Resolve to Save Lives

Troubleshooting Complex COVID-19 Vaccine Issues

Direction on how to quickly navigate and address challenging COVID-19 vaccine scenarios through clear, concise and scientifically accurate communication

As of October 2021, more than 66% of the US population 12 years and older has been fully vaccinated against COVID-19. Some challenges remain, including  vaccine refusal, hesitancy due to long-term safety concerns, and persistent lack of access in some communities despite ambitious campaigns by local, state and federal health authorities. Vaccination efforts have become increasingly complex due the recent Delta variant surge, the approval of booster doses, looming flu season in the U.S., and the pending approval of vaccinations for those under 11.

Key communication principle:  As the highly transmissible Delta variant continues to impact US communities, consistent messaging on vaccines and layered interventions, including mask-wearing as first line of defense needs to continue. Messaging should address confusion on changing mask mandates, COVID-19 fatigue, information on breakthroughs, and persistent vaccine hesitancy. Additional messaging may be necessary to target specific populations, particularly parents of children aged 5-11, pregnant people and others.

Scenario 1:

The public is experiencing general COVID-19 fatigue and conflicting messages around variants, breakthrough cases, and mask-wearing are leading to confusion and apathy.

Suggested Actions:

  • Continue to highlight the achievements made thus far in the U.S. When discussing continued risks, it’s important to first recognize the sacrifices, challenges and trauma that many people have faced over the past year and a half. Emphasis collective responsibility to further defeat COVID-19 surges.
  • Underscore the danger posed by the spread of variants, particularly the Delta variant.  Delta, now the dominant variant in the U.S., is more than twice as transmissible as previous variants detected in the U.S. In some states, Delta has led to higher hospitalization rates than in January 2021.
  • Highlight risks of new variants to teens and younger adults, who made up the largest share of infections and hospitalizations during the Delta surge.
  • Update communities on breakthrough infections and Delta. Emphasize that while breakthrough infections do happen, vaccinations largely prevent serious illness, hospitalization, and death.
  • Emphasize the impacts of long COVID syndrome on adults and children and how these can be avoided with vaccination of adults and adolescents, which reduce community prevalence and thus the risk of COVID-19 to unvaccinated children.
  • Continue to promote testing as a key tool to control the spread of COVID-19..
    • Underline the need for testing among vaccinated individuals if exposed or symptomatic.
    • Coordinate with testing providers (local government level/state/federally funded) to ensure that free testing is available and promote locations where individuals may get tested.
  • Continue to promote mask-wearing and social distancing among everyone, regardless of vaccination status, in areas with substantial transmission. Reinforce messaging on collective responsibility andlayering, and center mask messaging on reaching lower transmission levels.
  • Continue framing activities as higher and lower risk so that members of the public can make informed decisions. Consider adopting CDC guidance on daily activities and going out as well as  safer and higher risk activities with unvaccinated children.

Scenario 2:

Continued barriers including access to COVID-19 vaccines and vaccine hesitancy in the US.

There are various population groups in the US who remain hesitant to COVID-19 vaccines ranging from hesitancy in Black/African American and Hispanic/Latinx communities who have experienced transgenerational inequities, to communities who are vaccine skeptical, and those that may never vaccinate.

Suggested Actions:

  • Understand your audience, including reasons for hesitancy. There is no “one size fits all” strategy for effective vaccine communication so it’s important to first listen with empathy.
  • Continue to use strategies such as:
    • Acknowledging communities’ concerns as legitimate;
    • Asking existing community advisory groups for input on messaging, communication channels and building an inclusive communication plan. (See recommendations from NAACP and Langer Research Associates.)
  • Focus messaging and interventions on specific populations.Black and Hispanic/Latinx communities are not homogenous and different messages may be needed for different audiences/populations depending on urban/rural residence, religious beliefs, trusted information sources, perception of access etc.
  • Some Black and Hispanic/Latinx adults may have concerns over access to vaccines in their communities, needing to pay for vaccine, and ID requirements. To address these concerns, work with vaccine providers in geographic areas where vaccination rates are low and prioritize messaging about:
  • Pursue innovative and customized community mobilization/education strategies to address hesitancy.
    • Mobilize community members and structures by reaching out to faith- and community-based organizations, historically black colleges and universities (HBCUs), radio stations, employers, businesses to create coalitions to ramp up vaccinations in Black and Hispanic/Latinx communities
    • Organize COVID-19 Education Boot camps that work with community members to create a corps of grassroots trusted messengers who can influence family members andcolleagues, and hold conversations about vaccines at workplaces, places of worship and in other community settings to alleviate anxiety correct misperceptions..
    • Review strategies that have beenused across the country.
  • Work with providers to engage a broader network of health care professionals in vaccine delivery and prepare them to discuss COVID-19 vaccine with patients. While health care providers may sway some hesitant patients, they may feel challenged by others and exhausted by the burden of COVID-19.  Ensure that providers have support networks and can share ideas/resources.
    • Reach out to Black and Hispanic health provider networks in your area to devise communication strategies with them; promote resources created by the joint efforts of KFF, UnidosUS at the online platform The Conversation with videos, print resources, TV and social media tools available in Spanish.
  • Understand that some people/groups may be skeptical of vaccines and there are some community members who will not vaccinate.
    • Direct communications at other community members who may be swayed. Do not let the vaccine resistant individuals control the conversation. Review useful tips on how to address vaccine denial publicly.
    • Work with employers, government officials and communities to generate monetary, transportation or other incentives; according to KFF research, these may sway some resistant and/or “wait and see” individuals.
    • Incorporate messaging on the risks posed by the Delta variant (see Scenario 1), providing facts and avoiding fear mongering.

