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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2022 Jan 13;113(3):422–432. doi: 10.17269/s41997-021-00578-5

An equity-based assessment of immunization-related responses in urban Alberta during the 2014 measles outbreak: a comparative analysis between Calgary and Edmonton

Thilina Bandara 1,✉, Cory Neudorf 1, Nazeem Muhajarine 1
PMCID: PMC9043142  PMID: 35025101

Abstract

Objectives

This study investigates measles, mumps, and rubella (MMR) immunization rates during the measles outbreak in Calgary and Edmonton of 2014 stratified by four area-level socio-demographic indicators. This study also leverages this epidemiological data to assess the equity aspect of emergency measures instituted regarding immunization in those two cities.

Methods

A mixed-methods comparative case study analysis methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada. The epidemiological one-dose by age-2 MMR coverage data were stratified using four socio-demographic indicators: median household income, %-homeownership, %-Aboriginal population, and %-immigrant population. Document and content analysis was utilized to investigate the outbreak mitigation strategies deployed in each city.

Results

The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions in which Calgary deployed three mass immunization clinics in 2014, where Edmonton did not. The Calgary coverage data showed an increase in coverage inequalities across all indicators and the Edmonton data showed mixed results in terms of equity gains/losses. Calgary’s additive intervention of three mass immunization clinics in 2014 appears to have contributed to both the higher gross immunization rates in Calgary (90.77%) and an inequitable increase in coverage rates as compared with Edmonton (88.96%), in most cases.

Conclusion

Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.

Keywords: Health equity, Immunizations, Cities, Urban health, Pandemic response

Introduction

Immunization programs are highly effective in reducing the impact of infectious diseases and immunization coverage rates serve as a useful proxy for evaluating this important public health service. Ensuring that immunization services reach populations equitably helps mitigate risks of morbidity and mortality for vulnerable populations who are more likely to be exposed to pathogens, bear greater negative consequences, and are less likely to have access to preventive services than privileged populations (Brearley et al., 2013; Walker et al., 2014). For example, in Ontario, Wilson et al. (2019) demonstrated that material deprivation—which is an index that takes many factors into account, including housing status and income—was associated with childhood vaccine-preventable rotavirus hospitalizations before the rotavirus immunization program was implemented and eliminated this disparity. Immunization equity is especially salient when an outbreak occurs, as clusters of persistent vulnerability amid an active spread of pathogens may result in deadly health outcomes among already materially and socially deprived populations.

After a measles outbreak was declared in the rural parts of the province of Alberta, Canada, in late 2013, an outbreak was declared in Alberta’s two largest cities, Calgary (1.266 million in 2014) and Edmonton (928,182 in 2014) in April 2014 after nine confirmed cases in Calgary and seven cases in Edmonton. This study assesses the measles, mumps, and rubella (MMR) coverage rate changes that occurred as a result of the outbreak mitigation measures pertaining to immunizations implemented in these two cities, from an equity perspective. Specifically, this study investigates one-dose by age-2 MMR immunization rates stratified by four neighbourhood-level socio-demographic indicators: median household income, %-Aboriginal population, %-immigrant population, and %-homeownership, during the measles outbreak in Calgary and Edmonton of 2014. This study also leverages these epidemiological data to assess the equity aspect of emergency immunization measures instituted in those two cities.

These social determinants of health indicators were chosen for this study because they have consistently been shown to be associated with immunization status in Canada (Gilbert et al., 2017), the United States (Glatman-Freedman & Nichols, 2012), Australia (McIntyre & Menzies, 2005), and Europe (Vanbiervliet et al., 2014). Low income is often associated with poor outcomes across a multitude of indicators in Canada (Public Health Agency of Canada, 2018), also specifically, low immunization coverage rates in Alberta and Saskatchewan (Alberta Health, 2007; Sundquist et al., 2011; Cushon et al., 2012; Avis et al., 2007), where access to preventive health care services may be lower due to economic factors. Nationally, poor health outcomes are also disproportionately reported in areas with higher proportions of Indigenous populations. This is consistently shown across many health outcomes in Canada (Public Health Agency of Canada, 2018; UNICEF, 2009), and has been previously demonstrated specifically in Saskatoon and in Manitoba with regard to childhood immunization coverage (Lemstra et al., 2007; National Collaborating Centre for Determinants of Health, 2018). Indigenous health inequalities are associated with historical and continuing destabilization of Indigenous culture, and experiences of racism in Canadian life, including within the health system (Public Health Agency of Canada, 2018).

