CS000000-A | 7/7/23

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 

Quarter 4 Report | July 7, 2023

October 1 – December 31, 2022

SPECIAL UPDATE: CDC partners can now report vaccine 

related rumors directly to CDC. To report a rumor, go 

to wwwn.cdc.gov/dcs/ContactUs/Form and start the 

subject line with “Rumors:” and in the question box, 

give as much information about the rumor as you can, 

including a description of the rumor, where you heard it, 

and how many times you have heard it.
Page: 2

State of Vaccine Confidence Insights Report | July 7, 2023

Summary

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

impact vaccine confidence:a

 Some consumers, medical experts, and news outlets were concerned 

about concurrent surges of COVID-19, influenza, and RSV infections, but are 

divided about the risks, causes, and implications of the “tripledemic.” 

 Some parents and consumers were concerned about the Advisory 

Committee on Immunization Practices (ACIP) decision to add COVID-19 

vaccines to the recommended child and adolescent immunization 

schedule.

 Some consumers and social media users were doubtful about the 

effectiveness of COVID-19 vaccines against circulating variants, coinciding 

with increasing pandemic fatigue.

 The uptake of updated (bivalent) COVID-19 vaccine remained low due to 

concerns about safety and effectiveness.

 Some consumers were concerned about COVID-19 vaccine safety, side 

effects, and adverse events.

Ways public health and partners can take action to improve vaccine 

confidence:

 Continue to research the impacts of the COVID-19 pandemic on influenza 

and RSV seasonality and severity. 

 Communicate to consumers about vaccines in development that confer 

protection against illnesses for which there are currently no vaccines to 

normalize the prospect and benefits of receiving new vaccines as they 

become available.

 Continue to research safety concerns about variants and COVID-19 vaccines 

in children and immediately share any pertinent information with the 

public.

 Continue to share messages about why variants occur and how they are 

natural and expected as viruses evolve. Consider providing examples from 

other viruses.

 Continue working with trusted messengers, community leaders, and 

members of the public to craft and disseminate messages that promote 

the benefits, availability, eligibility, safety, and effectiveness of the updated 

COVID-19 vaccine.

For findings and ways to act from our other reports, see previousInsights Reports.

Resources: The following link contains social media resources such as graphics, 

language, and social media calendars that our partners can use to help educate 

their constituents and build vaccine confidence by addressing the themes in this 

report: https://centersfordiseasecontrol.sharefile.com/d-sfa3361305ba74c2da5c5

c60fa8c4f007

Contents

3 

Aims and Methods

4 

Theme 1: Some consumers, 

medical experts, and news 

outlets were concerned about 

surges of COVID-19, influenza, 

and RSV cases, but divided 

on the risks, causes, and 

implications of the “tripledemic

8 

Theme 2: Some parents and 

consumers were concerned 

about ACIP’s recommendation 

to add COVID-19 vaccines 

to the child and adolescent 

immunization schedule

10 

Theme 3: Some consumers were 

doubtful about the effectiveness 

of COVID-19 vaccines against 

circulating variants, coinciding 

with increasing pandemic fatigue

12 

Theme 4: Uptake of the updated 

(bivalent) COVID-19 vaccine 

remained low due to concerns 

about safety and effectiveness

14 

Theme 5: Some consumers were 

concerned about COVID-19 

vaccine safety, side effects, and 

adverse events

17

References

22 

Appendix: Inputs and Sources a

Themes for this report come from an integrated and thematic analysis of the data 

from the sources listed in the appendix.
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State of Vaccine Confidence Insights Report | July 7, 2023

Aims and Methods

By reviewing and analyzing numerous sources and inputs (see Appendix), the State of Vaccine 

Confidence Insights Report emphasizes major themes influencing vaccine hesitancy and uptake. 

These are characterized by the level and type of threat to vaccine confidence, degree of spread, 

and directionality. 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, disinformation, and places where intervention efforts can improve vaccine confidence 

across the United States. 

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.

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 vaccination

 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: 4

State of Vaccine Confidence Insights Report | July 7, 2023

Themes That Might Impact Vaccine 

Confidenceb

Theme 1: Some consumers, medical experts, and news 

outlets were concerned about concurrent surges of 

COVID-19, influenza, and RSV infections, but are divided about 

the risks, causes, and implications of the “tripledemic.” 

In addition to ongoing transmission of COVID-19, the 2022-2023 cold and flu season resulted in 

notable increases and early seasonal peaks for influenza and respiratory syncytial virus (RSV) cases 

throughout the United States.1,2,3

 This trifecta of surging respiratory illnesses has been described as a 

“tripledemic” by some health experts and media outlets, in 

line with similar concerns raised in 2020 and 2021 about a 

potential “twindemic” of COVID-19 and influenza cases.4

 In 

this context, the developing concept of immunity debt has 

gained popularity as an explanation for the “tripledemic,” 

especially on social media. 

