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Immunization Coverage in Canada (2002 to 2012)

Immunization is one of the most effective public health interventions available - safe and effective vaccines prevent serious diseases and save lives. Knowing what a populations' immunization uptake levels are (also called "coverage"), helps determine if that population is protected from a particular disease. If coverage is high, it is less likely that the disease will spread within that population. There are some people who cannot be immunized due to age (e.g. newborns too young to be immunized) or due to specific health conditions - this makes them vulnerable to infectious diseases, like measles and meningitis. If people around them are immunized (and therefore do not spread the infection to other people), the vulnerable are indirectly protected. This concept is known as "herd immunity".

Canada has published national goals and objectives for six vaccine-preventable diseases (invasive meningococcal disease (IMD), invasive pneumococcal disease (IPD), varicella, pertussis, influenza and rubella). Measles coverage goals had already been established and adopted by provinces and territories (see Table 1). The goals were established by consensus in 2005 for use by provinces and territories when planning immunization programs. Coverage is measured in Canada to determine if vaccine programs are meeting these desired goals.

Canada is also responsible for reporting coverage levels to international partners, like the World Health Organization, who measure health status and disease trends of the world's population.

Table 1: National Immunization Coverage Goals (2005) for Vaccines
Disease Vaccine Coverage Goal
Table 1 - Footnote *
NACI (National Advisory Committee on Immunization
Table 1 - Footnote **
Measles coverage goals located in NACI Statements: Volume 21-21, 15 Nov 1995External Link
Rubella Achieve and maintain age-appropriate immunization coverage for rubella-containing vaccine by 2010 as follows:
  • in 97% of children by their 2nd birthday (1 dose)
  • in 97% of children by their 7th birthday (2 doses)
  • in 97% of adolescents 14 to 16 years of age by 2010.

Achieve and maintain rubella postpartum immunization coverage in 99% of susceptible women prior to discharge by 2010.

Varicella Achieve and maintain age-appropriate immunization coverage with varicella vaccine by 2010 as follows:
  • in 85% of children by their 2nd birthday
  • in 85% of susceptible children by their 7th birthday
  • in 85% of susceptible adolescents by their 17th birthday

Achieve and maintain immunization coverage with varicella vaccine in 100% of postpartum women without evidence of immunity, unless contraindicated, by 2010.

Influenza
  • 95% coverage of residents of long-term care facilities and staff who have extensive contact with residents
  • 80% coverage of persons aged ≥ 65 years of age
  • 80% of persons < 65 years of age with high risk conditions
  • 80% coverage of health care workers
  • 100% coverage of vaccinators
  • 80% coverage of household contacts of people at high risk

(No national goals established for childhood vaccine coverage)

Pertussis (whooping cough) Achieve and maintain age-appropriate immunization coverage with acellular pertussis vaccine by 2010 as follows:
  • in 95% of infants by 3 months of age (first dose)
  • in 95% of infants by 7 months of age (3 doses)
  • in 95% of children by their 2nd birthday (4 doses)
  • in 95% of children by their 7th birthday (5 doses)

Achieve and maintain age-appropriate immunization coverage with Tdap vaccine by 2010 as follows:

  • in 85% of adolescents by their 18th birthday

Replace TD with Tdap (acellular pertussis) for adults by 2010

Invasive Meningococcal disease Achieve and maintain age-appropriate immunization coverage with meningococcal C conjugate vaccine by 2010 as follows:
  • in 97% of children by their 2nd birthday
  • in 90% of adolescents by their 17th birthday (by 2012)
  • 100% of close contacts (as defined by NACI*)
  • 95% of high-risk groups (as defined by NACI*)
Invasive Pneumococcal disease Achieve and maintain age-appropriate immunization coverage with pneumococcal conjugate vaccine in 90% of children by their 2nd birthday by 2008.

Achieve and maintain age-appropriate immunization coverage with pneumococcal polysaccharide vaccine in 95% of residents of long-term care facilities by 2008.

