Flu vaccine rates in kids dropped slightly during last year’s influenza season, according to a study from the Penn State College of Medicine, and it may be partly due to a recommendation from the Centers for Disease Control and Prevention against the nasal spray vaccine, FluMist.

When the nasal spray vaccine was first approved in 2003, studies showed that it was just as, if not more, effective than the injectable product. But research published in 2016 concluded that the nasal spray was less effective than its injectable counterpart in stopping the H1N1 strain of influenza.

In response to that work, the CDC advised healthcare workers to use the injectable flu vaccine instead of the nasal spray during last year’s flu season.

Dr. Ben Fogel, medical director of Penn State Pediatric Care, and Dr. Steven Hicks, assistant professor of pediatrics, wanted to understand how the CDC’s recommendation impacted vaccination rates across flu seasons – and they turned to their own clinic for the answer.

The team studied 9,591 patients ages 2 to 17 years old in the 2014 – 2015, 2015 – 2016 and 2016 – 2017 flu seasons at the Penn State Pediatric Care clinic. They found that without the option of the nasal spray, total flu vaccine rates were 1.6% lower in the 2016 – 2017 season compared to the year before.

The team also noted that revaccination rates were lower in kids who had opted for the nasal spray the year before.

Fogel thinks there are a number of reasons why flu vaccine rates vary each year and that for most kids, even if they aren’t excited about the idea of an injection, they will get it if it’s the only option.

“Last year I certainly had patients like an eight year old who would say ‘Well I don’t want a shot, can I just get the mist?’ and we say ‘We don’t have the mist,’ and they sort of get upset or frustrated and the dad says, ‘Well you’re getting it anyway,'” Fogel told Drug Delivery Business News.

“The eight year old is not in charge – so there’s been a lot of patients where the kids were not that happy about it but they ended up getting the vaccine anyway.”

The researchers also found that kids covered by public insurance were less likely to be revaccinated in the 2016 – 2017 season compared to kids covered by private insurance. Although vaccines are always covered under public insurance, the trend highlights an underlying problem, Fogel explained.

“Public insurance is usually a proxy for low socioeconomic status in general, so even if the vaccine is covered they may not be able to get off work to bring their kids in, they may not have money to pay for a cab because they don’t have a car,” he said. “It’s not the insurance that’s making them less likely, it’s the fact that they probably also don’t have the money or flexibility in their life to bring their kids in.”

Fogel was surprised at how easily people varied from being vaccinated one year to opting out of the vaccine in the next year – or vice versa. Instead of maintaining strongly-held beliefs about the flu vaccine, people seemed to be open to the vaccine if it was convenient for them. Fogel pointed out that this trend is unique to flu vaccines.

“The measles vaccine and most of the vaccines that we give are very effective, 99% effective, 100% effective. And schools require it so you’ve got to jump through some hoops to not do it. Flu vaccine is not like that,” he said.

“It is much better than nothing, but it is far from 100% effective, so I think that while there are decades of good will built up with the measles vaccine where we’ve been giving it to hundreds of millions of kids for decades and if you get it you don’t get the measles, that’s not the same as the flu vaccine. We give it to people all the time and people still get the flu even though they’ve gotten it because we know that happens, it just works some of the time.

“I think the public has a perception that this vaccine isn’t as good and they’re right, it’s not as good, so they’re maybe not as motivated to get it – and you’ve got to do it every year.”

At Fogel’s clinic, they are implementing changes to make it easier for people to be in the office and get their vaccine, he said. The clinic has called people who have visits during the flu season and asked if the patient has any siblings they would like to bring in that day to get a flu shot.

They are also trying to streamline the process by which patients can get flu shots, even if they’re visiting the office for an entirely unrelated issue – like a sprained ankle.

“We’re doing things like that to try to proactively identify the people who do seem to want it if it’s easy,” he said. “We’re not doing any arm-twisting or convincing. Our numbers suggest that there are lots of people out there who are willing to get it and who even want to get it, they’re just not gonna jump through hoops to do it.”

For the 2017 – 2018 flu season, the CDC has buckled down on its previous recommendation – the nasal spray flu vaccine should not be used. Fogel’s clinic doesn’t have it in stock, per the CDC’s advice.

Fogel pointed out that since doctor’s aren’t giving the FluMist to kids anymore, it will be difficult to ever get more data regarding the product’s efficacy at a population level.

“I wonder if this is the end of the spray,” he said.