Ever since the advent of pediatric vaccination, individuals have expressed concerns about both its risks and benefits. These concerns have once again resurfaced among some segments of the population and could potentially undermine national vaccination programs. The views of the public, however, must be considered and respected in the formulation of vaccination policy. We have conducted an analysis of the pediatric vaccination "debate" in the Canadian context. We believe that there is common ground between those who support pediatric vaccination and those who are concerned about these programs. Based on our findings, we believe that the goal of public health authorities should be to maintain trust in vaccines by continuing to meet certain reciprocal responsibilities. To do so, we recommend the following: 1) increased investment in adverse event reporting systems; 2) request for proposals for consideration of a no-fault compensation program; 3) developing pre-emptive strategies to deal with potential vaccine risks; 4) further examination of mechanisms to improve communication between physicians and parents concerned about vaccination. All of these approaches would require additional investment in pediatric vaccination. However, such an investment is easy to justify given the benefits offered by pediatric vaccination and the ramifications of failing to maintain confidence in vaccination programs or missing a vaccine-related adverse event.
Comment In: Can J Public Health. 2006 Mar-Apr;97(2):86-916619991
ICES uOttawa, Ottawa, Ontario, Canada ; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada ; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.
We investigated the association between a child's birth order and emergency room (ER) visits and hospital admissions following 2-,4-,6- and 12-month pediatric vaccinations.
We included all children born in Ontario between April 1(st), 2006 and March 31(st), 2009 who received a qualifying vaccination. We identified vaccinations, ER visits and admissions using health administrative data housed at the Institute for Clinical Evaluative Sciences. We used the self-controlled case series design to compare the relative incidence (RI) of events among 1(st)-born and later-born children using relative incidence ratios (RIR).
For the 2-month vaccination, the RIR for 1(st)-borns versus later-born children was 1.37 (95% CI: 1.19-1.57), which translates to 112 additional events/100,000 vaccinated. For the 4-month vaccination, the RIR for 1(st)-borns vs. later-borns was 1.70 (95% CI: 1.45-1.99), representing 157 additional events/100,000 vaccinated. At 6 months, the RIR for 1(st) vs. later-borns was 1.27 (95% CI: 1.09-1.48), or 77 excess events/100,000 vaccinated. At the 12-month vaccination, the RIR was 1.11 (95% CI: 1.02-1.21), or 249 excess events/100,000 vaccinated.
Birth order is associated with increased incidence of ER visits and hospitalizations following vaccination in infancy. 1(st)-born children had significantly higher relative incidence of events compared to later-born children.
Cites: Am J Epidemiol. 2002 Nov 1;156(9):882; author reply 883-412397007
Cites: J Epidemiol Community Health. 2002 Mar;56(3):209-1711854343
Using a population-based self-controlled case series design, we examined data on children born between the years 2002 and 2009 in the province of Ontario, Canada. We specifically examined how socioeconomic status (SES) influences rates of adverse events following immunization (AEFI), defined as emergency room visits and / or hospital admissions. For vaccination at 2, 4 and 6 mo combined, the relative incidence of AEFI (95% CI) in the first 72 h after vaccination was 0.69 (0.67 to 0.71). For all three vaccinations combined, we observed no relationship between the relative incidence of an event and quintile of socioeconomic status (p = 0.1433). For the 12-mo vaccination alone, the relative incidence of events (95% CI) on days 4 to 12 following immunization was 1.35 (1.31 to 1.38). We observed a significant relationship between socioeconomic status and vaccination at 12 mo, with lower SES being associated with a higher relative incidence of events (p = 0.0075). When the lowest 2 quintiles of income combined were compared with the highest 3 quintiles, the relative incidence ratio (95% CI) was 0.94 (0.89 to 0.99, p = 0.02). These results translate to 150 additional adverse events in the lower SES quintiles as compared with the higher SES quintiles for every 100,000 children vaccinated, or 1 additional event for every 666 individuals vaccinated. Future studies should explore potential explanations for this observation.
Cites: Stat Med. 2006 May 30;25(10):1768-9716220518
We have investigated the attitudes towards vaccination of undergraduate chiropractic and naturopathic students in the two major complementary and alternative medicine colleges in Canada. While the majority of the students were not averse to vaccination, we found in both colleges that anti-vaccination attitudes were more prevalent in the later years of the programs. Reasons for this are discussed, and we provide suggestions for strategies to address the situation.
The precautionary principle has influenced environmental and public health policy. It essentially states that complete evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risk. The application of precaution to public health issues is not straightforward and could paradoxically cause harm to the public's health when applied inappropriately. To avoid this, we propose a framework for applying the precautionary principle to potential public health risks. The framework consists of ten guiding questions to help establish whether a proposed application of the precautionary principle on a public health matter is based on adequacy of the evidence of causation, severity of harm and acceptability of the precautionary measures.
Prior to the 2009 H1N1 Influenza pandemic, public health authorities in Canada and elsewhere prepared for the future outbreak, partly guided by an ethical framework developed within the Canadian Program of Research on Ethics in a Pandemic (CanPREP). We developed a telephone-based survey based on that framework, which was delivered across Canada in late 2008. In June, 2009, the WHO declared pandemic Phase 6 status and from the subsequent October (2009) until May 2010, the CanPREP team fielded a second (revised) survey, collecting another 1,000 opinions from Canadians during a period of pre-pandemic anticipation and peri-pandemic experience.
Surveys were administered by telephone with random sampling achieved via random digit dialing. Eligible participants were adults, 18 years or older, with per province stratification approximating provincial percentages of national population. Descriptive results were tabulated and logistic regression analyses used to assess whether demographic factors were significantly associated with outcomes, and to identify divergences (between the pre-pandemic and intra-pandemic surveys).
N = 1,029 interviews were completed from 1,986 households, yielding a gross response rate of 52% (AAPOR Standard Definition 3). Over 90% of subjects indicated the most important goal of pandemic influenza preparations was saving lives, with 41% indicating that saving lives solely in Canada was the highest priority and 50% indicating saving lives globally was the highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with serious health conditions which that increased risks. Strong majorities favoured stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced.
Results suggest Canadians trust public health officials to make difficult decisions, providing emphasis is maintained on reciprocity and respect for individual rights. Canadians also support international obligations to help poorer countries and associated efforts to save lives outside the country, even if intra-national efforts are reduced.
Cites: N Engl J Med. 2009 Jun 18;360(25):2605-1519423869
The management of pandemic influenza creates public health challenges.An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning.
All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes.
5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p
Despite its being deliberated since at least the 1980s, a national vaccine injury compensation program still does not exist in Canada. The omission of such a program stands as a gap in Canadian immunization policy in comparison to many other equivalently developed countries. This article outlines the arguments for a compensation program and the design elements that would be best suited to a program in the Canadian context.
The use of complementary and alternative medicine (CAM) has grown substantially in North America and has drawn the attention of conventional-medicine practitioners. Conventional-medicine practitioners have expressed concern about the potential for unregulated CAM therapies to cause harm, the sometimes-uncertain cost-benefit ratios associated with these therapies, and the possibility that some CAM providers might advise against established conventional therapies, such as vaccination. These concerns are heightened with respect to the pediatric use of CAM products. To address this issue, we conducted a systematic audit of pediatric and adolescent case files at a large, college-based, Canadian naturopathic teaching clinic. We specifically sought to describe the demographic characteristics, reasons for presentation, use of CAM products, and vaccinations status of children presenting for naturopathic assessment. We also determined factors associated with the use of CAM products and vaccination status.