Immigrant populations require specialized public health programming strategies due to some unique concerns among these populations (Public Health Agency of Canada, 2011). Some immigrant populations have religious objections to immunization, as was the case with the Dutch-born populations who were associated with the 2013/2014 measles outbreak in Southern Alberta; have alternative health beliefs, as was the case with the Hutterite population during that same outbreak (Kulig et al., 2002); or are misinformed due to simple miscommunications between health professionals and immigrant parents (Kowal et al., 2015). Homeownership rate is a relatively under-researched indicator of socio-economic status (SES) with regard to childhood immunization coverage. One study shows that the areas with the lowest area-based rates of homeownership, when included into a model of total deprivation, exhibited the lowest MMR coverage rate areas in England, especially in urban areas (Wright & Polack, 2006).

Methods

A retrospective mixed-methods comparative case study methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada, and to investigate the immunization-focussed outbreak mitigation strategies deployed in each city. A mixed-methods approach was used because evaluation of the outbreak responses requires the integration of quantitative epidemiological and demographic coverage rate data, and the qualitative programmatic and policy-based intervention data. Quantitative data included one-dose by age-2 MMR immunization coverage rates collected from Calgary and Edmonton, by postal code for the years 2013, 2014, and 2015. The geographical areas denoted by postal codes were restricted to those with the first three characters that Canada Post deems within the municipal area (Canada Post, 2014).

Postal code-level one-dose MMR immunization numerators were extracted from the Alberta Health ImmARI immunization registry by analysts at Alberta Health. This registry captured all childhood immunizations during the study period, but all other immunizations were excluded from the extraction for this study. The denominators were extracted from the provincial vital statistics birth registry, where children born two years prior to 2013, 2014, and 2015, in each postal code, were used as the denominator. Coverage rates were calculated by dividing the numerators by the denominators.

These coverage rates by postal code were aggregated up to neighbourhood rates using 2015 neighbourhood boundaries. Publicly available neighbourhood-level after-tax median income, %-homeownership, %-Aboriginal, and %-immigrant population statistics were collected, and neighbourhoods were assigned into quintiles for the indicator (five groups, each representing 20% of the population) for each year. The socio-demographic data were those collected by the municipal governments themselves, from Statistics Canada, derived from the 2011 National Household Survey. Qualitative data describing the outbreak response programs and policies implemented in each case city were extracted from policy-related and media documents published around the time of the outbreak (2013, 2014). Ethics approval for this study was obtained from the University of Saskatchewan and Alberta Health Services.

The neighbourhood-level socio-demographic indicators were linked to neighbourhood-level (i.e., aggregated postal codes into neighbourhood) coverage data. For the years 2013–2015, one-dose by age-2 MMR coverage rate quintiles were constructed based on income such that quintile 1 represents the MMR coverage rates of the 20% of the population who live in neighbourhoods with the lowest after-tax median income and quintile 5 represents the MMR coverage rates of the 20% of the population who live in neighbourhoods with the highest after-tax median income. The same quintile coding system was used for %-Aboriginal, %-immigrant, and %-homeownership. A descriptive analysis was then conducted to explicate the stratified immunization coverage data trends between 2013 and 2014, during an active measles outbreak.

Deductive document content analysis was used to assess the immunization-focussed outbreak mitigation strategies deployed in 2014 in Calgary and Edmonton. Document content analysis is an iterative process of examination and interpretation of textual documents. This analysis is appropriate for detecting specific elements of textual documents for exploratory use, grouping qualitative data into units of analysis (Braun & Clarke 2006). The purpose of using this method in this study was to specifically detect, in often complex multi-subject documents, where and in what manner concepts related to childhood immunization during the 2013/2014 measles outbreak are specifically mentioned in a deductive manner. Documents analysis was conducted on a survey of news stories using Google search engine (n = 6 used in analysis) and public communications by AHS associated with the 2014 measles outbreak in those cities (n = 4 used in analysis) (Table 2). Keywords to collect these documents included the terms “outbreak”, “2014”, “immunization”, “measles”, “Edmonton”, “Calgary”, and “MMR”; and content that involved childhood immunization programming regarding measles during the measles outbreak of 2014 was extracted to create the policy timelines for each city (Table 2).