Initially coined in 2021, immunity debt refers to the idea 

that non-pharmaceutical interventions undertaken during the COVID-19 pandemic, such as maskwearing and social distancing, have reduced childhood exposure to RSV and other pathogens that 

would otherwise be regularly encountered in childhood, thus resulting in the surge of RSV infections 

as pandemic restrictions lifted.5,6

 Opinions are mixed, however, regarding the validity and implications 

of the concept, particularly in terms of whether the spike in RSV cases reflects a temporary backlog of 

immunologically naïve children who are being exposed en masse for the first time or that children’s 

immune systems have been permanently “weakened” due to social distancing, a claim for which no 

evidence exists.7

Perceptions, concerns, and threats to vaccine confidence 

 Concern over rising cases. Some consumers were concerned about rising numbers of 

COVID-19, influenza, and RSV cases that occurred during the reporting period.8

 The December 

2022 KFF Vaccine Monitor survey found that approximately half of the parents surveyed said 

they are worried about their children getting seriously sick from COVID-19, influenza, or RSV.9

 Support for preventative measures. Despite the easing of pandemic precautions, some 

consumers support non-pharmaceutical interventions such as masking as a key strategy 

to reduce transmission and mitigate the burden on healthcare systems.10,11 Nearly half of 

respondents surveyed by the KFF COVID-19 Vaccine Monitor reported that the “tripledemic” 

made them more likely to take at least one protective measure during the holiday season.12

b

Social media posts referenced throughout this report can be found in this online document.
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State of Vaccine Confidence Insights Report | July 7, 2023

 Lack of concern. Some social media 

users were not concerned about the 

recent marked increase in numbers 

of COVID-19, influenza and RSV 

cases, perceiving the “tripledemic” 

as overhyped, fearmongering, 

and irrelevant, instead emphasizing the role of individual responsibility to boost one’s immune 

system.13,14,15

 Increased awareness of RSV. Google Trends data indicate that search interest for RSV peaked 

in November 2022 at the highest level ever recorded, more than tripling the previous peak 

in August 2021 and over five times higher than any interest before the COVID-19 pandemic. 

Likewise, there was also a rise in Google searches comparing symptoms between COVID-19, 

influenza, and RSV, suggesting that people are seeking information to determine which 

respiratory illness they may be experiencing. 

 The potential influence of the “tripledemic” on 

vaccine uptake. The reporting period saw increased 

Google search activity inquiring about the existence 

and availability of an RSV vaccine, which may indicate 

consumer interest in and receptivity towards receiving 

an RSV vaccine once available. Similarly, a recent study 

examining patterns of COVID-19 vaccination and 

influenza vaccination found that “among individuals 

who historically never got the influenza vaccine, those 

receiving COVID-19 vaccine were substantially more 

likely to switch toward getting the influenza vaccine,” which “suggests that investing in vaccine 

acceptance has payoffs beyond the vaccine itself.”16

 Differing interpretations of immunity debt. Immunity debt is a theoretical concept that has 

been defined and used by different audiences to convey competing ideas about the human 

immune system.

 On social media, the term gained traction among vaccine skeptics and refers to the notion 

that reduced exposure to pathogens (e.g., social distancing) can permanently weaken an 

individual’s immune system; from this perspective, the “tripledemic” is evidence that pandemic 

precautions have caused long-term harm and that the benefits of social distancing during 

COVID-19 are outweighed by the consequences.17,18,19,20,21 This understanding of immunity debt 

is intuitive “common sense” to some social media users22

and appears to be easily assimilated alongside existing 

beliefs that may increase or sustain vaccine hesitancy, 

including opposition to lockdowns, preference for natural 

immunity, and distrust of public health.23 In response, 

some health experts and social media users have publicly 

rejected the “weakened immune system” hypothesis 

as misguided and dangerous,24 lacking evidence,25 and 

unlikely based on current scientific understanding.26,27

 By contrast, the alternative interpretation of immunity debt 

is used to describe the backlog of first-time infections following a period of reduced exposure 

– not that reduced exposure itself can impair the immune system. This conceptualization is 

more accepted among media and has some degree of usage in academic literature.1,28,29,30,31,32,33
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State of Vaccine Confidence Insights Report | July 7, 2023

 Messaging challenges. Some health experts are 

concerned that coverage of the “tripledemic” could be 

perceived as alarmist and may undermine future efforts 

in the event of another public health emergency.34

In addition, the lack of clarity around immunity debt 

has led to imprecise usage, differing definitions, and 

misinterpretation to the point where social media users 

reject the term altogether as false and made up,35,36 while others believe that online discussions 

of immunity debt are being commandeered by disinformation actors and that the media bears 

responsibility for repeating these misperceptions.37 It is for these reasons that some outlets have 

cautioned against media using the term entirely.38

Commonly asked questions and queries from the public

 How can someone distinguish between symptoms of COVID-19, influenza, and RSV?

