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Many Americans get vaccinations in the fall, to protect against any disease surges in the coming winter. Experts say interest in COVID-19 shots has been declining, and that trend could pick up this fall due to anti-vaccine sentiment and confusion about whether the shots are necessary.

The Centers for Disease Control and Prevention last month COVID-19 shots for anyone, instead leaving the choice up to patients. The government agency said it was adopting by advisers picked by U.S. Health Secretary Robert F. Kennedy Jr.

Before this year, U.S. health officials — following the advice of infectious disease experts — recommended annual COVID-19 boosters for all Americans ages 6 months and older. The idea was to update protection as the coronavirus evolves.

But that sentiment started to shift earlier this year when Kennedy, , said they for healthy children and pregnant women.

Dr. Amesh Adalja said vaccine rates have been “suboptimal” in recent years even for people considered a high risk for catching a bad case of COVID-19.

“That’s only going to fall off more this season,” the senior scholar at the Johns Hopkins Center for Health Security said recently.

The shifting guidance in September, once updated shots began arriving at drugstores, the main place Americans go to get vaccinated. Some locations required prescriptions or started asking customers if they had a condition that made them susceptible to a bad case of COVID-19.

The change in government guidance also created questions about whether insurance coverage would continue. A major industry group, America’s Health Insurance Plans, has since clarified that its members will cover the shots.

CVS Health announced earlier this month that it will not require prescriptions at its stores and clinics.

Pharmacy owner Theresa Tolle says this fall has probably been one of the more confusing seasons for her customers. Tolle runs the independent Bay Street Pharmacy in Sebastian, Florida.

She said her COVID-19 vaccine business has been busy because she has an older patient population. Many still want the shots. But she’s also had more customers tell her this year that they don’t want them.

“There’s just so many messages out there, they don’t know who to believe,” she said. “I’ve had people tell me they are afraid of it when they’ve had it many times.”

Pfizer saw U.S. Comirnaty sales drop to $870 million in the recently completed third quarter from $1.16 billion in the same time frame last year. That came after vaccine sales rose the first two quarters of the year.

Pfizer also said Tuesday that sales of its COVID-19 treatment, Paxlovid, dropped more than 50% in the quarter both in the U.S. and internationally due to lower infection rates.

Wall Street analysts also expect sales of the COVID-19 vaccine Spikevax from Moderna to tumble about 50% in the third quarter, according to the data firm FactSet.

Moderna will report its third-quarter results on Thursday.