When Nicola Mercer got the chance last year to vaccinate her children against influenza without subjecting them to the sting of a needle, she jumped at it.
Her children, then 11 and 12, were "very impressed," with FluMist, a vaccine they inhaled. And Dr. Mercer, the medical officer of health for the Wellington-Dufferin-Guelph Public Health Unit, west of Toronto, was happy to offer her son and daughter a vaccine that has been shown to better protect children against the flu.
"[The nasal spray vaccine] was very non-invasive. And my children are great with needles, that's not an issue. But I had an alternative," Dr. Mercer said. "The real challenge is that it's not widely available and it's not publicly funded [in Ontario.]"
As influenza season gets under way, public-health authorities across the country will be doing everything in their power to persuade Canadians to get immunized against a virus that could hit particularly hard this year, if the early signs bear out.
The nasal spray vaccine could boost that campaign, but public funding for the option is still limited or non-existent in some provinces, including Nova Scotia, New Brunswick and Ontario.
When free flu clinics open in Canada's largest city on Oct. 23, for example, FluMist will not be on the menu. Torontonians who want it will have to seek a prescription from their doctor and pay $20 to $30 to fill it.
The case for publicly funding nasal spray vaccine for young children goes beyond placating the needle-phobic, infectious-disease experts say.
A meta-analysis of eight clinical trials published in the journal Vaccine in 2012 found that children who received the nasal vaccine got between 44 and 48 per cent fewer cases of the flu than children who received the traditional shot, though the shield was stronger for younger children.
The evidence prompted the U.S. Centers for Disease Control and Prevention (CDC) to recommend the nasal spray over the shot for healthy children ages 2 to 8 for the 2014-2015 flu season – the only case in which the CDC has expressed a preference for one type of vaccine over another. In Canada, the National Advisory Committee on Immunization (NACI) had already been recommending the nasal spray vaccine for children ages 2-17; for this season, they prefer the nasal spray over the shot for children 2 to 6.
Unlike the regular shot, which is made of killed virus, the nasal spray vaccine is a live attenuated, or weakened, vaccine. The strains are cold-adapted and temperature-sensitive, which means they replicate in the nasal mucus instead of the lower respiratory tract like the inactivated strains in the shot.
The nasal spray protects against the same three strains as the regular vaccine, which this season includes the A strains H1N1 and H3N2 and a B strain. Although it is approved in Canada for people 2 to 59, the spray does not protect adults as well it does children, the experts said.
"This [nasal spray] vaccine is much better because it's live but what that means is that you can't really have been exposed to many influenza viruses, otherwise you have antibodies that are already present in your nose," said Caroline Quach, co-director of the McGill University Health Centre's vaccine study centre and a member of the NACI panel. "As people were getting older, we were really seeing in adults this vaccine was no better than the injectable and in the elderly, it was actually worse."
Although it is available across Canada, FluMist is only fully funded in Alberta, Manitoba, Saskatchewan and Newfoundland and Labrador. Prince Edward Island funds it for children 2 to 17. British Columbia and Quebec fund it for high-risk children. Ontario, Nova Scotia and New Brunswick do not fund it at all.
Part of the reason is cost. FluMist is more expensive than the regular shot, though it's hard to say how much more expensive because Ottawa does not disclose the price per dose it negotiates for its annual bulk purchase from vaccine makers.
"Every year, we reconsider the products. It's complex," said David Mowat, the interim chief medical officer of health for Ontario. He stressed that for children older than six, the nasal spray does not "offer any advantages" over the shot. "So we have to consider that. We have to consider that it's more expensive. What is the overall cost-benefit ratio for this particular vaccine?"
A spokesman for Ontario Health Minister Eric Hoskins said the ministry is reviewing FluMist and is considering adding it to the publicly funded mix for the 2015-16 flu season.
Some provinces may find themselves with more FluMist on their hands this year than they originally planned. Troubles at a GlaxoSmithKline plant in Quebec mean the vaccine maker, now known as GSK, will be two million doses short on its order for Canada this year of the traditional vaccine. Other drug companies, including MedImmune, the division of AstraZeneca that makes FluMist, are filling the breach.
Last winter, when a surprise, late-season surge in demand for the influenza vaccine prompted several provinces to seek out extra doses, Saskatchewan wound up with 100,000 doses of FluMist.
"That was our first experience with FluMist," said Saqib Shahab, chief medical officer of health for Saskatchewan. "The feedback that we got, actually, was that it was quite well-received. Obviously, parents of children who were eligible to have FluMist in general liked that they weren't getting a needle."
The product proved popular enough that this year Saskatchewan ordered 127,000 doses, 28 per cent of its total order.