 Because all three respiratory viruses can share many similar symptoms, such as coughing, 

runny nose, and fever, you cannot tell the difference based on symptoms alone and specific 

testing is needed to confirm a diagnosis. You can learn more about RSV symptoms as well as 

the similarities and differences between influenza and COVID-19 on CDC’s website. 

 How long is RSV contagious?

 People infected with RSV are usually contagious for 3 to 8 days and may become contagious a 

day or two before they start showing signs of illness. However, some infants, and people with 

weakened immune systems, can continue to spread the virus even after they stop showing 

symptoms, for as long as 4 weeks.39

 Is an RSV vaccine available?

 Researchers are working to develop RSV vaccines, but none are available yet. A drug called 

palivizumab is available to prevent severe RSV illness in certain infants and children who are 

at high risk for severe disease.40 There are several RSV vaccines currently undergoing U.S. trials, 

meaning that multiple RSV vaccines could be approved for different populations by the U.S. 

Food and Drug Administration (FDA) by the end of 2023.41 In May 2023, two RSV vaccines—

GSK’s Arexvy and Pfizer’s ABRYSVO (RSVpreF)—received FDA approval for individuals aged 

60 years and older. In June 2023, CDC’s Advisory Committee on Immunization Practices 

(ACIP) recommended that adults aged 60 and older be eligible to receive either RSV vaccine

after consulting with a healthcare provider; both RSV vaccines are expected to be ready for 

distribution this fall. On May 18, 2023, FDA’s Vaccines and Related Biological Products Advisory 

Committee voted in support of the safety and effectiveness of Pfizer’s RSVpreF vaccine to 

protect infants from RSV through maternal immunization; FDA is expected to make a decision 

on the potential approval of RSVpreF as a maternal vaccine in August 2023.
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State of Vaccine Confidence Insights Report | July 7, 2023

 Can individuals receive the influenza and COVID-19 vaccines at the same time?

 Yes, you can get a COVID-19 vaccine and an influenza 

vaccine at the same time if you are eligible and the 

timing coincides. Studies conducted throughout 

the COVID-19 pandemic indicate that it is safe to get 

both a COVID-19 vaccine and an influenza vaccine 

at the same visit. A recent CDC study published in 

JAMA suggests people who received a flu vaccine and 

an mRNA COVID-19 booster vaccine at the same time 

were slightly more likely (8% to 11%) to report systemic reactions including fatigue, headache, 

and muscle ache than people who only received a COVID-19 mRNA booster vaccine, but these 

reactions were mostly mild and resolved quickly.42 The findings of this study are consistent 

with safety data from clinical trials that did not identify any serious safety concerns with 

coadministration.43

 How effective is this year’s seasonal influenza vaccine?

 Influenza vaccine effectiveness can vary. The protection provided by a flu vaccine varies from 

season to season and depends in part on the age and health status of the person getting 

the vaccine and the similarity or “match” between the viruses in the vaccine and those in 

circulation.44 While data are not yet available for the current 2022-2023 influenza season, this 

year’s influenza vaccine appear to be “a very good match” according to Dr. Walensky.45

Identified inaccurate health information themes that may impact vaccine confidence

 Some social media users believe the 

“tripledemic” was caused by COVID-19 

vaccines.46,47

 Some social media users believe social 

distancing precautions have suppressed or 

damaged the immune system.48,49,50

Ways public health and partners can take action to improve vaccine confidence

 Continue to monitor influenza and RSV seasonality and severity in the context of COVID-19. 

 Exercise social media literacy by remaining aware of the differing interpretations of immunity 

debt to avoid inadvertently contributing to the spread of claims lacking scientific support. 

 Continue to research the scientific basis for immunity debt and disseminate accurate information 

in a way that mitigates the potential for conceptual ambiguity and misinterpretation.

 Communicate to consumers about vaccines in development that confer protection against 

illnesses for which there are currently no vaccines (e.g., universal influenza, norovirus) to 

normalize the prospect and benefits of receiving new vaccines (e.g., RSV) as they become 

available. 
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State of Vaccine Confidence Insights Report | July 7, 2023

Theme 2: Some parents and consumers were concerned 

about the ACIP decision to add COVID-19 vaccines to the 

recommended child and adolescent immunization schedule. 

Children as young as 6 months of age have been eligible and recommended to receive either the 

Moderna or Pfizer-BioNTech COVID-19 vaccine since 

June 2022.51 On October 19, 2022, the Advisory 

Committee on Immunization Practices (ACIP) voted to 

approve the Vaccines for Children (VFC) resolution for 

COVID-19 vaccines.52 The VFC program is a federally 

funded program that provides vaccines at no cost 

to children who might not otherwise be vaccinated 

because of inability to pay.53 The vote was an important step to be able to provide COVID-19 vaccines 

for the VFC program once the vaccine is no longer available free to anyone in the U.S. The inclusion 

of COVID-19 vaccines to ACIP’s recommended child and adolescent immunization schedule resulted 

in misinformation on social media among some consumers who believed that ACIP’s decision 

constituted a vaccine mandate for school entry, which is incorrect. While ACIP recommendations 

are used as guidelines for state and local officials, states are responsible for determining school 

immunization requirements.54

Perceptions, concerns, and threats to vaccine confidence 

 There was an increase in Google searches, including the terms “COVID-19 vaccine” and “vaccine 

mandate,” following the October 19, 2022, ACIP meeting.c

 Organizations such as the American Medical Association and the American Academy of Family 

