Item - 2012.HL10.4

Publicly funded immunization programs have significantly improved the health of children in Toronto. High immunization coverage rates are necessary to ensure that these health benefits continue by maintaining herd immunity, a level of protection in a community that prevents dangerous diseases such as measles and mumps from circulating in Toronto. Toronto Public Health (TPH) uses a number of strategies to maintain high immunization rates in Toronto including collecting and assessing immunization records for the immunizations mandated under Ontario's Immunization of School Pupils Act (ISPA) (measles, mumps, rubella, tetanus, diphtheria and polio), providing immunizations directly to school students and ensuring that all parents/guardians are provided with clear information about the benefits of immunizing their children and the immunization requirements for school attendance.

A previous report by TPH showed that City neighbourhoods with a larger proportion of people living with a low income had higher rates of disease and greater risk for poor health. Using this same methodology, TPH investigated whether student immunizations follow the same pattern, lower in areas of the City with a higher proportion of low income residents and higher in more affluent areas. Low immunization coverage rates put children at risk of preventable infectious diseases such as measles, which periodically are imported into Toronto through travel and immigration. Inequalities in immunization coverage rates would be a signal that TPH and other health sector organizations may need to refocus immunization programs and services to ensure equitable access to immunizations for all children in Toronto.

Using records gathered during the 2010-2011 school year, immunization coverage rates for children living in areas with different income levels were compared. Income was measured by the proportion of households with income below the Statistics Canada low income cut-off level (LICO). Comparisons showed that more children living in areas with lower income (higher proportion of households below the LICO) had incomplete immunization records at the beginning of the school year. This is the best indicator that TPH has that a child is not completely immunized with all of the mandatory immunizations required for school attendance. As the proportion of residents in a neighbourhood living below the LICO decreased, the proportion of students with up-to-date immunization records increased, although the differences in immunization coverage rates between the areas were not statistically significant.

After TPH sent reminders to parents of the immunization requirements for school attendance and followed up with suspension of a small proportion of Toronto students still lacking a complete record as per the ISPA, the relationship between income level and immunization coverage disappeared and virtually all school children's records were up to date for the mandated vaccines. The process of informing parents of gaps in their child's immunizations coupled with the possibility of suspension from school was successful at achieving almost complete uptake of the six mandatory vaccines.

The ISPA has been successful in ensuring very high immunization coverage rates for the six vaccines it mandates, however these six now form only a fraction of all those offered to Ontario children through the publicly funded immunization program. Since 2004, immunizations against chickenpox, invasive pneumococcal disease, meningitis, whooping cough (pertussis) for adolescents and adults, rotavirus and human papilloma virus (HPV) have all been added to Ontario's publicly funded immunization schedule. Some of these immunizations are offered through health care providers, and TPH offers HPV immunization to grade 8 girls and meningitis and hepatitis B immunizations to all grade 7 students through school-based clinics.

These additional publicly funded immunizations are voluntary and not included in the ISPA. So, while TPH can collect information from parents about their child's vaccine status, students cannot be suspended for not receiving these immunizations. Experience has shown that the reminders and suspensions linked to enforcement of the ISPA leads to higher immunization coverage rates when compared to vaccines that are offered in school-based clinics but are voluntary. This growing gap between the number of immunizations contained in the ISPA and those offered through the publicly funded immunization program also means that TPH records are less complete. Records are received for all immunizations but are most accurate and complete for the mandated vaccines because the potential for suspension leads to a higher response rate to requests for information sent to parents.

TPH is also mandated to collect and assess immunization information for children attending licensed day nurseries in Toronto. This is not being done due to a lack of resources. A more comprehensive approach to the collection of immunization information directly from health care providers would be more effective at building a complete picture of the immunization status of Toronto children.