Bloomberg Law
April 26, 2022, 9:35 AM

Evolving Covid Booster Guidelines Threaten to Widen Inequities

Celine Castronuovo
Celine Castronuovo

Ever-changing guidance on Covid-19 boosters could widen disparities in uptake for low-income and minority groups that tend to face barriers to health information and are often among the last to get vaccinated.

Several advisers to the Centers for Disease Control and Prevention said most Americans under 50 should wait for the next generation of boosters rather than get a fourth dose now to prevent Covid-19 infections. CDC Officer Sara Oliver said at a meeting last week that because second booster doses are already available for certain groups, the agency “can rapidly adjust recommendations” if the epidemiology of Covid-19 changes in the future.

But public health policy officials say repeatedly altering the guidelines will cause confusion and stir hesitancy among those with limited opportunities to get their questions answered from trusted health-care providers.

It “will initially result in profound equity issues,” Matthew Zahn, deputy health officer for the Orange County Health Care Agency, said during the meeting. “The communities that are at highest risk will initially be those with the lowest immunization rates.”

White, multiracial, and Asian populations have seen a higher percentage of people getting booster doses since late last year than Native Americans, Black, and Hispanic or Latino populations, according to CDC data presented in the meeting. The percentage of individuals who have received a primary Covid-19 vaccine series is now similar across racial and ethnic groups, according to the data.

Limited clarity on the rationale behind making changes to recommendations may fuel hesitancy to get updated shots early enough before new case surges arise. Worsening pandemic fatigue and the ongoing spread of medical misinformation online can also exacerbate mistrust in the health-care system among historically underserved communities.

Federal, state, and local health agencies should prioritize establishing relationships and clear lines of communication with these groups to prevent additional disparities as they continue the fight against future Covid-19 variants, policy watchers say.

Communication Barriers

The CDC recommends that all Americans 12 years of age and older receive a booster after completing their primary Covid-19 vaccination series. It expanded its guidance in March to say that certain groups, including adults over the age of 50 and some immunocompromised individuals, may get a second booster.

The agency has said that when determining whether to get a booster dose now, people should take into account specific factors like underlying health conditions and whether they live with someone at increased risk for severe disease from Covid-19.

But people from more vulnerable communities may have less access to providers and public health services where they can talk about those factors, policy watchers say.

“The more a community lacks that ready access to that communication, the longer it takes for that conversation to take place and the longer it takes for them to be comfortable with getting that booster dose,” Zahn, a representative of the National Association of County and City Health Officials, said.

Early clarification can be especially important before or during a new surge in cases, when “it’s important to get vaccinated quickly,” he said.

Communication from federal, state, and local health officials on changing Covid-19 guidance has “perhaps been the biggest fumble during the management of this pandemic,” said Katharine Head, chair of the Indiana Immunization Coalition’s advisory committee, who is also a health communications professor at Indiana University-Purdue University, Indianapolis.

“For some communities, changing guidance feels a little bit like these agencies don’t know what they’re doing, and that has significantly hurt their credibility,” she said in an email. “This is especially compounded by the fact that sometimes this changing guidance is not accompanied by any justification or reason.”

Zahn said public health leaders right now can at least help people understand the factors and questions that will be considered when determining who exactly will need booster doses in the future. The severity of future strains and the effectiveness of variant-based shots under development from Pfizer Inc. and Moderna Inc. will likely be part of those conversations, he said.

“Medical providers and public health can begin to communicate to their patients, to their clients, to the public, we’re not there right now, but this is what you can anticipate coming in the future, this is what you should pay attention to, and this is the logic for making that decision,” Zahn said.

Easier to Opt Out

Misinformation online can also lower a community’s willingness to accept additional booster recommendations.

“There has been so much misinformation spread about the Covid vaccine that many people are very confused about whether to get vaccinated,” Gary Kreps, director of the Center for Health and Risk Communication at George Mason University, said in an email. “Public health experts have been vilified by politicians, media hosts, and social influencers,” and “so many people are not listening to experts.”

For some members of high-risk communities, it has become “easier for them to ignore complicated health explanations and accept simpler misinformed explanations,” Kreps said. “It is always easier for them to opt out of following health recommendations than to follow them.”

Another issue is worsening pandemic fatigue, which Zahn said most people have experienced to some degree more than two years into the pandemic. But Americans shouldn’t lose confidence in the guidance from health agencies and vaccines that have been developed up to this point, he said.

“As we have more conversations about potential new vaccine recommendations, these additional recommendations are not an indication in any way that the vaccines that have been given thus far haven’t been extremely effective,” Zahn said. “They really have, and I think we shouldn’t lose sight of that as the pandemic goes on.”

Ongoing Mistrust

Historical abuses in medical research, including the Tuskegee syphilis study among Black men beginning in the 1930s, also continue to fuel mistrust in the health-care system among some minority groups, Kreps said. This can encourage hesitancy to accept shifting recommendations from health officials as new data on Covid-19 epidemiology becomes available.

“Health agencies need to get to know the unique concerns, needs, and preferences of the different audiences they want to communicate with about vaccination,” he said.

Zahn said health agencies “need to have community partners who assist you with that outreach.” Health officials in Orange County, for example, partner with organizations like the nonprofit Latino Health Access, which has helped improve health outreach to the local Latino community.

“You need to have specific avenues to develop outreach to those communities who have not historically been well attached and well served by the health-care system,” Zahn said.

To contact the reporter on this story: Celine Castronuovo at

To contact the editors responsible for this story: Alexis Kramer at; Karl Hardy at