CS000000-A | 5/18/23

Centers for Disease Control & Prevention, 

COVID-19 Response, Vaccine Task Force

Vaccine Confidence & Demand Team, Insights Unit

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).

CDC’s State of 

Vaccine Confidence 

Insights Report 

Long-Term Care Settings 

Special Report

May 18, 2023

Date Range: March 1, 2020 - February 17, 2023
Page: 2

State of Vaccine Confidence Insights Report | May 18, 2023

Summary

This report is a cumulative representation of themes affecting vaccine hesitancy, 

confidence, and uptake among older adults living in long-term care settings 

(nursing homes and residential care communities) from the beginning of the 

COVID-19 pandemic in 2020 through mid-February 2023.

Major themes identified from social media, news, and other sources that 

may impact vaccine confidence: 

 Facing new waves of misinformation and ongoing vaccine fatigue, older 

adults in long-term care settings have expressed less interest in receiving 

updated (bivalent) COVID-19 booster doses. Concerns about vaccine safety 

and effectiveness may be exacerbated by exposure to social media or news 

coverage emphasizing the severity and incidence of adverse reactions from 

COVID-19 vaccination, which can activate cognitive biases that undermine 

vaccine confidence.

 Some social media users have claimed that people 65 years and older are not 

receiving the updated COVID-19 booster because it is ineffective. 

 Older adults who take multiple medications may be hesitant to seek the 

updated COVID-19 booster doses as they are concerned that their medications 

would negatively impact the effectiveness of the COVID-19 vaccines. In 

addition, older adults taking multiple medications may believe that the 

updated COVID-19 booster dose could cause an allergic reaction or serious 

adverse event, putting their health at risk.

Ways public health and partners can take action to improve vaccine 

confidence: 

 Consider supporting and/or collaborating with long-term care settings to 

provide vaccinations on-site. 

 Provide clear and concise information tailored specifically to older adults 

regarding the safety and effectiveness of COVID-19 vaccines, especially to 

reduce the risk of severe disease from COVID-19. Use relevant images and 

culturally appropriate language. 

 Provide educational trainings to staff in long-term care settings that encourage 

vaccine confidence and uptake in staff, as well as increased confidence in 

recommending COVD-19 vaccination to residents. 

 Create or promote tools and resources to help health providers identify, discuss, 

and address incorrect COVID-19 vaccine information with patients in a respectful 

and empathetic manner.

 Disseminate or use resources provided by the American Health Care Association 

and the National Center for Assisted Living, Administration for Community 

Living, AMDA, and AARP, which include strategies to improve staff vaccination 

rates, talking points, one-pagers, graphics, and post-vaccination materials.

 Disseminate or use resources from CDC’s Vaccinate with Confidence initiative, 

including Myths and Facts about COVID-19 Vaccines and Talking with Patients 

about COVID-19 Vaccination.

Contents

3 

Introduction and Background

4 

Perceptions, Concerns, and 

Threats to Vaccine Confidence 

Affecting Older Adults Aged 

65+

5

Perceptions, Concerns, and 

Threats to Vaccine Confidence 

Affecting Long-Term Care 

Settings

7

Ways Public Health and 

Partners Can Take Action to 

Improve Vaccine Confidence

8

References

12

Appendix: Inputs and Sources
Page: 3

State of Vaccine Confidence Insights Report | May 18, 2023

Aims and Methods

a

Unless specified, “COVID-19 vaccines” refers to both the primary series and booster doses.

b

 Social media posts referenced throughout this report can be found in this online document.

By rapidly reviewing and analyzing numerous specific sources and inputs from long-term care settings, 

this State of Vaccine Confidence Insights Report emphasizes major themes influencing vaccine 

hesitancy and uptake among older adults living in nursing homes and residential care communities. In 

addition, 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 to help identify 

where intervention efforts can improve vaccine confidence. Data for this report were specifically 

gathered to help analyze themes across the United States before, during, and after the initial COVID-19 

vaccine rollout.a

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 comprehensively cover all content 

related to the highlighted themes. 

