Implementing the Immunization of School Pupils Act (ISPA)

Report to: Chair and members of the Board of Health

Meeting Date: September 7, 2016

Report Number: BH.01.SEP0716.R15

Prepared by: Marlene Jantzi-Bauman, Manager, VPD Program; Blair Hodgson, Health Promotion Specialist

Approved by: Dr. Nicola J. Mercer, Medical Officer of Health & CEO

Submitted by: Dr. Nicola J. Mercer, MD, MBA, MPH, FRCPC
                           Medical Officer of Health & CEO

 

Recommendations

It is recommended that the Board of Health:

1. Receive this report for information.

Key Point(s)

  • In Ontario, Public Health is mandated to assess, maintain and report the immunization records for students attending primary or secondary school in accordance with the Immunization of School Pupils Act (ISPA) and the Immunization Management Protocol, 2016.
  • In the 2015/16 school year, WDG Public Health sent 3900 immunization notices to families of children aged 7 years old (those entering grade 1) and 17 years old (those leaving grade 12) who did not have up-to-date immunization records with WDGPH.
  • 88% of families updated their children’s records within 6 weeks. 480 children were suspended from school. 90% updated their records and returned to school within a week.
  • The assessment of immunization records and suspension of students who did not meet ISPA requirements was effective at increasing immunization rates.
  • The ISPA compliance rate among 17 year olds has risen to 93%. The compliance rate for 7 year olds was 45% and is now 97%.
  • In June 2016, 15500 letters were sent to families of students aged 4 to 16 (not including previously assessed 7 year olds) who were due or overdue for ISPA immunizations. They were sent at the end of the school year to allow families additional time to update records prior to 2016/17 assessments and suspensions.
  • As of July, 13500 students still had incomplete records. All students with incomplete immunization records will be assessed and suspended during the next school year.
  • Through public information campaigns, collaboration with school boards and Public Health Nurses working with schools and parents, the compliance rate is expected to increase over the 2016/17 school year.

Implementing the Immunization of School Pupil's Act Infographic

Infographic Summary:

Implementing the Immunization of School Pupil’s Act

The immunization of School Pupils Act (ISPA) required all families with children attending school to provide Public Health with proof of their child’s immunization against designated diseases.

Health Units are required to assess students’ immunization records. Students without the required immunizations, or a legal exemption may be suspended from school.

2015/2016 Activities:

  • In the fall of 2015, a campaign was launched to promote immunization & inform parents that they are responsible for reporting their children’s immunizations.
  • A website was created to allow parents to report immunizations online.
  • 17500 students in WDG had incomplete immunization records as of January 2016.
  • In early 2016, 3900 letters were sent to the families of 7 and 17 year olds with incomplete records.
  • 88% of these families submitted completed records for their children within 5-6 weeks.
  • 480 students were suspended from school. 90% updated their records and returned to school within a week.
  • As of July, only 13500 students had incomplete immunization records.
  • That is a 23% decrease in only 6 months!

Planning for 2016/2017:

  • In the 2016/2017 school year, the immunization records of all students will be assessed. Students between 7 and 17 with incomplete records will be suspended.
  • 15500 students received letters asking them to updated their immunization records before the 2016/2017 school year. Since then, WDGPH has received 200-300 immunization records a week.
  • In the fall, another campaign will be launched to prepare physicians and families for the upcoming assessments and suspensions.
  • From December to February, suspension notices will be send in waves, warning students they will be suspended unless they update their records.
  • On March 22nd, all secondary students who have not reported their immunization records to public health will be suspended.
  • On April 5th and 6th elementary school students will be suspended.
  • Good Luck Next Year!

