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Relatively few Americans have received the new Omicron boosterand most dont plan to get it anytime soon, if at all, according to a new survey.Only 7.6 million Americansout of 333 million totalhave received the new COVID vaccine, which became widely available around Labor Day. That compares with 225 million people who received the initial jab. 

Everyone 12 and older is eligible for the booster if theyve received their primary shots. But most Americansmore than two-thirdshave put off receiving the jab or dont intend to at all, according to a Kaiser Family Foundation survey released last week.

Supply isnt an issue. The shot, purchased by the federal government, is free. And the updated jabsproduced by now-household names Pfizer and Modernause the same technology as the initial shots, with an added boost of protection against currently dominant Omicron strains BA.4 and BA.5.

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So why is vaccine hesitancy rising, especially with a new wave of infections predicted to hit in the coming weeks? And what might fall and winter look like with a population with waning COVID immunity?

Experts say COVID fatigue, among other factors, has the vaccine-friendlywho are weary of jabs that protect against death but dont prevent illnessjoining the ranks of the vaccine-hesitant, as the pandemic lingers into its third year.

Nobody is willing to take the vaccine, Dr. Ali Mokdad, a professor at the University of Washingtons Institute for Health Metrics and Evaluation, told Fortune. The centers modeling predicts a U.S. COVID wave that begins to rise in mid- to late-October and peaks in January.

Many Americans got their initial COVID shots, then boosters. But they still got COVID, he said. And they gave up. They said, Im not worried about this virus anymore, and theyve moved on.

Dazed and dismayed

Slightly more than half of Americans report that theyve already returned to their pre-COVID lives or are planning to in the near future, according to a September Ipsos poll. And roughly two-thirds believe the pandemic is over.

It comes as no surprise that most Americans have put the virus behind them, despite tens of thousands of new cases and hundreds of new deaths being reported daily. In May, leading U.S. infectious disease specialist Dr. Anthony Fauci told PBS News Hour that the country is out of the pandemic phase. And President Biden in September proclaimed that the pandemic is over.

If the pandemics over, why get a booster?

If someone says everythings over, people are not going to line up and get a booster the next day, Dr. Raj Rajnarayanan, assistant dean of research and associate professor at the New York Institute of Technology campus in Jonesboro, Ark., recently told Fortune. 

To add insult to injury, the CDCs community levels COVID map shows that the majority of the country is seeing low levels of the virus, Dr. Georges Benjamin, executive director of the American Public Health Association, told Fortune. Whats not immediately apparent is that the map is more reflective of hospital COVID admissions and capacity. A more buried map shows high levels of viral spread in the vast majority of the country.

Most of the nation is green on the CDC prevalence map, Benjamin said, referring to the color associated with low community levels.

I think peoples general perception is that the thing is going away. We just arent very good as a species at understanding risk, he said.

Some Americans dont question the countrys pandemic status but have lost faith in the shots, which were initially touted by public health officials as a one-time jab that would put an end to the pandemic, Mokdad says.

They say, My immune system has seen it, dealt with it, I dont need the vaccine, he said. But those people are among those who are still alive. They dont remember the 4,000 or so that are dying on a weekly basis. People look at the outcome they favor and make a decision not to get the vaccine.

Dr. Bruce Walker, director of the Ragon Institute of MGH, MIT, and Harvard, a medical institute focused on eradicating disease, and co-leader of the Massachusetts Consortium on Pathogen Readiness, agrees.

I think the fact that vaccines are not fully preventing infection but are attenuating disease is something that has confused people and left them less anxious to get immunized, he told Fortune.

Clueless about the booster

Some Americans arent actively rejecting the new boosterthey just dont know it exists. Slightly less than a third of Americans have only heard a little about new Omicron boosters, and 20% have heard nothing at all, according to the Kaiser survey.

Public health agencies arent messaging about the boosters availability and benefits with the same volume and frequency as they did when COVID vaccines first arrived. The White House held a press conference Sept. 6 to herald the availability of the Omicron-specific boostersthen, silence, by and large.

Quite frankly, there has not been a big push to get people the vaccine, Benjamin said. We told people it was there, but it was kind of a one-shot effort.

Then there are those who know about it, but think they dont qualify, according to Benjamin. Those 12 and older who have received their primary seriestwo shots of Modena and/or Pfizerand who are at least two months out from their last shot (booster or primary series) are eligible, according to the CDC.

But those who received one-shot vaccine Johnson & Johnson, or a different vaccine like Novavax, may not know they qualify. And some who had been boosted prior to the advent of the Omicron shots may think they dont need a new booster, Benjamin says.

While there has been some public health messagingabout the safety of getting your Omicron booster and flu vaccines togetherthe messaging focuses on the safety of receiving both at the same time, not that people should get both shots, Benjamin said.

I think thats a missed opportunity, he added.

Defining a pandemic

Adding to the countrys booster woes: Many Americans dont seem to grasp that vaccines are required both during and after pandemics, Amesh Adalja, an infectious-disease specialist and senior scholar at the Johns Hopkins Center for Health Security, told Fortune. 

Compounding the problem: There is no agreed-upon milestone the country must reach before exiting the pandemic and entering endemicity, in which a disease is present but doesnt significantly disrupt daily life.

People get the flu vaccine every year and theres not been a flu pandemic since 2009, Adalja said, referencing the 2009 H1N1 strain of flu.

Because COVID isnt paralyzing the health care system like it once did, Adjala tends to agree with the notion that the pandemic is over, and that its transitioned to an endemic phase. But booster shots are no less vital, he says.

There exists a false binary, a misconception that theres nothing in betweenits pandemic or its nothing, he said. But just because a pandemic is over doesnt mean there isnt work to be done to make COVID-19 even less of an issue.

Hope and trepidation

Adalja is optimistic. He says that booster rates may rise as those who recently received the old booster come to the end of their two-month waiting period for the new one. (The lag is supposed to reduce the risk of heart problems.) And many experts expect an uptick in booster rates if COVID rates again begin to rise this fall.

But as things stand, low booster rates mean new COVID variants will face less resistance in the U.S. Antibody immunityboth from vaccination and infectionfades after a few months, meaning those who havent recently been vaccinated or infected will be more susceptible to the virus.

New COVID variants are becoming increasingly more immune evasive, dodging manufactured antibody treatments, and potentially making the vaccine less effective down the road.

At this point we need to vaccinate as if [new variants] will not provide a new and critical challenge around immune evasion, Dr. Michael Osterholm, director of the University of Minnesotas Center for Infectious Disease Research and Policy, told Fortune. But we owe it to the public to say we could be seeing a future aspect of this pandemic unlike any weve seen today.