Table 2.

Timeline of the outbreak and the interventions implemented provincially, in Edmonton and in Calgary, to increase childhood MMR coverage rates during the 2013/2014 measles outbreak

April 29, 2014:
Measles outbreak declared in Calgary, Edmonton, and Central Alberta (Global News, 2014b)
Provincial “baseline” interventions (includes Calgary and Edmonton) Edmonton-specific interventions Calgary-specific interventions

Throughout 2013–2014:

- Measles and immunization-related news reports, communications, and website as a result of 2013 southern measles Alberta outbreak (Kershaw et al., 2015)

April 20, 2014:

- Provided immunizations to children as young as 6 months, rather than the previous 1-year old cut-off for regions experiencing outbreaks (temporary) (AHS, 2014b)

 - No specific Edmonton-only interventions reported

April 30, 2014:

- Three drop-in measles immunization clinics (CTV, 2014b)

- Recommended that while other routine childhood immunization should be sought at community health centres, MMR immunizations be received at the mass immunization clinics (AHS, 2014c)

May 13, 2014:

- Number of mass immunization clinics reduced to two

- Report that “more than 11,500 Calgary Zone residents have been immunized against measles. This includes 90 per cent of the six-month to 11-month-old population” (AHS, 2014a)

May 20, 2014:

- Mass immunization clinics closed; only by-appointment MMR vaccinations continue at community health centres (AHS, 2014a)

July 4, 2014:

- Outbreak declared over in Edmonton Zone (CTV, 2014a)

June 12, 2014:

- Outbreak declared over in Calgary and Central Zone (AHS, 2014b)
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The quantitative and qualitative data were collected independently and then integrated during the analysis phase to construct case studies of both Calgary and Edmonton. The coverage data trends pre-2014 and in 2014 across all stratifiers and the interventions deployed to mitigate the measles outbreak (2014) were compared between Calgary and Edmonton. Coverage data from 2015 are also included to assess the durability of the immunization surge after the outbreak.

Results

The epidemiological trend data suggest that both Edmonton and Calgary experienced higher overall one-dose MMR coverage rates by age 2 as a result of their responses to the measles outbreak in 2014 than in 2013. Calgary shows a more dramatic increase in coverage rates than Edmonton between 2013 (88.68%; 88.09%) and 2014 (90.77%; 88.96%). Coverage rates in both Calgary and Edmonton dropped from 2014 to 2015 (89.15%; 88.58%), but to levels higher than coverage rates in 2013 (88.68%; 88.09%) (Fig. 1 and Table 1).

Fig. 1.

Fig. 1

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One-dose by age-2 MMR immunization coverage rates in Calgary and Edmonton, Alberta, Canada (2013–2015)

Table 1.

Comparisons of overall one-dose by age-2 MMR coverage rates between Calgary and Edmonton, Alberta, Canada (2013–2015)

2013 2014 2015
Total number of children aged 2 with one dose of MMR Total # of 2-year-old children Coverage rate (%) Total number of children aged 2 with one dose of MMR Total # of 2-year-old children Coverage rate (%) Total number of children aged 2 with one dose of MMR Total # of 2-year-old children Coverage rate (%)
Calgary 12,132 13,681 88.68 12,769 14,067 90.77 12,638 14,176 89.15
Edmonton 9057 10,282 88.09 9412 10,580 88.96 9633 10,874 88.58
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Regarding interventions, news organizations reported that the outbreak was uniquely handled in Calgary, as compared with Edmonton. Both cities were subjected to the provincial “baseline” interventions, which included an immunization awareness campaign, and the modifications of the vaccination guidelines that increased eligibility for immunizations (Alberta Health Services, 2014a, b, c). Calgary, however, deployed three drop-in mass immunization clinics in addition to these interventions, where Edmonton did not. While it was reported that Alberta Health Services clinics and health phone lines were being overwhelmed overall across the province, these mass immunization clinics in Calgary were also being inundated with patients, creating “long lines” (CBC, 2014a; Global News, 2014a).

