A summary of presentations from the weekly Summit partner webinars

November 17, 2022 – The latest Summit Summary

Influenza and Bivalent COVID-19 Vaccine Confidence Report Summary Chris Voegeli (CDC)

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Chris Voegeli, PhD, MPH, National Center for Immunizations and Respiratory Diseases, CDC, presented on intent and perceptions of the updated booster and the annual flu vaccine. Dr. Voegeli is the acting vaccine confidence and demand lead in the Immunization Services Division.

Results from National Immunization Survey Adult COVID Module

The data for the survey was collected from October 9–15, 2022. This included a national representative sample of 8,723 participants over age 18. This survey first looked at bivalent COVID-19 booster status and the intent among adults who have completed the COVID-19 primary series by demographics. The study found that 32.2% definitely will get the booster, 15.3% have already received the booster, 19.5% are reluctant to get the booster, and 33% are reachable. As someone gets older, it seems more likely that they will get the vaccine.

The survey also looked at bivalent booster status and intent among adults who have completed the COVID-19 primary series by demographics. There are disparities that can be seen throughout COVID-19 in terms of people who have already received the vaccine. American Indian/Alaskan natives have the highest level of reluctance.

A healthcare provider’s recommendation is one of the strongest motivators. But if people don’t have insurance, then they most likely are not visiting a primary care provider, so they are less likely to get a recommendation and be vaccinated. Therefore, those without insurance have a lower chance of being vaccinated likely due, in part, to the missed recommendations.

Porter Novelli View 360 Survey

The data for the survey was collected from September 13–15, 2022. This included a national representative sample of 515 participants over age 18. Of those who received at least one dose of the COVID-19 primary series, 68% will definitely (45%) or probably get (23%) a/another COVID-19 booster dose. Seventeen percent are not sure, 7% will probably not, and 7% will definitely not get a booster.

When it comes to coadministration, of those who received at least one dose of the COVID-19 primary series and have not received their annual flu vaccine or updated booter (but are eligible), 78% said they would get (45%) or are somewhat likely (33%) to get a flu shot and COVID-19 shot at the same time. Those that make up the 22% leftover said that they are somewhat unlikely (15%) or very unlikely (7%) to get the flu shot and COVID-19 shot at the same time.

The top reasons that were given that make it more difficult for people to have the shots coadministered include concern for safety, no recommendation from a healthcare provider to coadminister, and not having enough information about coadministration. The cost wasn’t as big an issue for most people; however still a point of concern.

Literature shows that hesitancy around the COVID-19 vaccine applied to any vaccine and may or may not be related to the flu vaccine itself.

CDC’s State of Vaccine Confidence Insights: Bivalent Vaccine Report

The data for the survey was collected from August 30 to September 12, 2022. This report collects data from over 24 quantitative and qualitative data sources, which include digital media, social media, polls, peer-reviewed literature, CDC-INFO, web metrics, etc. Following the assessment, themes in stories in social media and google searches, for example, are identified using integrated and thematic analysis. Then, through a process called integrated analysis, the teams align the different sources and see how they are alike and different.

There is also a threat level assigned relative to the perceived threat to vaccine uptake and the degree to which it appears within and between the data sources. A theme that is positive and is common enough has the potential for increased vaccine confidence. One particular theme is for some health experts to suggest the combining messaging and promoting the uptake of the bivalent booster dose and the annual flu vaccine at the same time might not be effective for all people. There is no blanket strategy in terms of communication messages because that can be problematic in certain settings.

Theme 4: Some health experts and evidence suggest that combining messaging promoting uptake of the bivalent booster dose and the annual flu vaccine at the same time might not be effective for all people

First, there are the perceptions, concerns, and threats to vaccine confidence. One study that used CDC data found that the adult flu vaccine uptake decreased from 43.7% to 39.2% in states with the lowest COVID-19 vaccine uptake and only decreased after the COVID-19 vaccine was introduced. The authors of the article believe that this indicates that factors associated with COVID-19 vaccine confidence have carried over to affect flu vaccination rates. The researchers put all the states in quartiles based on their COVID-19 vaccination rates and plotted that with the annual flu vaccine uptake rate. Looking at 2019, the rates are very similar. By 2020 the uptake levels have decreased. By 2021 there is a stark difference where those in the first quartile with the lowest amount of COVID-19 vaccine uptake have taken a dip in flu uptake and states where there is a high uptake of COVID-19 vaccine have an increase in annual flu vaccination. It appears when people are more confident in one of the vaccines, they are more confident in the other, and vice versa.

