America’s Flu-Shot Problem Is Also Its Next COVID-Shot Problem
The successes and failures of annual flu-shot campaigns hold lessons for the future of COVID vaccines.
About 18 years ago, while delivering a talk at a CDC conference, Gregory Poland punked 2,000 of his fellow scientists. Ten minutes into his lecture, a member of the audience, under Poland’s instruction, raced up to the podium with a slip of paper. Poland skimmed the note and looked up, stony-faced. “Colleagues, I am unsure of what to say,” he said. “We have just been notified of a virus that’s been detected in the U.S. that will take somewhere between 10,000 and 15,000 lives this year.” The room erupted in a horrified, cinematic gasp. Poland paused, then leaned into the mic. “The name of the virus,” he declared, “is influenza.”
Call it funny, call it mean, but at least call it true. Poland, a physician and vaccinologist at Mayo Clinic, had done little more than recast two facts his colleagues already knew: Flu is highly contagious and highly dangerous, a staggering burden on public health; and for years and years and years, Americans, even those trained in disease control and prevention, have almost entirely ceased to care. Vaccines capable of curbing flu’s annual toll have existed since the 1940s. Close to a century later, some 50 to 60 percent of Americans adults still do not bother with the yearly shot. The crux of the uptake shortfall “is this normalization of death,” Poland told me. He predicts this pattern will play on repeat, and at higher volume, with SARS-CoV-2—another devastating respiratory virus that’s tough to durably thwart with shots.
COVID-19 is not the flu, and no one knows for sure exactly how often we’ll have to immunize ourselves against it. But it seems inevitable that someday, the entire American public will be asked to sign up for shots again—perhaps quite soon, perhaps every fall, as some vaccine makers would like. We have just one template for this: the flu shot. And expecting even similar levels of so-so uptake may be optimistic. “I’m guessing that flu-vaccine coverage is going to be a ceiling,” says Alison Buttenheim, a behavioral scientist at the University of Pennsylvania. “I just don’t think we’ll have 70 percent of U.S. adults saying, Oh, an annual COVID shot? Sure.”
Immunization ennui is already playing out. Months into the COVID-booster-shot rollout, only half of Americans eligible for an additional injection have gotten one—that’s with the pandemic still raging, with more than 1,000 people dying each day in the United States alone. “We’re already losing the immediate motivator of I’m afraid I’ll get sick and die,” says George Dehner, a flu historian at Wichita State University.
If the future of COVID shots ends up mirroring the past and present of flu vaccines, we’ll have our work cut out for us. But many of the barriers we face now in trying to get people to sign up for their shots, not just once, not just twice, but likely many times over, don’t have to feel like uncharted territory. Flu vaccines offer “a lot of parallels,” says Tony Yang, a health-policy expert at George Washington University. Again, the two diseases aren’t at all identical. But efforts to vaccinate against either have enough overlap that they can inform each other. Our experience with flu shots reminds us that Americans, cultured to become immune to the notion of unnecessary death from disease, still have a chance to shift that perspective—and chase the kind of immunity that will instead spare them from it.
Annual flu vaccines are both an old innovation and a new imperative. Originally developed in the 1940s, when World War II was still raging, the shots first went to the military, under orders from the surgeon general. By the end of the fall of 1945, “everyone in the U.S. Army was vaccinated,” Dehner told me. The shot was cleared for civilian use and soon became a regularly reformulated vaccine to keep pace with the viruses’ rapid mutational clip. The vaccine worked—flu deaths plummeted among those who received the shot. Still, only after the 1957 flu pandemic pummeled people who were over the age of 65, pregnant, or ill with a chronic disease did public-health officials begin actively recommending the vaccine for those groups. Another 45 years would pass before children six to 23 months old joined the list. And only in 2010 were annual flu vaccines recommended for everyone six months and up.
