Missed immunizations: Report details how to catch kids up in Ontario

Children wearing masks sit behind screened in cubicles as they learn in their classroom after getting their pictures taken at picture day at St. Barnabas Catholic School during the COVID-19 pandemic in Scarborough, Ont., on Tuesday, October 27, 2020. THE CANADIAN PRESS/Nathan Denette

TORONTO -

A roundtable report put out by health experts based in Ontario has set out a list of recommendations for how we can help children catch up on routine immunizations, such as tetanus or measles shots, that they may have missed due to the COVID-19 pandemic disrupting regular life.

The report emphasizes that a multi-pronged approach is necessary to ensure no one is missed in the catch-up, with school-based, community-based and primary care-based solutions needed.

One of the main recommendations from the report is that Ontario should also invest financially in the creation of a “centralized electronic immunization registry” in order to aggregate the currently scattered data on immunization levels.

The pandemic has disrupted almost every aspect of regular life, and one of those is the regular school schedule and regular immunizations for school-aged children.

Between the ages of around four and 16 years old, children in Ontario are recommended to receive roughly six different immunizations, ranging from addressing chicken pox to hepatitis B.

It’s hard to pinpoint the exact number of routine immunizations that children in Canada have missed. One study using models to estimate the global disruption to immunization published in the Lancet in July estimated that around 30 million children across the globe may have missed tetanus shots and measles vaccines in 2020.

In a survey published earlier in the summer of physicians in Ontario, 45 per cent of respondents who usually provide vaccination to children stated that their immunization services had been disrupted by the pandemic.

Kate Allan, a postdoctoral fellow at the Centre for Vaccine-Preventable Diseases with the University of Toronto, and one of the authors of the report, told CTVNews.ca in an email that we know for sure that some children have been impacted.

“While the precise number of missed routine immunization is challenging to identify, given the number of missed school-based immunization programs, at least two cohorts of children are likely to be affected by missed and delayed immunizations during the pandemic,” Allan said.

She pointed out that those who benefit the most from school-based immunization programs are children who may face barriers to accessing vaccines through other methods.

“For families who are not well-connected to the health-care system — for example, families struggling with poverty and newcomers to Canada — accessing immunizations in primary care settings may present a challenge,” Allan said. “If a comprehensive catch-up strategy is not undertaken, those families may be the ones who could slip through the cracks and never catch up on these immunizations, which are traditionally delivered in schools.”

The report stated that in a study of Ontario students in the 2016-2017 school year, more than half of the students who had no vaccine records at all lived in low-income neighbourhoods, “suggesting that structural barriers to access may be a contributing factor to sub-optimal vaccine coverage rates.”

“Due to missed primary care visits and limited school-based immunization clinics, there is a risk that these existing disparities may worsen in the context of the pandemic,” the report stated.

While it may seem like immunizations children receive every year are not exactly the biggest priority during a world-wide pandemic where everyone is thinking about COVID-19, these immunizations still matter, experts say.

Jeff Kwong, interim director of the Centre for Vaccine-Preventable Diseases as well as a professor at the Dalla Lana School of Public Health, told CTVNews.ca that children being vaccinated against measles is one of the most important of these routine immunizations.

“It is extremely contagious and can cause severe illness,” Kwong said in an email, adding that the MMR vaccine, which is a combination vaccine, addresses not only measles but mumps and rubella as well.

“The combination vaccine containing polio, pertussis (whooping cough), diphtheria, tetanus, and Haemophilus influenzae Type B is also important because each of these diseases can cause very serious disease in young children.”

These routine immunizations only become more of a concern as we start to open back up, he added, since public health measures taken to protect us from COVID-19 also cut down on other illnesses.

“As we relax public health restrictions and people have more social interactions again, there is an increased risk for these diseases to spread in the population,” Kwong said. “During lockdown periods, the risk of spread is minimized because the number of social contacts we have is reduced.”

