The Chief Public Health Officer's Report on the State of Public Health in Canada 2013 – Immunization and vaccine-preventable diseases – Staying protected

Immunization and Vaccine-Preventable Diseases—Staying Protected

Highlights

  • Vaccine-preventable diseases continue to be a global public health challenge.
  • Until vaccine-preventable diseases are eradicated worldwide, Canadians remain at risk.
  • Immunization is an effective protective measure against vaccine-preventable diseases.

Prevention of disease is a core function of public health. Immunization is a good protective measure against many infectious diseases and has shown remarkable success. Common infectious diseases that were once a major cause of morbidity and mortality in Canada, particularly among children, are now preventable with vaccines. Nevertheless, vaccine-preventable diseases are still a public health concern and prevention efforts must continue. Immunization is important for all Canadians to stay protected against vaccine-preventable diseases.

Immunization—a collective protection

Vaccines provide protection against specific infectious diseases for which they are directly targeted. Protection is provided not only for individuals immunized, but may also benefit others in the population.Footnote 1-Footnote 4 Immunization is defined as “the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine.”Footnote 3

Vaccines work by creating an immune response, which provides protection from infection.Footnote 5, Footnote 6 The body's immune system is stimulated to make antibodies in two ways: by getting an infection or by getting a vaccine.Footnote 5, Footnote 7 Getting vaccinated is a safer way to make antibodies, as a person does not have to suffer through the disease itself and risk disability or even death.Footnote 5, Footnote 7 After getting a vaccine, the body sets up its own defence system by producing antibodies that remember how to fight off the bacterium or virus.Footnote 5, Footnote 7 If the real bacteria or virus that causes this disease enters the body, the defence system knows how to fight it off.Footnote 5, Footnote 7

The immune system will often remember how to fight a bacterium or virus for the rest of a person's life.Footnote 5, Footnote 7 Sometimes, however, the immune system needs a reminder in the form of a booster shot (e.g. diphtheria and tetanus every 10 years).Footnote 6, Footnote 7 Some vaccines, such as those used to prevent influenza, require an annual dose for adults and children as the viruses that cause the disease keep changing and new vaccines against new strains are needed every year.Footnote 7

As the number of people who get immunized increases, the probability of infectious disease transmission decreases. As a result, the community resistance to the disease becomes stronger in a way that provides a protective barrier for those individuals who cannot be immunized for health reasons such as illness, age or allergy. This collective protection is called herd immunity.Footnote 2, Footnote 7-Footnote 9 However, the proportion of the population that must be immune to achieve a herd immunity threshold varies with each infectious disease and its transmission characteristics. Ideally, the highest possible coverage for a vaccine-preventable disease is preferable.Footnote 7, Footnote 8 Indeed, high immunization coverage in one region or country can benefit other jurisdictions, particularly since infectious diseases are able to easily cross borders as a result of global trade, migration and travel.Footnote 2

Vaccine effectiveness and programs

Immunization has been proven to cost-effectively improve longevity and quality of life–and save lives.Footnote 2, Footnote 4, Footnote 10, Footnote 11 Immunization can also help ease pressures on the healthcare system (e.g. less antibiotic use and fewer hospitalizations and long-term disabilities).Footnote 4, Footnote 10-Footnote 12 Beyond averted illnesses and deaths and direct healthcare cost savings, immunization can contribute to broader economic benefits in other areas, such as education (e.g. healthy children tend to perform better in school) and labour (e.g. by averting loss of income and productivity due to illness).Footnote 2, Footnote 4, Footnote 11, Footnote 12

In general, vaccination programs compare favourably with other public health interventions in terms of cost per life year saved. As a result, deciding to include inexpensive vaccines against common diseases (e.g. measles, mumps and rubella) in publicly funded immunization programs is fairly straightforward.Footnote 1, Footnote 4, Footnote 11, Footnote 13 That being said, some newer and relatively expensive vaccines (e.g. the meningococcal vaccine) result in health benefits but not always savings in terms of net cost per case prevented.Footnote 1, Footnote 13, Footnote 14 The decision to include these vaccines in publicly funded immunization programs, therefore, depends on public acceptance and general willingness to pay for the health benefits.Footnote 1

National Advisory Committee on Immunization (NACI) is a scientific technical body made of experts in the fields of pediatrics, infectious diseases, immunology and public health. NACI provides ongoing medical, scientific and public health advice about the vaccines approved for use in Canada, including vaccine schedules for individuals at different risk due to occupation, travel, underlying illness, lifestyle and age.Footnote 15, Footnote 16

