Infectious Disease

Understanding Barriers to Pediatric Flu Vaccination and Strategies to Increase Immunization Rates Based on Insights From Key Opinion Leaders

Pediatric Influenza Leadership Forum
Co chairs

Gary Marshall, MD

Chief, Division of Pediatric Infectious Diseases
University of Louisville School of Medicine Norton Children’s Hospital
Louisville, Kentucky

Donald Middleton, MD

Vice President of Family Medicine
University of Pittsburgh School of Medicine
UPMC St Margaret
Pittsburgh, Pennsylvania


Shelle Allen
Families Fighting Flu
Arlington, Va

Ruth Carrico, PhD, DNP,

Executive Director of the Infectious Diseases
Institute for Norton Healthcare
Professor and Family Nurse Practitioner,
gratis faculty, with the University of Louisville School of Medicine, Division of Infectious Diseases
Louisville, Kentucky

Claire Hannan, MPH
executive director
Association of Immunization Managers
Rockville, Maryland

Serese Marotta
Director, Advocacy & Education
Vaccinate Your Family
Washington, D.C

Carole Moloney, APRN, MSN, CPNP
Assistant Professor of Pediatrics
Department of Pediatrics
Division of Pediatric Infectious Diseases
Boston Medical Center
Boston, Mass

Flor Munoz, MD, MSc
Associate Professor of Pediatrics
Molecular Virology and Microbiology
Baylor College of Medicine
Medical Director
Transplant Infectious Diseases
Texas Children’s Hospital
Houston, Texas

Stephen Pelton, MD
Professor of Pediatrics
Boston University School of Medicine
Senior Attending Physician
Pediatric Infectious Diseases
Boston Medical Center
Boston, Mass

Litjen (LJ) Tan, MS, PhD
Chief Policy and Partnerships Officer (formerly, Immunization Action Coalition)
Co-Chair, National Adult and Influenza Immunization Summit
Saint Paul, Minnesota

Todd Wolynn, MD, MMM, IBCLC
President and CEO
Kids Plus Pediatrics
Pittsburgh, Pennsylvania

The Pediatric Influenza Leadership Forum convened on December 15, 2022, where an esteemed group of pediatricians, nurse practitioners, and members of advocacy groups came together to discuss influenza immunization in pediatric clinical practice, barriers to immunization, and strategies to overcome these barriers to increase immunization rates. dr Gary Marshall and Dr. Donald Middleton co-chaired the meeting.5

The burden of flu continues to be high, with pediatric hospitalizations peaking early in the 2022-2023 season4,6

Hospitalizations peaked early in the 2022-2023 season compared to previous seasons.4,6 This early peak brings into discussion the timing of the influenza vaccination. One advisor discussed vaccinating children earlier in the season, before the virus is circulating. “Unfortunately, people wait until October or later [for flu vaccination]and then it’s too late, as we saw this year.5”

According to the CDC, as of March 31, 2023, of the 1,263 children hospitalized with influenza for whom information was available, 65.8% had at least one reported underlying medical condition; the most commonly reported was asthma, followed by neurologic disease, and obesity.4

Data Source: National Immunization Survey-Flu (NIS-Flu).

40% to 60% of children who died from flu did not have any underlying medical conditions, and the majority of them were not vaccinated6,7

As of March 31, 2023, there have been a total of 138 influenza-associated pediatric deaths during the 2022-2023 flu season, whereas, in the past, the range of pediatric deaths were 1 (2020-2021) to 199 (2019- 2020) in the entire flu season.4 40% to 60% of the children who died due to flu between 2019 and 2023 did not have any underlying conditions.7 The advisory panel considered these important facts to convey to parents, especially that even healthy children can succumb to flu.5

Of the 106 children who died as of February 10, 2023, 103 were eligible for vaccination, and of the 81 children whose vaccination status were available, 90% were not fully vaccinated against flu. In past seasons, about 80% of children who died from flu have not been fully vaccinated.7

Data source: FluView. Centers for Disease Control and Prevention.

Despite the high burden of flu, the rates of flu vaccination have not reached the Healthy People 2020 and 2030 goal of 70%1-4

Despite the high burden of flu, the rates of flu vaccination have not reached the Healthy People 2020 goal of 70% for annual influenza vaccination for children 6 months through 17 years of age.1-4 According to the CDC, as of February 11, 2023, the overall vaccination rate for children 6 months and above is 53%, those 6 months to 4 years is 62.4%, those 5 to 12 years is 53.8%, and those 13 to 17 is 44.4% which are much lower than the target for Healthy People 2020 and 2030.1-3

Insurance claims data shows that since the beginning of the COVID-19 pandemic, pediatric flu vaccination claims have declined by 43.4% through December 20229

Data source: IQVIA Medical Claims.