The three mass immunization clinics in Calgary were drop-in clinics, placed in the south central, north east, and central west areas of Calgary. These clinics offered MMR immunizations to the following groups: “Infants six months of age to less than 12 months of age; Children 12 months of age or older who have not yet received their first dose of measles vaccine; Children four years of age and older who have not yet received their second dose of measles vaccine; Individuals born in or after 1970 who have not received two doses of measles vaccine. Health care workers, regardless of year of birth, who are not immune to measles.” These clinics provided mass immunization during the month of May 2014 where Alberta Health Services reports that between April 30 and May 10, “more than 11,500 Calgary Zone residents have been immunized against measles. This includes 90 per cent of the six-month to 11-month-old population.” (Alberta Health Services, 2014a). This report communicates that on May 14th, the number of drop-in clinics was reduced to two, and on May 20th, the clinics became by-appointment only in routine community health centres. The table below depicts the timeline of the outbreak and the interventions implemented provincially, in Edmonton and in Calgary (Table 2).

Mixed equity-related changes in Edmonton

Figure 2 and Table 3 show the changes in coverage rates in Edmonton during the study by quintile for each socio-demographic indicator, with the table focussing on the differences between 2013 and 2014. Of note are both the coverage rate gains and the resultant coverage rates associated with 2014. While the magnitude of the overall coverage gains was lower in Edmonton as compared with Calgary (Fig. 1 and Table 1), the 2014 increase in immunizations in Edmonton did disproportionately benefit the lowest income quintile compared with the highest income quintile and lowest %-homeownership quintile compared with the highest %-homeownership quintile. With regard to %-Aboriginal indicator, more gains were made in neighbourhoods with lower proportions of Aboriginal populations. The resultant 2014 coverage rates in these two stratifiers, however, still show stark inequities. The equity trend is mixed when considering %-immigrant. While there were almost null gains in the highest %-immigrant neighbourhoods (quintile 5), the second-highest (quintile 4) showed the highest gains (2.28%), with quintiles 2 and 3 gaining coverage rates by 1.36% and 1.46%, respectively. The quintile with the lowest %-immigrant population showed a reduction in coverage by 1.25% (Fig. 2 and Table 2). These results suggest that, in terms of equity, gaps were reduced in Edmonton across the income and %-homeownership indicators through gains in coverage rates, and through a mix of gains and losses in the %-immigrant indicator, as a result of the baseline level of provincial intervention (awareness campaign and immunization guideline update). The degree of these equitable gains did not, however, result in the elimination of noticeable inequities in 2014. The equity trend, however, is reversed when considering %-Aboriginal, where gains were not equitably distributed, exacerbating the inequitable coverage rates between quintiles in 2014. Figure 3 shows that in 2015, the coverage rates in the highest income, highest %-homeownership, and lowest %-Aboriginal remain higher than their lowest/highest counterparts, indicating durable inequities in those stratifiers. Highest %-immigrant neighbourhoods show the highest coverage rates in relation to other quintiles in this stratifier.

Fig. 2.

Fig. 2

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Edmonton MMR one-dose by age-2 immunization coverage trends based on quintiles across four socio-demographic indicators (2013–2015)

Table 3.

Coverage rate difference between 2013 and 2014, and coverage rates in 2014 in Edmonton of one-dose by age-2 MMR immunizations by socio-economic stratifier

Income %-Homeownership %-Aboriginal %-Immigrant
Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate* Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate* Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate

Quintile 5

(Highest)

  + 1.38 1294 1387 93.29  + 0.92 1158 1243 93.16  + 0.56 2667 3111 85.73  − .028 2173 2388 91.00
Quintile 4  + 0.06 2232 2429 91.89  + 0.65 2262 2456 92.10  + 0.05 1787 2059 86.79  + 2.28 2144 2364 90.69
Quintile 3  + 0.14 1649 1852 89.04  − 0.31 1734 1963 88.33  + 0.46 1341 1504 89.16  + 1.46 1966 2245 87.57
Quintile 2  + 0.76 1656 1902 87.07  + 1.20 1762 2020 87.23  + 2.09 2278 2465 92.41  + 1.36 2000 2297 87.07

Quintile 1

(Lowest)

  + 2.12 2579 3008 85.74  + 2.42 2496 2898 86.13  + 1.48 1339 1441 92.92  − 1.25 1180 1346 87.67
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Fig. 3.