Physicians support ACIP’s decision to include COVID-19 vaccines in the VFC program, which will 

provide vaccines for children who may not be able to afford them after COVID-19 vaccines are no 

longer provided free to everyone in the U.S. 54,55

 Some social media users believed COVID-19 vaccine requirements for children are ridiculous and 

unnecessary.56,57

 Some social media users expressed concerns about COVID-19 vaccine 

side effects that may occur in children.58,59

 Some social media users did not support ACIP’s decision to approve 

COVID-19 vaccines for the VFC program or for the childhood schedule.60,61

 Many social media users who are parents claimed they will begin 

homeschooling if COVID-19 vaccines are added to the routine 

immunization schedule, mistakenly believing that including COVID-19 

vaccination in the schedule implies that it will be required for school 

attendance.62,63,64

 Some social media users were seeking waivers and vaccine exemptions 

in light of ACIP’s decision because of their belief that including COVID-19 

vaccination in the child vaccine schedules may lead to vaccine requirements.65,66

c

Google Trends.
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State of Vaccine Confidence Insights Report | July 7, 2023

 Some social media users were supportive of ACIP’s decision to include COVID-19 vaccines in the 

vaccine schedules.67,68,69

Commonly asked questions and queries from the public

 What is ACIP, and how are immunization schedules determined?

 The Advisory Committee on Immunization Practices (ACIP) comprises medical and public 

health experts who develop recommendations on the use of vaccines in the civilian 

population of the United States. When FDA authorizes or approves a vaccine, ACIP reviews 

all available data about the epidemiology of the disease the vaccine prevents, and the 

safety and effectiveness of the vaccine to determine whether to recommend it and which 

groups of people who should receive it. These vaccine recommendations are then reviewed 

and approved by the CDC Director and U.S. Department of Health and Human Services, 

resulting in the official U.S. adult and childhood immunization schedules. ACIP typically holds 

three meetings each year at CDC in Atlanta, Georgia; all meetings are open to the public 

and available online via webcast. More information about ACIP can be found in this short 

educational video and on the ACIP website.

 Are side effects in children after COVID-19 vaccination normal?

 Side effects after COVID-19 vaccination tend to be mild, temporary, and like those experienced 

after routine vaccinations. They can vary across different age groups.70More detailed 

information about side effects in children ages 6 months-17 years can be found on CDC’s 

website: Possible Side Effects After Getting a COVID-19 Vaccine. 

 Does CDC recommend COVID-19 vaccines for all children?

 CDC recommends COVID-19 vaccination for everyone ages 6 months and older.71 More 

detailed information for children and teens aged 6 months-17 years can be found on CDC’s 

website: Stay Up to Date with COVID-19 Vaccines.

 Where can I find COVID-19 safety data for children?

 Through continued safety monitoring, COVID-19 vaccination has been found to be safe for 

children and teens. The known risks and possible severe complications of COVID-19 outweigh 

the potential risks of having a rare, adverse reaction to 

vaccination.71 More information about COVID-19 vaccine 

safety can be found on CDC’s website: Ensuring COVID-19 

Vaccine Safety in the US. 

Identified inaccurate health information themes that may impact 

vaccine confidence

 Some social media users believe ACIP did not approve the 

COVID-19 vaccines for the VFC program through the usual 

process.72

 Some social media users believe children are not at risk for COVID-19.73,74

 Some social media users believe the COVID-19 vaccines are experimental.75,76

 Some social media users believe COVID-19 vaccines compromise children’s immune systems, 

leading to increased Strep A cases in children.77,78,79
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State of Vaccine Confidence Insights Report | July 7, 2023

Ways public health and partners can take action to improve vaccine confidence

 Create informational materials for schools and 

daycares explaining the difference between the 

vaccine schedule and vaccine requirements.

 Encourage primary care providers and other medical 

professionals who care for children to explain and 

emphasize the benefits of COVID-19 vaccination to 

parents and guardians.

 Continue to research ongoing safety concerns about 

COVID-19 vaccines in children and immediately share any pertinent information with the public. 

Theme 3: Some consumers and social media users were 

doubtful about the effectiveness of COVID-19 vaccines 

against circulating variants, coinciding with increasing 

pandemic fatigue.

