CS000000-A | 05/24/21

Summary

Findings. CDC’s recent announcements of expanded guidance for fully vaccinated people was met with 

confusion in the news media and among consumers online. Unanswered questions about the implications 

of new guidance may undermine trust in COVID-19 vaccines and the U.S. vaccination system. To confront 

lagging vaccination rates, states and jurisdictions are employing novel tactics to reduce remaining access 

barriers and add incentives to reward vaccination. The overall effect of these novel tactics on vaccine uptake for 

unvaccinated adolescents and adults is still unknown. Online discussion of incentives is polarized, with some 

people welcoming the developments and others feeling suspicious of them which could be a threat to vaccine 

confidence for some. Lastly, consumers are receiving bills for COVID-19 vaccination, even though COVID-19 

vaccines are free and are offered regardless of insurance or immigration status. 

Ways to take action. Federal, state, and local partners should continue to work together to increase 

transparency around rationale for updated guidance, respond to gaps in information, and confront 

misinformation with evidence-based messaging. The goal of these efforts is to increase confidence in COVID-19 

vaccines and expand vaccine uptake more broadly. Communication efforts should be expanded to address 

concerns and questions about vaccine effectiveness and guidance for fully vaccinated individuals. Additional 

research could provide a better understanding of the role that incentives play in a person’s motivation and 

intent to get vaccinated.

COVID-19 State of Vaccine 

Confidence Insights Report

Report 8 | May 24, 2021 | Date Range: April 27-May 10, 2021

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

Contents

2 Aims and Methods

3 Major Themes

3 Consumers are confused about guidance for fully 

vaccinated people, which may undermine trust in 

COVID-19 vaccines and the U.S. vaccination system

5 States and jurisdictions are employing novel tactics 

to increase vaccine uptake, although impact on 

uptake and confidence is still unknown

6 Emerging Theme

6 Upcoming: Rapid Insights Report on response to 

COVID-19 adolescent vaccine roll-out.

7 Continuing and Evolving Themes

9 Appendix: Inputs and Sources

Centers for Disease Control & Prevention, 

COVID-19 Response, Vaccine Task Force

Vaccine Confidence Team, Insights Unit
Page: 2

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Aims and Methods

By rapidly reviewing and analyzing numerous sources and inputs (see ), the biweekly COVID-19 State 

of Vaccine Confidence Insights Report emphasizes major themes that influence COVID-19 vaccine hesitancy 

and uptake. This is categorized by their level and type of threat to vaccine confidence, degree of spread, and 

directionality. By examining how consumers think and feel, social processes, and the practical issues around 

vaccination, the Insights Report seeks to identify emerging issues of misinformation, disinformation, and places 

where intervention efforts can positively impact vaccine confidence across the United States.

Appendix

The information in this report is only a snapshot, and certain populations may be underrepresented. Images 

and quotes are illustrative examples and are not meant to be comprehensive of all content related to the 

highlighted themes.

Theme Classification

How do you classify this theme/information?

High risk Moderate risk Low risk Positive sentiment

















May lead to vaccine 

refusals and decreased 

uptake

Wide reach, pervasive

Potential to trigger 

hesitancy to vaccinate

Moderate reach, modest 

dissemination

Concerning, but low risk 

to vaccine confidence

Limited reach, limited 

dissemination

Could increase vaccine 

confidence, intent, or 

motivation

Variable reach and 

dissemination

How has this theme/idea changed over time (since last report or over the course of multiple reports)?

Increasing 

Information spreading rapidly

Stable 

Information remaining 

constant at prior level

Decreasing

Information is not gaining further 

traction and there has been no 

indication of additional activity
Page: 3

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Major Themes

Consumers are confused about guidance for fully vaccinated people, which may 

undermine trust in COVID-19 vaccines and the U.S. vaccination system.

CDC’s announcement of expanded guidance for fully vaccinated people on April 27, 2021 - which stated that fully vaccinated 

individuals could stop wearing masks in many outdoor situations1

 - was met with mixed reception in the news media and 

among some consumers online. While some consumers were happy to see this updated guidance for outdoor mask-wearing,2

others noted that the guidance could further divide people based on vaccination status.3,4

 One study, administered prior to any 

guidance changes, found that removing mask recommendations for vaccinated consumers may increase reluctant consumers’ 

intent to vaccinate.5 However, several comments on social media from self-reported unvaccinated people indicated they were 

unmoved by the guidance, commenting that they had already stopped wearing masks and had returned to pre-pandemic 

life.6,7

 Further, consumers speculated online that the April 27, 2021 expanded guidance was only put into place because it 

reflected typical behavior and was not created as a result of new scientific information,8

 which could lead to growing distrust 

in government agencies. Some consumers also felt the guidance excluded those who previously had COVID-19.9,10 Inquiries to 

