In January 2023, the U.S. FDA announced its plans for the future of COVID vaccination. COVID vaccines will follow the path of influenza vaccination, moving to a program of annual “boosters” that will be targeted to the latest dominant variant. The problem is that this approach does not work very well.
We learned this in 2005, when the U.S. Department of Health and Human Services launched the U.S. National Healthcare Reports, giving a first-ever performance review of the nation’s complex and often fragmented healthcare system. One key measure tracked was influenza vaccination. The findings were not favorable.
In 2005, just over half of all U.S. adults were vaccinated for influenza. Much worse, racial and ethnic minorities (Black and Hispanic) were significantly less likely get vaccinated for influenza: the gap was measured by double-digit percentage points. Poor households were also significantly less likely to be vaccinated. Consequently, minority populations were hospitalized due to influenza more than twice as frequently as white populations, with minority children hospitalized as high as four times more frequently. Unfortunately, since 2005 the U.S. has gotten worse at vaccinating for influenza, and these gaps for vulnerable groups have not improved and in some cases have gotten wider.
With the current U.S. Administration and many other countries adopting the stance that the COVID-19 pandemic “is over,” the expectation is that the governments will not be purchasing and distributing the vaccines. Instead, the U.S. and other countries will depend on “regular” systems to take over the public’s needs on COVID-19. Similar “ramp down” efforts will be underway at WHO and other organizations globally in 2023 with the global vaccination collaborative, COVAX, set to shut its doors this year.
But relying on existing systems to deliver on COVID vaccination is a weak plan, indeed. Since that 2005 first National Healthcare Report, the experience with influenza has been one of low vaccination rates, unfulfilled goals, and – in the U.S. and many countries – leaving the most vulnerable behind.
In view of this track record, it is risky just to turn COVID-19 over to the existing public health systems – the ones that have managed influenza vaccinations - unchanged and hope for the best. In the U.S. and globally, rather than mobilize more resources and community confidence for all vaccinations, COVID-19 has resulted in short-staffed immunization workforces, syringe shortages, and reductions in vaccine confidence.
According to UNICEF and WHO, we are at the lowest point in a decade in terms of numbers of children receiving routine immunization globally. Consequently, the past months have seen outbreaks of vaccine-preventable diseases killing children in countries from East Africa to Southeast Asia.
Recently, in 21 countries in the East and Southern Africa region, UNICEF counted 14 with major outbreaks. In the U.S., due largely to pressures on local health authorities because of COVID-19, childhood vaccination levels have fallen in some communities by as much as 20%.
What can be done? More funding is not likely. National and international resources to fill the gaps created by COVID-19 have dried up. If the U.S. is going to depend on existing systems, it is crucial to build on two areas where flu vaccination actually got it right.
First, targeted national programs focused on increasing access and quality in immunization can work. The expansion of vaccination coverage without cost-sharing for adults under the Affordable Care Act has significantly increased the percentage of adults who get influenza vaccination. New England boasts the largest gain in vaccinations, with Massachusetts vaccinating over 62% of adults in 2021.
Across the region and across the country, quality improvement programs operated over the past two decades and supported by the Centers for Medicare and Medicaid Services (CMS) have helped nursing homes significantly improve influenza vaccination rates for high-risk seniors and their caregivers.
Second, influenza vaccination programs have success when they include actually delivering safe and easy to use vaccinations to true community centers. For influenza, the delivery challenge has been reduced by expanding both the places and the workforce enlisted for immunization. Simpler and safer vaccination tools allow low- and middle-income areas to engage their community health workers in administering vaccinations. This approach also led to a shift for vaccination sites into workplaces, schools, churches, shopping centers, and markets, increasing rates and lowering hospitalizations.
The rise of the XBB variant in U.S. and elsewhere reminds us that we have to think longer term for COVID. It also reminds us that the next health danger may not be far away. It further reminds us that COVID-19 aggravated rather than improved existing health access inequities. In the U.S. and elsewhere, we have the chance to do better, but only if our new approach is not simply a return to business as usual.
Don Berwick is the former Administrator for the Centers for Medicare and Medicaid Services. Edward Kelley is the former Director of the National Healthcare Reports at the US Department of Health and Human Services and now serves as chief global health officer of ApiJect Systems Corp., which focuses on injectable medicines.