Stakeholder readiness in the evolving adult vaccine market

Summary

The adult vaccine market is undergoing rapid transformation, driven by an aging population and advancements in vaccine technology post-COVID. Research conducted in June 2022 highlights divergent stakeholder perspectives; policy makers and purchasers underestimate emerging challenges, while immunizers and consumers express concern about the increasingly complex vaccine landscape. Findings from over 750 participants reveal the need for strategic efforts to manage the integration of new vaccines and streamline communication among stakeholders. The study emphasizes improving data interoperability and adapting infrastructure, particularly through retail pharmacies, to meet rising demand. Collaborative efforts are critical to addressing bottlenecks and stakeholder overwhelm, ensuring a resilient vaccination ecosystem. This research provides actionable insights for navigating the evolving market and fostering success in a challenging era.

Graphical abstract

Highlights

• •Adult vaccine portfolio expected to triple to 100–120 products within 10 years
• •Recommenders feel ready, but immunizers and consumers foresee operational strain
• •Data fragmentation, co-payment burden, and forced seasonality are the top bottlenecks
• •Retail pharmacies can absorb dose growth if interoperable registries are scaled

Health sciences; Medical science; Social sciences

Introduction

The adult vaccine market is experiencing a swift transformation, accelerated by the COVID-19 pandemic and breakthroughs in RNA and vaccine technologies. The pandemic has unveiled the highly fragmented state of the adult vaccine infrastructure, underscoring the urgent need for transformation. This phenomenon is occurring against the backdrop of technological progress, particularly in the realm of RNA technology, which heralds a promising future of streamlined and flexible vaccine design and manufacturing.¹

Historically, the emphasis on pediatric vaccines has overshadowed the adult vaccine market.² However, this paradigm is shifting. Adult vaccines, still facing challenges such as limited awareness and vaccine hesitancy,³ are now at the forefront of a rapidly expanding market. The global vaccine market, including COVID-19 vaccines and valued at $19.48 billion in 2022, is forecasted to reach $27.65 billion by 2028.⁴ This growth is fueled by an aging global population, the rising incidence of vaccine-preventable diseases in adults, and groundbreaking technological innovations brought about by the “digital age” of vaccines, where only an antigen sequence and standard “plug-and-play” components (e.g., liposomes and RNA constructs) are required to develop new vaccines (e.g., RNA vaccines).^1,5,6

Within the next decade, we expect a dramatic increase in the number of vaccine products, with up to 120 emerging products targeting a wide array of diseases.⁷ This expansion is expected to be accompanied by intense competition among vaccine manufacturers, propelled by newcomers with innovative technologies and a reshuffling of the landscape in the aftermath of the COVID-19 pandemic.⁸ By 2032, the US adult vaccine market is projected to exceed 500 million doses annually, a volume that is approximately the same size as the entire global influenza vaccine market.⁷ This prediction underscores the colossal scale of the challenge confronting the existing immunization infrastructure and underlines the need for a paradigm shift in vaccine administration strategies. With this expansion of the adult vaccine market comes emerging vaccine products that necessitate a more complex adult immunization schedule and introduce challenges in consumer awareness and acceptance, vaccine administration and distribution.

It is important to note that the empirical work reported here was conducted in June 2022, when the COVID-19 vaccine rollout was stabilizing but pandemic-related operational strains were still fresh in stakeholder memory. The perceptions captured, therefore, represent a “descending-phase” snapshot that may evolve as health-system pressures recede; this temporal context is revisited in the Discussion.

Assessing the transformation of the adult vaccine market and its impact on key stakeholders is a complex task and requires a non-traditional market research design. To navigate this complexity, we conducted a multi-phase market research study, carefully structured to both qualitatively explore and quantify the changes in the adult vaccine market and their implications for key stakeholders. This market research study aimed to identify bottlenecks in a system that can be exacerbated or alleviated, uncover new market opportunities or challenges, and enhance our understanding of stakeholder motivations, decision-making factors, and their future role and influence in the changing landscape of adult vaccines. Our methodology consisted of an extensive review of current market trends, which laid the groundwork for thorough qualitative interviews with key stakeholders and key opinion leaders (KOLs). The insights derived from these interviews were critical in shaping the design of subsequent quantitative surveys, intended to corroborate and expand on the initial findings. Here, we present key insights into the state of the current and future adult vaccine market, identify potential growth areas and challenges, and provide strategic directions for stakeholders to consider to increase success navigating this rapidly evolving landscape.

Results and discussion

The results of the secondary research provide significant insights into the various scenarios that could play out in the evolving adult vaccine market. What we heard → The study predicts a future wherein the market is overwhelmed by the number of adult vaccines recommended (new and existing), increasing the market’s complexity. A noteworthy quantitative forecast from this research predicts a 3-fold increase in globally approved vaccines within the next decade, expanding from 35 products for 13 disease sectors to 100–120 risk-adjusted products for 40 distinct disease sectors. These results have been previously presented by Jones et al.⁷ Why it matters → This significant increase highlights the potential for market expansion, but it also underscores the need for effective management of vaccine distribution and administration, as well as interoperable electronic systems to capture vaccination histories.

The study also identified prospective barriers to growth, particularly the possibility of a “forced seasonality,” wherein new vaccine campaigns align with the influenza campaign season, potentially overwhelming the vaccine infrastructure during a 4-to-6-month period of the year. This issue could be exacerbated by the anticipated increase in seasonal vaccines, such as COVID-19 vaccines. Another identified challenge lies in the limited time of immunizers across channels to accommodate the increasing number of patients who require a growing number of vaccines.