CDC-INFO and comments on CDC social media channels largely echoed this confusion. The majority of inquiries focused on 

what to do if their household had both vaccinated adults and unvaccinated children, what to do about gatherings between 

unvaccinated and vaccinated people, and how consumers would know 

who was and wasn’t fully vaccinated.11

News coverage criticizing the above guidance increased with many 

articles pointing to a lack of information from CDC about the science 

behind the change and mixed messages from federal, state, and 

local leaders about masking and the role vaccines play in ending 

the pandemic.12,13,14,15 Some public health experts spoke out online, 

stating that the guidance would decrease confidence in vaccines. They 

expressed concern that the recommendation for fully vaccinated people 

to continue wearing masks in certain indoor situations could send the 

message to consumers that the vaccines are not effective at preventing 

both illness and the spread of the virus.16 Some consumers confirmed this sentiment, saying that this corroborated their 

suspicions that vaccines are not effective. 17,18,19

If that trust is not there, people won't 

agree "to change their lives, take 

preventive [measures], take vaccines." 

-Dr. Robert Blendon, emeritus professor 

at the Harvard Chan School

Source: https://www.npr.org/2021/05/13/996331692/

poll-finds-public-health-has-a-trust-problem

On May 13, 2021, CDC announced further expansion of the guidance for fully vaccinated people. This guidance 

states that they can resume activities they did prior to the pandemic - both indoors and outdoors - without wearing 

a mask or physically distancing, except where required.20 News media outlets focused coverage on the challenges 

of verifying vaccination, as well as concerns about unvaccinated people forgoing masks with requirements lifted. 

Media outlets also raised questions about how these new guidelines might impact young children, people who are 

immunocompromised, and those who have been unable 

to be vaccinated due to access barriers, especially among 

communities that have been disproportionately affected 

by COVID-19 such as communities of color.21,22,23 Public 

health and medical experts also expressed concern that this 

change was made too soon and the subsequent removal 

of mask mandates by state and local leaders and businesses 

may disincentivize vaccination.24,25 The dominant online 

conversation among consumers suggested social divide over 

the decision, with many vocal vaccine deniers indicating that 

this change in guidance would not change their intent to get 

vaccinated.26,27
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COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Ways to act.

 Expand and disseminate messages regarding the scientific process by which CDC develops guidance, to prevent the

spread of mis- and disinformation. Additionally, since the messaging needs of consumers are diverse, consider expanding 

communication materials that are easy to understand for those with limited English proficiency. Also expand content 

containing easy-to-understand data that are more scientifically sophisticated; some consumers indicate that plain language 

content does not provide enough information for them to make an informed decision about vaccination.32,33

Expand and disseminate messages about the effectiveness of COVID-19 vaccines, specifically explaining what is and is not 

known about the asymptomatic spread by vaccinated people, cases of illness among fully vaccinated individuals, and what is 

known about the effectiveness of current vaccines against common variants in the United States. 

Expand and disseminate messages about natural immunity, including information about what is known about length of 

immunity after COVID-19 illness. 

Expand and disseminate messages about mitigation and safety measures needed for those who have not or are not able to be 

fully vaccinated, such as young children and people with specific medical conditions. 

Support research to better understand the connection between policy and guidance changes and their effects on vaccine 

confidence and uptake.

However, a recent study reported that one-third of conservative-leaning consumers would be more likely to get 

vaccinated if they were no longer required to wear a mask.28 Some vaccine endorsers echoed public health and 

medical expert concerns that this decision was made too soon29,30 and expressed concern for children and people with 

immunocompromising conditions31 through comments online and through inquires to CDC-INFO. Several questions 

emerged from consumers, including:

 How long am I protected by the COVID-19 vaccine? When will I have to wear a mask again? 

 How should households with young children or immunocompromised people proceed – should children still wear 

masks indoors and outdoors?

 What if I already had COVID-19, can I follow these updated mask guidelines without being vaccinated?

 How much protection do the vaccines provide against variants? Should I worry about COVID-19 variants indoors 

without a mask?

 How can I protect my employees and clients? How should businesses respond to these new guidelines?
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COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

States and jurisdictions are employing novel tactics to increase vaccine uptake, 

although impact on uptake and confidence is still unknown.

