Introduction

The fall and winter seasons are known for an increase in respiratory illnesses, and the simultaneous presence of COVID-19, influenza (flu), and respiratory syncytial virus (RSV) could strain health care systems and result in adverse outcomes for individuals at high risk for these diseases, including a disruption in home and work life (Bekkat-Berkani et al., 2017; Putri et al., 2018). According to data reported in February 2022 by the Kaiser Family Foundation, “nearly four in ten (38%) U.S. adults report that their households had someone who was sick with at least one of these three viruses over the past several weeks” (Schumacher et al., 2023, para. 1). Fall 2023 is the first time that vaccines will be available for all three of these respiratory illnesses, marking a significant opportunity to prevent infections.

As with COVID-19, the disease burden for flu and RSV is usually borne disproportionately by communities that have historically been marginalized, including Black, Hispanic, and Native populations (Iwane et al., 2013; Vahidy et al., 2020), as well as those of lower socioeconomic status. The same is true for other comorbid diseases, such as diabetes and heart disease, that may exacerbate the risk of adverse outcomes from these infectious diseases (Centers for Disease Control and Prevention [CDC], 2022a,b).

The current vaccination landscape is complex. Two of the illnesses these vaccines are meant to prevent—flu and RSV—tend to peak at the same time⁴ (October–April) and have a more significant impact on older adults (over 65), children aged 5 years and younger, and adults and children with certain underlying conditions (e.g., chronic lung disease or heart disease). At the same time, the recommendations for each vaccine differ, making communication about them challenging. In such a crowded vaccine environment, compounded by a complex and seemingly contradictory information environment, messages can become muddled or confusing to the public, as was seen with the 2022 COVID-19 boosters (Atanasov et al., 2023). In addition, the introduction of three new vaccines to the adult population, which is not used to receiving as many vaccines as children do, may be challenging.

This rapid expert consultation provides guidance directed at mitigating morbidity and mortality associated with COVID-19, flu, and RSV this fall. This guidance addresses communicating with adults about the safety of the vaccines for these illnesses, the integration of the updated COVID-19 vaccines into ongoing public health efforts, and the effectiveness and safety of the new RSV vaccines. It also provides guidance on overcoming accessibility challenges. Provided as well is specific guidance on communicating with historically marginalized and minoritized communities.⁵

FALL 2023 VACCINATIONS FOR COVID-19, FLU, AND RSV

The vaccines currently available for COVID-19 are updated (2023–2024 formula) vaccines from Pfizer-BioNTech and Moderna that have been recently authorized for emergency use and recommended for everyone 6 months and older.⁶ These updated COVID-19 vaccines are designed to protect specifically against the Omicron variant XBB.1.5, with the hope that it will also have crossover

__________________

protection against other variants. The updated COVID-19 vaccines are also recommended for pregnant people, based on evidence from earlier COVID-19 vaccines that show that vaccination is safe, effective, and beneficial to both the pregnant person and the baby and that the benefits of receiving a COVID-19 vaccine outweigh any potential risks (Lipkind et al., 2022; Moro et al., 2022; Shimabukuro et al., 2021). The updated COVID-19 vaccines are manufactured using the same process as the original vaccines and the 2022 COVID-19 bivalent boosters; as such, they will be as safe and effective⁷ against severe illness, hospitalization, and death, although not necessarily transmission as were the original and boosters.⁸

Recent data indicate differences in the uptake of initial COVID-19 vaccines and the 2022 COVID-19 bivalent boosters. While approximately 70% of Americans completed the initial round of vaccinations, only 17% of the population received the bivalent booster dose recommended for fall 2022 (CDC, 2023a; KFF, 2023). Notably, the Centers for Disease Control and Prevention’s (CDC’s) COVID-19 vaccination distribution and coverage tracker reported that smaller percentages of Black and Hispanic adults (9.5% and 9.1%, respectively) received the bivalent booster compared with White adults (16.7%) (CDC, 2023b). These data highlight the importance of encouraging uptake of the fall 2023 COVID-19 vaccine within those racial/ethnic groups.