Furthermore, the research encapsulates two contrasting scenarios regarding market evolution (Figure 1 summarizes the multi-step research sequence that generated these scenarios).

• (1)Scenario A—High Resilience. The first scenario posits high resilience among stakeholders, characterized by robust recommendations, absence of enforced seasonality, and increased use of Real-World Evidence (RWE) and Health Economics and Outcomes Research (HEOR) to provide recommendations on newly approved vaccines. Success in this scenario is reliant on infrastructure enhancements, broader scope-of-practice requirements for non-physician immunizers, and improved policies and guidelines.
• (2)Scenario B—Business-as-usual. The second scenario, conversely, assumes stakeholders’ adherence to a “business-as-usual” approach, leading to segmented recommendations, a negative public perception from pandemic weariness, and financial disincentives limit uptake.

Figure 1.

Market research study methodology

(A) Qualitative interview methodology and sample.

(B) Quantitative survey methodology and sample.

(C) OUS (Outside United States) qualitative interview methodology and sample consisting of Australia, Brazil, France, Portugal, and South Korea (listed using country flags).

ACIPs, advisory committee on immunization practices; CDC, Centers for Disease Control and Prevention; GPOs, group purchasing organizations; HCPs, health care professionals; IDN, integrated delivery network; KOLs, key opinion leaders; PAs, physician assistants; PCPs, primary care providers; VTCs, vaccine technical committees.

These scenarios framed the primary research that follows with the goal of creating a future-looking understanding of the adult vaccine market, highlighting potential opportunities and challenges. Findings from the mixed-methods work are distilled into five insights; each is presented below in a “What we heard → Why it matters” micro-structure to maintain narrative flow. The complete results of this study are available in the supplemental information (results).

Insight 1: The lack of stakeholder concern and preparedness for future adult vaccine schedule

What we heard—A dichotomy exists in stakeholder perspectives about the future adult vaccine schedule. Stakeholders at the top of the value chain, such as recommenders and funders, appear to underestimate the challenges of adopting the future adult schedule, while immunizers and consumers expressed greater concern.

The rapid adaptation necessitated by the COVID-19 pandemic has resulted in certain stakeholders, such as recommenders and funders, developing a perceived enhanced capacity to manage new entrants into the vaccine market. This is echoed by a representative who was previously part of the ACIP, who stated, “ACIP may need to add one or two more meetings to their schedule during the year, but this was done during COVID.”

Our study also indicates that recommenders are likely to maintain their current approach to evaluations for future vaccines. Economic and operational factors (e.g., cold-chain burden and reimbursement complexity) are not expected to influence ACIP deliberations. Instead, stakeholders indicated that HEOR and RWE, and cost/economic data, will continue to hold greater significance. HEOR will continue to play a critical role in elucidating the broader socio-economic implications of vaccination, including its potential to reduce healthcare costs and enhance societal productivity. Meanwhile, RWE, derived from diverse real-world data sources such as electronic health records and patient registries, will serve as an invaluable complement to randomized controlled trial evidence, offering insights into vaccine effectiveness, safety, and usage patterns in routine clinical practice. Cost and economic data, meanwhile, will remain integral to evaluating the affordability and cost-effectiveness of vaccines, thereby informing pricing and reimbursement decisions.

Similarly, few changes were expected among stakeholders to recommendations, vaccine policy, and guidelines. There was no appetite for vaccine mandates, priority diseases, or preferred vaccines among former ACIP or policy makers. Providers and insurers expect to rely on ACIP recommendations for future recommendations and coverage decisions. Recommenders expected these future recommendations to be targeted toward specific subpopulations, segmented by age, geography, and/or risk factors, making roll-out and administration more manageable from the physician and patient perspectives. For example, some new vaccines, particularly travel and endemic vaccines, may see occupation or travel related criteria in guidelines, similar to the current rabies vaccine, which is recommended in animal-health related occupations.

However, this lack of prescriptiveness adds complexity to the implementation of future schedules. Our secondary research found that, due to the fragmented nature of future recommendations, Shared Clinical Decision Making (SCDM) is going to be relied upon at the provider level. This process, where healthcare providers and patients collaborate to make healthcare decisions that are tailored to the individual patient’s needs and preferences, adds complexity to vaccine rollouts and administration and is counter to the desires of immunizers. As one former ACIP stakeholder stated:

“ACIP are concerned about the schedule getting overly complicated, the feedback they get from healthcare providers is that ‘Please issue simple recommendations. Make them as simple as possible. Don’t involve informed decision-making or things like that, or more of negotiations or conversations with patients’. They really just want to know who’s indicated for, what, when and leave it at that.”

Few changes were anticipated by most stakeholders in vaccine infrastructure and administration channels. However, both the secondary and primary research pointed to the rise of pharmacies as alternative vaccination locations.⁹ In light of the hypothetical future adult vaccine schedule, immunizers indicated this change would require incremental changes in data processes, infrastructure, and reimbursement. As one US pharmacist noted, “We’d need to change our workflow to manage administering more vaccines.”

Future vaccine rollouts were also expected by stakeholders to occur gradually. However, as we enter the digital vaccine era, driven by the rise of RNA vaccine technology, vaccine development and manufacturing are becoming modular with “plug-and-play” components such as the vaccine RNA construct and antigen sequence.¹ As such, the rate at which new vaccine rollouts occur is expected to increase significantly, which has the potential to overwhelm existing vaccine infrastructure.