States and jurisdictions continue to turn away shipments of COVID-19 

vaccines, as the daily average of vaccine doses administered across the 

United States fell below two million for the first time since early March 

on May 3, 2021.34,35 In an effort to confront lagging vaccination rates and 

oversupply, states and jurisdictions, federal government, and private 

businesses have shifted strategies to facilitate, reduce remaining access 

barriers to, and add incentives to reward vaccination.36,37,38 States and 

jurisdictions are offering smaller vaccination settings like clinics with 

walk-in access, providing free transportation, and equipping family 

doctors in private offices with vaccines.39,40,41 Health departments are 

converting bars to COVID-19 vaccination sites and offering vaccines 

at festivals and on beaches.42,43 Some states are also offering incentives like alcohol, money to be distributed by lottery, and 

even sleeping tents and food for people experiencing homelessness.44,45,46 In response to these new tactics, some consumers 

indicated on social media that they hoped such rewards would spur more people to get vaccinated, while others perceived the 

incentives to be suspicious and wondered why such large-scale incentives are necessary.47,48,a

News media coverage suggests that providers are trusted vaccinators, 

and that familiar and trusted vaccination sites matter. But the impact of 

other tactics that incentivize behavior are not well-understood.49,50,51 Some 

polling data support the idea that monetary rewards for vaccination may 

be a motivating incentive among unvaccinated consumers,52,53 but other 

survey data indicate that financial incentives may have uneven or small 

positive effects on desired health behavior outcomes.54,55,56 Consumers’ 

reasons for not getting vaccinated remain mostly unchanged – among 

those who are unvaccinated, they express distrust in vaccine safety data, 

are worried about short- and long-term vaccine side effects, and are 

not certain that COVID-19 is a serious illness.57,58 If the main barrier to 

vaccination is mistrust, it is unknown if the novel tactics will push those 

who are hesitant towards vaccination.59.60

Ways to act.

 Identify emerging best practices to eliminate barriers in accessing vaccination and promote effective innovations broadly to

states and jurisdictions. Conduct rapid community assessments to understand remaining vaccination barriers and ensure that 

added conveniences, incentives, rewards, and compensation correspond to noted community needs. 

Support research to better understand the effect of incentives and rewards on the intent to vaccinate among consumers 

who are in the “wait and see” group before getting vaccinated. Examine how incentives and rewards might influence vaccine 

confidence, especially for those groups who are unvaccinated because they lack trust in the vaccine, vaccinators, or the health 

vaccination system more broadly.

a Social Listening Team. COVID-19 Interagency Social Listening Report. Washington, DC, Federal Emergency Management Agency; May 7, 2021.

"[This is] what needs to be done, because 

the primary care provider, the doctors 

will answer the questions. It's not like 

going to the pharmacy ... which has so 

many of those vaccines that they don't 

have the time to explain to the patient." 

-Dr. Francisco Rosario, practicing family 

physician, on the shift to offering 

vaccines in doctors’ offices

Source: https://www.cnn.com/2021/04/28/health/nycprimary-care-doctors-covid-vaccines/index.html
Page: 6

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Emerging Theme

Consumers are receiving bills for COVID-19 vaccination.

Reports have emerged in the news media of consumers receiving bills from 

vaccination sites for COVID-19 vaccine administration and then being forced 

to contest fees with medical clinics or hospitals,61,62,63 even though COVID-19 

vaccines are free, regardless of insurance or immigration status.64,65,66

Additionally, some consumers are confused about why they were asked for 

their insurance information when making a vaccine appointment or arriving 

for vaccination and are fearful that they will be billed for their COVID-19 

vaccination.67,68 A recent poll found that concerns about vaccination cost are 

especially predominant among Hispanic adults who are uninsured or make 

less than $40,000 per year.69 The same poll found that over half of Hispanic adults are unvaccinated. One-third of them report 

being asked for their insurance card when making a vaccination appointment and 52% are unaware that the vaccines are free.70

Ways to act:





Continue to clearly communicate that COVID-19 vaccines are free for all U.S. residents and that all adults and adolescents 

are eligible, regardless of insurance or immigration status.71,72 Partner with trusted local messengers to further amplify 

this message in multiple languages, especially in Spanish.73 Expand content to better explain why vaccinators may ask for 

insurance information, but note that it is not required for vaccination.

Educate healthcare providers and administrative health personnel that presenting an insurance card may be a barrier to 

vaccination for some, especially those with lower incomes

Upcoming: Rapid Insights Report on response to COVID-19 adolescent vaccine roll-out.