Achieve and maintain age-appropriate immunization coverage with a single dose of pneumococcal polysaccharide vaccine in 80% of adults ≥ 65 years of age by 2010

Measles** Eliminate indigenous measles in Canada by 2005.

Maintenance of 95% coverage of two doses of measles-containing vaccine

Since 1994, the Public Health Agency of Canada estimates vaccination coverage as well as attitudes and behaviours about immunization through National Immunization Coverage Surveys (NICS). These surveys, conducted approximately every two years, measure the level of vaccine coverage by children (ages 2, 7 and 17 Footnote 1) and adults (age 18+). For children, the vaccines assessed include the routine, publicly-funded (offered free of charge to the public) vaccines, such as measles, chicken pox and meningitis. From 2006 to 2010, the children were selected through random digit dialing and questions are answered by the parent or legal guardian using the immunization record at home. Since 2011, a sub-set of the surveys are validated (with permission) against the child's immunization records at their doctor and/or public health unit to compare the home record with the child's official record. This second validation step ensures the most accurate results possible. Children are no longer randomly selected for the survey. Instead, families are contacted because they agreed to be contacted by government departments for surveys.

For adults, vaccine coverage estimates are assessed for certain for vaccines recommended for adults. Vaccines are selected based on the fact that NACI recommends them for certain target groups of adults (for example influenza, Hepatitis B, tetanus). Participants are randomly selected to be interviewed over the phone using random digit dialing and questions are answered using immunization records they may have at home and/or memory recall. The second validation step used for the childhood survey is not used for the adult surveys.

In Canada, the National Advisory Committee on Immunization (NACI) recommends vaccines based on the vaccine's safety, effectiveness and benefit. Provinces and territories implement vaccine programs based on local information about who gets the disease, the extent of the disease, when they get the disease (i.e. age), severity of the illness as well as other factors. For this reason, there is some variation across the country on when vaccines are given. For the surveys, all coverage estimates are assessed using the NACI-recommended schedule at the time of the survey Footnote 2 to determine if they are considered "up-to-date" with their immunizations. If there is a difference in the vaccine program in that participant's province or territory, this was taken into account in the analysis.

Survey results are helpful but do have some limitations such as a low response rate and bias (e.g. self-reported immunization history from memory is not as accurate as reviewing a medical record, those who agree to participate may not reflect all Canadians). There may be lack of representation from certain groups such as First Nations populations, adults in institutions (e.g. in nursing homes, prisons), newcomers to Canada, those whose first language is not English or French and those without a land line phone. The Public Health Agency of Canada will continue to work to improve the survey methods until automated systems for recording immunizations are generally in place across Canada.

This summary provides an overview of vaccination coverage estimates for adults and children in Canada from 2002 to 2012, reflecting a total of approximately 1,200-4000 children (≤ 17 years of age) per survey cycle and approximately 3,000 adults (≥ 18 years of age) per adult survey cycle. A more in-depth analysis of the 2002 to 2012 coverage data will be available later in 2014.

Results (Childhood Surveys)

Overall, the results of the national childhood surveys are encouraging. More than 96% of parents have had their children immunized and coverage has remained relatively stable over time. Those children who are not immunized may include those with certain health conditions and cannot be immunized, or their parents have refused vaccines for other reasons.

While immunization coverage is relatively high for many diseases (such as polio, diphtheria, whooping cough, tetanus, measles, mumps and rubella) and the national goals for coverage are met for some immunizations (i.e. varicella and measles), there are still areas where improvements in coverage would better protect children (i.e. pneumococcal and meningococcal diseases). Immunization coverage is typically higher for vaccines that have been offered the longest such as polio, diphtheria, whooping cough, tetanus, measles, mumps, and rubella. Immunization coverage for newer vaccines such as chicken pox, pneumococcal and meningococcal diseases are still increasing over time. The main reason given for not immunizing children includes the perception that there are too many childhood vaccines, that vaccines are not needed, or that they are not safe.