The lack of concern regarding the adoption of an expanded schedule may reflect stakeholders’ limited understanding of the overall process, which results in “blind spots” around implications for implementation and an underestimation of the magnitude of change. None of the stakeholders we interviewed was taking proactive steps to plan for a more complex adult vaccine schedule. A centralized body tasked with encouraging vaccine use and educating providers on patient eligibility and patients on the benefits of vaccines could help close these education and awareness gaps.

Notwithstanding the perceived readiness of stakeholders, there was significant apprehension among consumers surveyed in this study regarding the future vaccine schedule. A considerable proportion of adult consumers, exceeding one-third, expressed that the prospective vaccine schedule appears “very overwhelming” (Figure 2). This sentiment primarily emanates from the anticipated increase in the number of vaccines and the consequent visits required for administration. The crux of this concern lies in the logistical challenges associated with an expanded schedule. The complexity of managing multiple appointments, coupled with the potential side effects of numerous vaccines, may inadvertently contribute to an elevated sense of apprehension among consumers.

Figure 2.

Consumers reactions toward an expanding adult vaccine schedule

Percent of consumers who responded “very overwhelming,” “neutral,” or “not at all overwhelming” when asked “What is your overall feeling about having more vaccines available in the future to protect adults from more diseases?” (Consumer Q15b; n = 500). Consumers were then asked, “Can you explain to us why do you feel overwhelmed?” (Consumer Q15c; n = 191).

Despite the aforementioned concerns, many consumers did acknowledge the positive implications of a more comprehensive vaccine schedule. They recognize that an increased number of vaccines would likely translate into a broader spectrum of protection against various diseases. This perspective is particularly prevalent among consumers aged 65 and above, 55% of whom believed vaccines had a very positive impact on the health of the general population (Figure S1). When shown the future schedule, a significant segment of this demographic (64%) did not foresee major difficulties in adopting the new expanded schedule (Figure S4B).

Why it matters—The lack of prescriptiveness adds complexity to implementation … (paragraphs unchanged). Taken together, these findings set the stage for consumer-facing challenges described in Insight 2.

Insight 2: The need for consumer acceptance and convenience in the future vaccination landscape

What we heard—In the future, adult vaccinations will require motivating consumer acceptance and increasing convenience, along with easing operational and administrative burdens for providers. Challenges are expected to focus on operations, infrastructure, and patient choice rather than policy or recommendations. The complexity of the future landscape is highlighted by concerns from immunizers and those involved in vaccine stocking and purchasing.

These stakeholders rated several aspects, including out-of-pocket costs for adults, infrastructure, and distribution, claims processing/reimbursement for providers, consumer/patient acceptance, and vaccine operations, as “difficult” or “very difficult” to accommodate if there is a 6-fold increase in volume of adult vaccines (Figure 3). These include out-of-pocket costs for adults (60%), infrastructure and distribution (54%), claims processing/reimbursement for providers (53%), acceptance on the part of consumers/patients (53%), and vaccine operations (52%).

Figure 3.

Most difficult aspects to accommodate if a 6-fold increase in volume of adult vaccines

(A–C) Percent of (A) Immunizers (n = 103), (B) S/P (n = 80), and (C) both Immunizers and S/P (n = 183) that responded “difficult” or “very difficult” when asked “Please now imagine a scenario of a 6-fold increase in the volume of adult vaccines in the future. How difficult will it be for each of the following areas to accommodate this?” (Immunizer Q5b/S&P Q7b). For each group, the top 5 most difficult aspects are presented in decreasing difficulty.

Out-of-pocket costs, for example, pose a considerable barrier to vaccination uptake, particularly when vaccines are not fully covered. A marked decrease in motivation to vaccinate has been observed among immunizers when more than a minimal co-payment is required. Some efforts are being made to increase the affordability of vaccines. Policies such as the Affordable Care Act (ACA) and the Inflation Reduction Act (IRA) have been put in place to alleviate some of the payment and reimbursement burden associated with adult vaccines; however, not all uninsured patients are guaranteed access to life-saving vaccines.¹⁰ The ACA guaranteed coverage of ACIP recommended vaccines to privately insured patients or those in states with expanded Medicaid. In 2023, this coverage was expanded by the IRA to cover patients enrolled in Medicare Part D, thereby improving vaccine access to older and low-income adults.¹¹ However, these policies only apply to ACIP recommend vaccines. As such, a vaccine without a universal ACIP recommendation will not be covered by the ACA or IRA and will likely not be covered by payers. This limits vaccine access to uninsured healthy adults under the age of 65 years. A related obstacle that vaccine providers face is the reluctance of consumers to pay for a preventive measure against a disease for which they do not perceive as a risk to their personal health or that they do not believe they will acquire. This is especially true for diseases that are new, rare, or complex, and that require a personalized assessment of risk factors and benefits.

Anticipated infrastructure and distribution challenges mainly revolve around inventory management. Stockers/Purchasers expressed concerns about the adequacy of their current training and forecasting systems for managing an expanded vaccine schedule. As such, they will need tools to help them estimate the appropriate volumes of vaccines to purchase, particularly for new disease areas. They will also require tools to help manage inventory, particularly for vaccines that have limited shelf life and require specific refrigeration requirements. With the increasing volume of vaccines entering the market, pharmacies will need to be better staffed and equipped to meet this new and growing demand.

