Preparing Patients for Respiratory Virus Season in Primary Care

Vaccines only protect patients who receive them, and who respond to them. Gaps can open at every step. Fear and pain are among the most common adverse effects of vaccine injections, and needle fear affects an estimated 33% to 63% of children and 14% to 63% of adults. Pain- and fear-related concerns influence vaccine hesitancy or refusal in about 10% of people.1 Even when patients are willing, clinicians may not offer vaccines that patients are eligible for. And among those who are vaccinated, responses vary widely: an estimated 6.6% of US adults had immunosuppression due to disease, medication, or both in 2021, putting them at risk for blunted vaccine responses.2

Primary care physicians (PCPs) are well positioned to address each of these gaps. Patient Care Online spoke with 3 experts about new research on how vaccines are delivered, who receives them, and who benefits: the corresponding author of a 2026 guideline on reducing distress during vaccine injections, the presenting author of a study on pneumococcal vaccination in pregnancy at the 2026 American College of Obstetricians and Gynecologists (ACOG) Annual Clinical & Scientific Meeting, and the corresponding author of a study on antibodies that predict weak vaccine responses.

Reducing distress during vaccine injections

In September 2026, the Help ELiminate Pain in Kids & Adults (HELPinKids&Adults) Collaborative published an update to its 2015 guideline on reducing distress during vaccine injections in CMAJ. The update includes 16 recommendations, 7 of them strong, organized across 5 domains: process, procedural, physical, pharmacologic, and psychological.1

“We often think of this area of vaccination care as a courtesy,” Anna Taddio, BScPhm, PhD, professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto and the guideline's corresponding author, said in an interview with Patient Care Online. “We don't really perceive people's experiences with vaccination and pain and fear…as important enough to systematically try to minimize them.” With so many injectable vaccines and treatments now available, a bad experience can become a barrier not just to vaccines but to other care involving needles, she explained. “We may be preventing people from getting diseases with vaccines, but we're actually talking about in our group…immunizing against pain and fear too.”

Stress-related responses are also a safety issue, Taddio emphasized. Unmitigated distress raises the risk of dizziness and fainting, which can lead to injuries from falls.1 “This is not a courtesy. This is an expectation,” she said.

Letting patients “play their CARDs”

One criticism of the 2015 guideline was that it listed what to do without explaining how. The update recommends multicomponent interventions, specifically the CARD system, a strong recommendation based on moderate-certainty evidence.1 The acronym was coined by a 16-year-old member of the research team and stands for 4 categories of coping strategies:

• Comfort: sitting upright, holding an infant, breastfeeding, or bringing a comfort item from home
• Ask: inviting questions, which can relieve worries that drive fear and pain
• Relax: deep breathing, music, or having a trusted support person present
• Distract: a toy, conversation, or other activity, for those who want it

The team first tested CARD in school-based vaccination clinics, then in community pharmacies, public health offices, and mass vaccination clinics. It helped across the lifespan, Taddio said. Older patients reported less pain and a better experience, while younger patients experienced a larger reduction in fear.

In practice, patients receive a CARD checklist at check-in, alongside other intake forms. Clinicians review it before the patient enters the vaccination room, so options such as a topical anesthetic, which needs time to take effect, can be applied in advance. “When they come in the room, everything's ready…you're just confirming,” Taddio said. That makes the visit shorter, not longer.

The approach also corrects a common assumption: that every patient wants to be distracted. “About a third of people actually want to pay attention to the procedure,” Taddio said. Some find constant chatter from a clinician stressful. “Don't fill the air with words just because you think it's too quiet,” she advised.

What clinicians control

On the clinician side, Taddio described a “4E” model: educate patients about CARD, adjust the environment to reduce fear cues, engage in ways that promote coping, and evaluate how the vaccination went. That includes avoiding the word “shot,” vaccinating patients privately rather than in front of others to prevent “fear contagion,” and asking neutrally afterward whether patients feel dizzy.

The guideline also recommends several changes to injection technique and workflow1:

• No aspiration, with a fast injection (strong recommendation, low-certainty evidence). Aspiration lengthens the procedure and moves the needle, adding pain. The CDC also advises that aspiration is not necessary because no large blood vessels are present at recommended injection sites.3
• Inject vaccines in order of increasing distress, starting with the least painful (strong recommendation, moderate-certainty evidence).
• Reduce fear cues, such as visible needles, before injection (conditional recommendation, very low-certainty evidence).
• Offer topical anesthetics to children and adults who want them (strong recommendation, moderate-certainty evidence).
• For infants, use breastfeeding, bottle-feeding, sweet-tasting solutions such as sucrose, or pacifiers (strong recommendations), and offer topical anesthetics or manual tapping.
• Drop non–evidence-based steps, including alcohol skin antisepsis and oral analgesics, which add cost and time without proven benefit.

Most of these changes cost nothing, Taddio said, and dropping unnecessary steps can free up resources for patients who need more support. “You don't have to use alcohol swabs. Why are you wasting money and time on those?” she said. “You could buy a few tubes of topical anesthetic, and when somebody needs it, you can just put a little bit on, and that'll make a big difference for them.”

Check out our full interview with Dr Taddio for more on the 2026 guideline.

Predicting who will respond to a vaccine

Even when patients are vaccinated, not all of them are protected equally. New research suggests a simple blood test may one day identify, before vaccination, who is likely to mount a weak response.

In a study published September 21, 2026, in Cell Press Blue, Joshua LaBaer, MD, PhD, of the Biodesign Institute at Arizona State University, and colleagues profiled antibodies to 185 antigens, including SARS-CoV-2, 157 common microbial pathogens, and 25 autoantigens, in 1644 immunosuppressed patients and 2445 healthy individuals before and after COVID-19 vaccination.2 Participants were enrolled through the National Cancer Institute's Serological Sciences Network (SeroNet).

