Joe Gonzales, 37, said he knows there's still a risk of contracting covid - he believes he was infected with the virus this summer. But after getting two doses of the vaccine, the Flower Mound, Tex., man doesn't understand why he needs the third and fourth "booster" shots urged by federal health officials.
"And then the president is saying things like, 'The pandemic is over,' " Gonzales said of President Biden's comments during a recent "60 Minutes" interview. "That doesn't help" motivate him to get a shot.
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Gonzales's lack of urgency typifies the view of many Americans, worn down by a never-ending pandemic and unsure about next steps as the nation enters its third covid winter. Some have stopped paying attention to health officials' recommendations altogether, despite projections of a fall and winter wave with the potential to sicken millions and kill tens of thousands, particularly the elderly and sick. About half of Americans say they've heard little or nothing about the shots, according to a recent tracking poll by the nonpartisan Kaiser Family Foundation.
"We have got to explain the value of these vaccines for the American people . . . [and] why this is probably the single most important health intervention they can make right now to protect themselves and their health for the next three to six months," Ashish Jha, the White House's coronavirus coordinator, said in an interview.
Federal officials have spent the past year urging Americans to get booster shots to bolster their protection against the coronavirus, which wanes over time. In early September, they rushed out the first new shots - reformulated to target the still-dominant omicron variants - to give people time to get inoculated before a likely cold weather surge, when respiratory infections increase as people head indoors, and recommended that all Americans 12 and older receive a third and fourth dose of vaccine.
But the campaigns have lagged badly. Only about 105 million U.S. adults - roughly 40 percent - have received the third shot of vaccine initially offered a year ago, according to federal data, a far lower rate than countries like the United Kingdom, where more than 70 percent of adults have gotten a third dose. That figure is also well behind the 200 million U.S. adults who completed their primary series of shots.
Early data shows that just over 11 million Americans - or about 4 percent of those eligible - have received the new bivalent booster shots. A third of adults say they eventually plan to get those shots, according to KFF polling.
For public health leaders, the low booster rate is startling in a nation that financed the shots' development, offers them free and touts them as the best way to protect against a virus that has already claimed more than 1 million lives in this country.
The lagging booster rate is also blamed as a major contributor to the high covid mortality rate last winter and the continuing deaths of more than 400 Americans on average per day linked to the virus, according to The Washington Post's coronavirus tracker. An analysis by the Commonwealth Fund, an independent research group, forecasts that more than 75,000 lives might be needlessly lost if the fall booster campaign comes up short.
Eric Topol, a professor of molecular medicine at Scripps Research Institute in the La Jolla neighborhood of San Diego, Calif., blamed federal agencies for being too cautious and sending mixed messages.
"Obviously, there's been a lot of missteps [in the government's response]," he said. "But to me, this is the most important one: When you have people who were willing to get two shots, and then you lose them to not get a third, or a fourth, or fifth, it's a travesty. These are people who are willing to get vaccinated."
Federal officials privately acknowledge mistakes in last year's initial booster shot rollout. After Biden announced in August 2021 that every American should get a booster shot in the fall, some advisers and experts at the Food and Drug Administration and the Centers for Disease Control and Prevention raised concerns that the decision appeared to have been made before they had fully reviewed the data.
Some public health experts outside the government, meanwhile, argued two doses of vaccine were sufficient to protect most people.
The competing sound bites confused and alienated many Americans, and intimidated officials, according to Topol. "CDC was afraid to boost the booster message, thinking that that would diminish confidence in [the] primary series vaccines and give the anti-vax groups fodder," he said.
"I blame the federal health bureaucracy," agreed Jon Favreau, a host of "Pod Save America," a progressive podcast, and former speechwriter for President Barack Obama. "This was not the White House's fault. This is not the top scientists in the administration's fault. This was the agencies dragging their feet and a small, very vocal group of experts who happen to be on Twitter a lot."