Introduction and Backgroundb

At the onset of the COVID-19 pandemic, approximately 2.1 million people were living in nursing homes

or residential care communities,

1

 a population at heightened risk for severe COVID-19 complications 

due to older age and/or underlying health conditions.2,3,4 Many of the earliest COVID-19 outbreaks 

occurred within long-term care settings,5,6,7,8 which were and continue to be heavily impacted by 

COVID-19.9,10 By August 2021, nursing home residents accounted for over 20% of all COVID-19 deaths 

in the United States.11 To protect individuals who live and work in long-term care settings, healthcare 

personnel and long-term care residents were included as priority populations in the initial phase of the 

COVID-19 vaccine rollout in December 2020.12

As of March 26, 2023, 85.6% of adults receiving care in nursing 

homes have completed their COVID-19 primary vaccine 

series.13,14 However, recent government efforts to increase 

coverage for the updated COVID-19 booster vaccines in this 

population have had limited success.15,16 To date, only 53% of 

nursing home residents have received the updated COVID-19 booster dose,13 which confer additional 

protection against SARS-CoV-2 infection and hospitalization in this population. Reasons for low 

COVID-19 vaccine uptake among adults in long-term care settings include high rates of vaccine 

hesitancy among residents and staff, a lack of awareness or confusion around the updated booster 

doses,17 a lack of staff to administer vaccines, differential levels of vaccine access,18,19 and pandemic 

fatigue.20 Due to these barriers of vaccine uptake, it is imperative that governmental organizations 

and long-term care settings emphasize, model, and utilize non-pharmaceutical interventions21,22,23 in 

addition to vaccination and engage in targeted vaccination campaigns to reduce the spread of and 

prevent severe illness from SARS-CoV-2 in long-term care settings.24
Page: 4

State of Vaccine Confidence Insights Report | May 18, 2023

Perceptions, Concerns, and Threats to Vaccine Confidence 

Affecting Older Adults Aged 65+

c

 CDC-INFO.

 Many factors influence vaccine confidence and vaccine hesitancy among older adults. In particular, misand disinformation regarding vaccine safety and effectiveness has led to increased vaccine hesitancy 

among older adults who may be unsure about which sources of information are trustworthy, indicating a 

need to provide clear and accurate information directly aimed at older adults.25,26,c

 Some older adults have shared that 

they received the COVID-19 vaccine and 

encourage others to receive COVID-19 

vaccines as well.27,28,29,30

 Some social media users believe that there 

has not been an emphasis on vaccinating 

older populations because culture in the 

United States deems older adults an “expendable” population.31

 Some social media users believe older populations should mitigate risk through non-pharmaceutical 

interventions, such as mask-wearing.32,33,34,35

 Some social media users believe that the push to vaccinate older populations is part of a conspiratorial 

plot to kill off senior citizens.36,37

Misinformation and Hesitancy Themes Among Older Adults Aged 65+

 Older adults are not only at higher risk of severe illness from COVID-19, but have been identified as 

a population that may be particularly vulnerable to mis- and disinformation about COVID-19 illness 

and vaccination.38 There are several factors that may impact older adults’ ability to discern mis- and 

disinformation, including cognitive decline, digital illiteracy, preferred information sources, and other 

cognitive barriers.26,38,39,40,41,42,43

Vaccine Safety and Effectiveness

 Some older adults who take multiple medications may be hesitant to seek the updated COVID-19 booster 

doses as they are concerned that their medications would negatively impact the effectiveness of the 

COVID-19 vaccines.c In addition, some older adults taking multiple medications may believe that the 

updated COVID-19 booster dose could cause an allergic reaction or serious adverse event, putting their 

health at risk.c

 The effectiveness of the COVID-19 vaccines was a concern for some older adults, fearing that they would 

have breakthrough cases regardless and that receiving the vaccine would therefore not be worth their 

time.c

 Misinformation about the effectiveness of the 

COVID-19 vaccines has generated confusion 

among some seniors, with sources portraying 

the length of effectiveness of COVID-19 vaccines 

incongruent with published clinical studies.c
Page: 5

State of Vaccine Confidence Insights Report | May 18, 2023

 Some older adults who are hesitant to receive COVID-19 vaccines are concerned about a potential 

increased risk of stroke associated with the COVID-19 vaccination (a safety signal was detected in a 

single U.S. vaccine surveillance system, but not in other U.S. systems or in other countries).44,c During 

the initial COVID-19 vaccine rollout in March 2021, the potential for less serious side effects—such 

as malaise, fatigue, nausea, fever, and soreness—was also a contributing factor to vaccine hesitancy 

among older adults.25

 Some social media users claim people 65 years of age and older are not receiving the updated 

COVID-19 booster because it is ineffective.45,46,47

Trusted Sources

 Many older adults who are hesitant to get vaccinated state that they are unsure about the accuracy 

of information, and unsure of which sources could be considered trustworthy.25 Approximately 74% 

of older adults trust their doctor to give them accurate information, compared to approximately 50% 

of older adults who trust information provided by the government.25

Vaccine Costs

 During the initial COVID-19 vaccine rollout, over 310,000 older adults indicated that they were not 

planning to receive their COVID-19 vaccine due to the misconception that the vaccine would be an 

out-of-pocket cost.48 While COVID-19 vaccines are and will continue to be available at no cost to all 

Medicare beneficiaries,49,50 the anticipated end to the federal emergency declarations for COVID-19 in 

May 2023 could cause additional confusion and misinformation about the affordability of COVID-19 

booster doses in the future. 

