and well-being of children and youth
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In Canada, the National Advisory Committee on Immunization systematically reviews the evidence for the effectiveness and safety of new and old vaccines, and sets a ‘minimum’ recommended schedule. However, in contrast to other industrialized countries where single, harmonized countrywide immunization schedules are de rigeur, Canada has a confusing system, with each province and territory defining its own schedule – and none are the same. The time has come to rectify this decades-old patient equity and safety problem. The Canadian Paediatric Society calls for a harmonized schedule to improve the health and safety of Canadian children and youth.
Key Words: Adolescent; Canada; Children; Immunization; Vaccine schedule
The development of effective vaccines has been called the most significant advance in human health of all time! Within the past 50 years, we have witnessed the control of tetanus, diphtheria, measles and polio, and the complete eradication of smallpox. These magnificent achievements can be attributed both to fundamental research and to national and international collaboration. For example, fundamental research made it possible to develop vaccines against measles, polio and hepatitis, but a strategy coordinated by the WHO was necessary to eradicate smallpox.
In Canada, the National Advisory Committee on Immunization (NACI) regularly and systematically reviews the evidence for effectiveness and safety for new and old vaccines, and sets a ‘minimum’ recommended schedule . However, in contrast to other industrialized countries such as the United States, Australia and the United Kingdom, where single, harmonized countrywide immunization schedules are de rigeur, Canada has a confusing system, with each province and territory defining its own schedule – and none are the same (see www.phac-aspc.gc.ca/im/is-pi-eng.php) . Note the complexity that this system introduces.
The Canadian Paediatric Society has called for a national harmonized immunization schedule for more than a decade . The current need is critical because of increasing schedule complexity due to the addition of many new NACI-recommended vaccines, as well as increasing rates of migration within the country. Canada’s children and youth are at potential risk for vaccine-preventable infections because of disharmony of schedules. In addition to confusing parents and health care providers, the patchwork of vaccine schedules creates access inequities and added safety (reliability) issues in our system.
The present system is not equitable. Access to vaccines for children or youth should be determined on the basis of evidence (as done for NACI-recommended schedules), and not on the basis of residence in Canada. Why, for instance, is there a catch-up program for human papilloma virus vaccine for adolescent girls in some provinces but not in others? Why were infants in one province not protected against meningococcal C infection until recently, while those in other provinces were offered the vaccine when NACI first recommended it several years earlier?
The present system is not safe. More and more Canadians are on the move within our country. Internal migration is increasing, with over 300,000 Canadians moving interprovincially in 2011-12 . Moving from one province to another can create risks for inadequate immunization because vaccine schedules differ significantly. For example, the second dose of the measles, mumps and rubella (MMR) vaccine is given at 18 months in 9 provinces or territories, and at four to six years in three others. Moving at the ‘wrong’ age may mean a missed second dose and vulnerability to these infections later in life. With hepatitis B vaccines, the potential for missed vaccines with a move is even higher because provincial and territorial programs vary widely by age.
While the Public Health Agency of Canada provides helpful information on provincial and territorial vaccine programs for health care providers on its website, it does not provide information on previous or catch-up programs, nor does it provide information on when a new vaccine program was introduced. Thus, parents are left to find this information on their own. Health care providers are often equally confounded by the lack of information on how to fill gaps created by mismatched schedules. The goal should be to make it easy for parents and health care providers to know if they are on track with an immunization schedule, not to make it difficult to determine whether a child is ‘up to date’. Clearly, a system problem exists in Canada. A harmonized schedule would not only be safer but also less costly for the system:
A harmonized core schedule would not preclude a province or territory from enhancing its program for a vaccine not yet universally recommended by the NACI. Similarly, provinces or territories could research a novel vaccine schedule. Then, once the data are assessed, the NACI would be able to recommend the best schedule across the country.
The most often cited objections to a harmonized schedule are that health is a provincial and territorial responsibility; harmonization might lead to a decrease in immunization rates as the change is underway; and so much work would be needed to change this that it is not worth it.
Although provinces and territories may have the right to determine their own vaccine schedules, this does not impede them from implementing a national harmonized schedule that reduces confusion and offers equal protection to all children and youth no matter where they live in Canada. In fact, the British North America Act actually does not cover immunization health services, focusing instead on institutions: “The Establishment, Maintenance, and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals” . Therefore, the responsibility concern is not a valid objection. While work and money would indeed be needed to minimize missed immunizations during the shift to a harmonized schedule, this is a feeble argument given the current equitable access problem and the system safety risks.
For many, a harmonized schedule is one of the dreams yet to be realized under the National Immunization Strategy of 2003 . However, it is neither too late nor too daunting a task. Targeted federal monies for the National Immunization Strategy, with a harmonized schedule based on NACI recommendations and a national immunization registry could reap many benefits for children and youth across this country. Continuing our disharmonious pathways only compounds the costs, and leaves many of our children and youth at unnecessary risk. The time has come for Canada to grow up and join the other developed nations with a uniform national immunization schedule across the country.
Members: Robert Bortolussi MD (Chair); Jane Finlay MD; Jane C McDonald MD; Heather Onyett MD; Joan L Robinson MD; Élisabeth Rousseau-Harsany MD (Board Representative)
Liaisons: Upton D Allen MD, Canadian Pediatric AIDS Research Group; Charles PS Hui MD, Canadian Paediatric Society Liaison to Health Canada, Committee to Advise on Tropical Medicine and Travel; Nicole Le Saux MD, Canadian Immunization Monitoring Program, ACTive; Larry Pickering MD, American Academy of Pediatrics; Marina I Salvadori MD, Canadian Paediatric Society Liaison to Health Canada, National Advisory Committee on Immunization
Consultants: James Kellner MD; Noni E MacDonald MD; Dorothy L Moore MD
Principal authors: Robert Bortolussi MD; Noni E MacDonald MD
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.