THE POWER OF PARTNERSHIPS
The spirit of partnership was in the air (and quite contagious, in fact) from the moment that the 1998 Canadian National Immunization Conference: Partnerships for Health Through Immunization, Calgary, Alberta, December 6 to 9, 1998, began. Organizing Committee Chair Dr Philippe Duclos said that the success of the event would be measured by the new partnerships and ongoing collaborations that it inspired. Dr Emmett Francoeur, President of the Canadian Paediatric Society, stressed that collaboration among health advocates is the only way to achieve the goals of excellence in immunization research and effective immunization programs.
A practical example of the power of partnerships came from Rotary International, which has played a central role in supporting the international goal of eradicating polio by 2000. When Rotary first put forward the idea of a global polio campaign, the World Health Organization estimated that more than $100 million would be needed to accomplish the goal. Rotary set a one-year goal of $120 million, trained a team of 3500 volunteer fundraisers and collected a total of $247 million.
COOPERATION AND COORDINATION WITHIN CANADA
There were strong signs during the conference that Canadian public health systems are working together more effectively. The results of the recent consensus conference on a national network of immunization registries set the stage for further developmental work, although the need to identify sufficient funding was abundantly clear.
Not all national immunization goals have been adopted or adopted uniformly by all provinces and territories. But on the positive side, the acellular pertussis vaccination initiative was adopted by all provinces and territories within one year compared with a six-year period for the adolescent hepatitis B program. In 1995, a timely response with vaccine also stalled an outbreak of 2400 measles cases that it was estimated would have touched 20,000 Canadians in 1996.
ADEQUACY OF RESOURCES
With an unprecedented variety of new opportunities on the horizon, the public health community finds itself with limited resources to fulfill its responsibilities. This suggests a need for stronger advocacy to reiterate the case that immunization is the single most cost effective use of health care dollars. With one new vaccine expected to enter the market each year for the next decade, now is the time to capture the attention of health policy-makers and lay the groundwork for a long term increase in funding.
PUBLIC AND PROFESSIONAL EDUCATION: THE CHALLENGE OF COMPLACENCY
In the effort to educate the public about the benefits of immunization, the public health community must learn to cope with its own success. The epidemics of debilitating or deadly disease that gave impetus to the development of the first vaccines are now a fading memory in the industrialized world – for the public and younger generations of health professionals. The benefits of immunization are now taken for granted, to the extent that many parents have no idea whether their children’s shots are up to date (or even where a record of immunizations might be found) and indeed, medical officers are aware of the situation! Parents are taking immunization for granted. One forgets why immunizations are important, just that it is part of baby care.
| Voices from the floor: Comments from the third National Conference on Immunization |
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| “Living with post polio syndrome means never, ever forgetting the value of universal immunization...This conference has heard about younger health professionals who may never have seen a case of measles, polio, or diphtheria. Our daily experience tells us that these practitioners are in definite need of a history lesson.” Calgary, Alberta |
| “Take the time to understand the communities you are working for. Discover what is appropriate...When you arrive in a place, you have to ask questions.” Norway House, Manitoba |
| “Street youth have a 13 times higher mortality rate than other youth in Quebec, and they die from preventable diseases and circumstances.” Montreal, Quebec |
| “As a family physician, I know there are also problems in our older age groups...If we’re going to deliver meaningful care to Canadians, [we have to understand] the bulk of Canadians aren’t kids.” Toronto, Ontario |
| “Immunize according to risk, not according to country visited.” Toronto, Ontario |
| ‘We’re seeing a slight increase in immunization refusals, and we need to educate staff to answer people’s questions before it gets too far ahead of us.” Lethbridge, Alberta |
| “Despite their huge net benefit in mortality and morbidity, vaccines come with a price, and that price is a certain incidence and frequency of adverse events.” Toronto, Ontario |
| “Ultimately, being honest about the uncertainties of vaccination will contribute to risk communications to ensure the public health.” Atlanta, Georgia |
Panelists suggested a variety of mechanisms for reaching the public. Family practitioners see 80% of the population at least once a year and, therefore, have an continuing opportunity to make the case for immunization. There is also an educational value in immunizing students when they enter postsecondary health care programs. Increasing students’ awareness of the importance of immunization will raise their own vaccination levels, while encouraging them to emphasize immunization with their future patients. More broadly, health professionals who vaccinate must maintain their level of competence through self-directed learning and other means to keep track of continuous change in the immunization field.
COUNTERING MISINFORMATION
There was little doubt about the importance of a continuing, worldwide effort to counter unsubstantiated, sensationalized attacks on immunization in the commercial media and on the Internet.
On the second morning of the conference, Dr Alan Hinman of the United States Task Force for Child Survival, grouped opponents of immunization into several categories. Only a small proportion ignore all evidence suggesting the value of immunization. Good information and education are often sufficient to address ignorance, fear or concerns about possible contraindications. As well, public health workers have demonstrated their ability to work effectively with communities that have religious or philosophical objections to immunization. Dr Hinman recalled that 75% of Amish children were immunized during the last American polio outbreak in 1979 – not because their parents had abandoned their view that illness is God’s will, but because they were willing to accept an intervention that would keep their community strong.