The annual flu vaccine effectively reduces hospitalizations and deaths (CDC, 2023c).⁹ Its effectiveness varies annually depending on several factors, such as the age and health of the recipient, the types and subtypes of circulating flu viruses, and the degree of similarity between circulating viruses and those included in the vaccine (Grohskopf et al., 2022). Yet the flu vaccine remains vital in preventing flu-related illnesses (Nypaver et al., 2021)¹⁰ and reducing illness severity in people who get vaccinated but still get sick.¹¹ Despite the universal recommendation for flu vaccination,¹² coverage remains low (CDC, 2021; O’Halloran et al., 2017),¹³ particularly among younger adults and within Black, Hispanic, and Native populations¹⁴ (CDC, 2022a). The CDC recommends that pregnant people receive flu and COVID-19 vaccines. These recommendations are based on vaccine safety data (Grohskopf et al., 2023; Moro et al., 2017, 2022).

The Food and Drug Administration (FDA) recently approved two vaccines designed to prevent RSV in older adults (Melgar et al., 2023). Each of these vaccines, Arexvy and Abrysvo,¹⁵ is administered in a single dose and has been proven safe¹⁶ and efficacious in clinical trials¹⁷ (Papi et al., 2023; Walsh et

__________________

al., 2023). The CDC recommends these vaccines for adults aged 60 and older in the context of shared clinical decision making (CDC, 2023d).¹⁸ Shared clinical decision making means these “recommendations are individually based and informed by a decision process between the health care provider and the patient or parent/guardian” (CDC, 2020b, para. 3). The RSV vaccines were approved for use under shared clinical decision making to allow flexibility for providers and patients based on individual needs, given the fact that, while for some individuals over age 60 the benefits of getting the RSV vaccine outweigh the risks, for others they do not (Melgar et al., 2023).

Because these RSV vaccines are new to the market and people will need to consult with their provider or pharmacist before they can receive them, healthcare providers and the public need education about the vaccines’ efficacy and safety, including how they were tested and what is currently known and not known about the vaccines, as well as education about how, when, and where the vaccines can be accessed.

Coadministration of vaccines

Coadministration of vaccines is a common practice for childhood immunization schedules, but less so for adults (Bonanni et al., 2023). While there is not much data on coadministration, the currently available safety data for coadministration of flu and COVID-19 vaccines indicate no concerns (Izikson et al., 2022; Lazarus et al., 2021; Toback et al., 2022). A CDC study showed that people who received a flu vaccine and an mRNA COVID-19 booster vaccine at the same time were slightly (8–11%) more likely to have reactions, including fatigue, headache, and muscle aches, compared with those who got only a COVID-19 mRNA booster vaccine. However, these mild reactions quickly disappeared (Hause et al., 2022). The Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization (CDC, 2023d) considers coadministration of the RSV vaccines and other adult vaccines acceptable, although coadministration of the vaccines may carry some risks, with mixed evidence on the risks of increased reactogenicity (i.e., the common reactions that occur soon after vaccination, including pain, redness, swelling, fever, headache, or rash) (Melgar et al., 2023). While there are no data on the coadministration of vaccines for pregnant people, routine vaccinations for flu (inactivated or recombinant) and COVID-19 vaccines are recommended (CDC, n.d.)

Coadministration has several potential benefits, including improved patient convenience and compliance, simplified immunization schedules, fewer missed opportunities to vaccinate, reduced costs, and logistical advantages (Bonanni et al., 2023; Gilchrist et al., 2012; Skibinski et al., 2011). At the same time, individuals may be hesitant to receive multiple vaccines concurrently for fear of potential side effects, unforeseen reactions, or perceived stress on the body and immune system.

Challenges with vaccine uptake

The low uptake of the 2022 bivalent COVID-19 booster and annual flu vaccines can be attributed to individuals’ feelings and perceptions and to community factors such as social norms and issues of access. Demographic characteristics associated with vaccine uptake include age, engagement with biomedicine research, geographic location, health insurance coverage, political affiliation, race and ethnicity, religion, and socioeconomic status (Ashwell et al., 2021; Callaghan et al., 2021; Hussain et

__________________

al., 2018; Lau et al., 2009; Lu et al., 2015a).

Inequity in vaccine uptake, especially differences by race and ethnicity and socioeconomic status, are a particular concern. Such inequities can be due to a lack of access (e.g., lack of insurance, lack of transportation, lack of health care providers in an area) and/or institutional and interpersonal racism and prejudice (Black et al., 2022; Callaghan et al., 2021). A CDC study found that adults with insurance, a health care provider, and a recent medical checkup, for example, were more likely to receive flu vaccines than adults without these resources (Black et al., 2022). Barriers to vaccine uptake also include lack of access due to deficits in economic stability, neighborhood and built environment, and health care quality that may lead to people being unvaccinated, but not by choice (Viswanath et al., 2021a). These circumstances may be particularly pertinent for the RSV vaccines, which are currently covered only by certain forms of insurance.¹⁹ Historic injustices (e.g., the Tuskegee Syphilis Study), long-standing mistreatment in medical settings (Callaghan et al., 2021), and reduced trust in health care systems writ large (Brunson et al., 2021), can also play a role in creating situations that make vaccine uptake less likely in some populations.