Vaccine expert and review committees, such as the National Advisory Committee on Immunization (NACI), have to consider many different aspects when making recommendations. They must deliberate on which new vaccines to recommend, the type of coverage (an entire population or high-risk groups only), combinations of vaccines, the dosing schedules and the vaccine delivery methods. New vaccines and programs must be evaluated carefully, and it is important that researchers and policy makers work together to identify programs that deliver the greatest benefit for the least cost.Footnote 1, Footnote 13

An ideal vaccine would protect, for life, against a disease after a single dose. It would have no adverse effects and would be effective for all immunized individuals, including infants and the elderly. It would be inexpensive, stable during shipping and storage and easy to administer. Researchers and vaccine manufacturers continue to work to improve on the effectiveness of vaccines; in the meantime, our existing vaccines save lives. The safety of vaccines and the effectiveness of immunization programs must be continually evaluated to attain the most benefit.Footnote 1, Footnote 17

Immunization in public health–past and present

Public health is the organized efforts of society to keep people healthy and prevent injury, illness and premature death. It is a combination of programs, services and policies that protect and promote health.Footnote 18, Footnote 19 Better hygiene and sanitation, access to safer and more nutritious foods, improved living standards, the development of antibiotics and other medical advancements have all helped make Canadians healthier.Footnote 20 So too have vaccines, which have improved the health of Canadians by decreasing and, in many cases, halting the spread of infectious diseases.Footnote 21

Reduction in incidence of vaccine-preventable diseases

The incidence of various infectious diseases began to drop dramatically after vaccines came into widespread use in Canada (see Table 1).Footnote 1, Footnote 21-Footnote 28 Through innovative tools, education and training, as well as effective immunization delivery strategies, common infectious diseases that were once a major cause of illness and death, particularly among children, have been significantly reduced through immunization.Footnote 1, Footnote 29

Table 1 Incidence of selected vaccine-preventable disease in Canada, pre-vaccine era compared with 2007 to 2011 Footnote 1, Footnote 22-Footnote 28, Footnote 30, Footnote 31
Disease Pre-vaccine eraTable 1 - Footnote *
Peak annual number of cases
2007–2011 Peak annual number of cases
*Five years preceding vaccine introduction.
Congenital rubella syndrome (CRS) 29 (1979–1983) 0
Diphtheria 9,010 (1925–1929) 4
Haemophilus influenzae type b
(Hib) (children <5 years)
526 (1986–1990) 12
Measles 61,370 (1950–1954) 750
Mumps 43,671 (1950–1954) 1,110
Pertussis (whooping cough) 19,878 (1938–1942) 1,967
Poliomyelitis 1,584 (1950–1954) 0
Rubella 37,917 (1950–1954) 12
Tetanus 19 (1957–1961) 6

However, as the incidence of a vaccine-preventable disease decreases following successful immunization programs, there is a potential for Canadians to become complacent and question the role of vaccines in preventive healthcare. This could lead to lower immunization coverage and resurgence of the disease.Footnote 1, Footnote 7, Footnote 10, Footnote 32-Footnote 34 The viruses and bacteria that cause such diseases are still common and circulate within Canada and around the world, meaning that people who are not protected by immunization can become infected with the disease.Footnote 7, Footnote 35

The recent measles outbreaks in Canada illustrate the need to remain vigilant.Footnote 24 Measles is a highly contagious virus, and health complications from the disease can be very serious, requiring hospitalization and even causing death.Footnote 24, Footnote 36 Before the vaccine was implemented in Canada in 1963, measles was widespread and large epidemics occurred every two to three years.Footnote 24, Footnote 31, Footnote 36 Immunization resulted in a dramatic decrease in the incidence rate of measles (see Figure 1).Footnote 24, Footnote 36-Footnote 38 However, there have been several measles outbreaks since 2005, including nine notable outbreaks (see the textbox “Measles: The need to remain vigilant”).Footnote 24 Until measles and other vaccine-preventable diseases are eradicated worldwide, Canadians remain at risk. A safe protection against emergence and re-emergence of infectious diseases is immunization.Footnote 24

Measles: The need to remain vigilant

Canada has made great progress in preventing and controlling measles. This is due in large part to the interruption of measles transmission, as a result of high vaccine coverage as part of routine infant and childhood immunization programs.Footnote 1, Footnote 24 Nevertheless, measles outbreaks still occur periodically in Canada.Footnote 24 For example, in recent years, Quebec, British Columbia and Ontario experienced measles outbreaks in 2011, 2010 and 2008, respectively.Footnote 24 Overall, between 2005 and 2011, a total of 1,046 confirmed cases of measles were reported in Canada.Footnote 24 As of March 2012, more than 776 cases had been recorded in Quebec.Footnote 39 This has been the biggest measles outbreak in the Americas since 2002.Footnote 40

