Report to/Rapport au : Ottawa Board of Health

Report to/Rapport au :
Ottawa Board of Health
Conseil de santé d’Ottawa
Monday, October 15, 2012/le lundi 15 octobre 2012
Submitted by/Soumis par :
Dr./Dr Isra Levy,
Medical Officer of Health/Médecin chef en santé publique
Contact Person / Personne ressource:
Siobhan Kearns, Manager/Gestionnaire
Environment, Health Protection & Outbreak Management / Direction de
l'environnement, de la protection de la santé et de la gestion des éclosions
Ottawa Public Health/Santé publique Ottawa
613-580-2424, ext./poste 23483, [email protected]
CITY WIDE / À L’ÉCHELLE DE LA VILLE
ASC2012-OPH-EHP-0003
SUBJECT:
SCHOOL IMMUNIZATIONS PROGRAM
OBJET :
PROGRAMME DE VACCINATION EN MILIEU SCOLAIRE
REPORT RECOMMENDATIONS
That the Board of Health for the City of Ottawa Health Unit:
1. Direct Ottawa Public Health staff to conduct a review of Ottawa Public
Health’s School Immunization Program and other vaccine-preventable
diseases program; and
2. Present the findings of the review and a strategy to improve vaccination
rates in Q3 of 2013.
RECOMMANDATIONS DU RAPPORT
Que le Conseil de santé de la circonscription sanitaire de la ville d’Ottawa :
1. Enjoindre au personnel de Santé publique Ottawa d’effectuer un examen de
son Programme d’immunisation dans les écoles et de tout autre
programme lié aux maladies évitables par la vaccination;
2. présenter les conclusions de l’examen et une stratégie visant à accroître
les taux de vaccination au troisième trimestre de 2013.
EXECUTIVE SUMMARY
―One hundred years ago, infectious diseases were the leading cause of death
worldwide. In Canada, they now cause less than 5% of all deaths—thanks to
immunization programs‖ (Canadian Public Health Association). Ottawa Public Health
(OPH) works to achieve high vaccine coverage in Ottawa’s school-aged children and
youth by providing vaccines through school-based clinics as well as assessing and
maintaining immunization records for all children attending licensed day cares and
schools in Ottawa. During the 2011-2012 school year, OPH provided a total of 32,305
immunizations at school-based clinics: 12,515 doses of hepatitis B vaccine, 8,212
doses of Meningococcal vaccine and 11,578 doses of human papilloma virus (HPV)
vaccine.
Recently, several initiatives aimed at enhancing vaccine uptake in eligible youth have
been undertaken:
Conducting HPV vaccine catch-up clinics for students by appointment
Collaborating with the Children’s Hospital of Eastern Ontario and several
Community Health Centres to administer the HPV vaccine to females identified
as high-risk for this infection
Working with OPH’s Sexual Health satellite clinics to provide the HPV vaccine to
their clients
Partnering with nurses in OPH’s School Health Team to participate in
administering immunizations at school clinics
However, there are several challenges to improving vaccination coverage rates for
school-age children and youth in a cost-efficient manner. The school-based delivery
model, while optimal for providing a means for achieving high immunization rates, often
exceeds its allocated annual budget of $400,000. In order to improve student
vaccination rates, while also adhering to the program’s budget, OPH will conduct a
review of programs that address vaccine-preventable diseases beginning in the first
quarter of 2013. OPH will present findings of the review and a strategy to improve
vaccination rates in 2013.
RÉSUMÉ
« Il y a cent ans, les maladies infectieuses étaient la principale cause de décès dans le
monde entier. Au Canada, elles causent maintenant moins de 5 % de tous les décès,
grâce aux programmes de vaccination. » (Association canadienne de santé publique)
Santé publique Ottawa (SPO) s’efforce d’atteindre une couverture vaccinale élevée
chez les enfants d’âge scolaire et les jeunes d'Ottawa en procédant à leur vaccination
lors des cliniques de vaccination en milieu scolaire et en évaluant et en mettant à jour
tous les dossiers d’immunisation des enfants fréquentant un service de garde autorisé
ou l’école à Ottawa. Pendant l’année scolaire 2011-2012, SPO a administré
32 305 vaccins lors des cliniques de vaccination en milieu scolaire, soit 12 515 doses
de vaccin contre l’hépatite B, 8 212 doses de vaccin contre la méningite et
11 578 doses de vaccin contre le virus du papillome humain (VPH).