Recent ethnographic research within Black and Hispanic/Latinx communities across the United States, for example, found that trust in the systems administering and recommending COVID-19 vaccines played an important role in individuals’ decisions to be vaccinated (Brunson et al., 2021). In this and other, similar contexts, it is essential for health care providers, public health officials, and government representatives to consciously build trust with communities over time; trust in health care systems, governments, and other institutions cannot be taken for granted.

Public health messaging emerged as another particular challenge with the COVID-19 vaccines. During the pandemic, the constant influx of communication about COVID-19 (including, but not limited to, public health communications) resulted in desensitization and decreased receptivity to further messages (Guan et al., 2022). As the COVID-19 public health emergency evolved, this situation led to an increasing sense of fatigue. Along with this, a lack of urgency developed around COVID-19 and COVID-19 vaccines. This stemmed from perceptions that COVID-19 was not as risky as initially thought and that only people with certain characteristics (e.g., older age) were vulnerable. This lack of urgency in turn may have led to some individuals underestimating the risks of not being vaccinated (Phillips et al., 2022; Viswanath et al., 2021b).²⁰ The perceived risk of the COVID-19 vaccines was another factor contributing to low uptake. In some cases, concerns regarding minor short-term side effects, unspecified long-term side effects, and confusion over public health communications on side effects might have contributed to people not being vaccinated (Adu et al., 2023; Phillips et al., 2022). Addressing these interrelated factors is vital to effective public health communication efforts.

The COVID-19 pandemic also brought renewed attention to the general issue of misinformation and disinformation.²¹ Vaccine confidence falls along a continuum and can shift during life events or as people receive accurate information or misinformation (McDonald, 2015; National Vaccine Advisory Committee, 2014). Although the impacts of medical and scientific misinformation and disinformation on vaccine uptake have long been recognized, the relatively rapid development of the COVID-19 vaccines compared with other vaccines and the increased reliance on social media during the pandemic amplified their effects (Lee et al., 2022; Skafle et al., 2022). A critical challenge for decision

__________________

makers, then, is providing reliable and accurate information about vaccines in an environment rich with persuasive misinformation and disinformation (Broniatowski et al., 2020).

STRATEGIES FOR THE FALL 2023 VACCINATION SEASON

As noted, fall 2023 marks the first time COVID-19, flu, and RSV vaccines will be available in the same season. While this simultaneous availability may benefit some communities familiar with and accepting of these vaccines, there may be missed opportunities for groups that are vaccine skeptical, those that are unaware of vaccine availability, and those that have difficulty accessing the vaccines. The situation presents complex challenges that include the following:

• Public awareness and understanding of the three vaccines: Will the public recognize the importance of each vaccine? How will the potential overlap of symptoms of COVID-19, flu, and RSV affect public understanding?
• People’s motivations to get vaccinated: Could negative sentiments about one vaccine influence perceptions of the others? Will the complexity of deciding among the three vaccines lead to decision fatigue and avoidance?
• Vaccine accessibility: What challenges will arise in coordinating vaccination schedules and ensuring the availability of all three vaccines? How will health care providers manage the increased demand for the three vaccines and associated strain on resources? How will inequities in vaccine access manifest and be addressed? How will the cost for those who are not insured affect uptake?

It is beyond the scope of this rapid expert consultation to delve deeply into all of these issues. Instead, the focus is on potential strategies for the coming fall season, including communication about vaccine availability and practical measures for overcoming accessibility challenges. The current broader context of COVID-19—its co-occurrence with flu and RSV— looms large, and there is a danger that people who are ambivalent or hesitant about the COVID-19 vaccine will generalize those concerns to the other vaccines. Thus, while many implementation and communication strategies apply to all three vaccines, it will be necessary in some cases to use strategies that are clear in the differences among the three illnesses, the benefits of the different vaccines, and the priority groups for whom the vaccines are authorized and recommended. For example, the focus for RSV vaccines, which are currently recommended for certain adults aged 60 years and older and are fairly new, will be different from the historically available flu vaccines, which are recommended for those aged 6 months and older, and from the updated COVID-19 vaccines, which are part of the evolving COVID-19 vaccine landscape since 2021 and will probably be recommended for those aged 6 months and older.