Worldwide, measles is still a leading cause of death in children.Footnote 10, Footnote 24 The World Health Organization (WHO) global goal was to reduce measles mortality by 90% by 2010 (compared with levels in 2000).Footnote 10, Footnote 24 While the goal was not achieved, global mortality due to measles was reduced by 74% from 535,300 deaths in 2000 to 139,300 deaths in 2010.Footnote 24 As long as people travel and the disease is still circulating, measles can continue to be imported into Canada. Thus, the best protection against measles is to be immunized.Footnote 1, Footnote 24

Figure 1 Incidence rate (per 1,000,000 population) of measles, by year, 1924 to 2011, and year of vaccine introduction in CanadaFootnote 24, Footnote 31, Footnote 37, Footnote 38

Figure 1
Text Equivalent - Figure 1

Before the introduction of measles vaccine in 1963 to 1964, measles incidence followed a cyclical pattern, with peaks every 2 to 3 years. Since the introduction of vaccine, the incidence has decreased considerably. Further decreases were seen following the introduction of routine 1-dose measles-mumps-rubella vaccine in 1983 and the introduction of routine 2-dose measles-mumps-rubella vaccine in 1996 to 1997 in the provinces and territories. The incidence rate decreased from 3,800 cases per 1,000,000 population from 1924 to 1958 to 68 cases per 1,000,000 population from 1984 to 2011. Note: measles was not nationally notifiable between 1959 and 1968.

* In 1963, live vaccine was approved for use in Canada, followed by the approval of killed vaccine in 1964. The killed vaccine had limited availability, and use was discontinued by the end of 1970. A single dose schedule with the live vaccine was introduced into all provincial/territorial routine immunization programs by the early 1970s. The routine one-dose measles-mumps-rubella vaccine was introduced in 1983.

Note: Measles was not nationally notifiable between 1959 and 1968.

Increase and maintain immunization coverage

Routine childhood immunization is, for the most part, accepted as standard practice in Canada.Footnote 1, Footnote 15 Adequate and well-timed immunization of infants and children is necessary to protect against vaccine-preventable diseases.Footnote 1, Footnote 41-Footnote 43 While newborns are protected against many diseases because they still have maternal antibodies, this immunity disappears within the first year of life.Footnote 1, Footnote 42 It is important for parents and caregivers to keep track of and maintain their child's immunization record to ensure it is up-to-date. This is also a good opportunity for parents to check that their own immunizations are current.Footnote 1, Footnote 41

Preventing disease by immunization is a lifelong process.Footnote 1 The proportion of the population aged 65 years and older is increasing more rapidly than that of any other age group, and if population projections remain consistent, there will be more seniors than children in Canada by 2015.Footnote 44 To prevent infections and control the spread of disease, Canadians should be made aware of, and encouraged to take part in, immunization programs beyond the childhood years.Footnote 1, Footnote 45 Specific immunization efforts should also target high-risk groups in Canada, such as healthcare providers, newcomers to Canada, international travellers and specific populations with low immunization coverage who may be vulnerable to vaccine-preventable diseases.Footnote 1, Footnote 46-Footnote 48

A number of vaccines–booster or annual doses–are recommended for those aged 15 years and over. Without them, Canadians remain vulnerable to infectious diseases such as pneumococcal infections, pertussis and influenza. For example, adults require a tetanus booster every 10 years to remain protected.Footnote 1, Footnote 49 Between 2000 and 2011, 97% of reported cases of tetanus in Canada were among Canadians aged 20 years and older.Footnote 30 Improved coordination of and delivery strategies for adult immunization as well as identification of barriers to vaccine uptake are needed to achieve and maintain adequate immunization coverage.Footnote 1, Footnote 29, Footnote 45

Seasonal influenza immunization rates are relatively low in Canada, even among those at highest risk.Footnote 50 In 2011, an estimated 30% of Canadians aged 12 years and older received the influenza vaccine in the past year.Footnote 51 Annual influenza vaccination is encouraged for all Canadians, particularly those at high risk of influenza-related complications, those capable of spreading influenza to individuals at risk and those who provide essential community services.Footnote 52 Among infants, the elderly and those with underlying medical conditions, influenza can cause severe illness and even death.Footnote 52-Footnote 55 Even healthy, young individuals are at risk.Footnote 52, Footnote 54 Some Canadians may perceive the influenza vaccine as “optional,” or not as crucial, as other vaccines.Footnote 56 However, an annual influenza vaccine offers the best protection, and the more Canadians are immunized, the greater the collective protection.Footnote 52, Footnote 54 To increase and maintain high immunization coverage, greater attention to education and public outreach is needed.Footnote 56, Footnote 57

