(CNN) -- As a dark winter approaches with "twindemics" of Covid-19 and the flu, an effort by the Trump administration to increase the number of children receiving flu shots is not working, according to a CNN investigation.
In August, the administration issued a declaration authorizing pharmacists nationwide to give flu shots to children ages 3 and older, which most states have not allowed.
"Today's action means easier access to lifesaving vaccines for our children, as we seek to ensure immunization rates remain high during the COVID-19 pandemic," US Health and Human Services Secretary Alex Azar said in a press release.
Time was of the essence -- the US Centers for Disease Control and Prevention recommends that everyone get their flu shot by the end of October.
"We want everyone to get their flu shots by Halloween," Surgeon General Dr. Jerome Adams said at a Senate hearing on September 9. "With both Covid-19 and the flu circulating this fall, this will be, in my opinion, the most important flu season of our lifetimes."
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But calls to more than 175 pharmacies, and discussions with large pharmacy chains, show that the policy landed with a thud. The vast majority of the pharmacies have not taken advantage of the Trump administration's declaration and still refuse to vaccinate children that young.
That means many parents are told no when they bring their children to the pharmacy for flu shots, even though the Trump declaration says they should be told yes.
Desiree Tabor Carter took her 6-year daughter, Margot, to get her flu shot at a pharmacy in Georgia on October 8, only to be told that the pharmacy wouldn't vaccinate a child that young.
"It was frustrating," Carter said. "I'm pregnant, and I'm really trying to limit my exposure because of Covid-19, but we had to go to the pharmacy to get my shot, and then to pediatrician's to get her shot."
"They ought to make this as easy as possible for parents," she added.
When the Trump administration issued the declaration, 30 states -- like Georgia -- did not allow pharmacists to vaccinate children ages 3 and up. Even though the August federal declaration supersedes those state laws, most of those states did not directly let pharmacies know about the new rule, and many of the pharmacies contacted by CNN were not aware of it.
Public health experts blamed the Trump administration for not properly implementing the declaration, turning it into a missed opportunity. They said implementing the policy could have saved children's lives, and could have helped stop children from spreading the flu to others.
"You can have the best policy in place, but there are many steps you have to take to implement that policy. There has to be a large, concerted effort," said Dr. Leana Wen, a CNN medical analyst and former Baltimore city health commissioner.
Michael Osterholm, an epidemiologist and disaster preparedness expert at the University of Minnesota, said since the federal government didn't actively engage pediatricians, pharmacies and insurance companies to encourage implementation, the policy declaration was bound to fail during this critical flu season.
"It takes much more than a declaration. It really needed follow through," he said.
"(The) declaration is one avenue we are taking to encourage vaccinating children on time. We are also promoting this topic via a variety of communications channels such as our 'Catch-up to Get Ahead' materials," according to an email to CNN from an HHS spokesperson.
"Flu is part of the routine vaccination schedule for children, teens and adults and (flu vaccines) are available in many doctor's offices and pharmacies," the email continued.
The spokesperson said "many groups at HHS and our partners are also promoting flu vaccination for everyone six months of age and older," and pointed out a tweet earlier this month with a photo of Azar getting a flu shot.
"Getting a #FluVaccine is more important than ever. That's why senior leaders from across HHS are getting their #flu vaccines and are encouraging Americans to do the same. Do your part to protect yourself and your community -- #SleeveUp and #FightFlu," the tweet reads.
Flu can be deadly for childrenThe CDC estimates that at least 434 children died of the flu in the 2019-2020 flu season.
More than a third of US children -- 36% -- didn't get a flu shot during the 2019-2020 flu season, according to the CDC, and the hope is that allowing pharmacists to vaccinate children will help.
Pharmacies are typically more convenient than doctors' offices, especially for working parents who might have to miss a half a day of work to take their child to the pediatrician for a vaccine. Pharmacies have evening and weekend hours, there's typically a much shorter wait, and at pharmacies, the entire family can get vaccinated all at once -- a benefit during Covid-19, when many families want to limit their exposure to indoor spaces.
When New York changed its policy a few years ago, it worked.
In 2018, New York started allowing pharmacists to give flu shots to children, and the number of children getting flu shots went up. In the 2016-2017 season, before the new rule, 778,706 children received a flu shot in New York. In the 2019-2020 season, after the new rule, 930,612 children received a flu shot -- that's a nearly 20% increase.