Figure 1: Up-to-date immunization coverage estimates by vaccine antigen by the 2nd birthday in Canada (2002 to 2011)

Figure 1

Text Equivalent - Figure 1

† Hep B = hepatitis B; Varicella = chicken pox; PCV-7/-10 = invasive pneumococcal disease; Men-C = invasive meningococcal disease

* Changes in survey methods in 2006 and 2011 may have had an impact on coverage estimates. In 2006, randomly selected telephone interviews (random digit dialing) were used versus targeted selection via telephone or mail-outs in previous years. In 2011, medical records were also validated after the telephone interview. 2011 estimates are likely the most accurate.

+ coverage for hepatitis B vaccine increased significantly in 2009. This year, the question was only asked if the vaccine was offered for free in the respondent’s province or territory.

$ between 2002 and 2011, uptake increased dramatically for these 3 vaccines because provinces and territories started offering them free as part of the routine childhood immunization program.

Figure 2: Up-to-date immunization coverage estimates by vaccine antigen by the 7th birthday in Canada (2002 to 2011)

Figure 2

Text Equivalent - Figure 2

* Changes in survey methods in 2006 and 2011 may have had an impact on coverage estimates. In 2006, randomly selected telephone interviews (random digit dialing) were used versus targeted selection via telephone or mail-outs in previous years. In 2011, medical records were also validated after the telephone interview. 2011 estimates are likely the most accurate.

Figure 3: Up-to-date immunization coverage estimates by vaccine antigen by the 17th birthday in Canada (2004 to 2011).

Figure 3

Text Equivalent - Figure 3

* Changes in survey methods in 2006 and 2011 may have had an impact on coverage estimates. In 2006, randomly selected telephone interviews (random digit dialing) were used versus targeted selection via telephone or mail-outs in previous years. In 2011, medical records were also validated after the telephone interview. 2011 estimates are likely the most accurate.

& HPV (human papillomavirus vaccine) was not assessed before 2011 because it was not available free of charge in all regions of Canada. Note that HPV vaccine estimates are for girls only.

Results (Adult Surveys)

Some people believe that immunizations are just for babies and children. This is not true, immunizations are also important for adults for two main reasons:

  • certain vaccine-preventable diseases can cause disability and death for adults, and
  • adult immunization helps protect vulnerable people who cannot be immunized, are not yet fully immunized or do not build strong immunity to vaccines (e.g. young infants, vulnerable patients in hospitals or institutions, those with immune-compromising conditions such as cancer or HIV)

The adult survey has been conducted approximately every 2 years since 2001. The latest survey results from 2012 are included in this summary. Knowing what the coverage is among Canadian adults and why they do not get vaccinated, helps improve vaccine programs and educational strategies. The surveys for adults include seniors, those with chronic medical conditions and health care workers. The vaccines that are measured include influenza (annual seasonal vaccine and the H1N1 vaccine during the 2009 outbreak), pneumococcal, hepatitis B, tetanus, acellular pertussis, varicella (chicken pox), and human papillomavirus (HPV) vaccines according to the NACI recommended schedule (see Table 2).

Table 2: NACI-recommended vaccination for adults (≥ 18 years of age), as of 2011
Vaccine Recommendations
Influenza:
  • Seasonal influenza
  • H1N1 vaccine
  • 1 dose on an annual basis
  • 1 dose was recommended during the 2009 outbreak
Pneumococcal 1 dose for:
Hepatitis B 3 doses for at-risk adults
Tetanus 1 dose every 10 years
Varicella (chicken pox) 2 doses for adults who have not had varicella infection as a child
Pertussis 1 dose of Tdap (Tetanus, diphtheria, acellular pertussis)
HPV (human papillomavirus vaccine) 3 doses for females 18-26 years

Additional questions were asked about knowledge, attitudes and behaviours surrounding immunization. For instance, more than half of adult Canadians think that the seasonal influenza immunization is important to their personal health. The most common questions asked of health care providers about immunization relate to vaccine safety, side effects or risks of complications. Of all the questions related to the immunization, these three subjects consume almost half of conversation (45.5%). Through those surveyed, it was found that if a health professional recommends a vaccine, an individual is more likely to get it than if they received information through the media, internet or books/pamphlets.