Be aware of the audience. When trying to message states with high vaccine uptake, it could be appropriate to message coadministration. In states with low uptake, messaging coadministration may be a problem. The same study found that adult flu vaccine uptake increased from 49% to 53% in states with the highest COVID-19 vaccine uptake, and they found a strong, consistent association over time since October 2021 for COVID-19 vaccine uptake and intent of flu vaccine since July 2021 in both children and adults. This association didn’t seem to appear in those age 65+.

A CDC probability-based Omnibus panel survey found a meaningful percentage of people were concerned about possible safety and decreased effectiveness associated with coadministration. Forty-two percent think that it is less safe to get both vaccines at the same time. People are concerned that the symptoms will be worse at a magnitude greater than if they get the shots separately. There is also the concern that they will be less effective and might cause more short-term side effects.

The survey from 2021 also showed high correspondence between an intent for flu vaccination for the 2020–2021 season and COVID-19 vaccination intention. It also found that concerns about coadministration impacting the vaccines’ effectiveness and safety differed by age, gender, race, and ethnicity. For those age 65+, there is a higher concern in females than males, and Black/non-Hispanics and Hispanics have more concern about safety than white non-Hispanics.

HHS Current Events Tracker Wave 74 reports that only 46% of adults said they thought someone would find a message about getting a COVID-19 booster and a flu vaccine at the same time to be motivating as a reason to get a booster. Sixty-two percent said they thought someone would find a message mentioning the original COVID-19 strain and Omicron to be motivating to get a booster. Forty-seven percent of adults said they found the message referencing both strains to be motivating, compared to 79% of boosted adults. Around two-thirds of boosted adults found the message about colder weather motivating compared to 37% of unboosted adults.

Some states are not allowing people to advertise about the COVID-19 vaccines, so they are left to advertise about the flu vaccine and give guidance to their providers to take the presumptive approach or to try to convince people to get a COVID-19 vaccine when they come in. If the states can’t put out messages about one type of vaccine, then they have to make do.

Reference: Flu Vaccination: Using the Health Belief Model to Increase Vaccine Uptake


Q: How do we sign up to receive the CDC’s State of Vaccine Confidence Insights Report?

Chris Voegeli: You may email oqo2@cdc.gov to sign up for the State of Vaccine Confidence Insights Report.


Provider Organization Panel Discussion on Influenza Vaccination Promotion Activities and Challenges – Summit Partners


Panelists include: Ruth Francis (ANA), Jen Frantz (AAP), Pam Carter-Smith (AAFP), Becky Snead (NASPA), Marie-Michele Leger (AAPA), Mitch Rothholz (3C Consulting/APhA), Melat Aklilu (ACP), Sarah Carrol (ACOG), and Noel Smith (AAPA).

Ruth Francis (ANA): Every year the American Nurses Association (ANA) sends a notice out to its nurse members reminding them of the importance of getting their flu shot, especially for those who work in hospitals and long-term care facilities, and smaller offices. We stress leading by example and talk to them about protecting their patients, families, and community. This information also goes on our Healthy Nurse, Healthy Nation website, where we have not just nurses that participate in intervention but also non-members that might be other healthcare professionals. We have about 250K that participate in Healthy Nurse, Healthy Nation.

This is our third year in collaboration with Sanofi in an unbranded campaign titled Not Today Flu. This includes key ANA leaders, the president Dr. Ernest Grant, and a celebrity spokesperson, Jason Alexander. The toolkit that accompanies the campaign includes everything needed to launch a campaign of your own. It includes talking points and graphics for social media, newsletter templates, posters and fliers that can be distributed, and a one-minute video that features Jason Alexander talking about the importance of protecting yourself and your community from flu. You can find the toolkit at Nottodayflu.com.


Jen Frantz (AAP): The American Academy of Pediatrics (AAP) has many resources it’s sending out to pediatric practices and hospitals for families and the public. The communications department has developed a new campaign called Don’t Let the Flu Stop You, which started running in September and goes to the end of December. The campaign is being promoted through AAP and Healthy Children on social media. The campaign includes social media graphics, videos, and PSAs.

This year, we developed some new materials for practices on how to set up a flu vaccination clinic. We have many materials for pediatricians to help promote influenza vaccines and address vaccine confidence. Materials include posters, educational materials for parents, a video, and a parent education site (Healthychildren.org). The team will be writing new materials throughout the season depending on what’s happening with flu.

Some of the challenges we are facing are high rates of flu along with other respiratory diseases, which are leading to increased hospitalization rates, especially in those age 0–4. Other challenges are the spot shortages of Tamavir, low vaccination rates among children age 6 months–17 years, a surge in pediatric offices and hospitals, and mental concerns.