Dernièrement, on a entrepris plusieurs initiatives destinées à accroître la vaccination
des jeunes admissibles :
Tenue de cliniques de vaccination de rattrapage contre le VPH sur rendez-vous
pour les élèves;
Collaboration avec le Centre hospitalier pour enfants de l’est de l’Ontario et
plusieurs centres de santé communautaires en vue de vacciner contre le VPH
les jeunes filles qui présentent un risque élevé d'infection;
Collaboration avec les cliniques satellites du Centre de santé-sexualité de SPO
afin qu’elles puissent fournir le vaccin contre le VPH à leurs clientes;
Partenariat avec l’équipe de santé en milieu scolaire de SPO pour
l'administration de vaccins lors des cliniques en milieu scolaire.
L’amélioration du rapport coût-efficacité du taux de vaccination des enfants d’âge
scolaire et des jeunes comporte cependant plusieurs difficultés. Le modèle de
prestation en milieu scolaire, bien qu'il soit optimal pour permettre l'atteinte de taux de
vaccination élevés, dépasse souvent le budget annuel alloué de 400 000 $. En 2012, on
prévoit un dépassement du budget du programme de 125 000 $. Pour améliorer le taux
de vaccination des élèves tout en respectant le budget du programme, SPO procèdera
à l’examen des programmes de vaccination contre les maladies pouvant être prévenues
par un vaccin au premier trimestre de 2013. SPO présentera ensuite les résultats de
son examen et une stratégie visant à améliorer le taux de vaccination.
BACKGROUND
―One hundred years ago, infectious diseases were the leading cause of death
worldwide. In Canada, they now cause less than 5% of all deaths — thanks to
immunization programs. Immunization has probably saved more lives in Canada in the
last 50 years than any other health intervention‖ (Canadian Public Health Association).
While many advances in immunization occurred during the 20th century, newer vaccines
are continuing to reduce the impact of infectious diseases in Canada. Immunization
remains one of the most cost-effective strategies to improve health. Meningococcal,
HPV and Hep B vaccines are all cost-effective immunizations that reduce downstream
health care costs. The economic burden of HPV is estimated to be $53.7 million in
Canada as strains of this virus cause genital or cervical disease. Research indicates
that the four types of HPV prevented through vaccination are responsible for 62.6 per
cent of these costs.
While rates of vaccine-preventable diseases have declined dramatically in Canada,
there have been a number of significant outbreaks of certain vaccine-preventable
diseases of concern in recent years. In 2007, more than 400 cases of mumps were
reported in seven provinces; in 2011-2012, the province of Quebec had an outbreak of
measles with over 750 cases reported; currently, Ontario is experiencing a pertussis
(whooping cough) outbreak with 354 cases in seven health units reported to date. The
majority of the cases reported are individuals with no history of immunization or with
incomplete immunization. The illnesses and subsequent complications of these
diseases can be very serious, including life-long sequelae and death. But many, if not
all, could have been prevented by immunization.
Maintaining high immunization coverage in the population is essential for the effective
control of vaccine-preventable diseases. Routine assessment of immunization coverage
by each local health unit establishes provincial and local immunization trends over time,
facilitates the identification of sub-populations with inadequate coverage and contributes
to the evaluation of the effectiveness of immunization promotion initiatives and
programs.
The Ministry of Health and Long-Term Care (MOHLTC) provides a number of routine
vaccines for all children through public funding (Document 1). These vaccines fall into
two categories: 12 vaccines that are administered mainly by primary care providers
during infancy and early childhood and three vaccines that are administered primarily by
health units through school-based programs. Local public health units distribute all
vaccines in both of these categories to the public or to primary care physicians. OPH
distributes a total of approximately 333,000 publicly-funded vaccines in Ottawa on
average every year.