Fig. 3

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Calgary MMR one-dose by age-2 immunization coverage trends based on quintiles across four socio-demographic indicators (2013–2015)

Emergence of immunization inequities in Calgary

While Calgary showed higher gains in coverage overall, coverage rate gains between 2013 and 2014 were disproportionately higher in the highest income, highest %-homeownership quintiles, and lowest %-immigrant neighbourhoods, with marked near-null gains in highest %-Aboriginal neighbourhood (Fig. 3 and Table 4).

Table 4.

Coverage rate difference between 2013 and 2014, and the coverage rates in 2014 in Calgary of one-dose by age-2 MMR immunizations by socio-economic stratifier

Income %-Homeownership %-Aboriginal %-Immigrant
Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate Difference between 2013 and 2014 Numerator Denominator 2014 coverage rate

Quintile 5

(Highest)

  + 3.29 2575 2760 93.30  + 2.95 2726 2913 93.58  + 0.31 2666 3025 88.13  + 0.51 2836 3110 91.19
Quintile 4  + 2.04 2873 3118 92.14  + 1.53 2352 2548 92.31  + 3.69 2691 2921 92.13  + 1.38 2383 2616 91.09
Quintile 3  + 0.32 2173 2385 91.11  + 3.09 2911 3186 91.37  + 1.51 2316 2519 91.94  + 1.35 2021 2256 89.58
Quintile 2  + 1.03 2714 3036 89.39  + 0.87 2411 2707 89.07  + 2.85 2635 2892 91.11  + 3.95 2583 2838 90.98

Quintile 1

(Lowest)

  + 1.80 2376 2707 87.77  + 2.00 2343 2687 87.20  + 2.15 2413 2661 90.68  + 3.37 2221 2466 90.06
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Figure 3 and Table 4 show the changes in coverage rates in Calgary during the study period by quintile for each indicator, with the table focussing on the differences between 2013 and 2014. Of note are both the gains and the resultant coverage rates associated with 2014. Regarding neighbourhood income, in 2014, the highest income quintile coverage rate surpassed all the other quintiles in terms of coverage rates, resulting in a sequential gradient in coverage rates in the year of the intervention, 2014: highest income quintiles show the highest coverage rates, second-highest income quintile shows the second-highest coverage rate, and so on in descending order. The largest coverage gains in 2014 were made in the highest income quintile (3.29%). With regard to %-homeownership, again, a true sequential gradient emerges only in 2014: highest %-homeownership quintiles show the highest coverage rates, second-highest %-homeownership quintile shows the second-highest coverage rate, and so on in descending order. The highest gains with this stratifier were made in quintile 3 (3.09%), but the resultant coverage rate in quintile 3 (91.37%) still did not reach the quintile 5 coverage rate (93.58%). Considering the %-Aboriginal stratifier, quintile 5 (highest proportion of %-Aboriginal populated-neighbourhoods) showed the lowest coverage rate at 88.01% and quintile 4 showed the highest coverage rate at 92.13%. In terms of gains in 2014, quintile 5 showed almost null coverage gains while other quintiles showed gains of 3.69%, 1.51%, 2.85%, and 2.15%, in quintiles 4 to 1, respectively. The quintile 4 coverage rate increase was the second highest among all the quintiles across all stratifiers. With regard to the %-immigrant population stratifier, the quintiles showed the narrowest variation in 2014 coverage between quintiles, ranging from 89.58% to 91.19%. These quintiles arrived at this narrow range due to gains of 1.38%, 1.35%, 3.95%, and 3.37% in quintiles 4 to 1, respectively, with quintile 2 showing the largest gain among all stratifiers. Figure 3 shows that in 2015, the coverage rates in the highest income, highest %-homeownership, and lowest %-Aboriginal remain higher than their lowest/highest counterparts, indicating durable inequities in those stratifiers.