SARS-CoV-2, the virus that causes COVID-19, is constantly changing and new variants of the virus are 

expected to occur. All variants of the SARS-CoV-2 virus are being tracked in the United States and 

globally during this pandemic. Some new variants emerge and disappear, while others may persist 

and circulate for some time. During the final week of this reporting period, Omicron subvariants 

BQ.1.1, BQ.1, and XBB.1.5 accounted for 38.2%, 20.2%, and 15.8% of all U.S. cases, respectively.80

Perceptions, concerns, and threats to vaccine confidence

 Consumers are concerned about the immunity evasion capabilities of Omicron subvariants due 

to the insufficiency of certain monoclonal antibody treatments such as Evusheld in preventing 

COVID-19 infection among individuals with compromised immune systems.81 Note that as 

of January 2023, Evusheld is not currently authorized for use in the U.S. due to its reduced 

effectiveness against circulating SARS-CoV-2 variants.

 Some consumer concerns centered around perceptions that the CDC’s approach to mitigating 

the spread of variants is too lax and should include more rigorous guidelines about proper 

masking and PCR testing.82,83

 Some social media users are continuing to not 

support vaccination in light of new variants, 

claiming that mRNA COVID-19 vaccines do 

not meaningfully mitigate severe disease or 

death and that vaccination is futile since there 

will never be a vaccine that confers immunity 

universally to all variants of the virus that 

causes COVID-19.84,85

 Social media users are worried that emerging 

new variants will result in constant, ongoing cycles of sickness on top of the potentially 

debilitating effects of long COVID.86
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State of Vaccine Confidence Insights Report | July 7, 2023

Commonly asked questions and queries from the public

 Is there a COVID-19 vaccine that protects against the Omicron variant BA.5?

 The updated (bivalent) COVID-19 vaccine includes the addition of Omicron BA.4 and BA.5 

spike protein components to previous COVID-19 vaccine formulations, helping to restore 

protection that has waned since previous vaccination by targeting newer variants. 

 Do COVID-19 vaccines cause variants?

 COVID-19 vaccines do not create or cause variants of the 

virus that causes COVID-19. New variants arise because the 

virus that causes COVID-19 constantly changes through a 

natural ongoing process of mutation (change).  As the virus 

spreads, it has more opportunities to change.87

 Do COVID-19 tests check for Delta, Omicron, and other 

variants?

 The SARS-CoV-2 virus, which causes COVID-19, has mutated 

over time, resulting in genetic variants throughout the COVID-19 pandemic. COVID-19 

diagnostic tests are designed to detect all known variants. However, they are typically unable 

to identify the specific type of SARS-CoV-2 variant (such as Delta or Omicron) present in a 

patient sample. The FDA continues to conduct analyses to identify tests for which performance 

may be impacted for known SARS-CoV-2 variants.88

 What is CDC doing to track SARS-CoV-2 variants?

 In the United States, CDC uses genomic surveillance to 

track emerging SARS-CoV-2 variants that cause COVID-19. 

CDC established multiple pipelines to connect genomic 

sequence data from CDC, public health laboratories, 

and commercial diagnostic laboratories within publicly 

accessible databases maintained by the National Center for 

Biotechnology Information (NCBI) and the Global Initiative 

on Sharing Avian Influenza Data (GISAID). As part of the 

CDC National SARS-CoV-2 Strain Surveillance (NS3) System, 

public health laboratories ship deidentified specimens to 

CDC to provide a representative set of viruses for sequencing. There are four main stages in the 

process of generating SARS-CoV-2 genetic sequence data from these specimens and making it 

available in public repositories.89

Identified inaccurate health information themes that may impact vaccine confidence

 Some social media users, noting that COVID-19 vaccines do not stop transmission, believe that 

the health risks to immunocompromised people were used to blackmail the public into being 

vaccinated.90

 Some social media users believe that health authorities are “boosting” young people with 

a vaccine that has serious side effects, does not stop transmission, and has diminishing 

effectiveness against new variants.91
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State of Vaccine Confidence Insights Report | July 7, 2023

Ways public health and partners can take action to improve vaccine confidence

 When data on new variants’ transmissibility and severity of symptoms are available, quickly 

disseminate findings and limitations of the data to the public.

 Amplify messages that promote the benefits of vaccination for all eligible people and explain 

how vaccination helps reduce the spread to the broader community.

 Continue to share messages about why variants occur and how they are natural and expected as 

viruses evolve. Consider providing examples from other viruses.

Theme 4: Uptake of the updated (bivalent) COVID-19 

vaccine remained low due to concerns about safety and 

effectiveness.

To increase protection against the evolving variants of SARSCoV-2, updated formulations of the Moderna and Pfizer-BioNTech 

COVID-19 vaccines were authorized by the FDA in August 2022. 

These newly updated (bivalent) formulations contain two 

messenger RNA (mRNA) components to protect against the initial 

SARS-CoV-2 virus and newer variants.92 In September 2022, the 

White House announced an updated COVID-19 vaccine initiative, 

which included the procurement of 170 million doses of the 

updated COVID-19 vaccines for distribution to the American 

public.93 However, uptake of the updated COVID-19 vaccine 

remains low; as of May 11, 2023, 17% of the U.S. population had received an updated vaccine 

compared with 69.5% of the population who completed the primary series.80

In December 2022, CDC published a State of Vaccine Confidence Insights Report focusing solely on the 

updated COVID-19 vaccines. 