Identifying the reasons Canadians accept or refuse vaccines is essential to learning how to develop, evaluate and promote effective strategies for immunization.Footnote 56 Hesitancy towards immunization can be due to a number of factors including personal beliefs, values, opinions, lifestyle choices and alternative personal health perspectives. Other factors include concerns about vaccine safety, perceptions of low disease risk and fear of vaccine “overload” in children.Footnote 33, Footnote 34, Footnote 56, Footnote 58-Footnote 61 Strategies to identify and overcome factors associated with less than optimal vaccine uptake are needed.Footnote 1, Footnote 33, Footnote 57 A combination of approaches may be beneficial; these include recommendations from healthcare professionals (e.g. physicians, nurses and pharmacists); education on the risks and benefits of vaccination; targeted messaging for specific groups; expanded opportunities for being immunized; coordinated immunization programs across Canada; and the availability of up-to-date immunization records, databases and information systems.Footnote 1, Footnote 60

Immunization–a shared responsibility

Canada's National Immunization Strategy

In 2003, Canada launched the National Immunization Strategy (NIS), a collaboration between federal and provincial and territorial governments to initiate consistent and comprehensive approaches to immunization planning, purchasing, delivery and education.Footnote 62-Footnote 64 In the past 10 years, the NIS has helped build stronger partnerships between federal and provincial/territorial governments and key stakeholders, thus improving access to vaccines across Canada and the effectiveness and efficiency of immunization programs.Footnote 63-Footnote 65

By and large, immunization in Canada is a public health success story. However, the future presents new challenges and opportunities for improvement. The continued success of immunization depends on the concerted efforts of all levels of government and of researchers, healthcare professionals and the public.

Maintaining vaccine effectiveness and safety

Vaccine effectiveness and safety are of the highest importance and concern for all vaccine stakeholders.Footnote 66 As the incidence of vaccine-preventable diseases declines, public and mass media concern has shifted to vaccine safety.Footnote 60 Perceived vaccine safety risks can get as much attention–if not more–than actual vaccine safety risks and can be difficult to dispel despite credible scientific evidence.Footnote 1 This can bring about hesitancy towards vaccines and a loss of confidence in immunization altogether.Footnote 1 This, in turn, threatens the continued success of immunization programs.Footnote 1, Footnote 32, Footnote 67

Many vaccines have been used in Canada for decades with no evidence of long-term adverse effects.Footnote 1, Footnote 66, Footnote 68, Footnote 69 While it is recognized that no vaccine is 100% effective or perfectly safe, vaccines are much safer than the diseases they prevent. For the majority of Canadians, vaccines offer an effective and safe protection against vaccine-preventable diseases.Footnote 1, Footnote 9, Footnote 66, Footnote 70, Footnote 71 Common short-term adverse events include redness, swelling and pain at the injection site. Serious adverse events following immunization are, however, rare.Footnote 1, Footnote 72

Debunked vaccine myths

Recent research using comprehensive scientific methods and reviews of studies worldwide have debunked the myths and confirmed that:Footnote 1, Footnote 68, Footnote 69, Footnote 73, Footnote 74

  • the measles-mumps-rubella (MMR) vaccine does NOT cause autism;
  • the hepatitis B vaccine does NOT cause multiple sclerosis (MS) or relapses of pre-existing MS;
  • the pertussis vaccine (DTaP, Tdap) does NOT cause brain damage;
  • the influenza vaccine does NOT give a person the seasonal flu;
  • childhood vaccines do NOT increase the risk of asthma; and
  • vaccines do NOT cause sudden infant death syndrome (SIDS).

Vaccines are developed in accordance with the highest standards and are continually monitored for safety in Canada and around the world.Footnote 1, Footnote 66 On average, it can take 10 years for the necessary data and evidence to be gathered before a vaccine is authorized for use in Canada.Footnote 71 Following Health Canada's regulatory approval, several surveillance systems are in place to monitor the safety of vaccines. These include the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS) and a pediatric hospital-based surveillance network known as IMPACT (Immunization Monitoring Program ACTive).Footnote 1, Footnote 66, Footnote 71, Footnote 75-Footnote 77

Although the vaccines used in Canada today are effective, efforts must continue to develop even better vaccines. Continuously exploring new ways to optimize vaccine surveillance systems so as to respond to vaccine-associated adverse events more efficiently is also essential. In addition, communicating effectively about vaccine safety and monitoring activities will help improve and maintain professional and public confidence.

