The re-emergence of vaccine-preventable illnesses is a major concern for Ontario’s public health officials.

Efforts to create a national vaccine registry have stalled.

A real time, comprehensive vaccine registry and surveillance system in Ontario may be the best answer to the information deficit.

Faced with a measles outbreak at an elementary school, nurse Susan Otten spent more than two days secluded in a school classroom, going through yellow immunization cards to determine which students had been vaccinated.

Many students were at risk for measles—those who were never immunized, were not up to date for their age, or whose parents couldn’t find proof of vaccination.

The challenges she faced in tracking down the information “didn’t help the control of the outbreak” says Otten, who was manager for vaccine-preventable diseases with Wellington Dufferin Guelph Public Health during the 2008 outbreak.

Children at risk were sent home, and most parents “flocked to get their children immunized,” says Otten, who is now program manager for the school health program.

Outbreaks of whooping cough and measles

The re-emergence of vaccine-preventable illnesses, combined with the fact that Ontario has no vaccine registry, is a major concern for the province’s public health officials.  A whooping cough outbreak of 240 cases in Ontario this summer caused alarm, and a large outbreak of measles in Quebec last year put the Pan American Health Organization, of which Canada is member, at risk of losing its measles eradication status, noted Natasha Crowcroft, chief of communicable diseases at Public Health Ontario.

Crowcroft is one of many in public health who warn that without a comprehensive vaccine registry and surveillance system, it is impossible to quickly and accurately pinpoint causes of outbreaks.

For example, the whooping cough outbreak appears to have begun in a religious community that opposed immunization, and then spread to a wider public. But it is not known whether, or to what degree, the spread was due to a low rate of immunization, or the imperfect immunity conferred by the pertussis vaccine.

Post-SARS plans stalled

Work on a national vaccine/immunization registry began in the wake of the 2003 SARS outbreak, after several reports on the outbreak stressed the need for better systems of information and cooperation among all levels of health officials.

The result was to be Panorama, a national communicable disease surveillance system, funded by Canada Health Infoway, that would allow “health authorities to collect, share and analyze a wide range of health information to manage public health issues, including outbreaks and vaccine coverage.” according to the Public Health Agency of Canada (PHAC).

But to date only Ontario and five other jurisdictions (Yukon Territory, British Columbia, Manitoba, Saskatchewan and Quebec) have signed on to Panorama, according to Canada Health Infoway. And the 2012 PHAC audit services report notes Panorama has not been implemented and, “as a result of data and information system deficiencies, PHAC is unable to answer basic questions such as the rate of spread/incidence of H1N1, or related cause/effect relationships.” The absence of good information jeopardizes public confidence in the public health system as well as access to, and provision of, vaccines that limit the burden of preventable diseases, says Doug Sider, Ontario’s associate chief medical officer of health.

Ontario to review immunization system, set 5-year plan

To address many of these issues, Ontario’s Ministry of Health and Long-Term care is leading a provincial review of the province’s publicly funded immunization system in order to develop a five-year plan. The review is chaired by Dan Burns, a former Ontario deputy minister of health, and will examine ways to better collect and analyze data and to improve effectiveness, efficiency, service delivery and education. It is due to report in spring 2013.

Ontario is doing quite well in terms of coming close to national immunization target rates for vaccinations such as Haemophilus influenzae type B (Hib), Measles Mumps Rubella (MMR) and Diptheria, says Sider. But he adds that relatively low immunization rates for Hepatitis B, Human Papilloma Virus (HPV) and influenza are a concern.

Overall immunization coverage for children ages 7 to 17 in Ontario (school years 2008/2009 to 2009/2010, for designated diseases under the Immunization of School Pupils Act)

	2008/09	2009/10	Target Rates
Measles	92.53	91.66	99%
Mumps	86.28	90.36	99%
Rubella	86.32	90.41	97%
Diphtheria	86.78	84.17	99%
Polio	92.04	90.83	99%
Tetanus	86.79	84.72	99%

Source: Ontario Ministry of Health and Long Term Care

Ontario’s Immunization of School Pupils Act requires students four to 18 years old to have a complete immunization record, although exemptions can be provided for medical reasons and for “sincerely held convictions based on the parent’s religion or conscience.” Children can be suspended from school if their immunizations are not up to date. (Ontario and New Brunswick are the only provinces that require evidence of immunization against specific diseases when children enter school.)  However, only a few of the vaccines that are publicly funded in the province are encompassed in the law which, Otten notes, does not even include new booster schedules for those vaccines included in the Act. (Licensed day nursery operators in Ontario are also required to collect proof of immunization, or a written statement declining immunization, for all children registered at the centre.) The Wellington Dufferin Guelph public health unit has written to Health Minister Deborah Matthews requesting that all funded and recommended vaccines be included in the Immunization of School Pupils Act. “It is difficult to explain to parents . . . some of them say, if a vaccine really is important, it would be included in the Act,” says Otten.

Kumanan Wilson, a physician and researcher with the Ottawa Hospital Research Institute who has published on vaccine-related issues, says that school and day care vaccination programs in Ontario are relatively effective and information is available, if not easily. But he said the information gap is for younger children and adults. “If there is an outbreak of pertussis [whooping cough] among two year olds, we won’t have basic information.”

What is known about younger children is concerning. For example, among young children in Ontario (age 6 to 23 months), full influenza coverage is less than 10 per cent, according to research co-authored by Jeffrey Kwong, a family physician and research scientist at the Institute for Clinical Evaluative Sciences. “Yet young children suffer considerable influenza-related disease burden and contribute to disease transmission in the elderly,” states the 2012 report.

Otten’s public health unit is taking steps to reduce the burden of tracking down at-risk students.  The unit is following the lead of some of its counterparts in Ontario and setting up an on-line self-reporting program for parents.

However, it’s clear that a vaccine registry and surveillance system—one that operates in real time and covers the whole population—is the most appropriate and best answer to the information deficit in Ontario. “There is no reason why we shouldn’t be able to know all this,” says Wilson.

This is part one of a two-part series on vaccine related issues. The second ‘Promoting vaccine benefits: public health officials call for a rethink of communication with parents’ is available here.