Perceptions, concerns, and threats to vaccine confidence 

 Consumers’ perceptions of the updated COVID-19 vaccine are centered around side effects as 

well as pandemic fatigue, lack of awareness, time and trust in 

the shots, all of which contribute to low vaccine uptake.94,95

 Roughly 40% of vaccinated adults who have not received an 

updated vaccine indicated that they have not yet done so 

because they do not see the point of another shot, are not 

worried about getting COVID-19, and do not trust that the 

updated vaccine works.96

 Some consumers believe that the updated COVID-19 vaccine 

will cause severe adverse reactions such as cancer, heart 

attacks, strokes, and blood clots.97,98

 Some consumers believe that the updated vaccine is ineffective against Omicron and the 

newest variant (XBB).99
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State of Vaccine Confidence Insights Report | July 7, 2023

Commonly asked questions and queries from the public

 Are there long-term symptoms after receiving a COVID-19 vaccine?

 Serious side effects that could cause a longterm health problem are rare following any 

vaccination, including COVID-19 vaccination. 

Side effects after a COVID-19 vaccination tend to 

be mild, temporary, and like those experienced 

after routine vaccinations. They can vary across 

different age groups. Reactions reported after 

getting an updated COVID-19 vaccine are similar 

to those after the two-dose or single-dose 

primary shots. The most commonly reported side 

effects are fever, headaches, fatigue, and pain at 

the injection site.70Rare cases of myocarditis and pericarditis have been observed following 

receipt of monovalent mRNA COVID-19 vaccines, as described later in this report.

 How can I report adverse reactions to vaccines?

 Severe allergic reactions to vaccines are rare but can happen. If you get a COVID-19 vaccine 

and you think you might be having a severe allergic reaction after leaving the vaccination 

provider site, seek immediate medical care by calling 911. A severe allergic reaction can cause 

difficulty breathing or wheezing, a drop in blood pressure, swelling of the tongue or throat, 

or a generalized rash or hives, which may include mucus membranes. If you had a severe 

allergic reaction after a dose of an mRNA COVID-19 vaccine or if you have had a severe allergic 

reaction to any ingredient in an mRNA COVID-19 vaccine, you may be able to get the Novavax 

COVID-19 vaccine, which is not an mRNA-based vaccine. If you have had an immediate allergic 

reaction (a reaction that started within 4 hours) to any vaccine other than a COVID-19 vaccine 

or any injectable therapy, you may still be able to get a COVID-19 vaccine. However, your 

doctor may refer you to an allergy and immunology specialist for additional care or advice.100

 Does CDC recommend COVID-19 vaccines for children under 4 years old? 

 CDC recommends COVID-19 vaccination for everyone ages 6 months and older. Through 

continued safety monitoring, COVID-19 vaccination has been found to be safe for children and 

teens. Millions of children and teens ages 5 through 17 years have already received at least one 

dose of a COVID-19 vaccine. The known risks and possible severe complications of COVID-19 

outweigh the potential risks of having a rare, adverse reaction to vaccination.101

 Can I get a Novavax booster vaccine? Should I start with a Novavax primary series and then a 

booster?

 You may get a Novavax booster if you are unable or unwilling to receive a Pfizer or Moderna 

updated COVID-19 vaccine and you meet the following requirements:101

 You are 18 years of age or older

 You completed a COVID-19 vaccine primary series at least 6 months ago

 You have not gotten any other COVID-19 vaccine

For more information, please visit CDC’s website on staying up to date with COVID-19 vaccines. 
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State of Vaccine Confidence Insights Report | July 7, 2023

Identified inaccurate health information themes that may impact 

vaccine confidence

 Some social media users believe that there is a 

pharmaceutical ploy created to profit from COVID-19 relief 

dollars.102

 Some social media users believe myocarditis is more 

common in young men following vaccination than after 

SARS-CoV-2 infection.103

Ways public health and partners can take action to improve 

vaccine confidence

 Continue to work with researchers and community leaders to ensure any serious side effects or 

adverse events from the updated COVID-19 vaccines are reported. Monitor the Vaccine Adverse 

Event Reporting System (VAERS) for similar data.

 Continue working with trusted messengers, community leaders, and members of the public to 

craft and disseminate messages that promote the benefits, availability, eligibility, safety, and 

effectiveness of the updated COVID-19 vaccine.

 Create or promote communication tools and resources to help health providers discuss 

COVID-19 vaccines with patients in a respectful and empathetic manner. 

Theme 5: Some consumers were concerned about 

COVID-19 vaccine safety, side effects, and adverse events.

Concerns about vaccine safety—one of the strongest correlates 

of vaccine refusal104—continue to circulate in the United States. 

