This study confirms the role of schools in implementing vaccination coverage. Indeed, comparing coverage of our children aged 2–4 years vaccinated in school with those vaccinated in all settings in Italy and Lombardy, as reported in 2022–2023 vaccination coverage data of Ministry of Health, we observed a similar, if not higher, coverage in those enrolled in our school vaccination program (2–4 years 12.6% at school versus Lombardy region 14.8% versus Italy 9.2%). Since there is no Italian and Lombardy coverage data of the 5–6 aged group, a comparison could not be made [5].

In addition the school project allowed us to vaccinate for flu a significant number of children not previously vaccinated (26.2%).

It is important to consider that, we vaccinated at different times in different school areas during the flu season and each area has a different number of family pediatricians who may or may not take part in vaccinations at their ambulatory. In addition, school staff participated with different enthusiasm in schools. For example, we noticed that in the schools in zones 1 and 5, which share the same headmaster, the same vaccination rates are observed. In our view, these aspects reduce homogeneity of the study population and could represent a limitation of the study.

However, these data highlight the relevant role of schools in ensuring adequate information, through tailor-made webinar with informative material for families, other than word of mouth among parents of the same school influencing positively other students and their families to get vaccination [11, 21].

Our findings also confirm how schools play a democratic role overcoming inequalities and disparities regardless of ethnicity, socioeconomic status, and parental education level. Indeed, in our investigation, this preventive intervention was proposed to all preschoolers’ families, reaching a similar percentage in children coming from an immigrant background and Italian children (14.3% vs 11.5%).

Despite a response rate of only 19.9%, we also collected interesting information from the questionnaires that led to important considerations that will help implement the vaccination campaigns in Italy in the years to come.

We observed that 85.6% of those who responded to the questionnaire were vaccinated with the qLAIV. This formulation represents a good opportunity for the vaccination campaign: the qLAIV is, indeed, safe, non-invasive, easy to administer, well-tolerated, associated with a less biological risk for the healthcare workers and lower special waste production. As widely reported, the nasal spray formulation of the qLAIV guarantees a greater pediatric and parental compliance making an ideal formulation for the pediatric age and suitable for any setting [22].

The obtained results also show the predominant role of the family pediatrician as main provider for the vaccination. The other settings, in particular vaccination center and hub, represent an additional solution. Furthermore, 21.8% of those families participating in the vaccination program and who responded to the questionnaire were vaccinated in school, suggesting a significant role of this setting. The low response rate to the Google Form proposed to all preschools’ families weakens the data on children who participated in our vaccination programme. In this light, further studies are required to expand the literature and explore the feasibility and potential benefits of school-based vaccination campaigns.