Misinformed objections are a different story. Dr Hinman was one of several panelists who cited hugely inflammatory messages from anti-immunization websites, such as one that included a graphic of an impossibly long needle and another site that displayed a photo of a syringe superimposed on a baby’s face. He noted that commercial media “thrive on controversy and tend to provide equal time to both sides”, even when minority opinion on one side runs counter to “the vast majority of the public and the medical profession”.
Rather than debating anti-immunization groups head-on, the public health community should focus its attention on communicating with the public, answering questions forthrightly, and openly acknowledging the uncertainties and imperfections that represent the limits of vaccine safety and efficacy. One part of the solution is to explain the difference between a temporal association and causality; infant fevers and the emergence of underlying seizure disorders are often incorrectly attributed to vaccinations simply because young children are vaccinated during the period in their lives when many illnesses first occur.
HARD-TO-REACH POPULATIONS
Hard-to-reach populations include immigrants and refugees, lesbians and gay men, street youth, First Nations, and remote communities, among others. Time, patience and sensitivity are the key ingredients for practitioners who hope to have a positive impact on immunization rates in an unfamiliar culture or setting.
The information and logistical needs of specific population groups are as diverse as the groups themselves. In Canada’s Northwest Territories, key issues are climate, geography and culture; trips can be delayed by extreme weather, vaccines occasionally freeze on the tarmac and immunization schedules must dovetail with traditional lifestyles that include two- to three-month periods when families go out on the land. For street youth, the best outreach techniques are those that engage patients in their own health care, incorporate follow-up methods that are compatible with street life and deliver key information to audience segments that need it.
ADOLESCENTS AND ADULTS
Societal changes continue to have a significant impact on immunization efforts. As the majority of Canadians move into their middle years and a whole new generation of vaccines becomes available, more emphasis will have to be placed on the idea than immunization is a life-long process. Many adults are unknowingly at risk if they fail to keep their vaccinations up to date. Adult immunization also protects children from diseases such as pertussis. While it is commonly accepted that adults contract pertussis from their school-age children, parents can also transmit the disease to their infants who then suffer the greatest harm.
INTERNATIONAL IMMUNIZATION ISSUES
Improved global communication and more frequent world travel have shifted the focus of immunization practice in two ways. Initiatives such as Rotary International’s Polio Plus Program demonstrate a sense of responsibility to all the world’s citizens, expressed as a commitment to eradicate vaccine-preventable diseases wherever they occur. On a more pragmatic level, a shrinking global village means that any country may be vulnerable to outbreaks of disease due to failed immunization efforts in other parts of the world.
Specific challenges arise from immigrants and refugees who legally enter Canada (in 1997 they numbered some 215,000 from 201 countries). Many of these people are underimmunized due to limited World Health Organization vaccination schedules, the questionable quality of some vaccines used in developing countries and the unknown durability of antibodies in people with borderline nutrition or compromised immune systems. The problem may be compounded in Canada by the low profile of adult immunization, immigrants’ and refugees’ ineligibility for health coverage during their first three months in the country, and a lack of monitoring.
SELECTED RECOMMENDATIONS FROM THE CONFERENCE
By far, the strongest recommendation to emerge was support for the formation of a national immunization registry network. This will require adequate funds, federal, provincial and local cooperation and participation, reliable mechanisms for respecting privacy, and clear timelines and objectives. The payoffs that support optimizing immunization coverage are enormous.
- Increased immunization education is required for health care workers, health care students and the general public, including students outside the health professions. Educational efforts should focus on benefits, risks, indicators, optimal delivery methods and evaluations.
- — Medical and nursing schools should be surveyed in relation to the quality, quantity and timing of their immunization curriculum.
- — Hospital accreditation, licensing examinations and peer review processes should be reviewed in relation to their coverage of immunization issues and opportunities.
The next immunization conference should be built around the theme of education and training, and should include a session that offers media training to participants.
- Concerned health professionals who work with First Nations communities expressed support for the National Vaccine Advisory Committee’s work to improve immunization rates among First Nations peoples. To sustain these efforts, the following elements must be incorporated into this national health strategy.
- — Resources: Adequate, protected funding for immunization programs under the envelope system in First Nations communities
- — Advocacy and lobbying: Inclusion of local, provincial and national leadership in promoting immunization within the First Nations population
- — Partnerships: Efforts on the part of provincial and federal governments to strengthen their communication links and commitments to First Nations
The next Canadian National Immunization Conference should include a session where First Nations can discuss specific issues.
Broader partnerships will play an important role in addressing immunization needs and countering barriers to immunization among hard-to-reach populations. New programs must be designed to accommodate the fears, needs, beliefs, values and community strengths in specific population groups (First Nations, remote populations, street youth, new Canadians and immunization refusers).
A permanent committee should be established to detect and react immediately to antivaccine allegations.
Physicians and nurses should be encouraged to work together more effectively in support of Canada’s immunization goals.
Recognizing that what gets measured gets done, immunization coverage at the local and clinic level should be assessed more thoroughly to provide a basis to provide feedback and to make tools to popularize vaccination available on the front lines.
Financial barriers must be removed to ensure universal access to free vaccine in support of the recommended schedule for children and adults. Access barriers for hard-to-reach populations, such as new Canadians and street youth, must be minimized.
Health professionals must receive fair remuneration when they immunize their patients.
The CPS and Health Canada should develop video materials to remind people of what vaccine-preventable diseases look like.