Tetanus case exposes gaps in vaccine tracking
Tetanus vaccine (Postmedia Network file photo)
While a six-year-old boy battles tetanus in a London hospital, public health officials say they have no idea how many Ontario kids have gone without a shot or whether immunization rates are getting worse.
For though cases of tetanus are rare, health officials say problems with our surveillance system are endemic.
In an age in which electronic patient records are the rage, we count on parents to carry immunization cards from doctors’ offices to public health units, either in person, or by phone — and that’s assuming parents remembered the complex sets of shots kids should get from infancy to adulthood.
The reliance on parents, paper and pencils has left health units with an incomplete picture of who’s been immunized. Though some have filled gaps with grunt work, others have not.
Of 36 public health units in Ontario, seven were unable to confirm that even two-thirds of seven-year-olds had been vaccinated against tetanus, a disease that kills about 10% of those afflicted. Laggards included Toronto, which confirmed 59%, and Ottawa, which confirmed just 38%.
“It’s a humongous and complex system,” Dr. Robin Williams, Ontario’s associate chief medical officer of health, told The Free Press Friday. “There’s a lot of variance.”
No public officials, including Williams, think vast numbers of Ontarians have gone without vaccinations — the occasional occurrence of a infectious disease here hasn’t spread, including a case of measles this past winter in Niagara Region.
But the problem with surveillance is a real one, so much so that Williams and her colleague have been working hard to make changes, replacing an antiquated computer program that didn’t allow health units to share data to one that does, called Panorama.
“We want real-time data (on) which kids are protected. That’s the ideal,” Williams said. “We absolutely need to have a good surveillance registry . . . (When) would I want it? Tomorrow.”
Until changes are made, though, public health officials won’t know if immunization rates are improving, holding steady or eroding toward a level at which outbreaks are likely.
“We don’t truly know (compliance rates),” said Sherry Nigro, who oversees health promotion and disease prevention at Ottawa Public Health.
Ottawa may be a poster child for surveillance in the province — it’s taking steps to improve but there’s a long way to go. “While we were limping along in the past, we don’t want to do so in the future,” Nigro said.
Every health unit but Durham Region has begun to use Panorama and officials from Thunder Bay to London praise its potential. But Panorama has opened a pandora’s box of extra work. When health units shared records, they found as many as 500,000 that might be duplicates for people who have moved around and been immunized in more than one place.
In Ottawa, that work of clearing up duplicates consumed so much time, nurses were told to not check for the missing records of seven-year-olds so they could instead seek missing records for 17-year-olds before they left the school system, Nigro said.
In Middlesex London, officials stopped sending notices to parents or seeking suspensions from schools. “We need more resources,” said Dr. Chris Mackie, the region’s medical officer of health.
Despite struggles, Mackie is confident that if an outbreak occurs, his health unit could harness resources and quickly confirm which students haven’t been vaccinated and protect them before they’re exposed to risk.
But that’s not the view of an American public health official who spent decades responding to outbreaks in Minneapolis and St. Paul, Minn.
“I don’t buy that at all,” said Diane Peterson, who left a public health agency 13 years ago to help lead a group that lobbies for better immunization and surveillance, the Immunization Action Coalition.
Health officials can seek records after an outbreak but those records can lack crucial information such as the dates of shots, she said. “They will find a lot of junk records,” she said.
Most American states have electronic registries for immunization and doctors update records electronically — they need to do so to get compensated by government-funded medicaid that covers the poor.
“You need the immune registry system,” Peterson said.
Williams is pushing for a registry that reminds parents when shots are needed and connects with electronic medical records in doctors’ offices so that the registry is up-to-date.
Asked about problems with surveillance, Health Minister Eric Hoskins said Panorama was key this past winter when there was a case of the measles in Niagara Region.
“Early identification of at-risk populations during an outbreak means we can take the appropriate steps to keep Ontarians safe,” Hoskins wrote in an e-mail.
But what was handled well in Niagara would have been a struggle elsewhere, said Williams, because Niagara was one of six health units that were given the Panorama program first.
“Are we in that place across Ontario? No, we’re not,” she said.
The lack of surveillance comes as the C. D. Howe Institute warns immunization coverage is below target in many regions across Canada. National estimates of vaccination coverage range between 70 and 95%, depending on the vaccine, the institute found.
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CLOSING THE GAPS
— Public health officials rely on parents to remember to vaccinate their kids and to drop off paper records or phone in results to public health.
— Public health has tracked tetanus shots for just 75% of seven-year-olds.
— A newer tracking system holds potential but has caused a backlog of work.
— Experts say we need an electronic registry that reminds parents when shots are needed and lets public health officials know who’s not protected.