Discussion

Implementing the assessment of all student records and targeting strategic age groups (those just starting school and those about to graduate) has created opportunities for collaboration with school boards and well as extensive interactions between public health nurses, students and parents.
A key risk for WDG Public Health is reputational because schools needed to understand their role, parents needed to understand and act on their responsibility, and children needed to be vaccinated. In addition, physicians’ offices were impacted because of the numbers of patients asking for their immunizations to be updated.
A comprehensive communications campaign targeting school boards, schools, physicians and the public informed and allayed some of the concerns raised by sending thousands of letters threatening suspension. Each school partnered with a public health nurse and extra staff updated records so Public Health could be accurate in what it communicated to schools, families and students. Public health nurses also staffed an intake line where parents, physicians, and school staff could call in with questions.
Moving into the 2016/17 school year, BOH members are encouraged to support efforts with community stakeholders about the importance of student immunization and the efforts of Public Health to protect the community from vaccine-preventable diseases. BOH members can also alert WDGPH to any concerns they hear from their constituency or community members.

Public Health’s Role and the ISPA

Ontario’s Immunization of School Pupils Act (ISPA) currently requires that parents of children attending primary or secondary school provide their local Medical Officer of Health with proof of their child’s immunization against designated diseases. Public health units are required to assess immunization records and contact parents of students for whom they do not have complete immunization records. Exemptions from immunization requirements are allowed for medical reasons such as prior immunity or medical contraindications, or can be based on an affidavit of conscience or religious belief. Students without required immunization records or a valid exemption may be suspended from school until the required records are provided to public health.1 Suspension of students is a last resort and it is the goal of WDGPH to provide ample opportunities to avoid this outcome.

During the 2015/16 school year, only the immunizations of students in public and Catholic schools were assessed. This was because public and Catholic schools have an established and consistent process for reporting student information, such as names, grades and contact information, to public health. Many private and parochial schools do not have an established process for reporting student information, which would make assessing their students’ immunizations extremely time consuming. As such, the decision was made to only assess public and Catholic schools in 2015/16 and expand to include private and parochial schools in 2016/17.

In February 2016, approximately 2300 17-year-old students received letters informing them that WDGPH did not have their complete immunization records. In April, another 1600 letters were also sent to the parents of 7-year-old students whose immunization records were incomplete. These letters also included the student’s overdue vaccinations and instructions for submitting records.

Parents and students were warned that failing to update their immunization records could result in suspension, and they were asked to have their records updated by a specific date, approximately 3 weeks before suspensions were delivered. Three measures were implemented to help support families that may experience additional challenges in having their children immunized:

  • The assessment and suspension timeline allowed 5 to 6 weeks for students with incomplete immunization records to become up to date before students were suspended. This was done to accommodate families who may have needed extra time to access immunizations or submit records. During this time, families had several options for both receiving immunizations and submitting records.
  • The decision was made to not suspend students who could have been at risk for adverse events if unable to attend school. Public health nurses worked closely with school staff to identify these students. Once identified, these families were contacted and offered support in accessing immunization or submitting records. In some cases, if a student’s records could not be brought up-to date, the decision was made to forgo suspension. Most of the school staff who responded to our surveys about the 2015/16 assessment and suspensions felt that appropriate measures were in place to address and support students who may have been at increased risk if suspended.
  • Over 90% of students returned to school within a week of receiving suspension orders. In cases where students were suspended for more than a week, public health nurses followed up with the principals and families to discuss any barriers that may have stopped families from updating their child’s immunization records. Support was offered to help these students update their records and return to school as soon as possible.

Table 1. The number of 17 and 7 year olds who did not meet ISPA requirements at specific points in the assessment and suspension process.

  17 year olds 7 year olds
Letters sent       2300      1600
Students with incomplete records after deadline (3 weeks before suspension date)       750       900
Students suspended       150       330
Students still suspended after one week        16        35
Students still suspended after 20 school days         3         3

Although many families had not submitted records by the deadline specified in the letters, 1170 completed records were received between the deadline and the date students were suspended. Only 6 suspended students did not update their immunization records within the suspension period. Public health nurses followed up with the families of these students. In several cases, families did not update their child’s records because the child was not attending school at that time. If the student was not going to be attending school anyways, there was little incentive to report immunizations to public health.

