1. COVID is 1.8 times deadlier than the flu yet people are more likely to get the flu shot than they are the COVID booster. Can you discuss the reasons behind this resistance?
(Note that except for changing my age from 78 to 79, this answer is word-for-word from my March 11 website post. But it hasn’t been published anywhere other than on my website.)
The main thing going on here, I think, is that COVID shots are controversial and polarizing, whereas flu shots (for the most part) are not.
The decision to get or not get a flu shot is made calmly. The questions in people’s minds are pretty straightforward:
- How likely do I think I am to catch the flu?
- If I catch it, how bad might it be? Can I accept a hellish week? Might it be worse than that? Might it kill me?
- How much good do I think the annual flu shot will do?
- What are the downsides of getting a flu shot? How inconvenient is it? Can I accept being under the weather for a day or two?
- What if anything has changed since my last flu shot? Is there any reason to rethink, or should I just keep getting it every fall?
Most people don’t “know” the medical and statistical answers to these questions. But they have intuitions about the answers, based largely on their past experience and what they’ve learned about consensus expert opinion. Those intuitions guide them to a calm yes-or-no decision.
Pretty much the same questions apply to getting a COVID booster. And once again, most people don’t “know” the answers. But unlike with flu shots, for COVID boosters many people have a sense that the experts don’t entirely know the answers either. Plus, the experts seem to disagree about the answers, even as both sides confidently insist they’re right and the other side is spewing misinformation. So people’s intuitions about whether or not to get a COVID shot may be very tentative. Or if their intuitions are firm, they’re likely to be grounded less in evidence than in allegiance to one side or the other.
And then there are the COVID questions that simply don’t come up for flu shots:
- The COVID vaccine is new. It was developed in a hurry and the government authorized it as an emergency measure. Is it really as safe as they say?
- Some scientists say the COVID vaccine might be dangerous for some people. Others say or imply that it’s completely safe. How can I tell who’s wrong? Or who’s lying?
- Some scientists say a COVID booster is unnecessary for healthy people who have already been infected or vaccinated or both. Others say it’s essential for everybody who’s eligible. How can I tell who’s wrong? Or who’s lying?
- Some people say COVID shots are an outgrowth of the same leftwing authoritarianism that brought us lockdowns and mask mandates. Should conservatives avoid getting boosted as a matter of principle? (Talk about self-defeating!)
- Nearly everyone agrees the worst of the COVID pandemic is over, at least for now. So why are public health agencies still insisting on yet another booster? When can we get back to normal?
Annual flu shots and COVID boosters are recommended most strongly for elderly and high-risk people. Most such people know that flu is an annual risk, especially for them. They’re not worried about a flu pandemic, and they don’t need a pandemic to think flu is worth protecting themselves against every year. They’re used to getting an annual flu shot, and don’t see any reason why this year would be different.
It’s not a newly developed vaccine made in a hurry using a new technology. They aren’t hearing a lot of expert disagreement or nonexpert rumors about the vaccine, or about the disease. The messaging they hear every year is pretty consistent. Flu is old news, and they know the drill.
By contrast, they’ve heard a lot of highly uncertain and rapidly changing information about COVID and COVID vaccines. Many agencies and experts have sounded confident – arguably often overconfident, given that they have changed their minds or been wrong a lot. And some people who claim they’re experts too are on the other side. They often sound just as overconfident about their radically different opinions – opinions the mainstream majority has worked hard to suppress.
Despite all that, most elderly and high-risk people eagerly got vaccinated against COVID in 2021. Better a controversial vaccine than a deadly disease, they figured. But the disease seems a lot less deadly now, while the vaccine is no less controversial. So getting yet another booster is a tougher call.
At age 79, I get every COVID booster I’m entitled to get. I’m a risk communication expert, immersed for decades in the emerging infectious diseases world. I can take in all the uncertainty and changing information – communicated by officials who have often sounded overconfident and sometimes been untrustworthy – and still decide to keep rolling up my sleeve. But I really understand why some elderly and high-risk people who are quite comfortable with their annual flu shot might be more leery about the COVID vaccine. I think they’re making a mistake not to keep getting boosted, but I sympathize with their doubts and worries.