OPH conducts a number of activities to protect students against vaccine-preventable
diseases and to support immunization of school-aged youth through the School
Immunization Program:
Administering Hep B, HPV and meningococcal vaccines in school-based and
catch-up clinics throughout the community
Promoting immunization through numerous community partnerships
Maximizing safety and potency of vaccines by ensuring all vaccine providers in
Ottawa store and handle vaccines according to provincial guidelines
Maintaining over 140,000 child immunization records for Ottawa residents in the
provincial Immunization Record Information System (IRIS)
Conducting annual surveillance of the immunization status of children and youth
attending licensed child care or school in Ottawa and performing necessary
follow-up to ensure they have up-to-date vaccinations
Managing queries from parents, principals and directors of child care facilities
regarding vaccine-preventable diseases and immunizations
Excluding students from school during a vaccine-preventable outbreak if they are
not immunized against the causative pathogen
Investigating adverse events following immunization reported by health care
providers and recommending follow-up as appropriate
School immunization clinics
OPH provides school-based immunizations to protect children and youth against the
following diseases:
Hep B, a serious infection which can lead to cirrhosis and cancer of the liver.
Rates of Hep B in Canada have been decreasing, coincident with the increasing
use of vaccine (Public Health Agency of Canada). Ottawa’s rate of Hep B is
lower than the rest of Ontario (Table 1).
Meningococcus, a bacteria that can cause meningitis and infections of the blood;
approximately 10 per cent of these serious forms of the disease are fatal.
Disease is most common in children under the age of five years, and those
between 15 and 24 years old. Ottawa’s rate is similar to the rest of Ontario (Table
1).
HPV, a virus that causes genital warts, cancer of the cervix and other cancers.
HPV infection itself is not a reportable disease; however, HPV-related cancers
are tracked. Each year in Ontario, approximately 500 women are diagnosed with
cervical cancer and about 140 women die from this disease. Moreover, there are
tens of thousands of women each year who have abnormal Pap tests (the test for
cervical cancer and pre-cancer) that require assessment and/or treatment.
Preventing HPV infection through immunization will reduce the pain and suffering
from these conditions.
Table 1: Hep B and meningococcal disease, mean number of cases per year and mean
incidence per 100,000, Ottawa and Ontario, 2007-2011
Hep B
Meningococcal disease
Mean number of cases per
year (2007-2011)
Ontario
Ottawa
less Ottawa
17
699
2
41
Mean Incidence per 100,000
(2007-2011)
Ontario less
Ottawa
Ottawa
0.4
1.2
0.2
0.3
Immunization clinics in schools allow students with signed consents to easily access
vaccines during regular school hours. OPH provides these vaccines to grade seven and
eight students in all four Ottawa-area school boards, as well as several independent
schools. Three cycles of clinics in 93 of the 115 schools that offer grades seven and
eight were conducted in 2011-2012 (Table 2), providing a total of 32,305 immunizations.
Three cycles of clinics in 93 schools are also scheduled for 2012-2013 with the number
of immunizations anticipated to be similar to last year. In addition, students who miss
their school clinic or who do not have a clinic scheduled in their school can receive Hep
B, meningococcal and HPV vaccinations at catch-up clinics offered in a number of
locations across the city.
Table 2 – Number of vaccines administered at school immunization clinics for students
in grades seven and eight during the 2011-2012 school year
Vaccine
Number of
Number of
students eligible doses
administered
Hep B
9,843
Meningococcal 9,406
HPV
4,925
12,515
8,212
11,578
Number of
students
completed
series
8,511
8,555
4,155
Per cent of
students with
completed
series (%)
86.47
88.30
79.26
New this year, OPH will also be making the HPV vaccine available through community
catch-up clinics to all female students in grades nine and up who did not start or
complete the HPV vaccination series during their initial period of eligibility (between
September 2007, when the vaccine was first introduced in Ontario, and September,
2012). This expanded program has been directed by the MOHLTC and is being offered
province-wide in all 36 public health units.