The multiplication of vaccines due to an expanded schedule also adds to the administrative burden associated with claims processing and reimbursement for providers, a situation that Medicare Part D reform alone does not fully alleviate. This administrative burden may be particularly high at alternative vaccination sites, such as retail pharmacies, which may be considered out-of-network by payers/insurers.²

Consumer acceptance was identified by immunizers as another key concern. Health literacy gaps, vaccine fatigue, multi-visit requirements and message confusion were cited by immunizers as factors that would undermine motivation and create additional barriers to vaccine uptake (Figure S3). Additionally, negative public sentiment, driven by various factors including, confusion surrounding the introduction of new vaccines and changing polices, a decline in trust of expertise and authority, a lack of understanding of the benefits of vaccines or risks of vaccine preventable diseases (VPDs), vaccine misinformation amplified by social media, and even a fear of needles^12,13 could very likely limit the uptake of future vaccines. For instance, the perception that COVID-19 vaccines do not prevent the spread of disease has diluted confidence in vaccine efficacy. Immunizers observed that misinformation circulated about the COVID-19 vaccine bred mistrust, creating a negative halo effect from COVID-19 to other adult vaccines among those already hesitant. Furthermore, vaccine mandates for COVID-19 were seen as off-putting, reinforcing the belief that vaccination should be a personal choice. Conflicting arguments from experts regarding COVID-19 vaccine requirements and efficacy also caused confusion. Lastly, the rush to market for COVID-19 vaccines raised questions and eroded public trust in the development and testing process. All of these trends observed by immunizers have been extensively documented in the literature.^14,15,16

Interestingly, immunizers also observed that the experience with COVID-19 sensitized some populations, especially those aged 65 and above, to the value of non-COVID vaccines. HCPs noted improved uptakes of the influenza vaccine in 2020 and 2021, suggesting that the COVID-19 experience has established “good practice” guidelines for other diseases. However, since this study was conducted, influenza vaccination rates have declined back to pre-pandemic levels,¹⁷ indicating that the urgency around vaccination has declined and vaccination fatigue and hesitancy have increased.

To support the successful implementation of an expanded schedule with emerging vaccine technology, public education, outreach, and personalized campaigns will be needed. In qualitative interviews, immunizers stated that consumers tend to prioritize vaccines for the diseases they are most familiar with, indicating a gap in understanding the broader implications of various diseases and the benefits of their respective vaccines. This suggests the need for more comprehensive educational efforts to ensure the public understands not only the risks associated with contracting these diseases, but also the benefits of vaccination in preventing them. This is especially true for diseases such as Zoster and Cytomegalovirus (CMV) where there may be a strong clinical rationale for vaccination but low public understanding. Considering social and behavioral elements of delivery alongside public education toward vaccination acceptance is also crucial. Unfortunately, healthcare providers, when interviewed, estimated that patients only retain 10-20% of information shared, meaning that practical support such as take-home materials and regular vaccination campaigns would be needed.

In terms of information sources, consumers predominantly look to their doctors for guidance, particularly those aged 65+ and 18–64 with comorbid conditions (e.g., at risk; Figure S2). Individuals aged 65+ tend to be more trusting of information sources, including pharmaceutical companies. They perceive themselves as having better control of their health and are generally more supportive of vaccines. However, the 18–64 at risk group tends to be less reliant on and trusting of doctors and pharmaceutical companies. They are the most hesitant about vaccines’ benefits outweighing risks, often out of caution about undermining other health conditions they may have or disrupting existing treatments that work for them (Figure 4). Conversely, the 18–64 demographic with no risk conditions, despite lower trust in doctors and pharmaceutical companies, acknowledge that the benefits of vaccines outweigh the risks.

Figure 4.

Consumer attitudes toward health and vaccines

Percent of consumers that selected 8, 9, 10 on a 10-point scale indicating that they strongly agree when asked “To what extent do you agree with the following statements about yourself?” (Consumer Q1) and “To what extent do you agree with the following statements about vaccination?” (Consumer Q2; n = 500). Green boxes represent percentages of adults 65+ that are statistically different from all other groups. Orange boxes represent percentages of adults 65+ that are significantly different from the 18–64 at risk adults only.

For the successful implementation of an expanded vaccine schedule, Immunizers and Stockers/Purchasers indicated a need for better vaccine tracking. The increasing decentralization of the adult vaccine administration infrastructure highlights the need for comprehensive vaccination records that can be easily accessed by both HCPs and patients, regardless of where a patient receives vaccines. Such immunization information systems (IISs) have long been sought by the Unites States Vaccine Program^18,19; however, one has yet to be established country wide. Most states have established their own IIS programs, meaning that IISs have operated under a patchwork of different regulations, laws, and policies.¹⁹ This often means that patients need to work with their HCPs to track their own vaccination records.

Several other areas for improvement or support, as identified by Immunizers and Stockers/Purchasers included, additional vaccine education, improvement to infrastructure, and more streamlined vaccine operations. By prioritizing public education and utilizing trusted sources for information dissemination, vaccine hesitancy can be reduced while also fostering informed decision-making. For example, a physician’s recommendation, which has been proven to increase immunization rates,²⁰ can increase consumer’s knowledge of available vaccines and motivate through the trust they have built with their patients. Expanding vaccine administration settings, which will be discussed in greater detail in Insight 4, and ensuring the availability of combination vaccines can increase consumer convenience and mitigate the impact of increased volume. Operational changes, such as simplifying provider billing and coding and improving capacity during “vaccine season”, can alleviate administrative burdens and equip healthcare systems to handle increased vaccination demand effectively. Accurate demand forecasting or more flexible delivery schedules will be crucial to prevent vaccine shortages and wastage, while expanded training for new immunizers such as pharmacy technicians ensures they are equipped with the latest knowledge and best practices as the vaccination landscape evolves.