Even before the pandemic, the report stated, immunizations in children were below national targets. In 1982, Ontario introduced the Immunization of School Pupils Act, which mandates proof of vaccination — or valid exemptions — for nine infectious diseases (diphtheria, tetanus, polio, measles, mumps, rubella, meningococcal disease, pertussis, varicella) in order for children to attend school. The persistence of gaps in immunizations shows that policy alone cannot solve the problem, the report pointed out.

HOW TO CATCH-UP

The report set out several recommendations for how Ontario can address immunizations that may have gone unfulfilled during the pandemic.

The first step is to identify who may have missed their routine immunizations.

Public health units generally place caregiver-reported information on immunizations in the repository Panorama, which is a public health interface that aggregates immunization information in the province.

However, the report pointed out, Panorama is not accessible to non-public-health immunization providers, meaning reporting on vaccination levels by primary-care physicians is inconsistent.

Without a more centralized electronic registry, the report recommends that caregivers, schools, primary care and health care providers, as well as public health units, work together to identify those who have missed their immunizations.

Schools can inform caregivers that certain immunizations are required and direct parents to local public health units to report on their child’s immunizations. Once there is a better picture of how many students are missing immunizations, public health can plan a school-based catch up program.

“Further, a call from the provincial government for primary care health providers and public health units to contact their school-age patients and follow-up on vaccination status may help mobilize caregivers to seek options to vaccinate their children,” the report stated.

If the provincial government provides financial assistance to expand immunization catch-up efforts, than there can be more avenues for catch-up, such as “a public health-hosted community clinic” or participating pharmacies aiding the effort.

“In suggesting a multi-pronged approach to catch-up immunization we are hoping to remove barriers to access that may prevent caregivers from accessing vaccines for their children in any one setting (such as offering immunizations outside of schools to meet the needs of children who continue to pursue remote learning),” Allan said.

The report pointed out that there are also socio-cultural barriers to accessing vaccines, “including language barriers and a lack of trust in the healthcare system based on a history of marginalization, structural racism, and trauma, particularly among Indigenous and Black communities,” and that these factors need to be taken into account to ensure equity in immunization catch-up programs.

This could mean more community-based solutions as well as training immunizers to know how to engage with different members of the community.

The report gave examples of regions that have had success in targeted approaches to catching children up on immunizations, such as the Huron-Perth health unit, which used a multi-pronged strategy in the summer of 2020 that involved mass immunization clinics, a temporary online booking system, mail outs to families, social media posts and clear messaging to school boards, caregivers and students about the catch-up program.

Allan emphasized that in the future, having a central electronic database would help keep track of immunizations better.

“A centralized immunization registry could help to identify missed immunizations more efficiently,” she said. “Right now, there are a number of repositories of vaccination records in Ontario. A centralized registry would replace these separate repositories and provide all stakeholders (public health, primary care, pharmacies, caregivers) access to a single common vaccination record system.”

Parents who are concerned about whether their child has missed a routine immunization should start by familiarizing themselves with which vaccines school-aged children should have, Allan said.

“Next, they can find out sites in their local area where their children can receive these missed vaccines (for instance Toronto Public Health is now offering missed school-based immunizations for student in Grade 7 and up at city-run immunization sites),” Allan added. “Finally, parents should report any catch-up routine immunizations received to their local public health unit.”

Health experts also recently put together a caregiver toolkit for parents and guardians to know what to do to maintain immunizations for their children.

Catching up may be stymied by the COVID-19 vaccine rollout as well. Children aged 12-17 are currently able to receive the vaccine, and children younger than 12 are expected to be cleared to receive the vaccine in the coming months. At this time, the National Advisory Committee on Immunization doesn’t recommend taking the COVID-19 vaccine within 14 days of any other immunization, so this needs to be taken into account as parents and students seek out those missed immunizations.

As the pandemic has raged on, routine immunizations have likely been far from the front of most minds. But moving forward, it’s important to catch up again, experts say, if we want to keep kids safe.

“If the number of unvaccinated children gets large enough, there will be the potential for widespread outbreaks of these vaccine-preventable diseases,” Kwong said.