Right after Biden announced the booster plan, Favreau sought out and got a third booster dose - not waiting for the health agencies to act. "I had a baby at home that was unvaccinated, and I didn't want to take my chances," he recalled.
A CDC spokesperson defended the agency's process to review and encourage the boosters last year.
"Suggesting that federal agencies' review of the boosters had some significant impact on their uptake is bizarre and wrong," said the CDC's Kevin Griffis. "We know the reasons why people don't get boosted . . . It's not because experts spent a few weeks reviewing the data" but because many vaccinated Americans believe that two shots are sufficient.
Jha acknowledged missteps last year, blaming "a group of public health people who I think unduly expressed skepticism."
"And what we saw was a lot of Americans get very sick and die in the omicron wave because they were unboosted," he said. " . . . There's more and more data out [now] that shows that when people get their boosters, they're far less likely to end up in the hospital, far less likely to die."
Jha said the administration will lean on that data while readying a campaign intended to pump up interest in the boosters starting this month. The federal health department is running digital ads that encourage people to get coronavirus vaccines and boosters along with their flu shots, and the administration is planning events, such as vaccine clinics at colleges and workplaces, to tout the new bivalent shots. The department will also run television ads about the updated shots beginning Oct. 17, and target Hispanic and Black communities in an ad blitz the following week, officials said.
The White House has also tweaked its messaging. Officials are describing the shots as an "updated covid vaccine," hoping that avoiding the word "booster" shores up confidence. They're also urging Americans to get "annual" covid shots, believing it will better prepare people to fight a virus that is expected to be around for years.
But there is scant evidence such a campaign will win over holdouts, with many Americans fatigued by covid messages, doubtful about the threat and having reached their own conclusions about how best to navigate a persistent pandemic. Forty-six percent of respondents to an Axios-Ipsos poll last month said they had returned to their pre-pandemic activities, the highest percentage since the poll began in January 2021.
Other Americans say they want to take necessary precautions but have tuned out the latest recommendations; still more have fallen prey to misinformation, or confess to sheer exhaustion with covid messages, roughly 1,000 days after federal officials first warned of a mysterious pneumonia in central China.
"A lot of people have wanted to move on from the pandemic," said Mollyann Brodie, who oversees KFF polling, listing reasons for the diminished attention. "Partly because the surge has abated, partly because of pandemic fatigue - and partly because the risk to an average healthy person is different than it was earlier."
Researchers also cite persistent gaps in knowledge about the vaccines, with rural populations and communities of color trailing White, suburban groups. For instance, among fully vaccinated adults, only 41 percent of Hispanics and 45 percent of Black Americans said they knew the CDC had recommended the new booster shot, compared to 51 percent of Whites, according to KFF polling.
"I don't know that people are necessarily listening to the messages of the government," said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, which represents public health agencies around the country. "Maybe it's time to bring in some other folks or messengers that may be more effective."
Brodie agreed, saying that "much of America has had to become their own sort of public health department, making decisions for themselves and their families."
A mixed response
Experts like Brodie and Plescia say that while some Americans have tuned out the booster and vaccination campaigns - with roughly one-third of adults not having gotten their primary shots against the coronavirus - there are likely tens of millions of highly motivated people planning to seek out the latest boosters.
"[I'm] beating down the door," said Alyssa Thacker, 33, at a Walgreens in Fox Point, Wis., last week, pushing a stroller with daughters, Ari, 4, and Aoife, 2. "I'm third trimester pregnant and I want to protect my fetus. I want to protect my children. I want to be able to travel and not catch it and not inadvertently infect anyone else."
Thacker said she plans to give her two daughters the new booster as soon as it is available to children.
Others say they intend to get the shots, but are putting them off because of recent infections or boosters.
"I'm in that waiting period," said Brodie, who said she received her last booster in August and wants to wait to get the new shot until November. Federal officials recommend that people wait three months since their most recent covid infection or at least two months from their last booster.
But a significant group is confused about the need for the new boosters and their benefits, or downright opposed to them.
