Report to/rapport au : Ottawa Board of Health Conseil de santé d Ottawa. Monday, October 15, 2012/le lundi 15 octobre 2012

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1 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./D r 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 , ext./poste 23483, CITY WIDE / À L ÉCHELLE DE LA VILLE ASC2012-OPH-EHP-0003 SUBJECT: OBJET : SCHOOL IMMUNIZATIONS PROGRAM 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 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 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

2 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 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 OPH will present findings of the review and a strategy to improve vaccination rates in 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 , SPO a administré vaccins lors des cliniques de vaccination en milieu scolaire, soit doses de vaccin contre l hépatite B, doses de vaccin contre la méningite et 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;

3 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 $. En 2012, on prévoit un dépassement du budget du programme de $. 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 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 20 th 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 , 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

4 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

5 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, Mean number of cases per year ( ) Ontario Mean Incidence per 100,000 ( ) Ontario less Ottawa less Ottawa Ottawa Ottawa Hep B Meningococcal disease 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 (Table 2), providing a total of 32,305 immunizations. Three cycles of clinics in 93 schools are also scheduled for 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 school year Vaccine Number of students eligible Number of doses administered Number of students completed series Hep B 9,843 12,515 8, Meningococcal 9,406 8,212 8, HPV 4,925 11,578 4, Per cent of students with completed series (%) 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.

6 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 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 old students who completed Hep B vaccine series 9b Per cent of 13 year old female students who completed HPV vaccine series 9c Per cent of 12 year old students who completed meningococcal vaccine Ontario median (%) Ottawa (%) Number of eligible Students in Ottawa , , ,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

7 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 , telephone or in-person. Annually, the program handles more than 27,000 calls, 22,000 faxes, 400 walk-in visits, 300 s 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 school year, OPH followed up with 9,860 students with incomplete immunization records and issued 1,900 suspension letters. By the end of the 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 Immunization complete for age (%) Number of completed vaccination series Measles 87 97,224 Mumps ,483 Rubella ,498 Diphtheria 70 78,348 Tetanus 70 78,360 Polio 80 89,700

8 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.

9 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 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 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 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.

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