‘It’s not just a minor rash’: Expert says vaccine coverage rates in Toronto schools need to be higher
In this Sept. 8, 2015 file photo, a reluctant student is pulled into the first day of kindergarten at an elementary School in Clio, Mich. (Christian Randolph/The Flint Journal via AP, File)
More than 300 schools in Toronto have immunization coverage rates for the vaccine that helps prevent tetanus and polio that are below the level recommended by Toronto Public Health, according to city data from the 2017-2018 school year.
In four of the schools, less than half the students have been vaccinated.
The data, which was released in early May by Toronto Public Health, analyzes the immunization records of students between the ages of seven and 17 at 808 schools for two types of vaccines—the vaccine that helps prevent diphtheria, tetanus and polio (DTP) and the vaccine that protects against measles, mumps, and rubella (MMR).
According to the data, the average immunization coverage rate for DTP is about 87 per cent, leaving a little more than 10 per cent of Toronto students within that age group who are either not fully vaccinated or have records that may be out of date.
Immunization coverage rates are slightly better for the measles, averaging about 92 per cent.
Dr. Vinita Dubey, associate medical officer of health, said that the public health agency aims to get an immunization coverage rate of near 90 per cent or more in all schools.
“These rates are close to or more than 90 per cent in a school setting, which is good,” she said. “It means there is good herd immunity in schools, so if a case of measles were to come to a school, the large proportion of students would be protected and act like a “wall” to keep the measles virus from spreading in a school setting.”
But according to Dr. Vivien Brown, chair of Immunize Canada, a national coalition dedicated to promoting the understanding and use of vaccines, the immunization coverage rate should be higher.
“Ideally, we would like those numbers to be higher, we would like them to be over 95 per cent,” said Brown.
Brown said that if someone contracts the measles and enters a room, the virus remains there for two hours in that airspace. About 90 per cent of people in that space will get sick if they are not vaccinated.
“These are well-known, well understandable vaccines that prevent major illness,” Brown said. “Sometimes coverage rates are because people didn’t understand or kids were away when things were given in school or oversight, but the bottom line is that we need to be more vigilant.”
A little more than 140 schools in the city have recorded immunization coverage rates for the MMR vaccine that are below the level recommended by Toronto Public Health. Two schools have immunization coverage rates less than 60 per cent, while none are below 50 per cent.
About seven per cent of students have either not been fully immunized with the MMR vaccine or do not have current records.
DTP requires boosters in teen years
Dubey attributes the difference between the immunization coverage rates for DTP and MMR to the number of shots required to be fully protected from the illnesses.
The measles vaccine requires two doses, one given typically at the age of one and then another anywhere between the ages of four and six.
The vaccine for DTP, however, requires numerous doses between two and 18 months, and then an additional booster dose between the ages of four to six years.
Another booster shot is then required 10 years later.
“Often adolescents are not always up-to-date with their teen booster, which is why the rates in adolescents can be lower for these antigens,” Dubey said.
It is also a challenge for recent immigrants, who may be behind on their vaccinations.
“For students who are newcomers, they may have to catch up their vaccinations and it can take many months to get all the doses,” Dubey says.
“Since student enrollment in Toronto is fluid, there are always new students who come to the city in the middle of the year who may be fully vaccinated, but have not provided records to us just yet.”
Record-keeping is one of the biggest challenges for newcomers, Brown said, and many families may not know what vaccines they have. But Brown also said that recent immigrants are often the most eager to get up to date with their shots.
“Often the people who are most anxious to be vaccinated are from other countries because they have seen the devastation these viruses can have,” she said.
“The average Canadian probably hasn’t seen a case of measles. They don’t fear it the way our parents and grandparents have.”
More than 11,000 students were suspended in 2017-2018 for out of date records
The immunization coverage rate may also be skewed by out-of-date records, Dubey said.
Every year, Toronto Public Health assesses student immunization records and issues suspension orders in cases where records have not been provided.
For the 2017-2018 year, TPH assessed students between Grades 2 and Grades 4, as well high school students from 729 schools for up-to-date immunization records. Parents who were unable to provide up-to-date records were issued a number of warning letters prior to a suspension order.
According to Dubey, about seven per cent of students—11,415—were suspended on the first day.
“Most of the suspensions resolved in one to three days,” Dubey said. “Those who are still outstanding after the assessment process either still require additional vaccines, eg. 1 to 6 months following a previous dose, or they may be new to the school system and have not been assessed.”
Toronto Public Health says that one of the biggest challenges with immunization rates is administrative and that there is no streamline process for the agency to receive records from doctors.
When a doctor or nurse gives a child a shot, the record of the vaccination remains in the clinic and on the parent’s yellow card.
“Having an electronic means to receive the immunization reports directly would assist a lot,” Dubey said.
TPH has already begun the process of moving towards electronic reporting through Immunization Connect Ontario (ICON). The platform allows parents to attach a copy of their child’s immunization record for easy access by health agencies.
TPH says that 1.7 per cent of students are not immunized for religious reasons
The exemption rate reflects students who have a philosophical or religious exemption to vaccination, Dubey said.
In order to be granted a religious exemption, parents and guardians must submit a medical exemption form or a “Statement of Conscious or Religious Belief.”
Parents must also attend an immunization education session facilitated by the city.
Dubey says the reasons why a parent has not chosen to vaccinate their children are “complex” and could include “inconvenience in accessing vaccines, lack of confidence about their safety and/or effectiveness and misinformation that is available on social media and the Internet, including false concern about side effects and ingredients.”
In April, a motion was adopted at the city’s Board of Health addressing vaccine hesitancy. It asked that the Medical Officer of Health investigate “the potential to restrict misleading advertising regarding vaccinations on City-owned land and infrastructure.”
At the same time, Brown says the number of people who choose to deliberately not vaccinate their children is very small.
“I think we have some people who are uncertain and want to talk to their physician about it and that’s fine, people who have missed vaccination for one reason or another.”
How does Toronto compare to nationally recommended levels?
The goal of Toronto Public Health is to reach immunization coverage rates that are close to the national vaccination goals put forward by Canada Public Health.
By the year 2025, the national public health agency hopes to have 95 per cent of children vaccinated for both DTP and MMR. By the age of 17, Canada Public Health hopes that 90 per cent of adolescents have had their teen boosters for DTP.
According to the 2015 National Immunization Coverage Survey, about 89 per cent of children in Canada have been vaccinated for MMR and about 77 per cent for the first four doses of DTP.
The measles is not just a rash
Brown says that ensuring children are properly vaccinated will prevent serious, debilitating health issues.
“As a family doctor I have seen the devastation that vaccine-preventable illnesses can cause,” she said.
Common consequences of the measles can result in ear infections and diarrhea. According to the Center for Disease Prevention and Control (CDC), one out of 20 children who contract the measles gets pneumonia.
One of 1,000 children with the measles will develop encephalitis—swelling of the brain—that can lead to convulsions, deafness, and intellectual disabilities.
The CDC says that one to three of every 1,000 children who contract the measles will die from these respiratory or neurological complications.
“It’s not just a minor rash,” Brown said. “It’s so important that the community is well immunized so we don’t see measles virus generally in the community."
There have been five confirmed cases of the measles in Toronto this year.