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Institute of Population and Public Health (IPPH) on a National Immunization Strategy "Vaccines are probably the single most important public health intervention that's provided to Canada through its public health system. That said, I think one of the main advantages of a national immunization strategy is an ability to set a national standard and to make vaccines available as an essential public health service. This is a really interesting area, I think, where the primary science that results in discovery and innovation is generated by scientists who are most often represented within III, and where the evaluation and assessment of the health impacts of these vaccines are most often done by scientists who are represented in IPPH." Dr. Robert Brunham, member of the IPPH Institute Advisory Board, is Director of the University of British Columbia Centre for Disease Control (UBC CDC), and Medical Director of the British Columbia Centre for Disease Control Society (BCCDC). He is a member of the III Immunization Awareness Working Group. |
A point many pediatricians and public health experts have been making for years was reiterated in the November 2002 report of the Commission on the Future of Health Care in Canada headed by Roy Romanow. "Immunization is one of the most effective illness prevention strategies," began the section focused on a national immunization strategy.
Dr. Joanne Embree, head of the Department of Medical Microbiology at the University of Manitoba, caught Romanow's ear when he came through Winnipeg in November 2002. As chair of the Canadian Paediatric Society's Infectious Disease and Immunization Committee, she is a strong advocate for a national immunization strategy. She was referenced in the final report, and immunization went on to appear in the 2003 federal budget. "We're happy that immunization was mentioned. And that's the first time it has been," she says.
Embree says the introduction of new vaccines has brought the lack of vaccine coordination across the country to a head, giving as an example the meningococcal meningitis vaccine which was approved in Canada in 2001. In Quebec, it's covered by the province. In Ontario, it's not-unless your child has HIV-costing parents $100 per dose. "I do see the complications of the diseases that ...the new vaccines are designed to prevent," says Embree. "I'm the one that sits in the ICU with parents whose children have meningococcal meningitis.and now that we have vaccines that can prevent that, I'd prefer not to do that anymore."
Leaving the choice up to individual provinces results in business decisions being made. Embree says that up to this point, provinces have been able to weigh the cost of the vaccines versus the cost of the illnesses and see savings. But the new vaccines are expensive, and at best, cost-neutral.
She also points out that the negotiating power of the country as a whole is much stronger in terms of netting large amounts of vaccine at a reasonable price. Large provinces can pay less per dose because they purchase large quantities. For disease threats like pandemic flu or smallpox, it's an important point.
Embree laughs describing the process behind development of a national strategy. "What you end up needing to do is get all 10 provinces, three territories and the federal government to agree on something." Not always an easy task. "But having said that, everybody agrees on the principles, we've gotten that across."
The success of vaccination programs depends on much more than Health Canada licensing. Vaccines for polio, pertussis, measles, and mumps are common fare. But in each province, the schedule by which vaccines for childhood diseases are administered varies, meaning that children moving into a new province could miss some vaccinations and have to pay for others.
Meanwhile, the success of these vaccines in preventing disease is undercutting their effectiveness. Parents who can't remember ever having seen a case of measles in the current generation focus on the side effects of the vaccines themselves, causing some parents to refrain altogether from vaccinating their children. How many parents do it? No one knows. "Because we don't have an immunization registry, we do not actually know who gets vaccinated in this country," says Embree, raising another reason for a national strategy.
She points out that for vaccines to control certain illnesses, coverage of at least 95% of the population is necessary. "We can't tell you what the measles vaccination rates have been with all the issues about MMR and autism.it'll be awhile until we find out whether our immunization rates have gone down to such an extent that we have a population that's in danger."
The MMR (measles-mumps-rubella) - autism link Embree alludes to is another issue sowing doubt as to the safety of vaccines. In England, 12 vaccinated, autistic children with gastrointestinal problems were treated at the same clinic. Doctors at that clinic published the hypothesis that the MMR vaccine caused the bowel problems, which in turn caused the autism. However, a British study of autistic children from the late 1970s to 1992 did not find a surge in autism when the MMR vaccine was introduced in 1998. Nor have additional studies unearthed a connection.
Embree lists immunization research issues not currently being addressed in Canada. She says good epidemiological data is required for pediatricians to decide which vaccines should be offered to children. "You also need to look at why some children respond well to the vaccine, whereas other children don't," she says, pointing out that manufacturers don't typically perform that kind of research. "We need to have a way of answering those other important medical questions for which there isn't an economic driving factor." There is also a raft of special populations with unique immunization issues, such as immunosuppressed individuals, refugees, pregnant mothers, and aboriginal populations.
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5 key components of a National Immunization Strategy
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The drive for a National Immunization Strategy (NIS) began in 2000, and Dr. Arlene King, Director of the Immunization and Respiratory Infections Division at Health Canada, says "I've been there from Day One." Co-directed by King and Dr. Greg Hammond (Director, Public Health Branch, Manitoba Health), the strategy was born of growing concerns about procurement issues, public ambivalence about vaccine safety, and, as King says, "a sort of complacency around vaccination, i.e. the diseases are out of sight and out of mind." It has evolved into five key components (see sidebar) which rest on a foundation of cross-cutting themes. King lists these as communication, professional education, vaccine-preventable disease surveillance, special populations, and research.
Described by King as an intergovernmental initiative, the strategy came to encompass these priorities through collaboration with the provinces and territories, and key stakeholders in each area. King says that investment contributed to an allocation of $45 million over five years in the 2003 federal budget to assist in the pursuit of a national immunization strategy (NIS) with the objective of improving access to recommended vaccines, thereby reducing the incidence of vaccine-preventable diseases. The federal investment will "really enable us to build the infrastructure and foundation upon which we can move forward," she says.
As stated in the budget, a national strategy will result in improved safety and effectiveness of vaccines, enhanced coordination and efficiency of immunization procurement, and better information on immunization coverage rates within Canada. The NIS would operate closely with the Health Canada National Advisory Committee on Immunization (NACI), of which King is Executive Secretary and Embree is a member, and incorporate feedback from consensus conferences and working groups.
Research will be fundamental to many aspects of the NIS, King points out, making CIHR a key player. Work is proceeding apace on a national immunization research agenda.
King says the federal budget commitment was a good sign. "Clearly there was a recognized need to invest in immunization and the way of the future - prevention and control of many infectious diseases."