Public confidence, education and promotion

False controversies about the measles-mumps-rubella (MMR) vaccine

In 1998, the British medical journal, The Lancet published a study by Dr. Andrew Wakefield that claimed to link the MMR vaccine to autism. The study was later discredited, and The Lancet retracted Dr. Wakefield's paper in 2010. Following release of the original article, vaccination levels plummeted in Britain and incidence rates of the diseases surged. The effect on immunization rates was felt worldwide.Footnote 1, Footnote 32, Footnote 67

Medical researchers and scientists worldwide have concluded there is no evidence of a link between autism and the MMR vaccine. Vaccines used to protect children from measles, mumps and rubella are effective and safe.Footnote 1, Footnote 66, Footnote 67, Footnote 69, Footnote 73

Social media can be a constant, but not always reliable, source of information-sharing for Canadians. Some media outlets can shift the focus away from recognizing the effectiveness of immunization towards other issues such as increased hesitancy and/or suspicion of adverse effects resulting from vaccination. This can have an impact on public perception and confidence in vaccine use in Canada.Footnote 1, Footnote 34, Footnote 57

Education and effective communication is paramount. Identifying alternative ways to inform Canadians about vaccine-preventable diseases, immunization programs and vaccine effectiveness is vital to overcoming any potential effects of misinformation or loss of trust.Footnote 1, Footnote 57 Information must be easy to understand, visible, current and evidence-based to spread key messages effectively.Footnote 57

A healthcare encounter in which an individual is eligible to be immunized, but is not, is considered a missed opportunity. Missed opportunities present challenges to achieving optimal immunization coverage.Footnote 59 High quality, standardized educational resources to help healthcare professionals effectively communicate about immunization are necessary. Transparency on risks and benefits of immunization, as well as clear and targeted messaging to specific audiences are essential to inform Canadians and maintain trust.Footnote 1, Footnote 57 Such resources can help healthcare professionals explain evidence-based information on the effectiveness and safety of vaccines.Footnote 1 As well, healthcare providers can help patients understand that there is no substitute for immunization, and that while there may be alternative therapies available, they are not as effective as immunization programs.

Improved coordination of immunization programs

Immunization recommendations for vaccines used in Canada are made by the National Advisory Committee on Immunization.Footnote 16 Provinces and territories remain responsible for immunization programming decisions following reviews and recommendations by their own scientific advisory committees or immunization leads. They implement immunization programs that meet their goals, policies and strategies as well as epidemiological and financial circumstances.Footnote 61, Footnote 65

Provincial or territorial immunization programs determine which recommended vaccines are provided at no direct cost to Canadians.Footnote 61, Footnote 63, Footnote 78 Though immunization schedules are more or less consistent among jurisdictions, there is some variation (e.g. in vaccine products used, combined vaccines, administration at different ages, number of booster doses required, etc.).Footnote 1, Footnote 79 Additional vaccines may be recommended to Canadians, depending on their state of health, occupation, activities or travel plans but not all are publicly funded.Footnote 1 This makes it a challenge for complete immunization coverage across Canada, given that some routine vaccines and vaccines for special circumstances are publicly funded in some jurisdictions, but not in others.Footnote 61, Footnote 62

Recent years have seen an increase in the number of new vaccines on the Canadian market and a rise in costs.Footnote 11, Footnote 13 As a result, provincial and territorial immunization schedules do diverge, as jurisdictions must choose between available health interventions to meet the needs of their population.Footnote 1, Footnote 79 However, such divergence can impose avoidable burdens on healthcare systems and families and make access to vaccines inequitable across jurisdictions and in different population groups, resulting in public confusion over the necessity, utility and safety of certain vaccines.Footnote 1, Footnote 57, Footnote 63

Improved coordination of immunization schedules and programs across Canada would support the demand for equitable access to needed vaccines for all Canadians. In addition, equitable access would offer the best coverage and protection for those Canadians who move between provinces and territories or conversely, risk infection due to differing provincial/territorial immunization schedules and programs.Footnote 57, Footnote 61-Footnote 63, Footnote 78, Footnote 79

Complete and compatible immunization registries

Accurate and timely information on those who have been immunized as well as information on the immunization coverage levels in specific population groups and regions are important to indicate the level of protection against specific vaccine-preventable diseases in a population. Such information helps target priority regions and populations for immunization during disease outbreaks and helps avoid unnecessary and costly re-immunization. It also helps identify any adverse events following immunization.Footnote 57, Footnote 61, Footnote 62, Footnote 78, Footnote 80, Footnote 81

Currently, six provinces and territories have some form of an immunization registry in place.Footnote 81, Footnote 82 An interconnected network of complete, compatible and accessible immunization registries across provinces and territories would make it easier to track immunization records when people move from one jurisdiction to another. Healthcare professionals and patients could easily find out which vaccines are missing, which booster doses are needed and which new vaccines are available.Footnote 57, Footnote 81, Footnote 82

Being able to effectively monitor uptake of vaccines and produce better surveillance information through compatible and accessible immunization registries would put Canada in the best position to evaluate and assess vaccines and immunization programs. Enhanced information would allow for better program evaluation and opportunities to be more strategic in identifying immunization needs.Footnote 57, Footnote 81

Actions for success

Infectious diseases can have an impact on an individual's quality of health and longevity. It is important that Canadians stay protected as outbreaks of vaccine-preventable diseases can, and do, occur in Canada. Immunization is a good prevention measure against vaccine-preventable diseases. Therefore, continued commitment to immunization programs in Canada is essential. Everyone has a role to play.