Perceptions, Concerns, and Threats to Vaccine Confidence 

Affecting Long-Term Care Settings

 Long-term care settings are subject to unique challenges that affect the perceptions and concerns 

surrounding COVID-19 vaccination. Sources of mis- and disinformation have fueled concerns 

regarding the costs, safety and effectiveness of COVID-19 vaccines among those living in longterm care settings.51 Some state regulations requiring COVID-19 vaccination have not been strictly 

enforced, and rapidly changing COVID-19 guidelines have led to confusion and have undermined 

vaccine confidence within long-term care settings.51,52,53

 Misperceptions about COVID-19 vaccine requirements for nursing home staff have led some social 

media users to believe that nursing home residents are being mandated to receive a COVID-19 

vaccine.54,55,56

 Some social media users are using social media to share experiences of family members in nursing 

homes during the COVID-19 pandemic and urging residents in long-term care to get vaccinated.57,58

 Through funded partnerships with CDC, HHS, and others, some nonprofit organizations are 

expanding use of vaccination clinics to increase vaccine uptake in nursing home staff and residents.59

 Some social media users believe that the number of COVID-19 deaths in nursing homes are 

preventable. This sentiment was especially prevalent during the early months of the pandemic 

before COVID-19 vaccines were available.60,61,62,63,64

 Some social media users believe residents in long-term care settings are refusing the COVID-19 

vaccines due to safety concerns.65,66,67,68
Page: 6

State of Vaccine Confidence Insights Report | May 18, 2023

Misinformation and Hesitancy Themes Affecting Long-Term Care Settings

c

 CDC-INFO.

Some older adults have been exposed to an array of misleading, inaccurate, or outdated information 

from various sources, resulting in confusion, frustration, and vaccine hesitancy.c Misinformation about 

the updated COVID-19 booster’s cost, effectiveness, and availability continues to circulate within longterm care settings.51,52

Vaccine Confusion in Long-Term Care Settings

 Many older adults who live in long-term care settings state the confusion caused by frequently 

changing guidelines, regulations, and locations to acquire updated COVID-19 booster doses.51 The 

volume and speed of incoming information from news sources, staff, and family members can make 

it difficult for older adults to understand how and when they should acquire their updated COVID-19 

booster doses.51,53

 Some long-term care staff who are not in favor 

of COVID-19 vaccines can unintentionally 

influence their patients to become more vaccine 

hesitant.d

c,52

 While long-term care facilities are held to federal 

regulations requiring vaccination and COVID-19 

infection reporting of both residents and staff, 

regulatory enforcement and inspection of these 15,000+ facilities are carried out at the state level 

approximately once per year on a rolling basis.52

 Fluctuating regulations between states and long-term care settings have affected older adults 

relocating or transferring into long-term care, as they may be unsure about COVID-19 vaccination 

requirements, if any, in a specific facility.c,52 Some long-term care residents expect to receive the 

vaccine at the facility itself and may delay vaccination until their arrival, only to discover the facility 

does not offer updated COVID-19 booster doses to their residents but instead requires vaccination 

before arrival.c

Vaccine Fatigue, Lack of Interest, and Misinformation in Long-Term Care Settings

 Facing new waves of misinformation and ongoing vaccine fatigue, older adults in long-term care 

settings have expressed less interest in receiving updated COVID-19 booster doses.16,17,69 Concerns 

about vaccine safety and effectiveness may be exacerbated by exposure to social media or news 

coverage emphasizing the severity and incidence of adverse reactions from COVID-19 vaccination, 

which can activate cognitive biases that undermine vaccine confidence.70,71,72
Page: 7

State of Vaccine Confidence Insights Report | May 18, 2023

Ways Public Health and Partners Can Take Action to 

Improve Vaccine Confidence

 Provide clear and concise information tailored specifically to older adults regarding the safety and 

effectiveness of COVID-19 vaccines, especially to reduce the risk of severe disease from COVID-19. 

Use relevant images and culturally appropriate language.

 Provide educational trainings to staff in long-term care settings that contain accurate information 

about COVID-19 vaccines and policies in order to encourage vaccine confidence and uptake among 

staff, and to increase staff confidence in recommending COVD-19 vaccination to residents. 

 Consider supporting and/or collaborating with long-term care settings to provide vaccinations 

on-site. 

 Create or promote tools and resources to help health providers identify, discuss, and address 

incorrect COVID-19 vaccine information with patients in a respectful and empathetic manner. 