Why it matters—Interviewees consistently emphasized that acceptance decisions hinge on product-specific clinical evidence rather than the underlying technology platform—signaling a largely technology-agnostic readiness stance. Out-of-pocket costs, inventory strain, administrative complexity, and fragmented information systems therefore emerge as the principal bottlenecks. Unless payers align coverage for non-universal ACIP vaccines, and unless interoperable immunization information systems are scaled nationally, the 6-fold volume growth envisaged by stakeholders could stall at the final delivery mile. Addressing these operational and behavioral hurdles is essential before the expanded schedule can be realized, and sets the stage for the channel-evolution and data-sharing requirements discussed in Insight 3.

Insight 3: The continual evolution of vaccination channels and the imperative for enhanced communication and data interoperability

What we heard—The landscape of adult vaccinations is undergoing a significant transformation, characterized by an evolution from traditional physician clinics to retail pharmacies and further fragmentation of vaccination channels. This transition, while enhancing accessibility and convenience, places substantial demands on improved communication between new channels (i.e., pharmacists) and physicians, as well as robust data interoperability.

The role of retail pharmacies is expected to grow in response to an expanding adult vaccine schedule. A considerable 66% of immunizers anticipate an increase in the number of patients receiving vaccinations at retail pharmacies (Figure S5). Further reinforcing this trend is consumer preference; 65% of consumers identify retail pharmacies among their top three preferred locations to receive vaccines.

Such alternative vaccinators have been growing in popularity as they can provide increased convenience in the form of longer hours of operation and closer geographical proximity to patients.^21,22,23,24 Immunizers also indicated that the expansion of the retail pharmacist’s role would alleviate the workload of physicians. However, the location of vaccine administration may vary depending on the disease in question. For instance, vaccinations addressing high unmet needs or nosocomial infections may still occur in PCP offices or hospital clinics due to more segmented recommendations.

Despite the anticipated expansion of the pharmacy’s role in vaccination, consumers continue to place significant trust in PCPs for information and recommendations. Approximately 76% of consumers over the age of 65 prioritize their vaccine needs based on physician recommendations, underscoring the need for PCPs to continue playing an active role in vaccine recommendations (Figure S6).

Additionally, while IDNs and most immunizers support this increasing role of pharmacies, these alternative sites will encounter obstacles in the realm of clinical education, necessitating potentially greater input from physicians for certain diseases, such as those requiring nosocomial vaccines. Currently, there exist delays in communication that not only impede immunizations but also engender resentment among healthcare professionals. This situation, which has been documented in literature,²⁵ is further complicated by the potential emergence of a gray zone or overlapping responsibilities between physicians and pharmacists. These overlapping duties can pose particularly profound challenges in terms of communication, requiring careful navigation and negotiation to manage disparate incentives and ensure effective patient care. It is thus crucial that these issues are addressed promptly and effectively, with a focus on improving communication channels and clearly delineating roles and responsibilities within the healthcare setting.

The increasing use of retail pharmacies and other non-traditional locations (i.e., urgent care centers) as vaccination sites places increased pressure on data systems. These systems must effectively track patients who have received recommendations and vaccines to minimize “leakage.” As such, communication between stakeholders becomes paramount in optimizing vaccine uptake. This includes fostering improved information transfer and mutual respect in vaccination roles and developing robust communications platforms that record patient information regarding when and where they received their vaccines.

Equitable access to vaccines is another critical issue that the expansion of non-traditional vaccination channels could help to address, particularly for certain communities such as African Americans, Latinos, the urban poor, and those residing in rural areas. Strategies to support equitable access to these populations include designating pharmacies as regional providers to enhance access and mitigate financial and transportation barriers, and utilizing mobile vans or home health provisions to reach rural areas.

Why it matters—Channel diversification can relieve capacity constraints identified in Insight 2, but only if bidirectional data flow and clear role definitions keep pace. Without a nationally interoperable immunization-information system—and without explicit hand-off protocols between pharmacists and physicians—dose documentation gaps (“data leakage”) will grow, undermining coverage estimates and reimbursement. In addition, unresolved grey-zone responsibilities risk eroding professional trust, slowing vaccine rollout in precisely the settings counted on to absorb the 6-fold volume increase. These communication and data-integrity demands foreshadow the market-development considerations explored in Insight 4.

Insight 4: The imperative for market development to facilitate the adoption of new vaccines

What we heard—In the evolving landscape of adult vaccinations, there is a pressing need for strategic market development efforts. These initiatives are crucial to support the integration of new vaccines, counteract stakeholder “overwhelm,” and encourage the expansion beyond diseases that are already well-addressed.

Despite the future availability of innovative vaccines, immunizers still expect to prioritize established routine products. For example, 83% of immunizers were willing to stock influenza vaccines, 71% the COVID-19 vaccines, 72% adult pneumococcal vaccines, and 66% Tdap vaccines (Figure 5). Yet there is a noticeable mismatch between willingness to recommend and willingness to stock emerging vaccines: 51% of immunizers would recommend a Human Immunodeficiency Virus (HIV) vaccine, but only 31% were prepared to stock it. This disparity between interest in recommending and stocking of at least 8% was observed across all high unmet need vaccines assessed in this study.

