Relatively speaking, 2023 has been the least dramatic year of COVID living to date. It kicked off with the mildest pandemic winter on record, followed by more than seven months of quietude. Before hospitalizations started to climb toward their September mini-spike, the country was in “the longest period we’ve had without a peak during the entire pandemic,” Shaun Truelove, an infectious-disease modeler at Johns Hopkins University, told me. So maybe it’s no surprise that, after a year of feeling normalish, most American adults simply aren’t that worried about getting seriously sick this coming winter.
They also are not particularly eager to get this year’s COVID shot. According to a recent CDC survey, just 7 percent of adults and 2 percent of kids have received the fall’s updated shot, as of October 14; at least another 25 percent intends to nab a shot for themselves or their children but haven’t yet. And even those lackluster stats could be an overestimate, because they’re drawn from the National Immunization Surveys, which is done by phone and so reflects the answers of people willing to take federal surveyors’ calls. Separate data collected by the CDC, current as of October 24, suggest that only 12 million Americans—less than 4 percent of the population—have gotten the new vaccine, according to Dave Daigle, the associate director for communications at the CDC’s Center for Global Health.
CDC Director Mandy Cohen still seems optimistic that the country will come close to the uptake rates of last autumn, when 17 percent of Americans received the updated bivalent vaccine. But for that to happen, Americans would have to maintain or exceed their current immunization clip—which Gregory Poland, a vaccine expert at Mayo Clinic, told me he isn’t betting on. (Already, he’s worried about the possible dampening effect of new data suggesting that getting flu and COVID shots simultaneously might slightly elevate the risk of stroke for older people.) As things stand, the United States could be heading into the winter with the fewest people recently vaccinated against COVID-19 since the end of 2020, when most people didn’t yet have the option to sign up at all.
This winter is highly unlikely to reprise that first one, when most of the population had no immunity, tests and good antivirals were scarce, and hospitals were overrun. It’s more likely to be an encore of this most recent winter, with its relative calm. But that’s not necessarily a comfort. If that winter was a kind of uncontrolled experiment in the damage COVID could do when unchecked, this one could codify that experiment into a too-complacent routine that cements our tolerance for suffering—and leaves us vulnerable to more.
To be fair, this year’s COVID vaccines have much been harder to get. With the end of the public-health emergency, the private sector is handling most distribution—a transition that’s made for a more uneven, chaotic rollout. In the weeks after the updated shot was cleared for use, many pharmacies were forced to cancel vaccination appointments or turn people away because of inadequate supply. At one point, Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego, who’s been running COVID and flu vaccination in her local community, was emailing her county’s office three times a week, trying to get vaccine vials. Even when vaccines have been available, many people have been dismayed to find they need to pay out of pocket for the cost. (Most people, regardless of insurance status, are supposed to be able to receive a free COVID-19 vaccine.)
The vaccine is now easier to find, in many places; insurance companies, too, seem to be fixing the kinks in compensation. But Abdul-Mutakabbir told me she worries that many of the people who were initially turned away may simply never come back. “You lose that window of opportunity,” she told me. Even people who haven’t gotten their autumn shot may be hesitating to try if they expect access to be difficult, as the emergency physician Jeremy Faust points out in his Inside Medicine newsletter.
Plus, because the rollout started later this year than in 2022, many people ended up infected before they could get vaccinated and may now be holding off on the shot—or skipping it entirely. And some Americans have simply decided against getting the shot. The CDC reported that 38 percent don’t plan to vaccinate themselves or their children; earlier this fall, more than half of respondents in a Kaiser Family Foundation poll said they probably or definitely wouldn’t be signing up themselves or their kids. More than 40 percent of those polled by KFF remain doubtful, too, that COVID shots are safe—dwarfing the numbers of people worried about flu shots, and even about RSV shots, which are newer than their COVID counterparts.
The consequences of low COVID-vaccine uptake are hard to parse. This year, like last year, most Americans have been vaccinated, infected, or both, many of them quite recently. COVID’s average severity has, for many months, been at a relatively consistent low. The last catastrophic SARS-CoV-2 variant—one immune-evasive enough to spark a massive wave of sickness, death, and long COVID—arrived two years ago. Barring another feat of viral evolution, perhaps these dynamics have reached something like a stable state, Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill, told me. So maybe the most likely scenario is a close repeat of last winter: a rise in hospitalizations and deaths that’s ultimately far more muted than any earlier in the outbreak. And the COVID-19 Scenario Modeling Hub, which Lessler co-leads alongside Truelove and a large cohort of other researchers, projects that “next year will look a lot like this year, whatever this year ends up looking like,” Lessler said.
But predictability is distinct from peace. COVID has still been producing roughly twice the annual mortality that flu does; roughly 17,000 people are being hospitalized for the disease each week. SARS-CoV-2 infections also still carry a risk, far higher than flu’s, of debilitating some people for years. “And I do think we’re going to experience a winter increase,” Truelove told me. Even if this year’s COVID-vaccine uptake were to climb above 30 percent, models suggest that January hospitalizations could rival numbers from early 2023. Go much lower than that, and several scenarios point to outcomes being worse.
Based on the limited data available, at least one trend is mildly encouraging: Adults 75 and older, the age demographic most vulnerable to COVID and that stands to benefit most from annual shots, also have the highest vaccine uptake so far, at about 20 percent. At the same time, Katelyn Jetelina, the epidemiologist who writes the popular Your Local Epidemiologist newsletter, points out that CDC data suggest that only 8 percent of nursing-home residents are up to date on their COVID shots. “That is what keeps me up at night,” Jetelina told me. Early National Immunization Surveys data also suggest that uptake is lagging among other groups that might fare less well against COVID—among them, rural populations, Hispanic people, American Indians and Alaskan Natives, the uninsured, and people living below the poverty line.
Last winter was widely considered to be a bullet dodged, and the reactions to the coming months may be similar: At least it’s no longer that bad. Since the winter of Omicron, the country has been living with lower vaccine uptake while experiencing lower COVID peaks. But those lower peaks shouldn’t undermine the importance of vaccines. Infection-induced immunity, past vaccinations, improvements in treatments, and other factors have combined to make COVID look like a gentler disease. Add more recent vaccination to that mix, and many of those gains would likely be enhanced, keeping immunity levels up without the risks of illness or passing the virus to someone else.
As relatively “okay” as this past year-plus has been, it could have been better. Missed vaccinations still translate into more days spent suffering, more chronic illnesses, more total lives lost—an enormous burden to put on an already stressed health-care system, Jetelina told me. For the flu, more Americans act as if they understand this relationship: This year, as of November 1, nearly 25 percent of American adults, and more than 20 percent of American kids, have gotten their fall flu shot. Most of the experts I spoke with would be surprised to see such rates for COVID vaccines even at the end of this rollout.
If last winter was a preview of future COVID winters, our behaviors, too, could predict the patterns we’ll follow going forward. We may not be slammed with the next terrible variant this year, or the next, or the next. When one does arrive, though, as chances are it will, the precedent we’re setting now may leave us particularly unprepared. At that point, people may be years out from their most recent COVID shot; whole swaths of babies and toddlers may have yet to receive their first dose. Some of us may still have some immunity from recent infections, sure—but it won’t be the same as dosing up right before respiratory-virus season with protection that’s both reliable and safe. Systems once poised to deliver COVID vaccines en masse may struggle to meet demand. Or maybe the public will be slow to react to the new emergency at all. Our choices now “will be self-reinforcing,” Poland told me. We still won’t be doomed to repeat our first full COVID winter. But we may get closer than anyone cares to endure.