Accountability Agreements: Vaccine Coverage and Wastage
In January 2011, Public Health Accountability Agreements were implemented between
the MOHLTC and all 36 boards of health in Ontario to ensure consistent performance
measurement and to inform continuous quality improvement strategies across the
province over a three-year period. As such, the Board of Health is responsible for the
following accountability agreement indicators regarding school immunizations:
Percentage of vaccine wasted by vaccine type (HPV and influenza) that are
stored/administered by the public health unit (indicator # 7)
Percentage of school-aged children who have completed immunizations for Hep
B, HPV and meningococcus (indicator #9)
Table 3 shows the proportion of school-age children who completed their immunization
against Hep B, HPV and meningococcal disease in the 2011-2012 school year.
Ottawa’s coverage is consistently above the provincial average and Ottawa’s HPV
immunization rate is one of the highest in the province.
Table 3 – Per cent and number of school-age children who have completed
immunizations for Hep B, HPV and meningococcal vaccine
Indicator Indicator description Provincial target
for
2012 & 2013
(%)
9a
Per cent of 12 year 95
old students who
completed Hep B
vaccine series
9b
Per cent of 13 year 90
old female students
who completed
HPV vaccine series
9c
Per cent of 12 year 90
old students who
completed
meningococcal
vaccine
Ontario
median
2011-2012
(%)
79
Ottawa
20112012 (%)
86
Number
of eligible
Students
in Ottawa
9,843
68
79
4,925
87
88
9,406
These indicators reflect the effectiveness of the program as well as the ability of the
local public health unit to assess and maintain children’s immunization records and to
report on the immunization status of children.
Assessing child immunization records
The Ontario Immunization of School Pupils Act requires Medical Officers of Health to
maintain immunization records for all students attending school in their jurisdiction, and
parents are required to ensure their children’s vaccinations against the six designated
diseases – diphtheria, tetanus, polio, measles, mumps and rubella – are up-to-date,
unless a valid medical exemption or statement of religious or conscientious objection is
provided.
Parents provide immunization records to OPH at the time of child care and school
registration. If a student is missing any of the vaccines designated as mandatory in the
Immunization of School Pupils Act, OPH will work extensively with the family to ensure
that the vaccines are provided by a primary health care provider. The Immunization
Program counsels parents, guardians and students by email, telephone or in-person.
Annually, the program handles more than 27,000 calls, 22,000 faxes, 400 walk-in visits,
300 emails and 1,400 on-line immunization reports.
When OPH conducts the annual review of students’ immunization records and identifies
students whose vaccinations are not complete for their age, parents and/or students are
notified that their immunization must be completed and that they must provide proof of
immunization to OPH by a specific date. If this does not occur, OPH issues suspension
letters requiring the student to be suspended until the necessary immunization for the
diseases designated in the Immunization of School Pupils Act is completed by a
specified date. OPH ensures all possible measures are taken, including working closely
with the affected school boards, prior to initiating the suspension process. In the 20102011 school year, OPH followed up with 9,860 students with incomplete immunization
records and issued 1,900 suspension letters. By the end of the 2011-2012 school year,
only seven of these student records were unresolved, primarily due to the students
leaving the school system.
Table 4 shows the immunization coverage in school-aged children for the six
designated diseases in the Immunization of School Pupils Act. The lower rates for
diphtheria, tetanus and polio tend to reflect a lack of reporting by parents of their
preschool children’s immunization for these vaccines, rather than an actual coverage
rate. If a parent fails to report one dose, then the vaccination status is considered
incomplete. However, experience has shown that the vast majority of primary school
children have actually received the five doses, but not all are on record.