Figure 5.

Willingness to recommend and stock emerging vaccines

Percent of Immunizers (teal) who selected 8, 9, or 10 on an 10-point scale (likely to recommend) when asked “How willing would you be to recommend each of the following vaccines in your practice/pharmacy if it were available and supported by ACIP/policy bodies?” (Immunizer Q13a; n = 103). Percent of Immunizers (light green) who selected 8, 9, or 10 on a 10-point scale when asked, “How willing would you be to stock each of the following vaccines in your practice/pharmacy if it were available and recommended by ACIP/policy bodies?” (Immunizer Q12a; n = 103). Percent of Stocking & Purchasing (blue) who selected 8, 9, or 10 on an 10-point scale when asked, “How willing would you be to stock each of the following vaccines in your practice/pharmacy if it were available and recommended by ACIP/policy bodies?” (S&P Q17; n = 80). Respondents were not educated on the emerging vaccines.

Interestingly, there is substantial interest in combination vaccines, such as those containing COVID-19 and influenza (67% of immunizers) and those combining respiratory syncytial virus (RSV) and influenza (44% of immunizers). However, turning interest into shelf space will require market-development programs that pair compelling clinical epidemiological evidence with operational support to overcome capacity constraints.

When it comes to prioritizing immunizations during a single visit, the lack of a dedicated adult-vaccine policy body forces stockers and immunizers to make ad-hoc decisions. This void necessitates that stockers and immunizers make ad hoc decisions regarding which vaccines to prioritize, adding complexity to an already intricate process.

Notably, the majority of recommending and funding stakeholders, along with IDN purchasers, do not perceive a need to prioritize vaccines. They trust that the ACIP will provide adequate guidance for all vaccines approved by the FDA, including segmented recommendations based on age, geography, and other factors.

In response to ACIP recommendations, most payers are likely to include all recommended vaccines in their formularies. Similarly, purchasers and stockers are expected to respond to client demand and make all recommended/funded vaccines available across systems and chains. However, some channel specialization may occur for certain vaccines, such as those related to travel or nosocomial infections, especially if processing Medicare Part D claims poses a challenge at alternative vaccination sites.

Immunizers, at the point of administration, may face the difficult decision of which vaccines to administer during initial versus subsequent visits if a patient is eligible for multiple vaccines. This decision-making process may be influenced by multiple dimensions, including patient type (age, risk factors, comorbidities, lifestyle), attitudes, number of doses required, and insurance coverage. The prevalence and perceived seriousness of the disease also impact recommendations and acceptance. When asked in quantitative surveys how they would prioritize immunizations within the scope of a single regular visit, immunizers indicated that they are likely to prioritize influenza and COVID-19, respectively, and make trade-offs between Tdap, pneumonia, and zoster (Figure 6). However, prioritization may change as patients perceive COVID-19 as less of a threat post-pandemic.

Figure 6.

Prioritized vaccines by immunizers in an appointment

Percent of Immunizers who would prioritize each high unmet need vaccine (Purple) and well-addressed diseases vaccine (Blue) when asked “How would you prioritize these vaccines in terms of the sequence you would give them, for each of the following age/risk groups. You may assign more than one vaccine per visit if you think this is realistic” (Q13b; n = 103). ∗Low risk is defined as patients without additional factors (e.g., comorbidities) that increase risk of more severe disease. ∗∗At risk is defined as patients with additional factors (e.g., comorbidities) that increase the risk of more severe disease. Vaccines not recommended for each patient population have been excluded. Respondents were not educated on the emerging vaccines.

PCPs and clinic-based HCPs are likely to specialize and carry limited stock based on local population needs, referring patients to retail pharmacies for travel or niche vaccines. Pharmacists, in turn, must build the expertise and throughput capacity to deliver a higher share of adult doses.

Patient acceptance for emerging vaccines again emerges as a potential barrier. In interviews, immunizers stated that patients tend to prioritize more known diseases, such as COVID-19, influenza, pneumonia, and HIV, over diseases with a less understood burden, such as RSV and CMV. To prioritize vaccinations within the new schedules, consumers will predominantly rely on HCP recommendations; however, they also cited general health and perceived risk of getting the disease as factors, particularly for those 65 and older and those with risk conditions (Figure S6).

New vaccines will also face a bottleneck based on limited vaccination opportunities. Consumers across all age groups indicated that they have an upper limit to the number of vaccines given in an appointment and visits per year, with a majority indicating a maximum of 3–4 visits per year and 1–2 vaccines per visit (Figure S4A). They also indicated they would be willing to go to the doctor’s office more than once per year to get all the recommended vaccines (Figure S4C). When asked how many vaccines they would be willing to get per year, those 65 and older and those with risk conditions said an average of approximately 4.5. This may be an overestimation; CDC data from 2018 states that patients across all age groups made less than one preventative care appointment per year with their physician.²⁶ If this trend holds true in the future adult vaccine market, the rise of annual vaccines such as COVID-19 limits the number of other vaccines patients may be able to take each year.

Why it matters—Interviewees reiterated that adoption decisions are product-specific and largely technology-agnostic; enthusiasm alone will not translate into uptake without practical tools to bridge the “recommend–stock” gap. Robust market-development efforts—spanning HCP education, demand forecasting, payer pull-through and streamlined Medicare Part D billing—will be essential to prevent shelf-space constraints and appointment bottlenecks from throttling high-unmet-need vaccines. Failure to resolve these commercial and operational hurdles risks cementing an imbalanced market in which well-established diseases continue to dominate inventory while emerging, potentially high-impact products struggle for real-world penetration—an imbalance with direct implications for global infrastructure questions discussed in Insight 5.