Moving forward

In preparation for the 2016/17 school year letters were sent in June to approximately 15 500 students aged 4 years old through 16 years old (excluding those 7 years old) requesting that they update their immunization records before the beginning of school in September. Completed immunization records among this group have been submitted steadily throughout the summer, with WDGPH receiving between 200 and 300 records every week. We expect to see a considerable increase in reporting as the families prepare for the start of school in September.
Although the 2015/16 activities targeted only public and Catholic schools, all schools in Wellington, Dufferin and Guelph will be assessed during the 2016/17 school year. This fall, we will implement a broad communications campaign to inform physicians, school boards and the public of our plans.

Beginning in mid-December WDGPH will send suspension notices to students ages 7 through 17 who are not up to date with their ISPA required immunizations. The suspension notices will advise families that the student’s immunization records are incomplete and will explain how to submit records to WDGPH. The notices will also warn families that the student will be suspended on a specific date if their immunization records are not received. These suspension notices will be sent out in in waves ending in early February. The wave approach was adopted to ensure that WDGPH has the capacity to answer calls and assist families in ensuring their child becomes compliant with ISPA.

In February, public health nurses will offer clinics in secondary schools. Parents of elementary children will be encouraged to have their vaccines updated by their family doctor or access WDGPH clinics. Extra clinic times will be made available for families who wish to access services directly from WDGPH. On March 22nd, secondary students who are not yet up to date will be issued suspension orders. Elementary students still outstanding will be issued orders for suspension on April 5th and 6th. The elementary school suspensions will be divided across two days to account for the high number of elementary schools that public health nurses have to coordinate with on suspension days. Public health nurses will work alongside our partners in the school system to assist suspended students in returning to school as quickly as possible.

Conclusion

Outbreaks of vaccine-preventable diseases have become more common across Canada. For example, in 2015 there was a mumps outbreak in two Guelph schools resulting in illness in the community, and increased workload for public health and local healthcare facilities. Because outbreaks of vaccine-preventable diseases put vulnerable populations at risk and are increasingly costly for health units, The Chief Medical Officer of Health for Ontario issued a strong reminder in 2015 to all health units, encouraging the enforcement of the Act through student suspensions. It was the goal of WDGPH to achieve immunization rates at or above the provincial average, as indicated in the Immunization Coverage Report for School Pupils for the 2012/13 school year.2 Immunization rates among 7 year olds in WDGPH surpassed the provincial average for all diseases. Among 17 year olds, immunization rates for all ISPA diseases except Rubella met or surpassed the provincial average. A comparison between Wellington, Dufferin, Guelph and provincial rates can be found in Appendix 1.

WDGPH experienced some challenges during the assessment and suspension process. In some cases, parents reported immunizations online that were incomplete. The high volume of phone calls from physicians, parents, students, and local school staff affected the workload of WDGPH staff. WDGPH also recognizes the increased workload for local physicians who collaborated with WDGPH in providing immunizations to students with outstanding records. High volumes of time sensitive records to process combined with some parents not taking suspensions seriously negatively impacted the ability of WDGPH to return suspended students to school quickly.

Collaboration with schools was crucial to ISPA-related assessments and suspensions. Surveys were distributed to elementary and secondary school staff to gather feedback regarding the 2016 suspensions. Responses highlighted challenges that school staff experienced as well as recommendations for future assessments and suspensions. Many of these recommendations have been incorporated into the 2016/17 plans. Overall, feedback regarding the collaboration between schools and Public Health was positive. In fact, more than half of the elementary and secondary school staff members who responded to the survey reported that it was “very easy” to collaborate with Public Health during the assessment and suspension process. One respondent wrote “I am VERY glad that we [public health and schools] worked together to enforce this. Immunization is essential for our society! So thank you for all of your hard work.”