Sitting at a table inside the Lewisville, Tex., public library, which she made sure was wiped down, Kay Cudjoe, 65, a retired educator, said she's already made her appointment for the new booster, which would be her fourth dose - but isn't planning on any more.
"This is the last one I'll have to get," Cudjoe added. "At least that's what I understand."
Maggie Clement, 27, who works at an art and pottery studio in Royal Oak, Mich., said she hadn't heard about the new boosters until her boyfriend mentioned the shots that morning. "I had no idea," she said. Clement, who said she was vaccinated twice and boosted in 2021, said she will get the new booster, but is worried about the need to plan around it.
"The first two shots, I missed a day of work. And with my booster, I missed two days," she said.
Some organizations, such as colleges and universities, are moving to require the boosters - as they did with earlier vaccines - amid evidence that such mandates compel uptake.
"Students must be compliant with all vaccine requirements in order to register for the spring term," Harvard University announced in September. "This includes the annual flu shot as well as the bivalent Omicron-specific COVID-19 booster."
But this time around, there is little appetite to try to persuade employers to mandate booster shots, said Ezekiel Emanuel, who coordinated efforts to persuade many health care organizations and universities to compel them last year. Emanuel said that while he believes such organizations should require the new shots, he has no plans for another campaign, citing legal challenges and other complications.
"A lot of people who were vaccinated later got omicron - I think that's not getting enough attention when we talk about the appetite for boosters," Emanuel added. "People have become a bit cynical about the vaccines' benefit. I know people who have gotten four shots and still got infected."
Not every expert believes that more shots are widely necessary. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia, was one of two members of the FDA advisory panel who voted against recommending authorization of the new booster in August.
"I just don't think we have any evidence that it's better," Offit said, pointing to a New England Journal of Medicine study that he said "shows underwhelming evidence" for it.
Still, he endorses the shot for more vulnerable groups: people over age 75 or living in nursing homes; those with chronic conditions such as severe Type 1 Diabetes, lung or heart disease; and those with weakened immune systems.
But Offit noted the public no longer recognizes covid-19 as the threat it was in the spring of 2020, adding that the low uptake numbers, in part, represent "booster fatigue."
Inside the White House, officials predict that interest in boosters will grow if covid infections rebound this fall and winter, as predicted. Americans could be particularly motivated by the arrival of "scary European variants," such as omicron descendants B.Q.1.1. and BA. 2.75.2, which are spreading overseas, show an ability to evade treatments and could lead to more serious illness, said a senior administration official who spoke on the condition of anonymity because they were not authorized to comment.
Biden officials also have been calling on GOP leaders to better highlight the continuing risks of the virus, citing persistent gaps in vaccinations between Democrats and Republicans. "A lot of [the booster lag] is because of political divisiveness," Anthony S. Fauci, the government's top infectious-disease expert, said in an interview Tuesday. "I mean, there's no secret that red states are under-vaccinated and blue states have a high level of vaccination."
And mindful that more than 150 million Americans every year receive a flu shot, officials have amped up efforts to link the two vaccines. "I really believe this is why God gave us two arms - one for the flu shot and the other one for the covid shot," Jha said at a recent briefing.
Others have pressed to use a diverse cast of messengers to explain the shots' benefits, particularly to communities of color.
"We really have to change the way that we reach out to people - we also have to change the face of those that are reaching out," said Kizzmekia Corbett, a Black scientist and Harvard immunology professor who helped develop the technology behind the vaccines, in a recent Washington Post Live interview.
"Working on the vaccine development early on in the pandemic, I felt . . . I should just step away and go on tour and just convince people to get the vaccine," she added. "And I wish I could do that here with the boosters as well."
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Diamond reported from Washington, Gahan from Dallas and Johnson from Fox Point, Wis. The Washington Post's Kayla Ruble in Royal Oak, Mich., and Jimmy Magahern in Phoenix contributed to this report.
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