Insight 5: International market findings—centralized infrastructures may have an advantage

What we heard—Countries take different approaches to adult vaccination campaigns. In some, such as the UK, programmes are highly centralized, whereas in others, such as Australia, they are more decentralized.²⁷ This necessitates tailored actions to immunize adults worldwide against preventable diseases. For instance, the Australian Immunization Register (AIR) stands out for its centralized records for adult vaccination.²⁸ In contrast, Australia leads in consumer acceptance of vaccines, while France struggles with a significant degree of vaccine hesitancy.^27,29

Furthermore, national infrastructure also shapes vaccination strategy. Over 90% of physicians in Korea work in private clinics,³⁰ indicating that the diversification of administration channels might have distinct implications in the Korean healthcare system. With the expanding vaccine market, country-specific research and policy pilots will be instrumental in identifying locally relevant solutions.

In most of the markets explored, stakeholders express optimism about managing the impending increase in adult-vaccine schedules (Figure S8). Nonetheless, they anticipate significant challenges in funding, the inclusion of vaccines into National Immunization Programs (NIPs), and public education on the value of vaccines.

In markets where vaccines are predominantly publicly funded, such as Australia, Brazil, and Portugal, the introduction of new products may encounter delays. Vaccines left outside of NIPs typically become out-of-pocket purchases, dampening uptake and widening equity gaps.

To bolster uptake, it is vital to enhance consumer understanding and make vaccinations more convenient. HCPs are expected to remain the most trusted source of information in most non-US markets. Unlike the US, stakeholders in markets such as Australia, Brazil, and Portugal anticipate that pharmacists’ role will be restricted to administering a limited number of vaccines, such as influenza, albeit with some exceptions. PCPs and nurses in vaccination centers are expected to remain the primary immunizers.

However, stakeholders in Brazil and South Korea generally oppose broadening non-physician vaccinations, preferring that all NIP-recommended products remain within vaccination clinics or private General Practitioners (GP) offices. Where pharmacists’ roles do expand, improved bidirectional communication between GPs and pharmacies will be required to prevent documentation gaps.

There is an emerging need for market development efforts to support new vaccines, particularly those not included in NIPs. Public health authorities are expected to prioritize vaccines in well-addressed and high unmet need categories. Travel and endemic vaccines that fall outside existing programmes will require intensive evidence-generation and value-communication campaigns to convince both immunizers and consumers. In some cases, country and even region-specific epidemiology may be required to inform funding decisions and prioritization.

OUS stakeholders reported limited concerns about future adult vaccine schedules and feel they will be able to manage the increase. As in the United States, this confidence may mask readiness gaps—particularly around funding flows and data interoperability—that could slow the adoption of high-unmet-need vaccines. As the global product landscape expands, coordinated policy, advocacy, scientific and health-system strategies will be critical to the goal of eliminating vaccine-preventable diseases worldwide.^31,32

Why it matters—Centralized registries and funding streams appear to confer an early-mover advantage: they simplify data capture, reduce out-of-pocket costs and enable rapid guideline updates. Markets lacking these features may face prolonged lags between product approval and real-world uptake, particularly for vaccines outside traditional NIPs. Proactively aligning funding pathways, strengthening national immunization information systems and clarifying pharmacist–physician hand-offs will be essential to ensure that the next wave of adult vaccines reaches target populations on a global scale.

Limitations of the study

This market-research analysis relies on self-reported perceptions collected in mid-2022, a period when COVID-19 operational pressures were still salient. Stakeholder sentiment may have shifted as pandemic memory fades and new vaccines, such as RSV, reach the market. Although international interviews spanned five countries, the quantitative survey was limited to the United States, constraining cross-country comparisons. Dynamic-network modeling was descriptive and did not simulate dose flow under alternative reimbursement scenarios. Finally, operational barriers were identified qualitatively; prospective measurement of actual throughput, wastage, and data-leakage rates will be required to validate the predicted 6-fold capacity gap.

Conclusion

The adult vaccination landscape presents a substantial mix of opportunity and operational risk. Realizing the former and mitigating the latter will require a coordinated, evidence-based response across the value chain.

• (1)Track and share data. Improving vaccination-history tracking and data interoperability is critical. Interoperable immunization-information systems will streamline administration, reduce leakage between sites, and support technology-agnostic, product-specific decision making.
• (2)Educate and motivate. Education initiatives that leverage trusted sources—particularly PCPs and pharmacists—are essential to alleviate hesitancy and promote informed decision-making.
• (3)Expand and simplify delivery. Expanding administration settings, prioritizing combination vaccines and simplifying billing processes can streamline the vaccination experience, allowing healthcare providers to focus on patient care.
• (4)Communicate across channels. Enhanced stakeholder communication and robust data exchange are crucial as vaccination channels diversify. Efficient bidirectional reporting ensures that vaccines reach their intended recipients and that payers have confidence in coverage data.
• (5)Develop the market. Targeted market-development programmes—underpinned by compelling clinical and epidemiological evidence—are needed to convert interest in high-unmet-need vaccines into real-world stocking and uptake.
• (6)Ensure equity. Equitable vaccine distribution demands the removal of financial, geographical, and informational barriers in marginalized communities.