More than a decade later, getting just half of American adults to nab the jab is “considered a good year,” Buttenheim told me. That level of uptake is paltry compared with the percentages of children who are, by the age of 2, up-to-date on their shots against chicken pox (90.2), hepatitis B (90.6), measles (90.8), and polio (92.6). But unlike those vaccines, flu shots are high maintenance, requiring refreshment through adolescence and adulthood, every single year. The annual vaccines have other factors working against them too. While they’re decently good at keeping people out of the hospital and the ICU, their protections against less-severe infections are relatively weak, topping out at about 60 percent effectiveness, and fast-fading. (They do far worse than that when there’s a mismatch between the vaccine’s contents and the circulating strain du jour.) “A lot of times, you still end up getting the flu even if you’ve had the vaccine”—which has given the shots a pretty bad rap, says Seema Mohapatra, a health-law expert at Southern Methodist University.
And when people, especially young, healthy adults, do end up with the flu, many of them simply don’t care. The worst flu outbreak in recorded history, in 1918, carried a mortality rate of about 2.5 percent. That was devastating, given how many people were infected. But instead people have, in the decades since, internalized that most did not die. If vaccine appeal tends to toggle by three metrics—the convenience of staying current on shots, the inoculation’s effectiveness, and the pathogen’s perceived threat—flu jabs aren’t much of a contender in any arena. “There are a lot of people who are very, very pro-vaccine, except for flu,” Rupali Limaye, a vaccine-behavior expert at the Johns Hopkins Bloomberg School of Public Health, told me. They just don’t think the juice is worth the annual squeeze.
COVID vaccines have already begun to follow flu shots’ problematic patterns. Set up to believe that the vaccines would instantly obliterate all infections, many people now consider the shots’ performance underwhelming, says Limaye, who has spoken with about 3,000 vaccine-hesitant people in the past two years. And since the start of the coronavirus crisis, it’s been tough to shake the false narrative in some circles that essentially “everyone” who gets the virus “seems to be just fine,” she said. In America, states with low annual flu-shot-uptake rates are near the bottom of the charts on the COVID-vaccine front as well. There’s a mirroring across demographics as well: For both flavors of shots, the elderly, the white, the wealthy, and the highly educated are more likely to be dosed up. These gaps are bound to widen, as the inequities of first doses become the inequities of boosters, and fewer and fewer people return for additional injections. “First to second, second to third, we already saw dropoff,” says Arrianna Marie Planey, a medical geographer at the University of North Carolina at Chapel Hill.
We don’t have to resign ourselves to this fate. Flu shots have had their failures, but they’ve clearly had their successes too. Roughly half of American adults don’t get an annual flu shot. The other half do. “The best predictor of whether you got a flu shot this year is if you got one last year,” says Gretchen Chapman, a cognitive scientist who studies vaccine behaviors at Carnegie Mellon University. To at least a degree, we have been doing a few things right.
First, when mandates are possible, they help. The military requires flu shots, for instance, as do some universities. And requirements are common across a bonanza of health-care settings—a result of intense advocacy efforts, spearheaded just over a decade ago, in part by scientists including the Mayo Clinic’s Poland. Here, the perks of mass inoculation are absolutely incontrovertible. More flu vaccines mean fewer health-care workers missing work, or coming to work sick; they mean fewer vulnerable patients being exposed to the virus and falling seriously ill. It just took an all-out requirement to get the workforce to invest: Following a wave of mandates, starting around the early- to mid-aughts, vaccine-uptake rates zoomed from about 40 percent to about 70 or 80 or more.
In other settings, though, mandates are much harder, for some of the same reasons that totally voluntary uptake remains in the pits. Schools might seem an obvious venue, because they already require other shots. But most of those vaccines require just a couple of doses that are done by adolescence at the latest; trying to track annual shots, meanwhile, is a bookkeeping nightmare, my colleague Rachel Gutman reported last fall. No states currently require annual vaccines for all K–12 students (though a few ask that day cares and preschools do). Attempts to change that have ended up dead in the water; even in health-care settings, mandates were an “arduous battle,” Angela Shen, a vaccine expert at Children’s Hospital of Philadelphia, told me.
Once people age out of the school system, they become even harder to convince and corral. Across the board, “adult immunization coverage is abysmal,” and not just for the flu, Shen told me. With the American mindset so entrained on liberty and individualism, out-and-out requirements in most industries—for flu shots, for COVID shots—feel doomed to fail. Mandates are “tremendously effective,” Chapman told me. “People just hate them.”