Communication Strategies for COVID-19, Flu, and RSV Vaccines

The communication design principles set forth in previous National Academies rapid expert consultations—Strategies for Building Confidence in the COVID-19 Vaccines; Understanding and Communicating About COVID-19 Vaccine Efficacy, Effectiveness, and Equity; and Communication Strategies for Building Confidence in COVID-19 Vaccines: Addressing Variants and Childhood Vaccinations—still apply for the fall 2023 season. These strategies include providing authoritative evidence with transparency if uncertainties remain about vaccine safety and efficacy, testing messages to see how well they work, and improving the messages using feedback from the testing (NASEM, 2021a,b,c). This previous work has shown that “the effectiveness of communications depends on their process and content: people respond to both how they learn about something and

what they learn about it” (NASEM, 2021a, p. 8). Process factors that influence the success of pro-vaccine communications include the timing of the message, the channel or medium through which the message is delivered (e.g., mail, social media, broadcast media, radio, community and faith-based organizations), the source of the message and the messenger (e.g., experts, health professionals, officials, family members, celebrities, trusted community leaders and members), and the tone of the message (e.g., sympathetic, authoritative, condescending) (Motta et al., 2021; NASEM, 2021a; Taylor & Lurie, 2004). The content of communications, including relevance, accuracy, authority, uncertainty, usability, comprehensibility, cultural competence, and linguistic appropriateness, is also a key factor (Breakwell, 2014; FDA, 2011; NASEM, 2017).

Communicate with Transparency and Openness

According to a previous National Academies rapid expert consultation, “public engagement is critical to overcoming mistrust and building confidence,” and it is “more likely to be impactful if the process is established and designed so that public values can be translated into practice and policy” (NASEM, 2021b, p. 6). Achieving this aim requires clear and transparent communication with the public about the vaccine development process—including clinical trials and the approval process, as well as any updates, changes in recommendations, or new findings—to foster clarity and maintain public trust (NASEM, 2021b). Furthermore, for the three illnesses that are the focus here, information should be presented in a way that clearly highlights the differences in susceptibility to infection and the consequences of not getting vaccinated. Providing regular updates on safety and efficacy data, both positive and negative,²² to build trust and confidence among the public is especially relevant for the new RSV vaccines and the updated COVID-19 vaccines, since safety and efficacy data continue to be collected and reported, and these vaccines are less familiar to the public relative to older vaccines. Initial communications regarding the RSV vaccine, which is new, can benefit from open dialogue about the knowns and unknowns, using crisis communications principles of empathy, promoting actions and respect, and being culturally sensitive instead of generic (Betsch et al., 2012; Larson et al., 2011; Lu et al., 2015b). In designing communications, it is essential to be clear on the:

• “What” (i.e., the importance and benefits of the vaccines, including their effectiveness in preventing hospitalizations and deaths, their availability, and the risks of contracting the diseases for those at high risk);
• “Why” (i.e., the reasons for designing the communication, including raising awareness, encouraging vaccination, and promoting health practices);
• “Who” (i.e., to whom is the communication targeted—for instance, pregnant people, older adults, younger children, or those who are immunocompromised); and the
• “When” (i.e., the timing of vaccination, such as before the flu/RSV seasons while or whenever updates are available, and year-round for COVID-19, since its seasonality is not yet known).

Each of these elements shapes how communication is designed and implemented. For example, pregnant people might be more receptive to communications that focus on the safety of the vaccines during pregnancy,²³ and those who are immunosuppressed might be more receptive to communications that show the protection the vaccine offers to similar people. In light of the slow uptake of the 2022 COVID-19 boosters, there is a danger that people ambivalent about those boosters will generalize those concerns to the RSV vaccine. Myths and perceptions about the flu

__________________

vaccine might also extend to the RSV vaccines. As noted earlier, then, it is essential to design communications that are clear about the differences among the three illnesses and the distinct benefits of the different vaccines.

Use New Data to Highlight Susceptibility to Infection

Individuals tend to abide by their prior decisions, whether expressed verbally or through action (Cialdini, 2021). Persuading them to deviate from those decisions by suggesting that they were mistaken is challenging, as it draws into question their self-perceptions as sound decision makers (NASEM, 2021c). Instead of telling unvaccinated individuals they made an incorrect decision, present them with new, relevant information that highlights recent events, allowing them to reconsider their initial stance given a changed environment (NASEM, 2021c).