Rey resources:

Q: Are you seeing any efforts to push out more flu vaccines?

Jen Frantz (AAP): Yes, our campaign, Don’t Let the Flu Stop You, has really cute graphics that have also been translated into Spanish. Our Healthychildren.org also has a Spanish version. And through our pediatricians, we are promoting influenza vaccination. We are giving them the tools so that they can directly promote vaccination to their patients and caregivers, which has been effective. There are also AAP chapter initiatives across the country, so we are hitting clinicians and parents/patients on many levels. We are working toward translating our materials so we have many different languages to reach more populations.


Becky Snead (NASPA): The pharmacy community is seeing a mix of challenges this year. We are trying to encourage appointment-based vaccination when possible and trying to encourage coadministration of COVID-19 and flu vaccines to maximize the opportunity. A big challenge has to do with staffing, so we are shifting patients to appointments; however, we are not turning anyone away. We also see less demand, so pharmacists are trying to target their high-risk patients first and prioritizing by reaching out when they are getting their refills to make sure the conversation is not missed.

The hesitancy over COVID-19 vaccine has now spread into hesitancy over the flu vaccine. We can’t lose an opportunity if someone is coming in for the flu vaccine to also talk to them about getting their COVID-19 vaccine booster; however, we don’t want to have someone walk away from getting the flu vaccine when we bring that up. It’s a delicate conversation.

Pam Carter-Smith (AAFP): Here at the American Academy of Family Physicians (AAFP) we are actively disseminating resources and messaging to clinicians and patients about the importance of the flu vaccine during this respiratory season, especially as people are gathering for the holidays. As family physicians, we see patients with respiratory illnesses, and we make sure we remind them or recommend to them that they get vaccinated. We are developing resources that address misinformation currently circulating and are developing some guidance documents about the recommended vaccines that should be given based on certain age groups. I am developing a special report, which is a collection of the news articles that we have done over this current flu season, and we are also planning dissemination efforts. We are reminding people about RSV, COVID-19, and flu circulating and to get vaccinated when available. We are also sending information out to our state chapters to get down on the state and local levels.

We plan to promote during National Influenza Vaccination Week, in that critical time when people are gathering for the holidays to make sure they are vaccinated. We are working with our transition partners and collaborating with them in developing messaging so we can have one voice as we speak about the importance of getting vaccinated.

Some of our challenges are to try to tell people who have gotten so many COVID-19 boosters to now get a flu shot. They are sick of vaccines. We have to continue the message that it’s important to get vaccinated. People have become complacent, and when they become sick, they blame it on allergies and other things and then go out and spread disease.


Q: Is there a problem with getting kids in for appointments, or do pediatricians and family physicians have enough space to get kids in? And would it be worth health departments or school locations or other kids of vaccine clinics for children?

Pam Carter-Smith (AAFP): We haven’t heard of appointment issues yet. As people start gathering more, there will be a harder time getting in for appointments.

Mitch Rothholz (3C Consulting/APhA): We haven’t heard of any issue in the pharmacy. A lot of practices are using appointments, but if someone walks in, they are not turned away. 

Jen Frantz (AAP): I have not heard of patients not being able to schedule appointments. I would just like to add that we encourage learning how to set up a flu clinic to have extended hours. The workforce is very stretched these days, but we do recommend extended hours that are family-friendly, for example, weekend hours. 

Marie-Michele Leger (AAPA): I went to the pharmacy and there was no wait. I asked for the flu shot and five minutes later I was done. Delay was no issue.

Mitch Rothholz (3C Consulting/APhA): I think one of the things missing is educating the public. We are seeing some communities with patients coming in saying they are going away for the holidays. We need to reiterate that you need to allow two weeks for optimal protection. If they are going to travel during the holidays, they need to get vaccinated before they run out of time for protection. 


Marie-Michele Leger (AAPA): At the American Academy of PAs back in September, the PA Foundation, which is the philanthropic arm, published a blog addressing flu vaccination using the health belief model. Patients perceive susceptibility benefits to getting a flu vaccine, and as clinicians, they would use calls to action to engage the conversations.

The President met earlier in October with about eleven other organizations at the White House. There was a round table discussion addressing the flu vaccine, the COVID-19 vaccine, and how we can get the message out to patients. And, of course, who are the trusted voices that parents what to hear from. They want the professional organization to provide a message to their constituents and patients so that they can engage the patient in the discussion of getting the vaccine, whether it’s flu or COVID-19.

