Modernization of Canada

1
Modernization of Canadas Yellow Fever
Vaccination Program

• Manitoba 6th Annual Travel Health Conference
• Dr. Denise H. Werker
• Migration and Travel Health

2
Modernization of Canadas Yellow Fever
Vaccination Program

• Objectives
• Meet obligations of International Health
  Regulations (2005)
• Better address Canadian context
• Facilitate entry and exit of Canadians requiring
  proof of yellow fever vaccination at
  international borders

3
International Health Regulations (2005)

• Purpose and scope
• Prevent, protect against and control the spread
  of disease
• Provide a public health response to the
  international spread of disease restricted to
  public health risks
• Avoid unnecessary interference with international
  traffic and trade

4
International tourist arrivals by region,
1950-2006
5
International Health Regulations (2005)

• Currently, yellow fever is only disease for which
  proof of vaccination can be required for
  travellers as a condition of entry into a country
  
• But
• Other requirements for vaccination/prophylaxis
  could be added to Annex 7
• Temporary recommendations for vaccination/prophyla
  xis in context of public health emergency of
  international concern

6
International Health Regulations (2005)

• State Parties shall designate specific yellow
  fever vaccination centres within their
  territories in order to ensure the quality and
  safety of the procedures and materials employed.
  
• IHR(2005) Annex 7, paragraph 2f

7
International Health Regulations (2005)

• Persons undergoing vaccination or other
• prophylaxis under these Regulations shall
• be provided with an international certificate
• of vaccination or prophylaxis
• IHR(2005) Annex 6, paragraph 2

8
International Health Regulations (2005)

• Country may require a traveller coming from an
  area with risk of yellow fever transmission to be
  quarantined or placed under surveillance
• Traveller is unable to produce a valid
  certificate of vaccination against yellow fever
• Until the certificate becomes valid
• Until a period of not more than six days
• Vaccination contraindicated on medical grounds
• Health care practitioner should provide person
  with documented reasons
• Authorities on arrival should take into account

9
Canadian Context

• Obligations of IHR(2005) are shared F/P/T
  responsibility
• Canada must designate yellow fever vaccination
  centres
• Purpose of designation is to ensure quality and
  safety of procedures and materials
• Existing mechanisms help achieve this purpose
• Federal Food and Drugs Act and Regulations
• P/T regulation of health care workers and
  provision of health care services

10
Canadian Context

• No national or provincial/territorial standards
  for training and certification in travel health
• Provision of travel vaccines is an uninsured
  health service in all provinces and territories
• Only one yellow fever vaccine authorized for sale

11
Changing Canadian Environment

• More Canadians travel more frequently to
  destinations previously considered exotic
• More health care clinics staffed with
  multidisciplinary teams rather than solo medical
  practitioners
• Scopes of practice of health care professionals
  have evolved

12
Canadian tourists returning from countries other
than the United States, 1972-2006
13
Modernization of Canadas Yellow Fever
Vaccination Program

• Short term
• Interim designation process that meets IHR(2005)
  requirements but better addresses current
  Canadian context
• Long term
• Development and implementation of a pan-Canadian
  approach to yellow fever vaccination in
  collaboration with P/T and other stakeholders

14
Designation of Yellow Fever Vaccination Centres
in CanadaInterim Process

• Requirements for initial designation
• Nominated health care practitioner
• License to practice is in good standing
• Authorized to administer yellow fever vaccine
• Responsible for policies/procedures related to
  safe and appropriate administration of yellow
  fever vaccine
• Appropriate and current reference resources
  available
• Capacity to maintain cold chain
• Receipt of completed application form and other
  documents

15
Designation of Yellow Fever Vaccination Centres
in CanadaInterim Process

• Requirements to maintain designation
• Nominated health care practitioner
• Restrict use of PHAC-issued International
  Certificates of Vaccination or Prophylaxis and
  PHAC stamps
• Appropriately complete International Certificates
  of Vaccination or Prophylaxis and documentation
  for medical contraindication
• Annual submission of completed application form
  and other documents
• Inform PHAC of any administrative changes

16
Yellow Fever Vaccination Centres in Canada by
Province/Territory March 2008
N241
Excludes DND clinics
17
International Certificate of Vaccination or
Prophylaxis
18
Certificate of Medical Contraindication to
Vaccination
19
Challenges International Certificate of
Vaccination or Prophylaxis

• No international guidelines for completion
• New information needed for completion
• Nationality
• National identification document
• Any amendment, or erasure, or failure to
  complete any part of it, may render it invalid
• IHR(2005) Annex 7

20
ChallengesCountry Entry Requirements

• WHO information does not constitute an
  endorsement or confirmation that requirements are
  in accordance with provisions of IHR (2005)
• May be triggered by visa requirements
• Political or economic considerations
• Government capacity and intradepartmental
  coordination
• Foreign Affairs, Health, Border Control

21
Yellow Fever VaccinationRequirements and
Recommendations

• Prevent international spread of disease by
  protecting countries from risk of importing or
  spreading yellow fever virus
• Mandatory requirements established by country
• Protect individual travelers who may be exposed
  to yellow fever infection
• Lack of country requirement ? Lack of risk

WHO. 2008. International Travel and Health
22
Map Countries at risk for yellow fever
transmission
Risk of Transmission of Yellow Fever
WHO. 2008. International Travel and Health
23
Simplified Risk Analysis
RISK OF YELLOW FEVER RISK OF YELLOW FEVER
YES NO
COUNTRY ENTRY REQUIREMENT YES Benefit of vaccine outweighs risk Risk of vaccine outweighs benefit
COUNTRY ENTRY REQUIREMENT NO Vaccine recommended Vaccine not recommended
Individual risk assessment always needed!
24
Moving Forward

• On-going partnership with stakeholders to
• Secure continued access to yellow fever vaccine
• Provide up-to-date, reliable and verified
  information about country entry requirements
• Define yellow fever vaccination centres in a
  Canadian context
• Establish processes for efficient introduction of
  other vaccines or prophylaxis as required under
  IHR (2005)
• Establish best practices in the implementation of
  required vaccination or prophylaxis under IHR
  (2005)

25

• Need more information?
• Contact yfinfofj_at_phac-aspc.gc.ca

26
Serious Adverse Events

• Neurologic
• Encephalitis
• Guillain-Barré syndrome
• Viscerotropic
• Febrile multiple organ system failure
• Onset 2 to 5 days after vaccination
• 0.3 to 0.4 per 100,000 vaccinated persons

27
Reported Adverse Events Following Yellow Fever
Vaccine in CanadaJanuary 1, 1987 September 30,
2007

• 390 reports
• 166 (43) following yellow fever vaccine alone
• Mostly mild and self-limiting
• 2 cases of Guillain-Barré syndrome
• 8 cases of anaphylaxis
• 0 deaths