In light of ongoing research assessing the potential (albeit 

rare) risks of heart-related adverse events following COVID-19 

vaccination,105,106 many consumers are worried that the COVID-19 

vaccines are unsafe and are responsible for a rise in myocarditis, blood clots, and other cardiac-related 

issues.107,108 Reports of young athletes and other prominent individuals experiencing heart-related 

events or unexpected deaths have led some consumers to believe that these events are connected to 

COVID-19 vaccines.109 These concerns were amplified in part due to the November 2022 release of Died 

Suddenly, a far-right conspiracist documentary alleging that adverse events from COVID-19 vaccines 

are part of a deliberate plot by global elites to depopulate the planet.110 While the film’s claims are 

easily refutable and have even been criticized by vaccine skeptics for being poorly researched,111

narratives about seemingly healthy individuals who “died suddenly” gained traction on social media 

during the reporting period.112
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State of Vaccine Confidence Insights Report | July 7, 2023

Perceptions, concerns, and threats to vaccine confidence 

 Despite consumer fears that COVID-19 vaccines are causing an increase in heart-related adverse 

events, the risk of myocarditis from SARS-CoV-2 infection is seven times greater than the risk 

associated with COVID-19 vaccination.113

 Some consumers continue to believe natural 

immunity is better and safer given the rare 

risk of blood clotting from the Johnson & 

Johnson COVID-19 vaccine, which is no 

longer available in the U.S.114,d

 Increased reporting about myocarditis, blood 

clots, and heart-related adverse events 

has been used as an opportunity for some political figures to garner support from their base by 

exaggerating the risks of COVID-19 vaccination.115,116

 Some consumers have attributed non-cardiac symptoms, such as mouth sores and respiratory 

problems, to COVID-19 vaccines.117,118

Commonly asked questions and queries from the public

 Do mRNA COVID-19 vaccines cause blood clots?

 There is no indication that the Pfizer-BioNTech and Moderna mRNA COVID-19 vaccines are 

associated with a risk of blood clots,119 and research has shown that the risk of blood clotting is 

much higher following SARS-CoV-2 infection than COVID-19 vaccination.120 Rare cases of blood 

clots were associated with the J&J COVID-19 vaccine, which is not an mRNA vaccine and is no 

longer available in the U.S. The J&J COVID-19 vaccine—which is not an mRNA vaccine—was 

associated with rare cases of blood clots; however, this vaccine is no longer available in the U.S. 

and its use has been limited since May 2022 due to safety concerns. 

 Can mRNA COVID-19 vaccines cause myocarditis?

 While absolute risk remains small, an elevated risk for myocarditis and pericarditis has been 

observed among mRNA COVID-19 vaccine recipients, particularly in males ages 12–39 years, 

more often after the second dose and usually within a week of vaccination. Most patients with 

myocarditis or pericarditis who received care responded well to medicine and rest and felt 

better quickly.121

 Some evidence122,123 suggests that the risk of myocarditis and pericarditis might be higher 

following vaccination with Moderna COVID-19 vaccine relative to Pfizer-BioNTech COVID-19 

vaccine; however, findings are not consistent in all U.S. monitoring systems.124 

 Extending the interval to 8 weeks between the first and second doses for some people might 

reduce the rare risk of vaccine-associated myocarditis and pericarditis.124

 For more information, refer to the latest guidance on the Interim Clinical Considerations for 

Use of COVID-19 Vaccines web page.

d

CDC-INFO.
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State of Vaccine Confidence Insights Report | July 7, 2023

 How do the risks of myocarditis compare between the updated COVID-19 vaccine and the 

original formulations of mRNA COVID-19 vaccines? 

 Adverse reactions are rare, typically mild, and comparable to the monovalent COVID-19 

booster dose.125 For adolescents and young adults, the risk for myocarditis and pericarditis 

after an updated mRNA COVID-19 vaccine appears generally similar to or lower than the risk 

after a second mRNA COVID-19 vaccine primary series dose.124

 Will the updated COVID-19 vaccine cause me to “die suddenly”?

 Deaths related directly to vaccines are extremely 

rare and unlikely.126 Vaccines are a proven and 

safe means to prevent and stop the spread 

and infection of dangerous diseases, including 

COVID-19.126 Vaccine safety is extremely 

important and must be treated with utmost 

seriousness; the claims made in films such as 

Died Suddenly are unfounded, misleading, and easily refutable.110

Identified inaccurate health information themes that may impact vaccine confidence

 The release of the documentary Died Suddenly has led some consumers to believe that the 

adverse events from COVID-19 vaccines are much more common and serious than they really 

are.127

 Echoing sentiments from Died Suddenly, some social media users believe COVID-19 vaccines will 

cause sudden death as part of a deliberate attempt to reduce the world’s population.109,110,128

Ways public health and partners can take action to improve vaccine confidence

 Provide easy-to-read clinical findings showing the safety of all U.S approved vaccines, including 

information about the possibility of rare adverse events.

 Depoliticize health by using neutral, trusted messengers to explain the risks and benefits of the 

updated COVID-19 vaccine. 