These quantitative and qualitative results together suggest that the relatively intense intervention of the mass immunization clinics in addition to baseline provincial interventions in Calgary in 2014 disproportionately reached the highest income, highest homeownership contingent, lower immigrant-populated, and lower Aboriginal-populated neighbourhoods, when compared to Edmonton, where Edmontonians were only exposed to provincial interventions (immunization awareness campaign; increased eligibility for immunizations).

Discussion

This study has some limitations. First, it is important to note that the immunization registries may be incomplete as they only capture children at a point in time when they are immunized, and miss children who move between postal codes, or to a greater extent who move between provincial boundaries. This remains a universal problem among immunization information systems across Canada. This issue may lead to undercounting rates in immigrated children as they may have already been immunized in their own country, but not captured into the registry in Canada. Second, there is a lack of a comprehensive public health intervention database; therefore, it is possible that other undocumented immunization-related interventions were instituted in Calgary and Edmonton. We used both official communications from the health authorities as well as news articles, as sources of interventions mitigate against this lack of systematic data.

Our findings are consistent with those of Guo et al. (2016) who demonstrated that high-income neighbourhoods are disproportionately vaccinated at a higher rate than lower income neighbourhoods during the measles outbreak in Alberta. Otherwise, the most analogous retrospective research in the literature on this topic of immunization equity during an outbreak is in regard to the H1N1 influenza outbreak in Canada, which includes all ages. In a systematic review, Brien et al., (2012a, b) found that high pandemic and seasonal influenza vaccinations were most commonly associated with high SES, including living in suburban, less deprived areas. In a more localized study of Montreal, Brien et al. also determined that in the wake of deploying an H1N1 mass immunization campaign in 2009 in Montreal, the higher the percentage of immigrant population within a neighbourhood, and the higher the material deprivation score, the lower the vaccine coverage rates. Here, they highlight the need to target campaigns to reach distinct populations (Brien et al., 2012b).

In our study, Calgary implemented their own city-specific intervention of mass immunization clinics over and above the provincial awareness campaign and immunization guideline modification to increase immunization eligibility. This additive intervention of mass immunization clinics in Calgary seemed to result in a more notable overall increase in coverage rates in Calgary as compared with Edmonton. It appears to have also contributed to an inequitable increase in coverage rates across many socio-demographic indicators.

The mass immunization clinics in Calgary presumably added extra public health capacity to administer immunizations as compared with Edmonton, thus the overall coverage gains. With respect to equity, however, the mass immunization clinics may have also been more accessible to higher SES/less marginalized groups.

Levesque et al. orient “access” to health care services around two dimensions: patient (demand) and provider (supply)-related determinants of access. Determinants of access regarding the demand side include ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side, the determinants include: approachability; acceptability, availability and accommodation, affordability, and appropriateness of health services. In the case of mass immunization clinics, many of these determinants are at play. For example, transportation to and ability to take time to wait in long lines for mass immunization clinics implicate demand (ability to reach, ability to engage) and supply side (availability and accommodation) determinants, despite these clinics technically being available to everyone and free of charge.

It is important to consider that Calgary has a reported history of inequitable immunization coverage rates during another outbreak. Retrospective reports on the 2009 H1N1 outbreaks and response in Calgary showed equity concerns around public health reaching populations equitably. Numerous reports and subsequent inquiry centred around the NHL hockey team Calgary Flames players and their family members receiving immunization ahead of others in private clinics, in a climate of inadequate H1N1 immunization supply (The Globe & Mail, 2013). Waegemakers, Schidd, and Lane’s (in Buccieri & Schiff, 2016) study also reported many barriers to achieving equitable coverage rates in Calgary during the H1N1 outbreak among populations experiencing homelessness. The practicalities of the day-to-day limitations of people experiencing homelessness require public health service planners to adapt to high-need populations. They report that targeted immunization efforts were inadequately executed: “This lack of foresight impacted the homelessness sector, as clinics were often at inconvenient locations, wait times were long and immunization schedules did not align with the demands of shelters that have strict sign-in, meal availability and ‘be in for the night’ times” (Buccieri & Schiff, 2016, p. 118). This sentiment also alludes to a mismatch between the demand (ability to reach; ability to engage) and supply (approachability; acceptability, availability and accommodation, affordability, and appropriateness of health services) for immunization services in a particular population. The results suggest that considerations around access to mass immunization clinics may be an essential element to ensure that dramatic gains in coverage rates do not increase coverage gaps.