Increase and maintain immunization coverage

Routine childhood immunization is, for the most part, accepted as standard practice in Canada.Footnote 1, Footnote 15 Adequate and well-timed immunization of infants and children is necessary to protect against vaccine-preventable diseases.Footnote 1, Footnote 41-Footnote 43 While newborns are protected against many diseases because they still have maternal antibodies, this immunity disappears within the first year of life.Footnote 1, Footnote 42 It is important for parents and caregivers to keep track of and maintain their child's immunization record to ensure it is up-to-date. This is also a good opportunity for parents to check that their own immunizations are current.Footnote 1, Footnote 41

Preventing disease by immunization is a lifelong process.Footnote 1 The proportion of the population aged 65 years and older is increasing more rapidly than that of any other age group, and if population projections remain consistent, there will be more seniors than children in Canada by 2015.Footnote 44 To prevent infections and control the spread of disease, Canadians should be made aware of, and encouraged to take part in, immunization programs beyond the childhood years.Footnote 1, Footnote 45 Specific immunization efforts should also target high-risk groups in Canada, such as healthcare providers, newcomers to Canada, international travellers and specific populations with low immunization coverage who may be vulnerable to vaccine-preventable diseases.Footnote 1, Footnote 46-Footnote 48

A number of vaccines–booster or annual doses–are recommended for those aged 15 years and over. Without them, Canadians remain vulnerable to infectious diseases such as pneumococcal infections, pertussis and influenza. For example, adults require a tetanus booster every 10 years to remain protected.Footnote 1, Footnote 49 Between 2000 and 2011, 97% of reported cases of tetanus in Canada were among Canadians aged 20 years and older.Footnote 30 Improved coordination of and delivery strategies for adult immunization as well as identification of barriers to vaccine uptake are needed to achieve and maintain adequate immunization coverage.Footnote 1, Footnote 29, Footnote 45

Seasonal influenza immunization rates are relatively low in Canada, even among those at highest risk.Footnote 50 In 2011, an estimated 30% of Canadians aged 12 years and older received the influenza vaccine in the past year.Footnote 51 Annual influenza vaccination is encouraged for all Canadians, particularly those at high risk of influenza-related complications, those capable of spreading influenza to individuals at risk and those who provide essential community services.Footnote 52 Among infants, the elderly and those with underlying medical conditions, influenza can cause severe illness and even death.Footnote 52-Footnote 55 Even healthy, young individuals are at risk.Footnote 52, Footnote 54 Some Canadians may perceive the influenza vaccine as “optional,” or not as crucial, as other vaccines.Footnote 56 However, an annual influenza vaccine offers the best protection, and the more Canadians are immunized, the greater the collective protection.Footnote 52, Footnote 54 To increase and maintain high immunization coverage, greater attention to education and public outreach is needed.Footnote 56, Footnote 57

Identifying the reasons Canadians accept or refuse vaccines is essential to learning how to develop, evaluate and promote effective strategies for immunization.Footnote 56 Hesitancy towards immunization can be due to a number of factors including personal beliefs, values, opinions, lifestyle choices and alternative personal health perspectives. Other factors include concerns about vaccine safety, perceptions of low disease risk and fear of vaccine “overload” in children.Footnote 33, Footnote 34, Footnote 56, Footnote 58-Footnote 61 Strategies to identify and overcome factors associated with less than optimal vaccine uptake are needed.Footnote 1, Footnote 33, Footnote 57 A combination of approaches may be beneficial; these include recommendations from healthcare professionals (e.g. physicians, nurses and pharmacists); education on the risks and benefits of vaccination; targeted messaging for specific groups; expanded opportunities for being immunized; coordinated immunization programs across Canada; and the availability of up-to-date immunization records, databases and information systems.Footnote 1, Footnote 60

Immunization–a shared responsibility

Canada's National Immunization Strategy

In 2003, Canada launched the National Immunization Strategy (NIS), a collaboration between federal and provincial and territorial governments to initiate consistent and comprehensive approaches to immunization planning, purchasing, delivery and education.Footnote 62-Footnote 64 In the past 10 years, the NIS has helped build stronger partnerships between federal and provincial/territorial governments and key stakeholders, thus improving access to vaccines across Canada and the effectiveness and efficiency of immunization programs.Footnote 63-Footnote 65

By and large, immunization in Canada is a public health success story. However, the future presents new challenges and opportunities for improvement. The continued success of immunization depends on the concerted efforts of all levels of government and of researchers, healthcare professionals and the public.

