses now available where Americans typically go for their vaccinations.[16,33]
Increased Integration of COVID-19 Vaccine into Routine Delivery of Care
Simplified vaccine messaging from trusted sources (i.e. public health, community partners and healthcare providers) can help increase vaccine awareness and address vaccine confidence and complacency.35 While it is important not to miss opportunities for non-respiratory vaccination, special focus should be given to influenza and COVID vaccination in the fall to ensure that patients are optimally protected ahead of the season.
Engaging Providers for Fall 2024 Delivery
Due to the many shared risk factors between influenza and COVID-19 vaccines, and with the ACIP/CDC providing clear recommendations of coadministration of the two vaccines, healthcare providers should be strongly encouraged to administer both vaccines on the same date for those ≥ 6 months of age.36
Improving Vaccine Access
Every healthcare provider has a chance to build trust and counter misinformation by offering evidence-based health guidance. It’s important to involve all groups—including public health officials, primary care providers, pharmacists, and community organizations—and to give them tools to discuss the potential impact of COVID-19 and strategies to reduce risk. This ensures that everyone has the information and access needed to make informed decisions about mitigating their COVID-19 risk.
Simplifying Vaccine Messaging and the Delivery of COVID-19 Vaccines
Healthcare provider recommendations are strongly associated with vaccine uptake.37 By making a strong recommendation to receive a vaccine, many patients are willing to accept it with little further discussion. Provider recommendations are especially effective if they take the form of a presumptive offer (i.e. “It is that time of year again, you need to get your COVID-19 shot today. Let’s start with it.”).[38] With this format, the default response is to accept vaccine uptake.[37] The use of presumptive language has been shown to significantly increase vaccine uptake and lower vaccine resistance.[39]
If immunizers encounter a person who is hesitant to receive a vaccine despite a presumptive recommendation, explore the reason(s) for hesitancy and engage the patient/caregiver in a discussion that could address their concern(s).[40] Communication strategies include linking COVID-19 and influenza vaccination, stressing the overlap in high-risk groups and the importance of receiving both vaccines for optimal protection, and engaging trusted community messengers for support.
Combating Misinformation and Disinformation
The misinformation that spreads online often reaches healthcare providers when having a discussion with patients about vaccination. Awareness of these trending topics is crucial for healthcare providers to better inform and educate their patients. Regularly checking an infodemiology dashboard can help HCPs identify and categorize these issues, allowing them to provide evidence-based reassurance about vaccine risks, safety, and effectiveness.
COVID-19 vaccination has been instrumental in averting millions of COVID-19 infections and hospitalizations.[41] However, ongoing strategies are needed to increase vaccine uptake. Healthcare providers remain essential in addressing barriers to COVID-19 vaccine uptake, countering misinformation, and helping keep patients up to date with vaccination.
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