It’s time to catch up on routine immunizations

Vaccination is widely credited to Edward Jenner; the familiar tale of using fluid from a milkmaid’s cowpox blister to induce a boy’s immunity against smallpox marked the onset of an era of undeniable success against childhood enemies such as polio, diphtheria, pertussis, and measles. This resounding public health success has in some ways contributed to paradoxical complacency about vaccine-preventable diseases and vaccine hesitancy, as many young parents have no historical memory of the diseases that were real dangers to previous generations. In fact, only 69% of 7-year-olds in BC were up-to-date with routine immunizations in 2019 and 2020.[1]

COVID-19 has resulted in further decreases in immunization rates. This decline is particularly problematic in school-age children, youth, and adults. There are multiple causes, including reduction of in-person physician office visits, physical-distancing measures, reassignment of public health nurses, delays and changes in vaccine distribution, deferral of vaccines administered in the school setting, and public perception that routine immunizations are less important during a pandemic.

In 2019, the human papillomavirus immunization rate in grade 6 girls in BC was 66.1%; this rate dropped to 28.1% in 2020. The rates were similar for grade 6 boys. Hepatitis B immunization coverage dropped below 90% provincially in 2020 for the first time in 7 years. In contrast, grade 9 pertussis immunization rates were unchanged in 2020 because the booster dose was administered early in the school year.[1] Alberta saw a 5% drop in measles immunization rates persisting into 2021.[2] Worldwide, UNICEF estimates that 23 million children missed routine vaccines in 2020 and 17 million probably did not receive even one immunization.[3] As a consequence, we are at risk of pertussis, measles, and polio outbreaks.

The current crisis in primary care with accompanying lack of access to preventive care has the potential to exacerbate decreasing immunization rates. Patients’ most trusted source of immunization information is their physician. Without a primary care provider who has the opportunity to identify gaps, counsel, and recommend non–publicly funded vaccines, our patients may not have optimal vaccine health.

Additionally, Indigenous people, including First Nations, Inuit, and Métis, are at an even higher risk of reduced immunization rates and vaccine-preventable diseases due to vaccine hesitancy, a direct result of colonization and mistrust in a historical system that inflicted medical experimentation, abuse, and exclusion. Social and economic disparity and lack of access to primary care have also led to inequitable access and compounded trust issues.

When vaccinations are delayed, there is a lessened likelihood of subsequent catch-up. A multipronged approach to immunization catch-up in children, youth, and adults is required:

• Active measures by public health and health authorities to communicate with the public and expansion of immunization clinic hours and locations.
• Public service messaging in mainstream media and on social media.
• A uniform provincial vaccine registry that can be easily accessed and downloaded by physician office EMRs, health authority and hospital EMRs, and residential care facilities.
• Continued striving to decolonize medical care and restore the trust of Indigenous people in the medical system using culturally safe resources (e.g., https://boldly.cma.ca/blog/knowledge-is-medicine-indigenous-health-care-experts-tackle-community-covid-19-vaccine-hesitancy-2).
• Investment in the development of EMRs with smart technology to highlight vaccine opportunities in special populations.
• A national vaccine registry.
• Physicians asking and advising at routine medical appointments.
• Practice support, including support for team-based care, so that family practice clinics can provide additional clinic hours and appointments for immunizations alone.
• Increased capacity for pharmacists to administer vaccines.

To close the gaps in vaccine coverage and optimize population vaccine health, effective strategizing requires recognition of the difference between lack of vaccine access and lack of uptake. Since vaccines were first developed, vaccine hesitancy and disparity have existed alongside them. Against a background of inequalities in the distribution of material goods, we have economic and social inequalities, mistrust, and a sense of personal autonomy—all factors that must inform our public health strategies and individual practices to achieve optimal health for all. Capitalizing on the increased vaccine literacy created by the COVID-19 pandemic is an opportunity that must be seized.
—Jennifer Balfour, MD, FRCPC
—Aven Poynter, MD, FRCPC
Members, Council on Health Promotion

hidden

This article is the opinion of the authors and not necessarily the Council on Health Promotion or Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    BC Centre for Disease Control. Immunization coverage reports. Accessed 26 July 2022. www.bccdc.ca/health-professionals/data-reports/immunizations.

2.    MacDonald SE, Paudel YR, Kiely M, et al. on behalf of the COVImm study team. Impact of the COVID-19 pandemic on vaccine coverage for early childhood vaccines in Alberta, Canada: A population-based retrospective cohort study. BMJ Open 2022;12:e055968.

3.    UNICEF. COVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows. Accessed 26 July 2022. www.unicef.org/press-releases/covid-19-pandemic-leads-major-backsliding-childhood-vaccinations-new-who-unicef-data.