1. Vaccine coverage for Ontario's three school-based vaccination programs: 2012/13 school year and recent trends S Wilson, GH Lim, CY Seo, T Harris, MA McIntyre, J Fediurek, SL Deeks CPHA conference, Toronto, ON May 27, 2014

2. www.oahpp.ca Disclosures I have no financial or other conflicts of interest 2

3. www.oahpp.ca Rationale for school-based immunization delivery Provide a platform to reach adolescents Adolescents have low HCP attendance 1, especially males 2 Improve compliance/coverage of multiple-dose vaccines Immunize before onset of risk behaviours Sexual debut, injection drug use, etc. 3 1. Rand et al. Pediatrics 2007;120:461e6. 2. Dempsey & Freed. Pediatrics 2010;125:43e9.

4. www.oahpp.ca Benefits of school-based immunization delivery Cost-effectiveness as compared to HCP-delivered Demonstrated for Hepatitis B 1,2 and meningococcal conjugate 3 Convenience leading to increased coverage 1 Improved health equity? Reverse gradient found for HPV vaccine uptake in BC 4, not ON 5 Peer support at the time of vaccination 6 Opportunity to evaluate new schedules 7 4 1. Guay et al. CJPH 2003;94:64-67. 2. Dueson et al. Am J Public Health 1999;89:1722-27. 3. Trotter et al. BMJ 2002;324:809. 4. Ogilvie et al. PLoS Med. 2010 May 4;7(5):e1000270. 5. Smith et al. BMC Public Health. 2011 Aug 13;11:645. 6. Robbins et al. Sex Health 2010;7(3):271-78. 7. Eggertson L. CMAJ August 28, 2007 vol. 177 no. 5 doi: 10.1503/cmaj.071048

5. www.oahpp.ca Ontario’s school-based immunization programs Hepatitis B vaccine (1994) 2 dose program Delivery in grade 7, extended eligibility until end of grade 8 Invasive meningococcal disease (2005, MCV4 since 2009) 1 dose (Men-C program for toddlers) Delivery in grade 7, once eligible, always eligible Human papillomavirus (HPV, 2007) 3 dose program Delivery to grade 8 girls, extended eligibility until end of grade 12 5

6. www.oahpp.ca National coverage targets Hepatitis B vaccine Achieve and maintain 95% hepatitis B immunization of populations targeted in universal programs by 1997 Meningococcal conjugate vaccine Coverage target of 90% for Men-C vaccine at age 17 by 2012 No coverage target specific to MCV4 vaccine HPV vaccine Coverage targets of 80% within 2 years and 90% within 5 years 6 1. Health Canada. Canadian National Report on Immunization, 1996. CCDR 1997;23S4. 2.Public Health Agency of Canada. Final Report of Outcomes from the National Consensus Conference for Vaccine- Preventable Diseases in Canada. CCDR 2007;33S3:1-56. 3. Canadian Immunization Committee. Recommendations on a human papillomavirus immunization program. Ottawa, ON: Public Health Agency of Canada; December 2007.

7. www.oahpp.ca Methods June 2013: PHUs contacted to request coverage data Immunizations received as of June 30, 2013 entered into the Immunization Records Information System (IRIS) Coverage was expressed as the proportion of enrolled students who were assessed to be “complete for age” using IRIS logic Assessed for each antigen and birth cohort Data validation with PHUs for 2010/11 to 2012/13 data PHU-specific data compiled to derive provincial estimates Temporal trend data Historical IRIS data with the exception of survey in 2011/12; Supplementary data on HPV via survey methodology (2007/8 to 2009/10) 7

8. www.oahpp.ca Ontario Hepatitis B immunization coverage: 2007/08 to 2012/13 8

9. www.oahpp.ca Ontario adolescent meningococcal immunization coverage: 2007/08 to 2012/13 9

10. www.oahpp.ca Ontario HPV immunization coverage: 2007/08 to 2009/10 10 1 Wilson SE, Harris T, Sethi P, Fediurek J, Macdonald L, Deeks SL. Coverage from Ontario, Canada's school-based HPV vaccine program: The first three years. Vaccine. 2013 Jan 21;31(5):757-62. doi: 10.1016/j.vaccine.2012.11.090. Epub 2012 Dec 13 1

11. www.oahpp.ca School-based immunization coverage: 2007/08 to 2012/13 11

12. www.oahpp.ca Limitations Coverage estimates reported here do not include extended eligibility doses, with exception of HPV vaccine coverage survey Likely underestimates true program uptake Completeness of denominator data Mismatch between program eligibility (grade-based) and coverage calculation (age-based) Coverage reports not specific to vaccine products Men-C vaccine versus MCV4 12

13. www.oahpp.ca Conclusions School-based immunization delivery is an effective platform to achieve high immunization coverage Ontario’s coverage estimates meets national coverage target for meningococcal conjugate Direction of recent trends encouraging for HPV and Hepatitis B New information system (Panorama) presents opportunities for more detailed assessment of coverage and analysis of predictors of uptake 13

14. www.oahpp.ca Acknowledgements VPD managers and staff at Ontario’s 36 Public Health Units Immunization coverage team at PHO Dr. Shelley Deeks Jill Fediurek Tara Harris Gillian Lim Margaret McIntyre Chi Yon Seo Immunization Policy and Programs Section of the Ontario Ministry of Health and Long-Term Care 14