With regard to Edmonton, the mixed equity results suggest that baseline provincial interventions did not systematically reach all under-immunized populations. As to why only implementing the awareness campaign and allowance for an earlier dose disproportionately reached the lowest-income, lowest homeownership neighbourhoods so markedly, while at the same time, these efforts resulted in losses in low-immigrant neighbourhoods and overall did not reach higher %-Aboriginal neighbourhoods, is unclear. The highest increase in any quintile in Edmonton is 2.28%, while in Calgary the highest increase is 3.69%, suggesting Edmonton’s ‘lighter-touch’ interventions may not have been intense enough to cause a clear sorting of immunization behaviour in any systematic manner. The results suggest that further investigation is required into what type of immunization programs can be optimized to reach subpopulations such that they do not, at the very least, cause segments of the population to decrease coverage rates.

A proportionate universalist approach is a model of public health program design that can countervail emergent equity concerns when ramping up public health programs such as immunizations. Originating out of the Marmot review, proportionate universalism is a program design approach that augments universal interventions with increasing levels of intensity for higher-need groups (Marmot, 2010). For example, in Saskatoon, residents of the “core” neighbourhoods have been recognized to face a disproportionate number of barriers to healthcare access, exhibiting, for example, consistently lower immunization rates than more affluent neighbourhoods. During the H1N1 pandemic, the Saskatoon Health Region employed a proportionate universalism approach where, during the general mass immunization period for the whole city, a specialized public health professional team was designated to provide immunization services at the Food Bank, Friendship Inn, and drop-in satellite clinics that specifically served the core neighbourhoods (Opondo et al., 2011). Core schools were also targeted first, and a health bus was dedicated to the core neighbourhoods as well to reach under-served populations (Health Standards, 2020). Overall, these findings suggest that immunization policy and programming may need to be tailored to a neighbourhood level to meet the needs of specific groups.

Conclusion

The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions. The baseline provincial intervention implemented in Edmonton decreased inequity gaps in some indicators, while Calgary’s more intense intervention by means of including mass immunization clinics more dramatically increased overall coverage rates, and also disproportionately reached less marginalized groups across all indicators. Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.

Contributions to knowledge

What does this study add to the existing knowledge?

  • Uses neighbourhood-level coverage rates to assess impact of immunization interventions during an active outbreak between two cities within the same province.

  • Demonstrates that mass immunization clinics may reach more-advantaged populations over others.

What are the key implications for public health interventions, practice or policy?

  • Interventions targeted at a neighbourhood level can help reduce disparities in immunizations.

  • It is important to link socio-demographic data with public health outcome data to assess which subgroups public health interventions are disproportionately reaching.

Acknowledgements

The authors would like to acknowledge the financial support of the Natural Sciences and Engineering Research Council, the Government of Saskatchewan, and the Urban Public Health Network. The Urban Public Health Network is also acknowledged for being an integrated knowledge translation partner. This research is based on the published dissertation of the principal author, Dr. Thilina Bandara.

Author contributions

Thilina Bandara designed the study, conducted data collection and analysis, and is the primary author of the manuscript. Cory Neudorf led the study design as primary supervisor to Thilina Bandara and assisted in the writing and editing of the manuscript. Nazeem Muhajarine was a committee member on Thilina Bandara’s thesis committee, was involved in the study design, and assisted in the writing of the manuscript.

Funding

Funding was provided by the Natural Sciences and Engineering Research Council, the Government of Saskatchewan, and the Urban Public Health Network.

Data availability

Not applicable.

Code availability

Not applicable.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethics approval

Ethics approval for the quantitative data collection and analysis was provided by the University of Saskatchewan and Alberta Health Services.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Footnotes

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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