 Disseminate or use resources provided by the American Health Care Association and the National 

Center for Assisted Living, Administration for Community Living, AMDA, and AARP, which include 

strategies to improve staff vaccination rates, talking points, one-pagers, graphics, and postvaccination materials.

 Disseminate or use resources from CDC’s Vaccinate with Confidence initiative, including Myths and 

Facts about COVID-19 Vaccines and Talking with Patients about COVID-19 Vaccination.
Page: 8

State of Vaccine Confidence Insights Report | May 18, 2023

References

Note: omitted numbers are social media citations, which can be accessed here.

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report-january.html

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G. M., Edmunds, W. J., & Centre for Mathematical Modelling of Infectious Diseases COVID-19 

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& Toth, D. J. A. (2021). Continued need for non-pharmaceutical interventions after COVID-19 

vaccination in long-term-care facilities. Scientific Reports, 11, 18093. https://doi.org/10.1038/

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(COVID-19) Pandemic. U.S. Department of Health and Human Services. https://www.cdc.gov/

coronavirus/2019-ncov/hcp/infection-control-recommendations.html
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24. Paun, C., Leonard, B., Reader, R., & Schumaker, E. (2023, February 17). The abysmal nursing home booster campaign. Politico. https://www.politico.com/newsletters/future-pulse/2023/02/17/the-abysmal-nursing-home-booster-campaign-00083457

25. Lampkin, C. (2021). 2020 AARP Vaccine Survey. AARP Research. https://doi.org/10.26419/

res.00432.001

26. Bhagianadh, D., & Arora, K. (2022). COVID-19 Vaccine Hesitancy Among Community-Dwelling Older Adults: The Role of Information Sources. Journal of Applied Gerontology, 41(1), 

4–11. https://doi.org/10.1177/07334648211037507

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COVID-19 infodemic and digital health literacy in vulnerable populations: A scoping review. 

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older adults. Frontiers in Medicine, 8. https://www.frontiersin.org/articles/10.3389/

fmed.2021.756275

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41. van der Linden, S. (2022). Misinformation: Susceptibility, spread, and interventions to immunize 

the public. Nature Medicine, 28(3), 460-467. https://doi.org/10.1038/s41591-022-01713-6

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(2022). Aging in an “infodemic”: The role of analytical reasoning, affect, and news consumption frequency on news veracity detection.Journal of Experimental Psychology: Applied, 28(3), 

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080/10584609.2023.2187496
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State of Vaccine Confidence Insights Report | May 18, 2023

Appendix: Inputs and Sources

Social Media Listening & Media Monitoring Data Sources

Input Cadence Sources Tactics for Utilization

Communication 

Surveillance Report

Daily on 

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 (Office of the 

Associate Director 

of Communication) 

Channel COVID-19 

Post metrics

Weekly Sprout Social

Native OADC (Office of 

the Associate Director 

of Communication) 

account analytics

Analyze # of posts, topics 

Success of messages, # of 

impressions, reach, # engagements

OADC Channel 

Comment Analysis

Daily on 

weekdays

Native platform 

searches

Sentiment analysis

Identify message gaps/voids

Direct Report Data Sources

Input Cadence Sources Tactics for Utilization

CDC-INFO Metrics Weekly 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 Media request line list Leading indicator for news 

coverage

Identify information gaps/voids

Web Metrics Weekly Top pages

Google search queries

Top FAQs

Referring domains

Identify information gaps/voids,

Identify keywords/search terms, 

changes in web traffic
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State of Vaccine Confidence Insights Report | May 18, 2023

Research and Literature Data Sources

Input Cadence Sources Tactics for Utilization

Poll Review Weekly Harris Poll, PEW 

research, Gallup Poll, 

KFF, Annenberg Public 

Policy Center 

New data related to 

vaccine hesitancy

Identify socio-behavior indicators 

related to motivation and intention 

to vaccinate 

Literature Review Weekly PubMed, LitCovid, 

ProQuest Central, 

Altmetric 

New data related to 

vaccine hesitancy

Identify current vaccination 

intention

Identify barriers to vaccination

Third Party Report Data Sources

Input Cadence Sources Tactics for Utilization

Tanaq Social 

Listening +Media 

Monitoring Report

Weekly Meltwater

Sprout Social

First Draft

Native platform 

searches

Trending topics

Demographic and geographic 

conversation monitoring

Washington St. 

Louis iHeard

Weekly Proprietary methods Survey results

Emerging threats and data deficits

Vaccine narratives

Project VCTR Weekly Proprietary methods National and regional trends 

in negative attitudes toward 

vaccination

Conversations around Legislation