Ontario excludes thousands of children from schools for lack of vaccination

BMJ 2013; 346 doi: (Published 10 May 2013) Cite this as: BMJ 2013;346:f3068
  1. Owen Dyer
  1. 1Montreal

Canada’s most populous province, Ontario, has issued suspension notices to thousands of high school children who lack proof of vaccination in what is becoming an annual enforcement campaign aimed at school age children.

Three Canadian provinces, Ontario, Manitoba, and New Brunswick, have laws that demand vaccination records as a prerequisite for school attendance, as do all 50 US states. Ontario’s law covers vaccination against six diseases: measles, mumps, rubella, diphtheria, tetanus, and polio. Discussions are under way to add pertussis and meningococcal disease. Ontario is the only Canadian province to have exercised its power to suspend students.

“It’s an extremely effective approach,” said Bill Sherlock, vaccine coordinator with the Hastings & Prince Edward Counties Health Unit, in southeast Ontario. “You can print all the pamphlets you like, but it doesn’t grab their attention in the same way. We’re reaching well over 90% coverage among those receiving suspension notices.”

With 36 health districts each responsible for local enforcement, there are no province-wide data on suspensions, but Toronto has issued over 5400 suspension notices, while Ottawa has sent out over 900.

The notices are typically the third or fourth warning in a process that began last November, when schools handed out parental consent forms to high school students. Health authorities usually visit about six weeks later to vaccinate consenting students on school premises. Letters are sent to the parents of students who have not brought back signed consent forms, and a second round of vaccination takes place around January, with further letters sent to the parents of those still unvaccinated.

In Ottawa about 18 000 families of students without vaccination records received letters in November, about 8000 in February, and 5000 in March. When the suspension notices were received last week 900 students still had no vaccine records.

Suspensions last for 20 days or until the student provides vaccination records or a notarised affidavit requesting exemption on medical, religious, or philosophical grounds. About 2% of students have such exemptions. Students allowed back to school without having been vaccinated, as a result of an exemption or having served their 20 days, are on notice to be sent home again should the relevant disease break out.

Although Unicef recently gave Canada a failing grade on overall vaccine coverage,1 there is little evidence of strong antivaccination sentiment and no organised resistance to the suspension programme.

Ian Gemmill, medical officer for Kingston, Frontenac and Lennox & Addington Public Health, southeast Ontario, said that many of the students targeted for suspension had actually been vaccinated but had lost their records. “A lot of this effort could be avoided if the province had an effective vaccine registry,” he noted.

Sherlock said he thought that many consent forms were never reaching the parents at all. “We certainly don’t see much concern over vaccine safety from the students. I think needle phobia and simple forgetfulness are bigger factors [in failure to return consent forms],” he said.

At high school age the most common missing vaccinations were those against diphtheria and tetanus. But the province of Quebec, which borders Ontario, saw North America’s largest outbreak of measles of recent years, in 2011. Toronto has reported an above average seven cases of measles so far in 2013, including the strain currently in Wales and that which struck France heavily in 2008-11. Toronto Public Health estimated that a drop of 10% in measles, mumps, and rubella vaccine coverage now would expose the city to measles epidemics of up to 10 000 cases by 2018.

The Canadian Paediatric Society this week issued a position statement, “Working with vaccine-hesitant parents,” urging doctors not to dismiss the children of vaccine refusing parents from their practices.2 It prompts doctors to remind their patients of the risk posed by disease and to avoid discussing vaccines in terms of risk. It suggests that saying, “A vaccine is 99% safe” is more effective than saying, “There is a 1% chance of side effects.” It also urges doctors not to underestimate the role played by fear of pain in people’s reluctance to be vaccinated.


Cite this as: BMJ 2013;346:f3068