Documents that Dr. Romero sent from CDC were tailored to the constituents in all medical specialties and disciplines. This went to about 150K PAs across the country. The state chapters will tailor the templates and turn the message over to their own constituent to their PAs in each specialty.

In December, as part of National Influenza Vaccination Week, our president will have a message addressing the importance of PAs to be immunized against flu and also having their patients immunized against flu.


Noel Smith (AAPA): We developed a survey sponsored by Sanofi on awareness of the flu vaccine. The survey was sent to the PAs on September 12, 2022 (16 days after the ACIP flu recommendations were released), on the new flu recommendations. Findings show that 69% of PAs were somewhat aware already of the release of the ACIP recommendations. Considering the new recommendation for people age 65+, 80% were at least somewhat aware of the new recommendation. According to the survey, PAs were found to be 90% confident in their abilities to do education and counseling of patients on the impact of flu on patient healthcare outcomes. Sixty-five percent of PAs claimed to be somewhat confident in their abilities to overcome patient objections to the flu vaccine.

What PAs are hearing from their patients is that vaccines are not reliable and that they will get the flu/have side effects from the vaccine. They are also hearing that vaccines are used for political purposed and that they you can avoid getting sick without the vaccine.

When asked if PAs have more than one type of flu vaccine in their clinic, if they said they had, 75% said they were at least somewhat likely to make a recommendation for more than one flu vaccine targeted to their patient’s profile. When more than one vaccine isn’t available, it drops to 36% percent.


Melat Aklilu (ACP): At the American College of Physicians, we are doing a lot of the things that other organizations are doing. We have an influenza vaccination campaign, and at the start of the season, we sent out communications to our members highlighting the importance of continuing the recommendation. We also have social media campaigns and emails going out to our members as reminders. We have developed bite-sized resources providing basic practical strategies for increasing vaccine confidence and summarizing flu vaccine recommendations. We have also developed adult immunization referral resources to help our members and our sub-specialty partners who may not be carrying vaccines within their clinic to help facilitate a more effective and collaborative immunization referral process. We’re also sharing the communication template sent by Dr. Romero with our communications team, so they can tailor that for our state chapters.

Additionally, some of the challenges are that a lot of people are asking for ingredient lists of the flu vaccine. Patients are tired of vaccines and are scared of coadministration.


Sarah Carrol (ACOG): At the American College of Obstetricians and Gynecologists, we are doing a lot of the same things as other organizations, such as sending out email communications and doing social media campaigns. We did one in partnership with several other organizations where we put out messaging related to COVID-19, Tdap, and flu vaccines. It was a broader maternal immunization social media campaign but included flu.

We have our annual Flu Fact Friday campaign that’s going on also on social media right now. We’ve done a little more targeted messaging to our ACOG leadership this year than we’ve done in the past. We usually reach out to our leadership at the beginning of flu season, but we have been kind of touching base with them more frequently throughout this season since, as the season is developing, we are seeing higher flu activity.

ACOG is starting to engage more with some of the other maternal immunization partners on how we can put something out in more of a collective voice to urge vaccination and highlight the severity of the flu. We’re seeing and hearing from our members that patients are disinterested in the flu vaccine. It’s not even a refusal. It’s just not something that they are asking about or really wanting to talk about or entertain.

There’s some controversy and vaccine fatigue among patients. It’s certainly a challenge to push the message about coadministration. We are seeing a lot more scrutiny.


Mitch Rothholz (3C Consulting/APhA): It’s more distrust in the system, but I think we are with everyone else in terms of printing out the message and accommodating administration. The positive for providers with the flu vaccine being in single doses is that it’s easier for them to coadminister. But, again, it’s really about the public and getting out the message that they need protection over the holidays. That is the message that a lot of the pharmacy groups are putting out to their constituents. It’s fatigued by the patients and the providers, which is something we are all having to deal with. It’s about keeping people motivated.


  • Thank you to everyone who helped with organizing, who participated, and who attended the NAIIS in person Summit. You should have received an email from Casey Pauly with a survey and we would love to have your feedback.
  • The Summit released Get Adults’ Vaccinations Back on Track, a 2-page clinician tip sheet on new CDC recommendations and tools to help adults catch up on needed vaccinations. NAIIS is a large coalition of public and private organizations dedicated to increasing immunization rates, co-led by Immunize.org, CDC, and the Health and Human Services Office of Infectious Disease and HIV/AIDS Policy.
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  • If you have any agenda items that you are interested in sharing with the Summit, please let us know and we can add you to an upcoming call as a speaker or panelist. Contact information: info@izsummitpartners.org.


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