Public Health

How physicians can address COVID-19 vaccine booster fatigue

Sara Berg, MS , News Editor

For nearly three years now, there has been nonstop discussion and emphasis on the importance of COVID-19 vaccines and boosters. With many people developing COVID-19 booster fatigue, physicians must find ways to break through without adding further burden on their patients.

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Much like pandemic fatigue, this phenomenon is defined as unwillingness or inaction towards vaccine information or instruction due to perceived burden or burnout. In turn, patients are slow to line up for their COVID-19 bivalent boosters even as the highly transmissible XBB.1.5 Omicron subvariant has become the dominant strain of SARS-CoV-2 in the U.S. To date, only 15.8% of the U.S. population have received an updated bivalent booster dose.

In a recent public service announcement, AMA President Jack Resneck Jr., MD, and leaders of the American Hospital Association and American Nurses Association again urged patients to get vaccinated—and boosted. Meanwhile, the Department of Health and Human Services’ “We Can Do This” campaign helps physicians and communities address COVID-19 vaccine misconceptions and reinforce basic prevention measures. 

And with the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices adding COVID-19 vaccines to its routine immunization schedules for children and adults, addressing booster fatigue takes on increased importance.

Preeti Malani, MD
Preeti Malani, MD, infectious diseases physician and deputy editor of JAMA

In an interview with the AMA, Preeti Malani, MD, an infectious diseases specialist and professor of medicine in the infectious diseases division at the University of Michigan Medical School, discussed the ongoing pandemic and what physicians can do to address COVID-19 vaccine booster fatigue. Dr. Malani is also deputy editor of JAMA®.

AMA: Is the biggest difference between now and how we were in 2020, having vaccines and boosters?

Dr. Malani: It’s a combination. It’s being vaccinated. It’s being boosted. It’s having prior infection, which many of us have had, including myself. All those things additively do provide protection against severe illness. These days, we’re not seeing as large of numbers of people dying of COVID-19, thankfully, but there is that rare person who hasn’t been vaccinated and hasn’t had illness. We do see that. It’s not very common, but when we see that people are still sick, you remember what it used to be like.

But with boosters, the other piece that is interesting is that we’re often seeing severe infection in older adults who haven’t had a recent booster. They’ve had their primary series. They might have gotten one booster, but then they just didn’t get around to getting a more recent booster.

We’ve forgotten what it was like before vaccines where this was something you would die from. And now with vaccines, it’s become a much more manageable condition. But we’re still trying to understand how long protection lasts. Unfortunately, the oldest patients still end up being hospitalized on occasion.

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Answering patients’ questions about the bivalent COVID-19 vaccine

AMA: Where do we stand with COVID-19 bivalent booster uptake?

Dr. Malani: There are a lot of individuals who got the primary series and even the first booster who haven’t gotten the bivalent booster and that’s concerning. Some of the data that my research colleagues and I collected with the National Poll on Healthy Aging suggested that people who had gotten the first series and even the first booster were not sure if they were going to get the bivalent. And that is that idea of booster fatigue or confusion that maybe they don’t need these things or it’s hard to make a decision because there’s so much noise.

People go to different sources for information. They may go to their family or their friends who aren’t medical professionals and they may go to Facebook and other social media platforms. They may not ask their doctor because there are other pressing things to talk to their doctor about.

Those early days where people were lined up and driving to different states are gone and the demand is not high. There is the ‘I don’t know if I really need this’ or ‘Well, I don’t really feel like making an appointment and going in’ or ‘I just didn’t get around to it.’

In our emergency department—I’ve been there a bunch this month rounding—there’s a sign that says: If you haven’t had your COVID-19 booster, let us know. We can give it to you on your way out. It has to be the type of thing where we have vaccines available in places that people go. Like we did with flu shots—schools and workplaces have been central.

People’s lives are complicated so one thing we can do is make it easy to get vaccinated against COVID-19 and get good information to everyone.

AMA: Is that one way to address booster fatigue?

Dr. Malani: That certainly is part of it. And there are some issues around having it easy to give in primary care clinics. There are some barriers including needing low storage temperatures and additional training and paperwork. But what you can do is say: On Saturday morning, anyone who wants to come can come get a booster. We’ll be here. No need for an appointment.

We can certainly do those types of things to reach people. And as we’re moving to a place where people are likely to be getting a yearly booster, we do need to make it easy for people the way we make flu shots easy because even making an appointment and waiting a half hour can be a barrier.

So, if we can remove some of those barriers, we might get to a portion of people. But there’s another layer of individuals who are just confused and they’re concerned about safety. That needs to be approached differently.

AMA: How do you approach patients who are confused or concerned about the COVID-19 bivalent booster? 

Dr. Malani: Booster fatigue is also a reality for physicians and other health care professionals. Early on in the pandemic, when vaccines became available, I was really willing to engage in those discussions. And sometimes now I feel like, well, do I really want to go there when I have all these other things to discuss and will it even make a difference?

So, it is difficult, but it’s about opening the door—it may not be you, but maybe someone else on your staff like the medical assistant who does the check-in or the nurse—and saying: Hey, I noticed that you haven't gotten your booster. Is that something you'd like to talk about? Do you have any questions about the COVID vaccine?

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How doctors can talk about COVID-19 bivalent boosters with patients

AMA: Is it important to share information about the COVID-19 bivalent boosters such as their purpose and the role of variants?

Dr. Malani: Absolutely. And again, depending on the patient, that education could look different. One of the things that I share is that I am vaccinated, my family is vaccinated, and this is something I recommend strongly to you as your doctor. I do try to leverage that relationship.

Thankfully we’re in a different place in terms of COVID-19 deaths, but we’re not at zero. It feels like everything has come down and it’s at a low but steady level and perhaps this is the endemicity that we’ve been talking about, but we do worry if a new variant comes. So far, it’s been all these Omicron subvariants. It’s about explaining to people that you could still get COVID even with vaccination, but you’re unlikely to get severely ill.

And while we talk about vaccines, we should also talk about treatments, who would be eligible and what treatment might look like because there's still confusion on treatments and effective treatments. The same people who are often not vaccinated and boosted may be seeking treatments that are not effective.

AMA: What does the future of COVID-19 vaccines look like?

Dr. Malani: I don't suspect anything's going to happen very quickly. The current mRNA vaccines are pretty good as far as vaccines go, but the protection is not durable. And again, with some of the newer subvariants like XBB.1.5 that have come through, perhaps it's less effective. But at the same time, there are fewer infections and infections are milder in general, so there are a couple of different things happening.

But just like with flu vaccines, we need better vaccines. It would be nice to have one that just prevents all infection, prevents spread, that lasts longer in terms of protection. And we don't have a good way to measure whether you are still protected or not.

In time we'll know more and whatever we learn will probably be helpful if there's another pandemic. And many people say, not if, but when there’s another pandemic. Again, it’s not completely over. There’s still workplaces and hospitals that still look different and I’m not sure if they’re ever going to go back to looking the way they did before COVID. I do know for sure that you’re going to fare better if you’re vaccinated than if you’re not.