Table 4 – Immunization Coverage in children aged 7-17, June 2012
Vaccine
Measles
Mumps
Rubella
Diphtheria
Tetanus
Polio
Immunization complete for
age (%)
Number of completed
vaccination series
87
97
97
70
70
80
97,224
108,483
108,498
78,348
78,360
89,700
DISCUSSION
Successes and continuous quality improvement
Successful vaccination coverage rates are a reflection of the ability of the School
Immunization Programs to forge and maintain partnerships, both within OPH and with
community stakeholders. Several initiatives aimed at enhancing vaccine uptake in
eligible children have been undertaken recently:
Conducting catch-up clinics for students by appointment if they are unable or
uncomfortable in receiving their vaccinations in a school clinic. Small,
appointment-based clinics often help students who are more nervous about
receiving a vaccine to stay calm as there are no line-ups and fewer crowds.
Collaborating with the Children’s Hospital of Eastern Ontario and several
Community Health Centres to administer the HPV vaccine to girls identified as
high-risk for this infection
Working with OPH’s Sexual Health satellite clinics to provide the HPV vaccine to
their clients
Partnering with nurses in OPH’s School Health Team to participate in
administering immunizations at school clinics
Continuous quality improvement measures are being implemented to ensure quality of
service and a well-trained workforce, such as the provision of ongoing training and
certification of OPH nurses in immunization competency and adherence to best
practices in clinic policies and processes.
Challenges
There are several significant challenges to maintaining and improving vaccination
coverage rates for school-age children in Ottawa:
Despite extensive planning and coordination with school administrators, and
preparatory communications with parents and school office staff, immunization
clinics often compete with other school activities, such as field trips, invited
speakers and track meets. This impacts the efficiency and cost-effectiveness of
the clinics.
A lack of understanding regarding the benefits of immunization and
misconceptions about the risks of vaccines may affect parents’ and students’
willingness to be immunized. More targeted educational activities and
development of effective strategies to promote key immunization messages to
the residents of Ottawa are needed.
The school-based delivery model, while optimal for achieving high immunization
rates, is challenging to provide in a cost-efficient manner. The program often
exceeds its allocated annual budget of $400,000. Minimum levels of nursing staff
must be maintained for safety reasons and greater time is needed to screen
students and to ensure informed consent prior to administering the vaccines. A
review of the current school immunization delivery model is intended to develop
and implement cost-saving measures that do not compromise the high
vaccination coverage rates achieved to date in Ottawa.
Obtaining children’s immunization records is a labour-intensive process due to a
number of factors, including a lack of technology to electronically transfer records
from primary care providers’ offices to OPH. It is anticipated that a new provincial
public health information technology application, Panorama, will assist in this
process, but full implementation and increased efficiency is several years away.
Next Steps
A review of the OPH programs that address vaccine-preventable diseases will be
undertaken, beginning in the first quarter of 2013. The review will identify strategies to
improve the effectiveness and efficiency of the School Immunization Program and
vaccination coverage rates in Ottawa. This review will include an extensive needs
assessment, consultation with community partners, literature review, environmental
scan and development of an action plan. OPH will present findings of the review to the
Board in 2013.
LEGAL IMPLICATIONS
There are no legal impediments to receiving the information in this report and there are
no legal impediments to the implementation of the report recommendations.
FINANCIAL IMPLICATIONS
There are no financial implications associated with the recommendations of this report.
TECHNOLOGY IMPLICATIONS
There are no technology implications associated with this report.
BOARD OF HEALTH STRATEGIC PRIORITES
The recommendations in this report support the Board of Health Strategic Priorities:
A2 Increase integration with other City departments and community agencies; B5
Reduce health risks related to preventable infectious and non-infectious diseases; E2
Leverage technology to extend our services and make better connections with our
citizens.
TERM OF COUNCIL PRIORITIES
The recommendations in this report support the 2010-2014 Term of Council Priorities
under ―Healthy and Caring Communities‖.
SUPPORTING DOCUMENTATION
Document 1 – Publicly Funded Immunization Schedules for Ontario, August 2011
DISPOSITION
Ottawa Public Health staff will implement a plan for a program review and report to the
Board on findings in 2013.