Maintaining vaccine effectiveness and safety

Vaccine effectiveness and safety are of the highest importance and concern for all vaccine stakeholders.Footnote 66 As the incidence of vaccine-preventable diseases declines, public and mass media concern has shifted to vaccine safety.Footnote 60 Perceived vaccine safety risks can get as much attention–if not more–than actual vaccine safety risks and can be difficult to dispel despite credible scientific evidence.Footnote 1 This can bring about hesitancy towards vaccines and a loss of confidence in immunization altogether.Footnote 1 This, in turn, threatens the continued success of immunization programs.Footnote 1, Footnote 32, Footnote 67

Many vaccines have been used in Canada for decades with no evidence of long-term adverse effects.Footnote 1, Footnote 66, Footnote 68, Footnote 69 While it is recognized that no vaccine is 100% effective or perfectly safe, vaccines are much safer than the diseases they prevent. For the majority of Canadians, vaccines offer an effective and safe protection against vaccine-preventable diseases.Footnote 1, Footnote 9, Footnote 66, Footnote 70, Footnote 71 Common short-term adverse events include redness, swelling and pain at the injection site. Serious adverse events following immunization are, however, rare.Footnote 1, Footnote 72

Debunked vaccine myths

Recent research using comprehensive scientific methods and reviews of studies worldwide have debunked the myths and confirmed that:Footnote 1, Footnote 68, Footnote 69, Footnote 73, Footnote 74

  • the measles-mumps-rubella (MMR) vaccine does NOT cause autism;
  • the hepatitis B vaccine does NOT cause multiple sclerosis (MS) or relapses of pre-existing MS;
  • the pertussis vaccine (DTaP, Tdap) does NOT cause brain damage;
  • the influenza vaccine does NOT give a person the seasonal flu;
  • childhood vaccines do NOT increase the risk of asthma; and
  • vaccines do NOT cause sudden infant death syndrome (SIDS).

Vaccines are developed in accordance with the highest standards and are continually monitored for safety in Canada and around the world.Footnote 1, Footnote 66 On average, it can take 10 years for the necessary data and evidence to be gathered before a vaccine is authorized for use in Canada.Footnote 71 Following Health Canada's regulatory approval, several surveillance systems are in place to monitor the safety of vaccines. These include the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS) and a pediatric hospital-based surveillance network known as IMPACT (Immunization Monitoring Program ACTive).Footnote 1, Footnote 66, Footnote 71, Footnote 75-Footnote 77

Although the vaccines used in Canada today are effective, efforts must continue to develop even better vaccines. Continuously exploring new ways to optimize vaccine surveillance systems so as to respond to vaccine-associated adverse events more efficiently is also essential. In addition, communicating effectively about vaccine safety and monitoring activities will help improve and maintain professional and public confidence.

Public confidence, education and promotion

False controversies about the measles-mumps-rubella (MMR) vaccine

In 1998, the British medical journal, The Lancet published a study by Dr. Andrew Wakefield that claimed to link the MMR vaccine to autism. The study was later discredited, and The Lancet retracted Dr. Wakefield's paper in 2010. Following release of the original article, vaccination levels plummeted in Britain and incidence rates of the diseases surged. The effect on immunization rates was felt worldwide.Footnote 1, Footnote 32, Footnote 67

Medical researchers and scientists worldwide have concluded there is no evidence of a link between autism and the MMR vaccine. Vaccines used to protect children from measles, mumps and rubella are effective and safe.Footnote 1, Footnote 66, Footnote 67, Footnote 69, Footnote 73

Social media can be a constant, but not always reliable, source of information-sharing for Canadians. Some media outlets can shift the focus away from recognizing the effectiveness of immunization towards other issues such as increased hesitancy and/or suspicion of adverse effects resulting from vaccination. This can have an impact on public perception and confidence in vaccine use in Canada.Footnote 1, Footnote 34, Footnote 57

Education and effective communication is paramount. Identifying alternative ways to inform Canadians about vaccine-preventable diseases, immunization programs and vaccine effectiveness is vital to overcoming any potential effects of misinformation or loss of trust.Footnote 1, Footnote 57 Information must be easy to understand, visible, current and evidence-based to spread key messages effectively.Footnote 57

A healthcare encounter in which an individual is eligible to be immunized, but is not, is considered a missed opportunity. Missed opportunities present challenges to achieving optimal immunization coverage.Footnote 59 High quality, standardized educational resources to help healthcare professionals effectively communicate about immunization are necessary. Transparency on risks and benefits of immunization, as well as clear and targeted messaging to specific audiences are essential to inform Canadians and maintain trust.Footnote 1, Footnote 57 Such resources can help healthcare professionals explain evidence-based information on the effectiveness and safety of vaccines.Footnote 1 As well, healthcare providers can help patients understand that there is no substitute for immunization, and that while there may be alternative therapies available, they are not as effective as immunization programs.