Without mandates, shot uptake depends on the miscellany of motivation. So-called nudge tactics have sometimes worked with flu shots, especially when they’re laced with a financial incentive—gift cards, coupons, salary bonuses, and the like, Southern Methodist University’s Mohapatra told me. But they can also flop, or even backfire; the COVID era has provided plenty of evidence for that, even with a few pretty creative pot-sweeteners (boats! sports cars! free gas for 10 years!) in the mix. Some individuals may grow suspicious of the hype, worried they’re being duped. Incentives can also go overboard with cash value, and make people feel like they don’t actually have a choice in the matter at all. “You still want there to be autonomy,” Mohapatra said, so it remains a true nudge, and not a coercive shove. Really, incentives work best on people who just need an extra little push. They’re much less likely to totally overhaul someone’s sociopolitical worldview.
Increasing vaccine uptake, then, isn’t just about making shots desirable. It’s also about making them convenient and, in some cases, feasible at all. For many people, getting a vaccine still represents a huge disruption—time spent away from work, or child care, or other responsibilities—especially for those who live in rural regions or don’t have reliable access to health care. Simple venue changes can help. In 2009, a policy shift that finally allowed pharmacists to administer flu vaccines became an “absolute game changer,” says Ross Silverman, a vaccine-policy expert at Temple University’s College of Public Health. Just over a decade later, more than a third of American adults receive their annual shots at pharmacies and stores. Community vaccination sites and mobile clinics, UNC’s Planey told me, can help too. (Unfortunately some of the ones that popped up during the COVID pandemic have since disappeared.) And for those who straight-up forget to get a flu shot, or hit scheduling inertia, Chapman and her colleagues have found that auto-generating appointments can help—it becomes a default option, and people tend to follow through.
Decades of slips and stumbles have also made clear what other changes might help efforts to vaccinate against both flu and COVID. Eliminating financial barriers is essential—to do that, policy makers could ensure that shots of all kinds remain free of charge, regardless of insurance status, Shen told me. For those who have to travel to appointments, officials could also instate measures to ensure that their transportation costs are covered, and put paid sick leave on the table so work hours aren’t lost. Changes like these would likely help address some equity gaps in uptake, especially among essential employees and their children, who might be more exposed to infection to begin with, and need the shots that much more. “All of these barriers add up,” Planey told me, but so does chipping away at them.
Still, changes that focus on nudges and logistics can go only so far when much of the public has been cultured to view vaccines as not just annoying or unneeded, but outright dangerous, immoral, or partisan. These views are part of why, even after years of scientific toil, flu-vaccine uptake is “stagnant,” Poland said. With COVID, the immunization obstinance may be even worse. Vaccination has become “a hot-button issue in a way that it has never been,” Silverman told me.
Here, the lessons from flu shots match the ones already clear from current COVID-vaccination campaigns: People must be met where they are. Sometimes, that’s about hearing a vaccine-enthusiastic message from the right person. George Washington’s Yang notes that a strong recommendation for a flu vaccine from a health-care provider can be enough to tip some people toward dosing up. Trusted community messengers—some of whom might even go door-to-door in some cities—are powerful motivators as well. These conversations are about compassion, not dismissal, says Limaye, who works in vaccine hesitancy at Johns Hopkins University. She’s running a study to see if tapping into Republican Party values, such as individualism, freedom, and protecting small businesses, might make headway among conservatives who remain skeptical of shots.
Larger-scale cultural shifts, too, are needed—amending people’s perspective on communal risk, and the price of ignoring it, as Poland emphasized at that CDC conference. Some of those lessons can be ingrained early in children, the primary target of most shots to begin with, he told me. Decades ago, when Poland’s youngest son was in second grade, he brought home an assignment he’d filled out in science class. The page was headed with a prompt: “Flu (influenza) kills and hurts people. A flu vaccine exists. What should we do every fall?” Beneath it, Poland told me, his son had scrawled, We should get a shot. So his son did. And so he has, ever since.