Elimination of Measles, Rubella and Congenital Rubella Syndrome in Canada: Documentation and Verification Report

Executive Summary

This report on elimination of measles, rubella, and congenital rubella syndrome in Canada is prepared for the Pan American Health Organization (PAHO), Regional Office of the World Health Organization (WHO), for review by the International Expert Committee.

This is essentially Canada's technical "report card", detailing the country's progress in controlling and eliminating measles and rubella. Achievements are assessed against performance indicators set by PAHO/WHO for surveillance, laboratory capacity, and immunization through review of data collated by the Centre for Immunization and Respiratory Diseases, the National Microbiology Laboratory, and the Canadian Immunization Committee, which represents the ten provinces and three territories. The last section of the report makes recommendations as to what is required to sustain elimination in Canada over the years to come.

Highlights of the report findings include:

1) Indigenous measles was eliminated from Canada.

• Last endemic case of measles was reported in 1997
• Measles cases in Canada in recent years have been due to importation from endemic regions, some resulting in outbreaks.

2) Indigenous rubella has been eliminated from Canada.

• No new cases of indigenous rubella have been reported since 2005 according to epidemiological and laboratory data.

3) Congenital rubella syndrome has also been eliminated but sporadic cases occur through prenatal infection acquired in endemic areas.

• There have been no cases of CRS due to a rubella exposure in Canada since 2000.

4) High but uneven immunization coverage in Canada is insufficient to prevent outbreaks.

• There is a lack of uniformly high immunization coverage across the country and in subpopulations such as immigrants, vaccine objectors, and unimmunized persons;
• The Childhood National Immunization Coverage Survey in 2009 showed 92% of 2-year-olds had received the first dose of measles and rubella containing vaccine; only 69% of 7-year-olds had received the second dose;
• Provinces and territories reported 86% to 97% for the first dose and 69% to 94% for the second dose.

5) Lack of immunization coverage data available at the regional/local public health authority levels.

Through examination of the evidence presented by the Secretariat and the Measles and Rubella Elimination Working Group, the National Certification Committee concludes that rubella and CRS elimination have been achieved in Canada, consistent with the intent and letter of the PAHO/WHO Plan of Action. Although there is consensus that measles was also eliminated, the Committee recognizes that a 7-month measles outbreak in one province has brought into question the sustained elimination of measles. We expect that concerted and successful efforts to control secondary measles transmission in that part of the country will permit confirmation that measles elimination has been sustained.

Canada does recognize, that the threat of imported measles, combined with sub-optimal immunization coverage in some areas, poses a risk of re-introduction and domestic transmission. Strengthening immunization programs, maintaining heightened vigilance, and achieving rapid containment of imported infections are essential for sustaining measles elimination.

In order to sustain the performance Canada has achieved to date, efforts in a number of key areas need to be closely considered. Among those identified in the report, are the ways and means to:

• Strengthen immunization programs, identifying and targeting the hard to reach populations; Improve and maintain high vaccine coverage;
• Strengthen immunization coverage monitoring at provincial/territorial and regional/local public health authority levels;
• Secure the vaccine supply to include lowest available cost at a pan-Canadian level;
• Strengthen surveillance activities and rapid outbreak response;
• Strengthen program evaluation to identify issues before they arise; and to
• Strengthen laboratory capacity.

For Canada to sustain measles and rubella elimination, all jurisdictions will continue to strengthen collaboration and support high-quality immunization programs. An ongoing review of the National Immunization Strategy provides a timely opportunity to confirm and/or identify new immunization priorities in Canada. The Public Health Agency of Canada will consult with provincial and territorial partners to develop and implement a multi-year plan building on earlier accomplishments.

To obtain a copy of the full report, including figures and reference tables, send your request to:

Vaccine Preventable Diseases
Surveillance and Outbreak Response Division
Centre for Immunization and Respiratory Infectious Diseases
Public Health Agency of Canada

vpd@phac-aspc.gc.ca