Scenario 3:

Pregnant people are hesitant to receive the vaccine. In addition, vaccination rates for pregnant people differ by race and ethnicity, with vaccination rates being lowest for Black and Hispanic pregnant people.

Suggested Actions:

  • Review the September 29, 2021  health advisory alert from CDC on COVID-19 Vaccination for Pregnant People to Prevent Serious Illness, Deaths, and Adverse Pregnancy Outcomes from COVID-19.
  • Emphasize the increased risks that  pregnant and recently pregnant people are at for severe illness from COVID-19 when compared with non-pregnant people. Pregnant people with COVID-19 are also at increased risk for preterm birth and might be at increased risk for other negative pregnancy outcomes.
  • Continue and increase efforts to reach and partner with communities to encourage and offer vaccination to people who are pregnant, recently pregnant (including those who are lactating), trying to get pregnant, or who might become pregnant in the future.
  • Expand vaccine equity outreach and strategies to increase vaccination rates in people from racial and ethnic minority groups who are pregnant, recently pregnant, trying to get pregnant now, or who might become pregnant in the future.
  • Encourage health care providers to offer and recommend COVID-19 vaccination to their patients and community members who are pregnant, recently pregnant,trying to get pregnant now, or who might become pregnant in the future.
    • Highlight that the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, the two leading organizations representing specialists in obstetric care, recommend that all pregnant people be vaccinated against COVID-19.
  • Work with community maternal health experts to produce messages and hold townhalls/discussions to answer questions about vaccine safety for pregnant people.
  • Share resources to promote accurate information about COVID-19 vaccines and pregnant people.

Scenario 4:

Schools safely remain open for in-person learning while building vaccine confidence in eligible youth and parents who are hesitant to vaccinate their children.
Children ages 12 and older have been approved for Pfizer COVID-19 vaccine. However, nearly 1 in 4 new cases of COVID-19 are in children.

Suggested Actions:

  • Continue to promote vaccination in eligible children ages 12 and older. Promoting vaccination can help schools safely return to in-person learning, extracurricular activities and sports.
  • Review the updated CDC guidance on safely returning to in-person instruction.
  • Provide guidance to local school districts, charter schools and private institutions on implementing interventions to help slow the spread of COVID-19 in schools, ranging from requiring masks regardless of vaccination status to testing strategies for staff and students. Testing guidance should highlight the need for confirmatory PCR testing if a person is symptomatic and rapid test results are negative.
  • Review a list of measures from the American Academy of Pediatrics that families and schools can take to keep institutions safe during the pandemic.
  • Emphasize the risks of complications posed by new variants and the risk of long COVID for young people and children.
  • Work with providers and public health stakeholders to incorporate COVID-19 vaccine into routine immunization and/or as a part of back-to-school health checks.
  • Work with community pediatric experts to produce messages and hold townhalls/discussions with parents and/or youth to answer questions about COVID-19 and the latest data on vaccinations for children, vaccine safety and efficacy, upcoming authorizations for youth, and safely returning to in-person activities.
  • Address concerns about myocarditis by referencing the May 2021 American Academy of Pediatrics Statement that cites the relative rarity and mildness of the condition among the already vaccinated; continue monitoring CDC Advisory Committee on Immunization Practices discussion on the issue.
  • Follow National Youth Poll, MyVoice to access data on vaccine acceptance and hesitancy among young people; establish opportunities for collecting similar data, facilitating Q&As with youth in your community.
  • Create youth-specific media/reach out to youth on platforms they use regularly, as exemplified by this toolkit from Minnesota.
  • Encourage colleges in your community to sign up for the COVID-19 Vaccine College Challenge.
  • Work with youth-centric organizations and create/tap into existing Youth Advisory Councils to understand how adolescents and young adults feel about the vaccine and what motivates them and their peers.; Ask questions about how youth’s choices and voice may influence parents and other members of the community.
  • Collect testimonials from parents in the community have had, or are eager to have,their children vaccinated.

Scenario 5: Preparing your community for additional doses or boosters.

Although vaccination remains highly effective against severe COVID-19, protection against mild and moderate COVID-19 infections may decline over time.

Suggested Actions:

  • Continue to reiterate that COVID-19 vaccines are effective, and that vaccines provide the best protection from the virus by reducing risk of severe disease, hospitalization and death, even against the widely circulating Delta variant

Create messaging that clearly differentiates the available COVID-19 vaccine options:

  • Additional dose (or “third shot”): additional vaccine protection that’s needed to help improve immune response when a person’s immune system likely hasn’t responded fully to the vaccine after the first doses (for example, people with moderately to severely compromised immune systems.)
  • Booster: an additional dose that’s needed to help prolong protective immunity in someone who responded fully after the first two doses, but may have waning protecton over time.Consider the following suggested messaging:
    • Additional doses authorized for immunocompromised people:
    • Currently, CDC recommends that moderately to severely immunocompromised people receive an additional dose of mRNa vaccines— Pfizer or Moderna— four weeks after the initial two doses.
    • Additional doses are available now. You should talk to your health care provider about your medical condition to determine whether getting an additional dose is appropriate for you.
    • Recent studies indicate some immunocompromised people don’t always build the same level of immunity even after getting both doses of either Pfizer or Moderna. Additional studies  show that fully vaccinated, immunocompromised people account for a percentage of hospitalized “breakthrough cases,” and may be more likely to transmit the virus to others in their home.Utilize communication toolkits and other publically available outreach resource documents when developing communication campaigns.

Boosters: Pfizer, Moderna, Janssen, mix and match:

Image credit: Durham Public Health

Image credit: NC DHSS

Scenario 6: Access to Monoclonal Antibodies infusion therapy [mAb]

There are continued barriers of health education and access to mAb treatment among Black/Hispanic populations.