CNN
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The flu season ramped up early in the United States this year, but vaccination rates are far from keeping pace.

Flu vaccines are always a tough sell for Americans. The US Department of Health and Human Services set a target vaccination rate of 70% in the Healthy People 2030 plan. But less than half of the population has actually gotten their annual flu shot each year for at least the past decade.

Public health leaders say it has been especially challenging to get people to get their flu vaccine this year because they’re growing tired of hearing about shots.

What once was an annual push to get people vaccinated at the start of each flu season has become near-constant messaging about vaccines, with an announcement about new Covid-19 vaccine availability or eligibility seeming to come every couple of months.

“There’s a great deal of vaccine fatigue out there. Asking people this year to get not just one vaccine but to get the annual influenza vaccine, as well as the Covid booster, has really been what I have called a hard sell,” said Dr. William Schaffner, medical director of the National Foundation for Infectious Diseases and professor at Vanderbilt University Medical Center.

“There’s the old saying, ‘familiarity breeds contempt.’ Well, perhaps that’s a bit strong, but familiarity does seem to breed a certain nonchalance,” he said.

Millions fewer flu vaccine doses have been distributed this season compared with this point in seasons past, according to data from the US Centers for Disease Control and Prevention. Just 26% of adults had gotten their flu shot by the end of October, a deadline that medical experts have long encouraged for optimal protection throughout the season. About 43% of children had gotten their flu shot by the end of November.

The first year of the Covid-19 pandemic – the 2020-21 flu season – was a notable outlier, experts say.

Flu vaccination rates soared higher than usual amid fears of a “twindemic,” with the coronavirus and flu circulating together.

“The public health message – and I think we did it very effectively – was, you can’t protect yourself against Covid right now, but you can definitely take flu off the table,” said LJ Tan, chief strategy officer for the Immunization Action Coalition and co-chair of the National Adult and Influenza Immunization Summit, nonprofits dedicated to improving vaccination coverage in the US.

“We were coming out of lockdowns, and people wanted to be active as opposed to passive. So when we told people at that time, ‘You don’t have a Covid vaccine, but you can certainly take flu off the table by getting a flu vaccine,’ people said, ‘Yeah, I’m doing that.’ “

But that double threat didn’t materialize. Flu seasons have been uncharacteristically mild for the past two years, and people have let their guard down, experts say.

“I’ve almost had to remind people about influenza,” Schaffner said. “We’ve had two quite curtailed, very low influenza years. And of course, everyone’s been preoccupied with Covid, and they want to put Covid behind them and get on with their lives.”

Now, continued messaging about a triple threat of viruses – flu, Covid and RSV – isn’t hitting in quite the same way. The urgency is real, as hospitals across the country stretch their capacity to record levels, but it’s not driving people to action.

“It strikes me that people have gotten used to bad flu seasons for the elderly. So this is kind of just the same, with a few other viruses around. There’s a sense that this is what we’re going to expect and this is what we have to live with,” said Dr. Jesse Hackell, a pediatrician who co-authored a clinical report about countering vaccine hesitancy in 2016.

“What we’re missing is the fact that kids and children’s hospitals are suffering in ways that we’ve never seen before.”

Numerous studies have found that flu and Covid-19 vaccines significantly reduce the risk of severe outcomes for those who become infected, including hospitalization and death – thus reducing the burden on the health care work force.

Exacerbating the general vaccine fatigue is decision fatigue, Hackell said.

People have to choose whether to get the flu vaccine each year – and more recently, they have to make decisions about Covid-19 vaccine updates. Each new decision opens the door for misinformation or disinformation to seep into the process.

“If it were a vaccine like measles, where it is really effective and it’s not repeated, it might be different,” Hackell said. “But we have to compare it to Covid and flu vaccines, where the efficacy is less than dramatic, and when there’s a lot of controversy going on, I think that spills over.”

Health care professionals are worn out too, experts say.

“I think there’s fatigue, moral injury, call it burnout on the part of providers as well. We’re not pushing it as hard,” said Hackell, who is also chair of the American Academy of Pediatrics Committee on Practice and Ambulatory Medicine. “It gets very difficult to keep having these unproductive conversations over and over again. And there’s so much more respiratory illness now that I don’t know that the time is there to have these long discussions when your office is packed with sick kids.”

Uptake for the updated Covid-19 booster has also been lackluster: Fewer than 1 in 7 eligible people have gotten one since it was authorized in the fall, according to CDC data.

Ongoing messaging from the White House urges Americans to get their updated Covid-19 booster shot and the flu shot at the same time.

But despite the convenience of getting both shots at once, there’s evidence that linking the two isn’t the best way to boost coverage rates for either.

There has always been hesitancy around vaccination, but it has become highly politicized during the Covid-19 pandemic.

“We still have plenty of people in this country who do not believe in the flu or the Covid vaccine that we haven’t been able to win over,” said Lori Tremmel Freeman, chief executive officer of the National Association of County and City Health Officials. “Flu is serious in our country, and it kills a lot of people, and it hospitalizes a lot of people, and it attacks the young and old. And so we should pay more attention to it.”

But even when interest in booster shots was highest, it was rare for people to get both shots simultaneously.

Self-reports to the CDC’s V-safe monitoring system show that fewer than 1 in 10 people who got a Covid-19 booster between September 2021 and May 2022 got a flu shot at the same time.

“We give multiple vaccines to our kids at the same time, but we haven’t typically done that for adults,” said Tan, former liaison to the CDC’s vaccine advisory committee for the American Medical Association.

Trying to persuade people to do something new can add to the hesitancy that’s already become so pervasive and make them less likely to come in at all. Instead, people seem to be much more likely to accept the offer of a flu vaccine at an appointment they scheduled to get a Covid-19 vaccine booster, or vice versa.

“Some confidence is given by direct interaction with a health-care provider – in this case, the pharmacist or the physician or the clinician – who is able to reassure the patient that it’s safe,” Tan said. “In that personal conversation between the provider and the patient, the patient ends up being converted and getting the vaccine. It’s a testimony also to our remarkable health-care providers.”

The message might finally be sticking. At Walgreens locations, co-administration of the flu and Covid-19 vaccine is 70% higher this year than it was last year, according to data shared with CNN.

Tan says there have been signs of improvement in recent weeks.

Pharmacies are becoming significantly more popular than doctors offices among adults as they choose where to get the flu shot, and CDC data shows that the number of flu vaccines given in pharmacies this season is actually outpacing last year. It’s a sign that there are more opportunities to reach a broader group of otherwise healthy adults who are less likely to have a primary care provider, Tan said.

“At least we’ve got the uptick now, as opposed to this continuous decline that we were seeing four weeks ago,” he said. “But while I’m sounding positive, I want to remind us all that we need to be better than we currently are.”

And while battling vaccine fatigue is a challenge, it’s not an excuse to let vaccination rates lapse.

“In many circumstances, we can overcome fatigue with access,” Tan said.

In public health, “we need to start looking outside the box to find out what messaging needs to change so that we can think out of the box and make people motivated to look for the flu vaccine again. Right now, it’s way too much of a vaccine of convenience.”