 Avoid reliance on politically controversial figures to promote vaccine safety.

 Keep literature consistent and available for medical professionals to stay up to date.

 Promote positive vaccine experiences, emphasize vaccine safety, and communicate the rarity of 

severe adverse events from the updated COVID-19 vaccines.
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State of Vaccine Confidence Insights Report | July 7, 2023

References

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

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105. Lovelace, B., Jr. (2022, November 12). Myocarditis after Covid vaccination: Research on possible long-term risks underway. NBC News. https://www.nbcnews.com/health/health-news/

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106. Naveed, Z., Li, J., Wilton, J., Spencer, M., Naus, M., Garcia, H. H., Kwong, J. C., Rose, C., Otterstatter, M., & Janjua, N. Z. (2022b). Comparative Risk of Myocarditis/Pericarditis Following Second 

Doses of BNT162b2 and mRNA-1273 Coronavirus Vaccines. Journal of the American College of 

Cardiology, 80(20), 1900–1908. https://doi.org/10.1016/j.jacc.2022.08.799

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Claims About Covid-19 Vaccine. Forbes. https://www.forbes.com/sites/brucelee/2022/11/22/

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111. Merlan, A. (2022, December 8). Now the Anti-Vaccine World is Mad at ‘Died Suddenly,’ The Viral 

Anti-Vax Documentary. Vice. https://www.vice.com/en/article/g5v9yj/now-the-anti-vaccineworld-is-mad-at-died-suddenly-the-viral-anti-vax-documentary

113. Voleti, N., Reddy, S. P., & Ssentongo, P. (2022). Myocarditis in SARS-CoV-2 infection vs. 

COVID-19 vaccination: A systematic review and meta-analysis. Frontiers in Cardiovascular 

Medicine, 9. https://doi.org/10.3389/fcvm.2022.951314

116. Blaff, A. (2022, December 23). Florida Supreme Court Approves DeSantis’s Request for Grand 

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119. Nicholson, M., Goubran, H., Chan, N. C., & Siegal, D. M. (2022). No apparent association between mRNA COVID-19 vaccination and venous thromboembolism. Blood Reviews, 56, 

100970. https://doi.org/10.1016/j.blre.2022.100970

120. Health Feedback. (2022, November 28). Photos of blood clots removed during embalming don’t 

show any link with COVID-19 vaccines; blood clotting risk is much higher after COVID-19 than 

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After mRNA COVID-19 Vaccination. U.S. Department of Health and Human Services. https://

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122. Naveed, Z., Li, J., Wilton, J., Spencer, M., Naus, M., Garcia, H. H., Kwong, J. C., Rose, C., Otterstatter, M., & Janjua, N. Z. (2022). Comparative Risk of Myocarditis/Pericarditis Following Second 

Doses of BNT162b2 and mRNA-1273 Coronavirus Vaccines. Journal of the American College of 

Cardiology, 80(20), 1900–1908. https://doi.org/10.1016/j.jacc.2022.08.799

123. Goddard, K., Lewis, N., Fireman, B., Weintraub, E., Shimabukuro, T. T., Zerbo, O., Boyce, T. G., 

Oster, M. E., Hanson, K. E., Donahue, J. P., Ross, P., Naleway, A. L., Nelson, J. C., Lewin, B., Glanz, 

J. M., Williams, J. T. B., Kharbanda, E. O., Yih, W. K., & Klein, N. P. (2022). Risk of myocarditis and 

pericarditis following BNT162b2 and mRNA-1273 COVID-19 vaccination. Vaccine, 40(35), 

5153–5159. https://doi.org/10.1016/j.vaccine.2022.07.007

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Use of COVID-19 Vaccines in the United States. U.S. Department of Health and Human Services. 

https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.

html

125. Hause, A. M., Marquez, P., Zhang, B., Myers, T. L., Gee, J., Su, J. C., Blanc, P. G., Thomas, A., 

Thompson, D., Shimabukuro, T. T., & Shay, D. K. (2022). Safety Monitoring of Bivalent 

COVID-19 mRNA Vaccine Booster Doses Among Persons Aged ≥12 Years — United States, 

August 31–October 23, 2022. Morbidity and Mortality Weekly Report, 71(44), 1401–1406. 

https://doi.org/10.15585/mmwr.mm7144a3

126. Centers for Disease Control and Prevention. (2023, March 7). Selected Adverse Events Reported 

after COVID-19 Vaccination. U.S. Department of Health and Human Services. https://www.

cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html

127. Swenson, A & Fichera, A. (2023, February 4). “Died suddenly” posts twist tragedies to push 

vaccine lies. Associated Press. https://apnews.com/article/vaccine-died-suddenly-misinformation-a8e3a80a015ba9bf78b6bd4f3c271f58
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State of Vaccine Confidence Insights Report | July 7, 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
Page: 23

State of Vaccine Confidence Insights Report | July 7, 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