For the updated COVID-19 vaccines, communication about new information or events could include how the vaccines target variants; an uptick in cases, hospitalizations, and deaths; and new information about the continued safety and efficacy. The uptick information—which currently shows that those aged 60 years and older are being hospitalized more than other groups—might be used to encourage uptake among this age group. For the flu vaccine, such communication might include highlighting the burden of disease that the vaccine has prevented in the past years and the increase in uptake of flu vaccination seen during the COVID-19 pandemic (Kuehn, 2021).²⁴

For all three illnesses, present information in a way that clearly highlights the susceptibility to infection and the potential risks of not getting vaccinated. For COVID-19, for example, people may feel that the worst is over and there is no need to be vaccinated. The same is true for the flu; people who usually do not get vaccinated may feel that nothing bad has happened to them before, so there is no need to worry. These perceptions are strengthened by people’s tendency to favor information that confirms their existing beliefs while rejecting facts that contradict those beliefs (Azarpanah et al., 2021; Blumental-Barby & Krieger, 2015). Accordingly, frame information to align with the general worldview of the target audience to reduce the dissonance that can trigger confirmation bias²⁵ (Azarpanah et al., 2021; Blumental-Barby & Krieger, 2015).

Use Trusted Messengers

As previously discussed, the “what,” “why,” “who,” and “when” are essential components of effective vaccine communications; however, another “who” also matters—who delivers the information. When trusted individuals share messages people can be more receptive to the information (NASEM, 2021a; Shen et al., 2023). While the individuals regarded as trusted sources vary, trusted messengers are typically those with preexisting connections within communities who are often looked to for guidance, information, or support.

Examples of trusted messengers include religious leaders, such as pastors, who previously have shared messages about the human papilloma virus vaccine effectively (Lahijani et al., 2021); farmers and other local leaders, such as those who addressed questions about COVID-19 in cooperation with the Michigan State Extension Office (Williamson et al., 2021); and community nonprofits, such as the disability rights groups and immigration rights organizations in Wyoming that fostered trust between communities of color and state health officials to promote COVID-19 vaccination (LeBlanc et al.,

__________________

2021). These relationships were made possible through long-term, equitable partnerships with public health departments and others.

Health care providers can also be powerful and effective trusted messengers. Research has shown that a recommendation from a health care provider is a strong motivator of vaccine uptake (Brewer, 2021; Brewer et al., 2017). In a study of flu vaccination in adults, for example, patients who reported receiving a recommendation and offer for the flu vaccine during their office visit were 1.76 times more likely to get vaccinated than those who did not receive a similar recommendation (Benedict et al., 2017).

Tackle Misinformation and Disinformation

The persistent spread of false information related to vaccines, in general and aimed specifically at particular groups, has amplified vaccination reluctance (NASEM, 2021c; Neely et al., 2022), particularly for the COVID-19 and flu vaccines. Misinformation refers to false or inaccurate information that is unintentionally shared or spread without malicious intent; disinformation involves deliberate deception or manipulation produced and spread for deceptive purposes (Vraga & Bode, 2020). Research in risk communication indicates that addressing misinformation and disinformation effectively necessitates public messaging that:

• provides reliable, precise, and unequivocal details that acknowledge uncertainty through trusted official mediums;
• offers consistent messaging, ensuring that public figures convey unified messages that avoid overwhelming the public, even if the details are still evolving, and engage in open dialogue about the current situation;
• ensures that accurate information is made available quickly and widely;
• optimizes communication content for searches on the internet to ensure that vaccine information can be accessed easily, enforces community standards, uses warning labels for misleading posts, and implements surveillance algorithms; and
• presents information on vaccine safety and efficacy from authoritative sources such as the CDC and highlights medical consensus on vaccine safety (Berkowitz & Vann, 2023; Finnegan et al., 2018; Galvão, 2021; Nyhan & Reifler, 2015; Organisation for Economic Cooperation and Development, 2020; Van der Linden et al., 2015; Vraga & Bode, 2017).

For the RSV vaccines, there is an opportunity, from the start, to follow the successful practice of providing accurate, clear, accessible, and tailored educational materials that avoid overly technical language. Such information can aid in informed decision making, help in tackling misinformation and disinformation, and improve vaccine acceptance. For pregnant people, it is important to address concerns and myths that include vaccines causing infertility or increasing the risk of miscarriage or stillbirth.