A Rapid State of Vaccine Confidence Insights Report is in progress to better understand the consumer response to authorization 

and recommendation of Pfizer-BioNTech COVID-19 vaccine for adolescents 12 – 15 years old. This special report will be released 

following this report.

On May 10, 2021, the Food and Drug Administration (FDA) expanded the emergency use authorization for Pfizer-BioNTech's 

COVID-19 vaccine to include adolescents 12 – 15 years old, making nearly 17 million more people or 85% of the U.S. population 

eligible to receive a COVID-19 vaccine.74,75 Although many parents were eagerly anticipating this news, others were nervous 

about the safety of COVID-19 vaccines for children and whether vaccination was necessary, given their belief that the risk of 

severe COVID-19 illness to children is low.76,77 Recent polling data indicate that 29% of parents reported they would get their 

children vaccinated right away, and 32% said they wanted to wait to see whether the vaccine is safe and effective in children.78

While most schools have yet to make a 

decision regarding COVID-19 vaccination 

requirements for students, a recent survey 

indicates that, although over half of 

parents believe that schools should be fully 

in-person in the fall, 65% oppose requiring 

COVID-19 vaccination for in-person 

school attendance.79,80 Meanwhile, vocal 

vaccine deniers circulated misinformation 

about COVID-19 vaccines and children, 

amplifying claims that adverse events 

in children and adolescents occurred 

after vaccination or during clinical trials, 

signalling to some that vaccines may not 

be as safe as the current data indicate.81,82,83

"It makes me feel like people are taking

advantage of us... my husband was 

billed for his shot too." 

-Chicago area resident, IL

Source: https://abc7chicago.com/

charged-for-covid-vaccine-free-bill-vaccination/10561655/

Source: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/
Page: 7

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Continuing and Evolving Themes

Themes below have been noted in previous reports and continue to undermine vaccine confidence. The information 

highlighted below focuses on what is new or different from previous reports. For additional context and previous 

recommendations on these themes see previous Insights Reports.b,c,d,e,f,g,h

 Vaccine series completion. News media highlights concerns across multiple states that consumers are not returning for their

second dose of COVID-19 vaccine.90,91,92 News media points to consumer concerns about acute side effects after a second dose 

and a belief that one dose will provide sufficient protection from COVID-19.93

New ways to act:

Amplify messages regarding the importance of completing both doses of a 2-dose COVID-19 vaccine, including information 

regarding the lowered effectiveness that could result from not receiving the second dose. Additionally, develop messages 

to reassure consumers who have delayed their second dose that completing their vaccination series is important for 

protection from COVID-19 illness.

Vaccine mandates. As more institutions of higher education (IHEs) announce vaccine mandates for students, the American 

College Health Association issued a recommendation that IHEs make COVID-19 vaccination a requirement for on-campus 

students this fall.94 Additionally, a new poll indicated that more than 60% of companies plan to require employees to prove 

they have been vaccinated.95 While some IHEs and employers cannot require vaccination with vaccines available under 

emergency use authorization, news coverage of Pfizer-BioNTech likely seeking full FDA approval for their vaccine as soon as 

fall could increase the number of vaccine mandates across the United States.96

Mis- and disinformation. A recent poll found that people who are least likely to intend to be vaccinated are more likely 

to believe or be unsure about at least one COVID-19 vaccine myth.84 During this report period, a number of pieces of 

mis- and disinformation spread widely:

 Viral shedding. Claims that mRNA

COVID-19 vaccines “shed” virus continue 

to circulate widely on social media 

platforms,85 despite being debunked.86

While the initial misinformation focused 

on “viral shedding” affecting menstrual 

cycles, it has now evolved to affecting 

all unvaccinated people, regardless of 

gender.87

Adverse events. High-visibility 

vocal vaccine deniers continue to 

misrepresent VAERS data to reduce trust 

in the safety of recommended COVID-19 

vaccines.88 A mainstream news anchor erroneously claimed that “30 people every day” die from vaccination.89

New ways to act:

Update and expand CDC’s COVID-19 vaccine myths and frequently asked question webpages to including 

information on viral shedding, heart inflammation, and adverse events. Disseminate messages promoting the vaccine 

myths page on social media platforms and through states, jurisdictions, partners, and trusted messengers.

Develop and deploy prepared responses for CDC-INFO to address above topics. 
Page: 8

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Continuing and Evolving Themes (cont.)

