COVID-19 Resource Center

COVID-19 Resource Center


Healio Interviews.

Disclosures: Lee reports no relevant financial disclosures. Kuppalli reports being on an advisory committee for GlaxoSmithKline.
June 18, 2021
4 min read

What will COVID-19 look like in the fall for unvaccinated Americans?


Healio Interviews.

Disclosures: Lee reports no relevant financial disclosures. Kuppalli reports being on an advisory committee for GlaxoSmithKline.
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As of June 16, more than half of Americans were fully vaccinated against COVID-19, including more than 76% of adults aged 65 years or older.

On June 8, CDC Director Rochelle P. Walensky, MD, MPH, announced that the average daily case count in the United States dipped below 15,000 for the first time since March 2020, and that new hospitalizations from COVID-19 had declined by 83% since January.

COVID variant
Experts said the emergence of the delta variant and the fact that many Americans are not getting vaccinated could contribute to a dangerous fall season.
: Adobe Stock.

“Overall, the pandemic is looking better in the U.S. than it has in a long time,” Krutika Kuppalli, MD, assistant professor of medicine in the division of infectious diseases at the Medical University of South Carolina and an emerging leader in biosecurity fellow at Johns Hopkins Center for Health Security, told Healio.

“The improvement in numbers is a testament to the overall effectiveness of the COVID-19 vaccine rollout,” Kuppalli said. “That being said, there are still pockets of the country that have had low rates of vaccine uptake that are concerning ... in particular, rural areas and areas in the southern part of the country.”

Rochelle P. Walensky
Krutika Kuppalli

Walensky said mounting data indicate that the vaccines are “moving us out of this pandemic.” Indeed, officials have been lifting pandemic-related mitigation measures for months.

Still, although COVID-19 vaccine hesitancy has declined, experts agree that many eligible people simply will never get vaccinated. What will the pandemic look like for them in the fall?

Variants, flu complicate outlook

According to Kuppalli, all you have to do to get an idea of what this fall might look like for unvaccinated people is look at last fall and winter.

“However, you have to add in the fact that we have several variants circulating that have been shown to be increasingly transmissible and possibly more virulent,” Kuppalli said. “Additionally, there is concern over how bad the flu season could be this year, which could cause extra complications for those not vaccinated.”

Bruce Y. Lee

One of the most dangerous variants is the delta variant, first identified in India, which Bruce Y. Lee, MD, MBA, said has a “fitness advantage,” meaning it has some characteristics or qualities that allow it to spread more easily, be more contagious and take over as the dominate variant, as it has done in the United Kingdom.

“All you have to do is look at the chaos the delta variant caused in India to see how destructive it can be,” Kuppalli added. “I am concerned about how much more transmissible it is and what that means for individuals who have not been vaccinated but also those who have only received one dose of the vaccine as well as individuals who are immunocompromised and may not have developed a strong antibody response.”

As long as SARS-CoV-2 continues to spread, reproducing in people, more variants will probably emerge, said Lee, a professor of health policy and management at the City University of New York Graduate School of Public Health & Health Policy.

“That’s another reason to try to get this spread down as quickly as possible,” Lee told Healio. “The more it spreads, and the more viruses are reproducing or replicating, you’re just giving more and more opportunities for more variants to emerge.”

Higher coverage

Survey results published recently in JAMA showed that the prevalence of COVID-19 vaccine hesitancy among a cohort of more than 7,000 U.S. adults declined from 46% in October to around 35% in March, months after vaccinations began.

The largest declines occurred among Black and Hispanic people, researchers reported. They said hesitancy was most common among younger adults, people without a college degree, and in households earning $50,000 or less annually.

“I think we really need to work on developing our grass roots campaign to understand why certain people aren’t getting vaccinated,” Kuppalli said. “We need to meet people where they are and try to understand and counsel people. I think there still is a lot of misinformation and fear out there about the vaccine, and many times it takes an individual discussion to understand why people believe this misinformation and to appropriately educate them.”

Lee explained that unvaccinated Americans can largely be grouped in several categories. The first, he says, are people who will not get vaccinated under any condition.

“In that case, there's not much you can do because they've already decided that they're actually not going to do this,” Lee said, adding that clinicians must help these people understand that COVID-19 is serious and there are serious risks to not being vaccinated. From there, all you can do is help them take the necessary precautions to limit their risk, Lee said.

The second group consists of people who will not get vaccinated based on misinformation or other information not based on science.

“So, one of the keys here is to help them understand and sort through what's real information and what's not real information,” Lee said. “Help them understand that everyone wants each person to make an informed decision and this is a situation where something unknown is being forced upon people, but when you're determining what information is appropriate or not, you have to be able to look at the source, you have to be able to look at the reason behind what a person or organization or a bot or a social media account is trying to say.”

The third group consists of people who may have correct information on hand, but they distrust health systems, Lee said. This group needs someone they know or trust to reach out and steer them in the direction that is best for them, he said.

Then there are people who would like to get vaccinated but have been unable to. For them, it is a matter of making the vaccines available, Lee said.

“Unvaccinated people will be left vulnerable,” Lee said, adding that a big concern is getting enough people vaccinated to exceed herd immunity thresholds where the chain of transmission can be broken.

“This ultimately will not only help the people who are not vaccinated but also the people who are vaccinated because we have to remember the vaccine is not 100% effective and you can still have breakthrough cases,” Lee said. “That means people who are not vaccinated will continue to have to maintain social distancing, wear a face mask and protect themselves as much as possible come this fall.”


CDC. COVID data tracker: COVID-19 vaccinations in the United States. Accessed June 16, 2021.

Daly M, et al. JAMA. 2021;doi:10.1001/jama.2021.8246.