Strategies for Overcoming Accessibility Challenges

Effective communication alone is insufficient to increase vaccine uptake; the vaccines must be accessible to all individuals, regardless of socioeconomic, geographic, or demographic background. Historically, barriers to access have resulted in disparities in vaccine distribution and uptake. These barriers include logistical hurdles (such as lack of transportation to vaccination sites, difficulty in scheduling and remembering vaccinations, financial costs to obtain the vaccinations, and the need for multiple appointments), language barriers, and sociocultural and attitudinal impediments (such as mistreatment, mistrust, and misinformation). Addressing these challenges requires a multifaceted and

holistic approach.

Ensuring Equity in Vaccine Accessibility

Ensuring equity is crucial for vaccines to be accessible so that all individuals have equal opportunity to benefit from vaccine protection, irrespective of their socioeconomic, racial, ethnic, age, or geographic background. Access barriers affect historically marginalized communities as well as other adults who might have limited mobility due to age or disability, lack transportation to vaccination sites, or do not live near health care facilities (Kuehn et al., 2022; Schneeberg, et al., 2014). Strategies for ensuring equity include (Assomou et al., 2022; Dada et al., 2022; NASEM, 2020):

• community engagement and education,
• prioritizing of groups disproportionately impacted by illness and communities hit hardest by health disparities,
• mobile vaccination units,
• integrating vaccination with routine care (e.g., having flu vaccinations with routine antenatal care has been seen to increase vaccine uptake amongst pregnant people [Swamy & Heine, 2015]),
• flexible days and times for vaccine administration,
• measures that address transportation and cost barriers,
• involvement of representatives from diverse communities, and
• leveraging of digital platforms.

Necessary as well is recognizing broader structural issues that can influence vaccine uptake, including lack of access to health care, housing instability, and food insecurity (Njoku et al., 2021; Peña et al., 2023).

Questions of accessibility are fundamental to encouraging people to get vaccinated. The more accessible a vaccine is, the higher its uptake will be. Some successful interventions for increasing access include reducing the distance to vaccination sites, offering home visits or mobile clinics, and eliminating cost barriers. The Vaccine Outreach Program in Davidson County, Tennessee, for example, provides free flu vaccinations to uninsured, unemployed, and unhoused individuals with high barriers to vaccination (Brown et al., 2021). A similar program conducted from 2011 to 2014 in Rockford, Illinois, used college students majoring in healthcare professions to implement mass vaccination campaigns, taking vaccines directly to economically disadvantaged, at-risk, medically underserved, and uninsured individuals. This program led to a 459% increase in total flu vaccinations in Rockford (Hays et al., 2018).

Another important dimension of the equity issue is addressing “communication inequalities—the differences in how individuals or groups access, engage with, process, and act upon health information,” which potentially contribute to health disparities (Viswanath et al., 2021b, p. 426). Examples of strategies employed during the COVID-19 pandemic include work within Latinx communities aimed at providing clear information on vaccine access, including booking information, in Spanish; offering answers on vaccine development and safety; clarifying details on eligibility, citizenship, and health insurance through multimedia campaigns; highlighting testimonials; and connecting people with community workers (Demeke et al., 2023).

Improve Provider- and System-Based Interventions

For individuals who can access health care, improving how healthcare providers and health systems

promote and deliver updated COVID-19, flu, and RSV vaccines can significantly affect vaccination rates. Interventions to this end include reminders for providers about patient vaccinations, and use of electronic health records (EHRs) and standing orders. Research has shown that such interventions with multiple rather than single components are more effective at improving vaccination rates (Lau et al., 2012). An example is the 4 Pillars Program, which focuses on convenience, patient communication, enhanced office systems, and staff motivation (Hawk et al., 2017). Evaluations of the 4 Pillars Program have shown that it increases uptake of flu, Tdap, and pneumococcal vaccines in older adults (Hawk et al., 2017; Nowalk et al., 2014; Zimmerman et al., 2017).