 Proof of vaccination. A recent poll, prior to any shift in guidance for fully vaccinated people, found that consumers are

divided over whether they believe businesses should require proof of vaccination for services. Favor and opposition of these 

systems varied by activity, with those in favor more likely to have already been vaccinated or be planning to be vaccinated, 

and those more likely to be opposed not planning to be vaccinated.97 Additionally, news coverage regarding fake vaccination 

cards increased during this period, with reports of boxes of fake cards being seized by law enforcement,98 business owners 

being charged with selling fake vaccination cards,99,100 and the FBI issuing a warning that fines and imprisonment are possible 

penalties for forging or falsifying vaccination cards.101

Essential workers. New media reports of police officers refusing vaccination emerged across the country.102,103 Additionally, 

a report emerged that subway and bus workers had the lowest vaccination rate of workers within the New York Metropolitan 

Transportation Authority (MTA), even though 93% of MTA workers who died from COVID-19 were subway and bus workers.104

Young adults. A suggestion by a popular podcaster that young, otherwise healthy young adults don’t need to get vaccinated 

spread broadly across social media.105 As the reports were quickly fact-checked, vocal vaccine deniers commented online 

that the podcaster's claims were speaking "the truth" but were being unfairly represented by media that is biased towards 

positively framing only vaccine advocates and not vaccine skeptics.106 At the same time, reports have emerged across the 

United States of younger people beginning to experience serious illness3 and school-based outbreaks.107

b Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 1. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

c Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 2. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

d Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 3. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

e Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 4. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

f Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 5. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

g Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 6. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

h Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 7. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021
Page: 9

COVID-19 State of Vaccine Confidence Insights Report | Report 8 | May 24, 2021

Appendix: Inputs and Sources

Type Input Cadence Sources Tactics for Utilization

Social 

Media 

Listening 

& Media 

Monitoring

Communication Surveillance 

Report

Daily, 

weekdays

Google news

 Meltwater

CrowdTangle

Native platform searches

 Share of voice topic analysis to identify 

themes

 Emerging topics 

Meltwater Daily  Facebook, Twitter, Instagram

 Blogs

News media

Online forums

 Share of voice topic analysis

 Emerging theme topics

Identify high reach/velocity topics

 OADC Channel COVID-19 

Post Metrics

Weekly  Sprout Social

Native OADC account analytics

Analyze # of posts, topics 

 Success of messages, # of impressions, 

reach, # engagements

OADC Channel Comment 

Analysis

Daily, 

weekdays Native platform searches  Sentiment analysis

Identify message gaps/voids

Direct 

Reports

CDC-INFO Metrics Weekly, 

Mondays

CDC-INFO inquiry line list

 Prepared response (PR) usage 

report

Cross-compare PR usage with inquiry 

theme analysis

 Sentiment analysis

Identify information gaps/voids

VTF Media Requests Weekly, 

Mondays

 Media request line list  Leading indicator for news coverage

Identify information gaps/voids

Web Metrics Weekly, 

Wednesdays

 Top pages

Google search queries

 Top FAQs

 Referring domains

Identify information gaps/voids,

Identify keywords/search terms, changes in 

web traffic

Research

Poll Review Weekly, 

Mondays

Harris Poll, PEW research, Gallup 

Poll, KFF 

New data related to vaccine 

hesitancy

Identify socio-behavior indicators related 

to motivation and intention to vaccinate 

Literature Review Weekly, 

Mondays

 PubMed, LitCovid, ProQuest Central 

New data related to vaccine 

hesitancy

Identify current vaccination intention

Identify barriers to vaccination

Third Party 

Reports

Tanaq Social Listening +Media 

Monitoring Report

Weekly  Meltwater

 Sprout Social

 First Draft

Native platform searches

 Trending topics

Demographic and geographic conversation 

monitoring

CrowdTangle content insights 

report

Biweekly  Facebook  Top pages (voices), groups

General trends/sentiment analysis

News analysis through posts

FEMA Social Listening Report Daily Hootsuite

 Brandwatch

CrowdTangle

 Meltwater

 Trends/sentiment analysis

National and global news analysis

First Draft News Vaccine 

Misinformation Insights 

Report

Monthly  Proprietary methods  Media trends analysis

 Emerging threats and data deficits

Online vaccine narratives

Project VCTR Weekly  Proprietary methods National and regional trends in negative 

attitudes toward vaccination

Conversations around Legislation

Virality Project Weekly  Proprietary methods  Mis- and disinformation trends related to 

COVID-19 vaccine