Bringing these insights to fruition will demand sustained collaboration among manufacturers, policymakers, payers, clinicians, pharmacists, and patient advocates. With joint action, a resilient and efficient adult-vaccination infrastructure can be built—one capable of absorbing the projected 6-fold volume increase and safeguarding population health in the decade ahead.

Resource availability

Lead contact

Further information and requests for resources should be directed to and will be fulfilled by the lead contact, Charles Jones (jones.houston.charles@gmail.com).

Materials availability

No new materials were generated.

Data and code availability

• •Data: De-identified, aggregate tabulations underlying all panels in Figures 2, 3, 4, 5, and 6 and Figures S1–S18 are provided in Data S1 (within the supplemental information). Raw row-level survey responses and unredacted interview transcripts cannot be made public due to third-party panel confidentiality obligations; redacted transcripts and additional aggregates are available from the lead contact under a data-use agreement for qualified researchers.
• •Code: No custom code was used. Analyses were performed in Microsoft Excel 365 and NVivo 12 (RRIDs in key resources table).
• •Other: Full screeners, moderator guides, questionnaires, and visual stimuli (showcards) are available in Methods S1 (supplemental information).
• •All data are included in the article and/or supplemental information.

Acknowledgments

We gratefully acknowledge the invaluable contributions of all Pfizer employees involved in this work, including M.P.J., A.H., A.F.F., V.W., J.M.T., and C.H.J., whose dedication, expertise, and collaborative efforts were instrumental in developing and executing the research and article. Editorial support was provided by M.B. and A.B.H at Bulmore Consulting and this support was funded by Pfizer. This work was sponsored by Pfizer.

Author contributions

M.P.J. developed the outline, researched sources, and drafted and edited the article. A.H., A.F.F., V.W., and J.M.T. provided strategic input, as well as drafting and editing support. C.H.J. conceptualized and designed the overall research studies and provided oversight and executional assistance in the planning and development of the publication.

Declaration of interests

M.P.J., A.H., A.F.F., V.W., J.M.T., and C.H.J. report that they are employees of Pfizer Inc. and may hold stock or stock options in the company.

STAR★Methods

Key resources table

REAGENT or RESOURCE	SOURCE	IDENTIFIER
Deposited data
U.S. qualitative interview transcripts (n = 53)	This study	Not publicly available; see data and code availability; contact lead contact
International qualitative interview transcripts (n = 65)	This study	Not publicly available; see data and code availability; contact lead contact
U.S. quantitative survey datasets (Stocking & Purchasing n = 80; Immunizers n = 103; Consumers n = 500)	This study	Not publicly available; see data and code availability; contact lead contact
Other
Interview discussion guides & show-cards	supplemental information	Methods S1
Consumer & HCP questionnaires	supplemental information	Methods S1
Software and algorithms
NVivo 12 (QSR)	QSR International	RRID:SCR_014802
Microsoft Excel 365	Microsoft	RRID:SCR_016137

Experimental model and study participant details

U.S. stakeholders

Fifty-three qualitative participants spanning policy makers, payers, wholesalers/distributors, purchasing managers, and immunizing HCPs were recruited through specialist panels (Figure 1A for role split). Quantitative panels comprised 80 stocking/purchasing managers, 103 immunizers, and 500 adult consumers representative of age-risk strata (Figure 1B); consumers scoring ≥ 7/10 on an anti-vaccine sentiment screener were excluded.

International stakeholders

Sixty-five qualitative interviewees from Australia, Brazil, France, Portugal (immunizers only) and South Korea were recruited via local fieldwork partners; sampling summarized in Figure 1C.

Allocation to groups

Consumers were quota-sampled and allocated into three cohorts using screener items aligned to CDC risk definitions: 65+ (n = 242); 18–64 with ≥1 risk condition (n = 186); 18–64 without a risk condition (n = 72). The U.S. immunizer sample included PCPs/IM/GPs (n = 60), nurses/NPs/PAs and physician administrators (n = 23), and retail pharmacists (n = 20); the stocking & purchasing sample comprised retail pharmacy purchasers (n = 50)and IDN purchasers (n = 30). Fieldwork dates and role splits are shown in Figure 1/supplemental information.

All participants provided informed consent and received honoraria commensurate with local market-research standards. The activity was deemed exempt from IRB review because no protected health information was collected.

Method details

Secondary desk research

An extensive literature and pipeline review established baseline hypotheses on adult-vaccine market evolution.

Sequential mixed-methods design

An overview of the five-step iterative research process—including hypothesis generation, qualitative exploration, and quantitative validation—is depicted in Figures 1A–1C. The sequence allowed initial desk-research insights to be probed qualitatively and then quantified.

Qualitative interviews

Semi-structured guides and visual stimuli (supplemental information pp. 1–35) were used in 60-minute virtual interviews; sessions were recorded, transcribed verbatim, and dual-coded in NVivo 12.

Quantitative surveys

Web-based questionnaires (≈20 min) were fielded via Ipsos panels (survey architecture in supplemental information pp. 36-69). Quotas were set for region, channel type, and demographic variables. Soft-launch checks, speed-screens, and attention-checks ensured data quality.

Quantification and statistical analysis

Descriptive statistics (frequencies; means ± SD) and cross-tabulations were produced in Excel 365. Two-sample t-tests or χ² tests compared sub-groups with α = 0.05 (two-sided). Qualitative code prevalence was expressed as % of stakeholders mentioning a theme ≥ once.

Published: August 16, 2025