It’s worth noting that the American public health establishment is more enthusiastic about universal annual flu vaccination than comparable agencies in most peer countries. As a result, far more Americans than people in most other countries have successfully been taught that annual flu shots are a must. From an international perspective, “Why do so many Americans get a flu shot every year?” is as reasonable and perplexing a question as “Why are so many Americans not getting their COVID boosters?”
2. How can doctors convince their patients to opt for the COVID booster in the same way that they do a flu shot?
I don’t think it’s possible for doctors to convince their patients to opt for the COVID booster in the same way that they do for the flu shot. For reasons I discussed at length in my answer to #1, the two decisions don’t pose the same questions.
For most people who get an annual flu shot, getting that shot is a routine chore, hardly a decision at all. Getting a COVID booster, on the other hand, is very much a decision – a pretty complicated decision. First you have to figure out if the CDC has decided you’re eligible or not eligible, based on your age, your health, and the date of your last booster or infection. That’s already a broad hint that getting a COVID shot isn’t routine. (You don’t have to wonder whether or not you’re eligible for your annual flu shot.) Assuming the CDC says you’re good to go, that just means the agency experts think you’re the sort of person who’s allowed to get a COVID booster now. You still have to decide if you think you’re the sort of person who should get a booster.
This isn’t a dichotomous question. For someone of your age, health, etc., is getting yet another COVID booster a bad idea, or an okay-but-unimportant idea, or a good idea, or a really important urgent priority? The more you know about COVID vaccination controversies, the clearer it gets that the answer to this question isn’t obvious. The science is unclear about how much good another booster is likely to do for someone like you. The experts sound very confident – but their advice is all over the map. Some people who claim they’re experts too even think another booster might do you more harm than good.
Most people trust their doctor a lot more than the CDC. (They shouldn’t. Their doctor almost certainly knows less than the CDC about COVID vaccination, and is probably just regurgitating the CDC’s bottom lines. But that’s a question for another day.) Doctors are in a good place to help their patients think through the pros and cons of getting another COVID booster today.
Assuming the doctor is convinced that the pros outweigh the cons in the case of a specific individual patient, I would advise the doctor to start by assessing that patient’s state of mind. If she’s dead set against getting a COVID booster today, drop the issue. If she’s leaning negative but open to discussion, do more listening than talking, focusing mostly on responding factually but empathetically to her concerns. If she’s leaning positive but not quite there yet, reinforce her understanding of the benefits, while being careful not to push too hard. Only if she confidently says she wants another booster today would I recommend treating the decision as routine, just like getting her annual flu shot.
3. Should a COVID booster be an annual aspect of your booster schedule?
This is a medical question, not a risk communication question. So I pass.
4. How can doctors make their patients understand that a COVID booster reduces your risk of getting long COVID after an acute COVID infection?
I’m not an expert on the effect of COVID boosters on long COVID. But for what it’s worth, my impression is that there’s growing though not yet dispositive evidence that the more boosters you get before your first COVID infection, the less likely that infection is to lead to long COVID. But of course a lot of us have been infected already. The important question for us is this: Given that I have been infected a time or two already, how much protection against long COVID will my nth COVID booster give me? I’m not aware of much evidence about that.
As I said, this isn’t my field, and maybe you’re aware of evidence that I have missed. Or maybe you’re a bit too willing to think doctors should gild the lily.
My recommendation to doctors: To preserve your credibility as well as your integrity, resist the temptation to gild the lily. Settle for what is really known: “If you do catch COVID despite the booster, there’s some evidence that you may be less likely to end up with long COVID. We’re pretty sure that’s true for people’s first infection. We’re not so sure how much the booster helps, if at all, for people who have already had COVID before. But I don’t know of any expert who thinks another booster will make somebody likelier to get long COVID. It’s just a question of how much less likely.”
Copyright © 2024 by Peter M. Sandman