Studies on reminder systems and recall strategies have continually shown that provider reminders improve flu vaccination rates (Thomas & Lorenzetti, 2018). For example, a large hospital used a flu vaccine screening tool to identify eligible patients and generate a physician order notification, leading to a 44% postintervention vaccination rate compared with 6% preintervention (Duvall, 2019). An evaluation of randomized controlled trials using the University of California, Los Angeles (UCLA) Health COVID-19 patient reminder program (which used text messaging) found that reminders boosted appointment rates by 6% and vaccination rates by 3.6% within the health care system (Dai et al., 2021). In those randomized controlled trials, messages that included ownership language, such as “a vaccination is reserved for you,” performed the best compared with the control group, as did messages that included an educational video (Dai et al., 2021). Adopting similar reminder messages might help encourage the uptake of RSV vaccines. However, messaging may be limited on its own in encouraging vaccination, and so needs to be accompanied by other strategies (Rabb et al., 2022). Other studies have shown the potential of using SMS [short message service] education paired with reminders to increase vaccination rates (Panda et al., 2011; Yudin et al., 2017).²⁶

Another way to identify unvaccinated patients, send reminders, and track vaccination status is through EHRs, which has, for example, effectively increased provider outreach by prompting them to reach out to those due for a vaccine (Heintzman et al., 2014). This finding aligns with work showing that patient tracking/recall/outreach and provider prompts are successful in increasing rates of seasonal flu vaccination, particularly among seniors (Humiston et al., 2011; Hurley et al., 2018). A study among seniors aged 65 and older in New York found that these strategies increased their seasonal flu vaccination rates (Humiston et al., 2011).

Research has demonstrated that standing orders significantly increase adult vaccination rates through allowing nonphysician personnel to vaccinate patients without physician involvement (Albert et al., 2012; Zimmerman et al., 2009). A review of the effectiveness of interventions to improve uptake of the flu vaccine among pregnant people found that nudge-based interventions, such as provider prompts and standing orders, that build on favorable intentions to vaccinate were significantly successful in improving uptake (Ellingson et al., 2019).

Increase Community Demand

Given the historical disparities in vaccination rates and the adverse outcomes for communities that have been subject to structural racism in the health care system and underreached by health communication, increasing community demand for vaccines is essential. Community-based campaigns that are cocreated or intentionally designed with priority audiences, that are culturally sensitive, have community buy-in, and include partnerships with community-based organizations can

__________________

potentially increase vaccination rates among marginalized populations (Demeke et al., 2023; Vlahov et al., 2007).

Any intervention to increase community demand needs to be culturally tailored. An example is the community campaigns designed by the Ad Council, the American Medical Association, and the CDC tailored to reach Black and Hispanic audiences, which feature culturally responsive content shared through commonly used and trusted communication channels (Black et al., 2022). The project provides tools and resources designed together with organizations like the Black Coalition Against COVID-19, NAACP, National Alliance for Hispanic Health, National Hispanic Medical Association, National Medical Association, National Urban League, UnidosUS, and the United States Hispanic Chamber of Commerce. Some of the communication channels used by the projects include the National Faith Steering Committee (which includes 20 highly influential faith leaders across the Black and Hispanic faith communities) and custom social media platforms spreading the “It’s Up to You” message in seven languages (English, Spanish, Simplified Chinese, Korean, Russian, Haitian Creole, and Vietnamese). After 2 years, an evaluation of the campaign showed a decrease in concerns about the risks or side effects of the flu vaccine among Black (43% to 33%) and Hispanic (41% to 32%) adults (Black et al., 2022). Reaching populations at elevated risk entails tailoring interventions for at-risk racial and ethnic groups by understanding differences among groups and contexts and identifying missed vaccination opportunities. The second CommuniVax²⁷ report provides strategies to employ with communities of color that include using wording that is meaningful to them, working with respected community members to share information, and acknowledging the concerns and barriers that exist within the community (Brunson et al., 2021).

CONCLUSION

The convergence of the COVID-19, flu, and RSV respiratory illnesses in fall 2023 demands a comprehensive and coordinated approach to vaccine uptake. This approach needs to focus on clear, transparent information that addresses each vaccine’s unique characteristics and on issues of access, particularly among communities that have historically been marginalized and bear a disproportionate burden of these diseases. Trust in vaccines can be fostered by acknowledging and working to address structural inequalities, engaging with communities in a culturally responsive manner, and implementing community-based initiatives. Collaboration with trusted community leaders and healthcare providers can foster vaccine confidence among marginalized populations, along with equitable vaccine distribution and uptake.

SEAN is interested in your feedback. Was this rapid expert consultation useful? Send comments to sean@nas.edu or (202) 334-3440.

__________________