As our minds turn to back-to-school, it is urgent to increase Canada’s COVID-19 vaccination rates among young people.

Currently eligible children (12-17) and young people (18-29) have the lowest rate of vaccination of any age group in the province: 49.2 per cent of 12- to 17-year-olds and 56.2 per cent of 18- to 29-year-olds have received two vaccinations.

Many universities have decided not to make vaccination mandatory but to encourage it. Ontario’s back-to-school plan for viral safety does not include mandating COVID-19 vaccines for eligible students and staff, prompting criticism from some health experts.

The experience with Ontario’s current compulsory school immunization for other diseases shows there are advantages and disadvantages of requiring vaccination. Mandating vaccines for school attendance may not be the best way to increase vaccination rates for COVID-19.

Ontario’s 1982 legislation

Ontario is one of only two provinces in Canada that requires students to have up-to-date vaccinations in order to attend school. The other is New Brunswick.

Ontario’s legislation has been in place since 1982, and currently requires that students be inoculated against nine diseases including mumps, measles, diphtheria and polio. Children who are not vaccinated can be suspended from school for up to 20 days, and their parents can be forced to pay fines of up to $1,000.

There are exemptions for medical, religious and philosophical reasons. The total number of exemptions is small (1.8 per cent among seven-year-old students in 2012-13), although the number of exemptions for religious and conscientious reasons is rising.

Of even more concern is the fact that exemptions are geographically concentrated. An epidemic could race through a school where many parents have sought exemptions.

Parents who chose to object for conscientious reasons are now required to attend a vaccine education session. The National Post reports that according to a survey it did of Ontario’s province 35 health units, this education is ineffective in changing parents’ minds.

Measles rates, U.S. example affected legislation

A vaccine against the measles was first used in Canada in 1964, and after that rates of the disease fell substantially. But measles infections fell even faster in the United States, where many states passed laws requiring vaccinations to attend school.

By 1980, all U.S. states required immunization for school attendance. In 1979, as rates in the U.S. continued to fall, Canada experienced a significant outbreak with over 20,000 infections across the country. But vaccine mandates were not the only reason why measles rates were falling more rapidly in the U.S.

Vaccination rates in Canada were fairly high. In some provinces, more than 90 per cent of children were immunized by the time they went to school. But not all Canadian children were fully protected against the measles despite having received their shots.

In the early years of the measles vaccination program, a killed virus was often used, but this turned out to be less effective than the live virus. Also, physicians often administered half doses of the live vaccine to conserve the supply. The killed virus vaccine was only used in the U.S. for one year, but it was used in Canada for four years, particularly in Ontario and Alberta.

During the 1979 epidemic in Alberta, 78 per cent of the students infected with the measles had a documented history of being vaccinated against the disease. Despite this, public health officials in Canada looked at the American success at reducing measles and recommended similar measures be taken here. In 1981, the Canadian Paediatric Society called for mandatory measles vaccinations.

In 1982, three officials at the Department of National Health and Welfare in Ottawa published an article in the Canadian Medical Association Journal, saying that the U.S. experience showed that “more can and must be done.” They recommended that provinces enact compulsory measles vaccination programs.

Did compulsory vaccination work?

There was a significant uptick in vaccination rates in Ontario schools in the years following the introduction of the vaccine mandate. From 1983 to 1984, the number of vaccinated children in grades 1-6 increased from 92 per cent to 95 per cent. For high school students, the results were more dramatic. Vaccination rates increased from 53 per cent in 1983 to 87 per cent in 1984.

But vaccine compulsion also hardened opposition to vaccination. While there had been anti-vaccine groups in Ontario in the early decades of the 20th century, these groups had disappeared before the Second World War.

The passage of the 1982 legislation spurred the formation of the Committee Against Compulsory Vaccination, which lobbied for exemptions to be extended to people who objected to vaccination for reasons of conscience, not just religion. The legislation was amended accordingly in 1984. Anti-vaccination advocates have continued their fight against the legislation ever since.

Provincial comparisons

Nor has the vaccine mandate resulted in elevated rates of vaccination in Ontario compared to provinces without vaccine mandates. According to the 2017 Childhood National Immunization Coverage Survey, two-year-old children in Alberta and Newfoundland are significantly more likely to be fully vaccinated than Ontario children. New Brunswick, the other province with a vaccine requirement for school entry, is similar to the countrywide average.

The Childhood National Immunization Coverage Survey only provides countrywide data on the vaccination status of seven-year-olds. But data from Public Health Ontario suggests that seven-year-olds in Ontario are slightly more likely to be vaccinated than their peers in other provinces.

Ontario vaccination rates against measles, mumps and rubella are very similar to national averages, but Ontario children are slightly more likely to be vaccinated against tetanus (85.8 per cent compared to 80.5 per cent), and pertussis, popularly known as “whooping cough” (85.7 per cent compared to 80.5 per cent).

Other ways of improving vaccination rates

A 2015 report by the C.D. Howe Institute argued that relatively few parents are actively opposed to vaccination. Instead, “barriers to access, complacency or procrastination” are more important.

The institute recommended adopting Ontario’s policy of forcing parents to make a deliberate choice about vaccinating their children along with elements of Alberta’s early intervention. Alberta makes extensive use of public health nurses at community health centres.

Public health nurses reach out to parents after their children are born to talk to them about health services, including immunization. If a child is not immunized by the time they reach two months of age, the nurse calls the parents or sends them a letter to remind them. Up to three calls are made to ensure vaccination.

While mandating vaccines for children in school holds the promise of increasing vaccination rates, for now, it seems prudent to increase access and education around vaccines to encourage uptake.