Weak responders aren't only the immunosuppressed

As expected, blunted responses were more common in solid organ transplant recipients and in patients with multiple myeloma, autoimmune disease, inflammatory bowel disease, and HIV. During the initial vaccine series, weak responses occurred in 71.6% of transplant recipients, 48.5% of patients with multiple myeloma, 43.0% with inflammatory bowel disease, and 39.0% with autoimmune disease.2

But responses varied widely within every group, and about 5% to 6% of healthy individuals also mounted weak responses.2 Immunosuppression was a strong risk factor for a poor response, but it was not by itself a sufficient predictor.

“Sentinel” antibodies

The researchers found that pre-existing antibodies to common microbes, including Staphylococcus aureus, respiratory syncytial virus, and human respirovirus 3, consistently predicted how strongly individuals responded to COVID-19 vaccination, in both healthy and immunosuppressed groups.2 These antibody levels remained stable over the 18-month study period, suggesting they reflect a person's baseline humoral immune readiness rather than a recent exposure. The authors call them “sentinel antibodies.”

Using these antibody profiles plus demographic information, the team built a deep-learning model to flag likely low responders. The model achieved a mean area under the curve (AUC) of 0.766 across cohorts and 0.803 in healthy individuals, stratifying low responders among healthy people with more than 75% accuracy.2 It performed poorly in transplant recipients and patients with autoimmune disease (AUC < 0.6), groups the authors identified for further study.

The findings may extend beyond COVID-19. Antibody levels to the measles vaccine strain also tracked with COVID-19 vaccine response, suggesting shared signatures across vaccines, though the authors note this needs formal testing with other vaccines.2

Check out our full interview with Dr LaBaer for more on sentinel antibodies.

Pneumococcal vaccination in pregnancy

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis, and invasive disease, and ACOG recommends pneumococcal vaccination during pregnancy for individuals at high risk, according to the study authors.4 Yet uptake appears to be very low.

At ACOG 2026, Maria Cristina Marcos, MD, a third-year resident at Thomas Jefferson University Hospital, presented a retrospective cohort study of 492 pneumococcal vaccine–eligible pregnant individuals who delivered at her institution in 2024.4 More than half of participants (54%) were Black, 24% were White, and 13% were Hispanic. The most common qualifying conditions were asthma (72.2%), tobacco use (18.5%), and preexisting diabetes (10.3%).

Only 1% received a pneumococcal vaccine during pregnancy, and only 7.7% were up to date on their series, either before or during pregnancy.4 Participants with HIV were vaccinated during pregnancy less often (2% vs 20%; P = .004), while those with preexisting diabetes had nearly 3 times higher odds of being up to date (adjusted odds ratio, 2.766; 95% CI, 1.208-6.329).4

A primary care connection

That diabetes finding may point to the role of primary care. “Our hypothesis as to why type 2 diabetics are most likely to have the series completed [is that] oftentimes, those are patients that prior to pregnancy are frequently seeking care with a primary care provider that is a little bit more knowledgeable on pneumococcal vaccine recommendations,” Marcos said in an interview with Patient Care Online.

She pointed to 2 main drivers of low rates: provider awareness and vaccine access. “It's unfortunately, like, not on our radar,” she said. And while her clinic stocks the pneumococcal vaccine, “in some clinics, it's not a vaccine that is widely carried.”

Closing the gap

An electronic health record prompt that flags patients with qualifying conditions could help, Marcos said, but it should be used “judiciously to not overwhelm the provider,” given alert fatigue.

Her most practical advice was simpler: offer the vaccine. Many qualifying conditions, such as asthma, are already discussed during routine care, making vaccination a natural part of that counseling. “Just understanding what the qualifying medical conditions [are], reviewing that, and then offering it to your patients and taking time to discuss with them,” she said. “And if there is any vaccine hesitancy, understand maybe where that's coming from.”

Check out our full interview with Dr Marcos for more on pneumococcal vaccination in pregnancy.

A note to primary care

Taken together, the 3 studies point to opportunities at each step of vaccination: making the experience less distressing so patients come back, offering vaccines to every eligible patient, and, eventually, identifying in advance the patients likely to mount weak responses.

Many of the changes require little time or money. Clinicians can drop aspiration and alcohol swabs, ask patients ahead of time how they'd like their vaccination to go, and review qualifying conditions for vaccines such as pneumococcal vaccine at routine visits.

Taddio encouraged clinicians to treat these practices as part of evidence-based care, and to update habits accordingly. “People kind of need to go with the times, I think, and update how we practice,” she said. “We have evidence for how to [give] vaccines that make it safer, make it more comfortable for everybody, make it a better experience. So go and do it.”

References

1. Taddio A, Shah V, McMurtry CM, et al. Reducing distress during vaccine injections: 2026 clinical practice guideline update. CMAJ. 2026;198(32):E1243-E1263. doi:10.1503/cmaj.260123
2. Song L, Park JG, Qiu J, et al. Pre-vaccine sentinel antibodies predict blunted vaccine responses. Cell Press Blue. 2026;1:100088. doi:10.1016/j.cpblue.2026.100088
3. Vaccine administration. Centers for Disease Control and Prevention. Updated June 18, 2024. Accessed November 9, 2026. https://www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html
4. Marcos MC, Habash E, Dutra K. Pneumococcal vaccination series completion among eligible pregnant individuals. Abstract 3390. Presented at: 2026 ACOG Annual Clinical & Scientific Meeting; May 2026.