As per preliminary interim estimates from the New Vaccine Surveillance Network (NVSN), during the 2022-2023 season, as of January 25, 2023, flu vaccination resulted in a 68% effectiveness against flu-related pediatric hospitalizations and a 42% effectiveness against flu -related pediatric emergency department (ED) visits9

  • Through January 25, 2023, influenza vaccination significantly reduced laboratory-confirmed medically attended influenza in the 2022-2023 season10
    • 68% (95% CI, 46, 81) reduction in pediatric hospitalization visits
    • 42% (95% CI, 25, 56) reduction in pediatric ED visits
  • There was notable protection against both A/H3N2 and A/H1N1 associated illnesses10
  • Even though the flu vaccine does not always prevent influenza infection, it significantly reduces risks of severe disease and complications.10 This was a message that was important to convey to parents, as discussed in the Pediatric Influenza Leadership Forum5

Insights from the Pediatric Influenza Leadership Forum5

As discussed in the Pediatric Influenza Leadership Forum meeting on December 15, 2022, below are some of the many barriers to flu vaccination in children.

Barriers to flu vaccination5

  • Parents generally lack awareness of the seriousness of influenza and its complications. Misconceptions about its impact influence their decision not to immunize their children
    • Timing of the flu vaccine and back to school visit may not align and vaccination may be missed, especially as it is not required for school
    • Many parents delay flu vaccination due to misconceptions on timing and risk of waning immunity
  • Misinformation and myths related to the efficacy and safety of the flu vaccination has been compounded by the COVID-19 pandemic, increasing vaccine hesitancy, leading to low flu vaccination rates
    • A common misconception is that the flu vaccine may be safe but does not work. However, flu vaccines prevent serious disease which can lead to hospitalization and death10
    • Unfounded myths about the COVID-19 vaccines have triggered concerns regarding the safety and efficacy of other vaccines, including the flu vaccine, leading to an increase in anti-science and anti-vaccine sentiments
  • Social media plays an influential role in shaping consumer perceptions and can be dominated by misinformation with anti-vaccine campaigns, leading to vaccine hesitancy
  • Staffing constraints have reduced opportunities to receive a flu vaccination at some clinics. Both parents and providers can unintentionally deprioritize flu vaccination
    • Advisors shared that, during a clinic visit, often multiple vaccines are due and parents choose only the ones which were required for school, deprioritizing flu vaccination
    • In addition, staff shortages may be a factor in parents’ decision, often requiring rescheduling and planning for clinic/pharmacy visits

Strategies to increase pediatric flu immunization rates5

  • HCPs need to engage with patients to build trust and encourage vaccination
    • According to the CDC, a strong provider recommendation is a critical factor in determining whether a child gets a flu vaccination11
  • Patients need to be educated by their HCPs regarding the risks of flu and the need for flu vaccination
    • The influence of face-to-face communication with a provider cannot be underestimated
  • It is important to educate parents that flu vaccination is recommended even for healthy children with no underlying diseases. Flu does not discriminate
    • Parents should be reminded early in the flu season, or even before, to get their children immunized against flu
    • Emphasize that flu is preventable, and clarify that the goal of vaccination is to increase protection so that severe illness can be avoided
    • Emphasize that flu is a family illness, affecting school and work attendance
  • Personal accounts/anecdotes during patient visits should be utilized to convey the importance of flu vaccination and strongly recommend flu vaccination. “Storytelling Works”
  • Analogies may help to explain the importance of flu vaccination
    • Seatbelt analogy: A seat belt is not 100% effective but provides the best chances of survival in case of an accident
    • Car mechanic analogy: When a car breaks down, a mechanic or specialist is consulted. Similarly, pediatricians should be consulted when it concerns flu vaccination
  • HCPs can utilize social media to convey the importance of flu vaccination and bust myths
  • HCPs should methodically address confusion surrounding the COVID-19 vaccine and misinformation regarding the flu vaccine, especially its efficacy and safety
    • Explain that there are similarities but also differences between COVID and flu vaccines
    • Stress that the flu vaccine has a demonstrated safety record over a number of years12
  • People should be educated that, even if the flu vaccine is not 100% effective, it is the best option we have to protect children from severe flu
    • Emphasize the risk of disease versus the risk of vaccination
  • Advocacy for positive vaccine policies is required to increase flu vaccination rates
    • The flu vaccine is underutilized because it is a seasonal vaccine and unintentionally deprioritized by parents
    • Efforts should be made at the Federal, State, and regional levels to support positive vaccination policies to increase flu vaccination rates

Lack of awareness regarding the risks of flu and the numerous misconceptions regarding the flu vaccine, especially on social media during the COVID era, makes it imperative that healthcare providers build trust and communicate effectively with parents, encourage pediatric flu vaccination and preventing adverse outcomes


  1. Healthy People 2020. 2020 topics & objectives: immunization and infectious diseases. Accessed March 21, 2023.
  2. CDC. Accessed April 3, 2023.
  3. Healthy People 2030. Accessed March 14, 2023. iid-09/data
  4. CDC. Accessed April 3, 2023.
  5. Data on file. Meeting takeaway. Seqirus USA Inc. Summit, NJ
  6. CDC. Accessed March 2, 2023.
  7. CDC. Accessed March 14, 2023.
  8. CDC. Accessed March 1, 2023.
  9. Data on file. IQVIA Medical Claims. Seqirus USA Inc. Summit, NJ
  10. CDC. Accessed March 1, 2023.
  11. CDC. Accessed March 14, 2023.
  12. CDC. Accessed March 14, 2023.

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