Improved coordination of immunization programs

Immunization recommendations for vaccines used in Canada are made by the National Advisory Committee on Immunization.Footnote 16 Provinces and territories remain responsible for immunization programming decisions following reviews and recommendations by their own scientific advisory committees or immunization leads. They implement immunization programs that meet their goals, policies and strategies as well as epidemiological and financial circumstances.Footnote 61, Footnote 65

Provincial or territorial immunization programs determine which recommended vaccines are provided at no direct cost to Canadians.Footnote 61, Footnote 63, Footnote 78 Though immunization schedules are more or less consistent among jurisdictions, there is some variation (e.g. in vaccine products used, combined vaccines, administration at different ages, number of booster doses required, etc.).Footnote 1, Footnote 79 Additional vaccines may be recommended to Canadians, depending on their state of health, occupation, activities or travel plans but not all are publicly funded.Footnote 1 This makes it a challenge for complete immunization coverage across Canada, given that some routine vaccines and vaccines for special circumstances are publicly funded in some jurisdictions, but not in others.Footnote 61, Footnote 62

Recent years have seen an increase in the number of new vaccines on the Canadian market and a rise in costs.Footnote 11, Footnote 13 As a result, provincial and territorial immunization schedules do diverge, as jurisdictions must choose between available health interventions to meet the needs of their population.Footnote 1, Footnote 79 However, such divergence can impose avoidable burdens on healthcare systems and families and make access to vaccines inequitable across jurisdictions and in different population groups, resulting in public confusion over the necessity, utility and safety of certain vaccines.Footnote 1, Footnote 57, Footnote 63

Improved coordination of immunization schedules and programs across Canada would support the demand for equitable access to needed vaccines for all Canadians. In addition, equitable access would offer the best coverage and protection for those Canadians who move between provinces and territories or conversely, risk infection due to differing provincial/territorial immunization schedules and programs.Footnote 57, Footnote 61-Footnote 63, Footnote 78, Footnote 79

Complete and compatible immunization registries

Accurate and timely information on those who have been immunized as well as information on the immunization coverage levels in specific population groups and regions are important to indicate the level of protection against specific vaccine-preventable diseases in a population. Such information helps target priority regions and populations for immunization during disease outbreaks and helps avoid unnecessary and costly re-immunization. It also helps identify any adverse events following immunization.Footnote 57, Footnote 61, Footnote 62, Footnote 78, Footnote 80, Footnote 81

Currently, six provinces and territories have some form of an immunization registry in place.Footnote 81, Footnote 82 An interconnected network of complete, compatible and accessible immunization registries across provinces and territories would make it easier to track immunization records when people move from one jurisdiction to another. Healthcare professionals and patients could easily find out which vaccines are missing, which booster doses are needed and which new vaccines are available.Footnote 57, Footnote 81, Footnote 82

Being able to effectively monitor uptake of vaccines and produce better surveillance information through compatible and accessible immunization registries would put Canada in the best position to evaluate and assess vaccines and immunization programs. Enhanced information would allow for better program evaluation and opportunities to be more strategic in identifying immunization needs.Footnote 57, Footnote 81

Actions for success

Infectious diseases can have an impact on an individual's quality of health and longevity. It is important that Canadians stay protected as outbreaks of vaccine-preventable diseases can, and do, occur in Canada. Immunization is a good prevention measure against vaccine-preventable diseases. Therefore, continued commitment to immunization programs in Canada is essential. Everyone has a role to play.

  • Accurate and accessible information about vaccine-preventable diseases helps Canadians stay protected.
  • Healthcare professionals and those who care for people at high risk need to promote and embrace immunization to reduce the transmission of disease.
  • Healthcare professionals need to be more engaged in promoting vaccine uptake, in identifying barriers to immunization and developing solutions.
  • Canada can continue to improve strategies to strengthen and maintain public confidence in immunization.
  • Coordination of routine immunization schedules and programs across Canada is a shared responsibility.
  • Compatible immunization registries would facilitate the sharing of surveillance data across Canada.
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