In general, immunization coverage for certain vaccines (such as influenza and varicella in health care workers and pertussis in the general adult population) has improved over time for Canadian adults. Seasonal influenza immunization rates have improved in adults with chronic medical conditions and health care workers. Although influenza immunization coverage for adults 65 years and older is high, it is still below the national goal of 80%. Pneumococcal vaccine coverage has also increased over time. However, it also remains below the national goal of 80%. While hepatitis B vaccine coverage is approximately 40% in the general population and in adults with chronic medical conditions, it is much higher in health care workers where 65% of this group is Hep B immunized. The uptake of varicella vaccine for adults at-risk of developing varicella has been slow at 43% as it has only been available for adults since 2006 and there is a perception that varicella is a childhood disease. Tetanus immunization coverage has been stable at approximately 49%. However, tetanus coverage is high among adults who have been treated for a wound. While there appears to be a trend for increasing pertussis coverage, more information is needed over time. Figure 4 illustrates estimated coverage for adults in the general population for seasonal influenza, hepatitis B and HPV vaccines. The full report addresses other vaccines and specific adult sub-groups where other vaccines may be recommended (and their risk factors) in the analysis.

Figure 4: Estimated vaccine coverage among the general adult population (18-64 years) in Canada from 2001 to 2012 for the seasonal influenza, hepatitis B and HPV vaccines

Figure 4

Text Equivalent - Figure 4

$ The 2001 survey used a different methodology than that used since 2006 so it is difficult to compare the 2001 results with those obtained from 2006 onwards. The survey methodology used a predetermined sampling frame in 2001 and switched to random digit dialing in 2006.

* The HPV vaccine coverage estimates are not available prior to 2010.

# 2009 H1N1 outbreak led to decrease in seasonal vaccine uptake.

Key Messages

Immunizations are important throughout the life cycle given their ability to prevent serious diseases for those who are immunized as well as those who are not (by providing herd immunity). When comparing how well Canada is doing to other industrialized countries, comparisons must be made with caution since programs and survey methods differ. Nevertheless, immunization coverage in Canada is similar to other industrialized countries like the United States and Australia. Canadians are doing fairly well in getting their children immunized, but there is still room for improvement. Immunization coverage for adults against vaccine-preventable diseases seems to be improving, but it is still too low for adequate protection. Many serious diseases continue to occur and could be prevented by immunization. Coverage surveys will continue to improve our understanding of vaccine coverage and attitudes toward immunization. The Public Health Agency of Canada learns from every survey process and continues to improve survey methods by making adjustments over time. Though survey methods will improve - it is expected that better coverage information will become available from electronic immunization records (registries) that are being implemented across Canada.

Unimmunized Canadians, adults and children alike, are vulnerable when they come in contact with vaccine-preventable diseases. Many of these diseases are still present and can spread in Canada. Canadians can also come into contact with these diseases when they travel or through travellers or visitors from other countries where immunization protection may be less adequate or diseases more common. Canadians should talk to their health care provider to make sure they and their families are adequately protected.

Footnotes

Footnote 1
17 year olds were added to the survey in 2004. Data is not available for this age group before that time.
Footnote 2
Note that recommended schedules change over time as new vaccines become available and new research is published. The NACI schedule that is posted may not be the same as it was when the survey was conducted.

Latest Reports

Vaccine Coverage in Canadian Children: Results from the 2011 Childhood National Immunization Coverage Survey

Vaccine Coverage amongst Adult Canadians: Results from the 2012 Adult National Immunization Coverage Survey