The American Academy of Pediatrics has not objected to pharmacists administering flu vaccines, although it did object to the HHS declaration, which allows pharmacists to give all childhood vaccinations.
Jennifer Miller wishes her home state, New Jersey, had allowed her to get her daughter a flu vaccine at a pharmacy eight years ago
Throughout the fall and early winter of 2012, Miller intended to get her then-5-year-old daughter, Caroline, a flu shot. New Jersey law, then and now, prohibits pharmacists from giving a flu shot to a child that age.
A busy mother of two, Miller never got around to taking Caroline to the pediatrician for her flu shot. Then just days before Christmas, Caroline woke up with the sniffles and a cough. By that evening, her breathing had become labored. Her parents took her to a local hospital, where she was put on a ventilator and airlifted to a children's hospital.
Thankfully, Caroline survived.
"That fall, I absolutely would've taken advantage of having her go to a pharmacy to get vaccinated," Miller said. "You're passing by these pharmacies on a regular basis. You're already there. It's one quick step and you can go in anytime."
Before the Trump administration's August declaration, 20 states already allowed pharmacists to vaccinate children ages 3 and up without a prescription.
The other 30 states did not. Pharmacists in those states could only vaccinate children over a certain age or couldn't vaccinate children at all.
That's according to the US Department of Health and Human Services, information on state government websites and emails from states to CNN.
According to HHS, the new federal rule allowing pharmacists to vaccinate children ages 3 and older supersedes the 30 state laws with stricter age limits.
Whatever the laws, pharmacies are free to say no to children of any age if they don't want to vaccinate them, and CNN's investigation found that most pharmacies are not following the Trump administration's suggestion.
CNN called at least five pharmacies in each of those 30 states between September 30 and October 23 to ask if they would vaccinate a 3-year-old. Most of the pharmacies belonged to national chain drug stores.
Of those 176 pharmacies, only 31 said they would vaccinate a 3-year-old without a prescription.
The National Association of Chain Drug Stores, which has argued for years that pharmacists should be allowed to vaccinate children, said while it was pleased to see the Trump administration's declaration, it was challenging to make such a change so quickly and in so many states all at one time.
"The complexities, contradictions and far-reaching effects of the web of federal and state barriers means that no one policy change flips a switch for rapid action," according to a statement to CNN last week from the National Association of Chain Drug Stores, whose members operate over 40,000 pharmacies.
"Implementation of the (HHS declaration) shows the need for continued and tenacious work to resolve barriers."
What needs to happen for children to get flu shots at pharmacies
Dr. Julie Morita, former commissioner of the Chicago Department of Public Health, remembers a measure in her city to allow pharmacists to give flu vaccines to children -- and it worked only after diligent efforts at implementation.
It was 2009, the year of the pandemic flu. It was especially deadly for children, but Illinois had limits on pharmacists administering flu shots to children, with pharmacists only allowed to vaccinate children 14 and older.
Morita's department made the law more flexible so that younger children could get shots at pharmacies.
She said the rule change was only effective after extensive work with pharmacies, pediatricians and insurance companies.
She said pharmacists needed to feel comfortable giving children shots. Pediatricians needed to feel comfortable referring patients to pharmacies. Insurance companies needed to agree to pay for children to get flu shots at pharmacies.
"If the goal is to get more kids vaccinated at pharmacies, there's a lot of planning, a lot of implementation, a lot of homework that needs to be done," said Morita, who is currently executive vice president of the Robert Wood Johnson Foundation.
Wen, who ran the Baltimore department of health from 2014 to 2018, said planning and implementation is crucial.
Wen remembers when her department changed the rules so pharmacists could give out naloxone, an opioid antidote, without a prescription.
"We had media attention on this, it was in the news every day, and so we were particularly shocked that pharmacists just didn't know about it," she said. "So I had one person who went from pharmacy to pharmacy to pharmacy to distribute education. It takes so many steps to implement a policy, and constant monitoring."
There's no indication the federal government has taken similar steps with the flu shot change for children.
"Just making the declaration isn't enough. There are so many other steps that are needed," Wen said. "It really is a huge undertaking."
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