The lessons from this year’s activities have been considered and incorporated into planning as WDGPH moves forward with assessing student records for 2016/17.

Ontario Public Health Standard(s)

  • VPD Goal: To reduce or eliminate the burden of vaccine preventable diseases.
  • There is reduced incidence of vaccine preventable diseases.
  • Target coverage rates for vaccine preventable diseases are achieved.
  • There is increased health care provider knowledge of immunization.
  • There is increased public knowledge of immunization.
  • There is improved effectiveness of publicly funded immunization programs.

WDGPH Strategic Directions

Strategic Directions
DIRECTION APPLIES? (YES/NO)
Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.      YES
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.        NO
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health.      YES
Building Healthy Communities: We will work with communities to support the health and well-being of everyone.      YES

 

Health Equity

Immunization rates for vaccine preventable diseases are a recognized health equity concern. Families with fewer social and economic resources are more likely to have children that are not fully immunized.3 Recent analysis of MMR immunization rates in Guelph neighbourhoods, determined that 7 year olds living in priority neighbourhoods in Guelph were significantly less likely to be fully immunized against MMR than 7 year olds living in non-priority neighbourhoods.4

To accommodate families who may need extra time to access immunizations or submit records the assessment and suspension timeline allowed 6 weeks for students with incomplete immunization records to become up to date before suspending students. Public health nurses also worked closely with school staff to identify students who could have been at risk for adverse events if unable to attend school and once identified these families were contacted and offered support in accessing immunization or submitting records.

Two schools have been identified as having increased numbers of students from a priority population. These students were deemed to be at a greater risk of dropping out of school entirely if suspended. It was decided that, although these students did receive immunization notices, no students were suspended. Moving forward in 2016/2017, a similar approach will be taken as we expand our assessment and suspension efforts to include private and parochial schools where students may be at increased risk.

References

1. Population and Public Health Division, Ministry of Health and Long-Term Care. Immunization management Protocol, 2016. 2016 May. Available from http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/d…
2. Public Health Ontario. Immunization coverage for report for school pupils: 2012-13 school year. Toronto, ON. 2014 Sept. Available from https://www.publichealthontario.ca/en/eRepository/Immunization_coverage_…
3. Child Trends Data Bank. Immunization: Indicators on children and youth. 2015, Dec. Available from http://www.childtrends.org/?indicators=immunization.
4. Carty AP. Child Health in the Province of Ontario: Establishing baselines for reproductive health and vaccine preventable diseases. University of Guelph- Thesis. 2015, Aug. Available from https://atrium.lib.uoguelph.ca/xmlui/handle/10214/9182

Appendices

Appendix 1

Table 2. Comparison of Wellington, Dufferin and Guelph’s (WDG) public and Catholic school student’s immunizations coverage (%) for ISPA diseases to the Ontario average from 2012/2016
ISPA Disease 7 year olds 17 year olds
  WDG Ontario Average1 WDG Ontario Average1
Diphtheria  94.5          74.6  89.9          84.0
Tetanus  94.5          74.6  90.0          84.0             
Pertussis  94.4          72.6  89.7          69.9
Polio  94.3          74.2  95.2          94.3
Measles  94.9          88.3  95.4          95.4
Mumps  94.9          87.9  95.1          93.7
Rubella  95.9          95.2  95.9          97.1
Meningococcal  94.7          81.5  93.7          NA2
Varicella  65.6          NA3  83.7          NA3

NOTE: WDG rates reflect the percentage of public and Catholic school students who are immunized against ISPA diseases. This does not include students with legal exemptions. 1Ontario averages retrieved from the Immunization Coverage Report for School Pupils 2012-13 School Year report.
2The Ontario average for Meningococcal immunization coverage was not reported for this age group as they were not eligible for the publicly-funded vaccine.
3The Ontario average for Varicella immunization coverage was not reported for these age groups as they were not eligible for the publicly-funded vaccine.