A total of 5,063 public elementary students were suspended in Toronto this school year after getting caught in what one doctor called, a “1970s-style, cumbersome process” over immunization records.

The number of students suspended amounted to 7 per cent of the 73,262 elementary students in 586 Toronto public elementary schools assessed by Toronto Public Health from July to mid-December 2017. That’s a jump from 5.6 per cent last year.

“All of the students who were suspended either didn’t meet the immunization requirements as they were not up-to-date, their records were not filed on time, or they did not have a valid exemption,” said Dr. Vinita Dubey, associate medical officer at Toronto Public Health.

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All the students are back in school and up-to-date on their immunizations, said Dubey.

Immunization requirements changed this year for children born in 2010 (currently Grade 2 students), said Dubey, who now require two doses of varicella vaccine (for chicken pox) to attend school under the Immunization of School Pupils Act.

It is estimated that the varicella vaccine in children will offer 85 per cent protection after the first dose and 98 per cent after the second dose, said Ontario Ministry of Health spokesperson Laura Gallant in an email.

“As a result of this change, the number of Grade 2 students who were outstanding was higher than previous years,” said Dubey.

Last year, 46,726 elementary students were assessed in 584 schools; 2,622 (5.6 per cent) students were suspended.

Upon initial assessment, 25,653 of the assessed students were found to have out of date immunization records, and a first notice was sent to parents. A second notice was sent to 18,622 students three weeks later. A suspension order was then sent to 11,974 students, letting their parents know the date that their child would be suspended if Toronto Public Health did not receive updated information.

“The number of suspensions depends on the number of students who are assessed,” said Dubey, adding that not all students are assessed each year.

“We increase the numbers to match our staff capacity to handle the volume of work generated,” said Dubey.

Dr. Fatima Kamalia, a Thornhill-based pediatrician, has noticed an increase to the number of kids coming in for “emergency vaccination.”

“Those that get the (suspension)…they’re the ones that just missed the (deadline),” said Kamalia. “It’s more negligence on the parent’s part, not a deliberate decision to not vaccinate.”

Kamalia said that part of the problem is that there’s no system for doctors to remind parents about their kid’s immunization, and no system for parents to keep updated about it.

“No one has a record of (vaccination shots) except the hospital,” she said. “There’s no system that allows access of data by hospitals, public health, schools, and physicians.”

In Ontario, all parents and guardians of children attending elementary and secondary school must provide their local public health unit with proof of their child’s immunization against a number of vaccine-preventable diseases or a valid exemption.

Currently, Toronto Public Health is using a system called Panorama to input immunization information provided to them by parents and guardians.

Parents are sent at least two to three letters to inform them about the need to obtain updated immunization information prior to the deadline, and given a couple of weeks to respond to each letter.

If, after this time, students remain not in compliance, they are suspended until proof of vaccination is provided.

“The majority of suspensions last less than 5 days and most are resolved on day 1 to 3 of the suspension period,” said Dubey.

In 2014, the provincial auditor general’s report program found that the current reporting practice with Panorama “continues to result in problems with data accuracy and completeness” because it doesn’t allow for direct input from health care providers.

In December 2015, the province released a long-term vaccination plan called Immunization 2020, and said it would look at ways to streamline the reporting process to possibly allow physicians and parents to input information directly.

“The (Immunization of School Pupils Act) is over 20 years old and parents and guardians are considered the primary reporters of immunization records to public health,” said Dubey.

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One of the main challenges continues to be that “no one knows the requirements or has access to (immunization) records,” said Kumanan Wilson, an immunization specialist at the Ottawa Hospital Research Institute.

Wilson is helping create a national immunization app called CANImmunize, and aiding the Ontario government in developing a web tool called Immunization Connect Ontario (ICON) (or Digital Yellow Card) for the public to securely look up their immunization records and report it to the Digital Health Immunization Repository.

“I think the use of the paper record is very problematic,” said Wilson. “The advantage of having it through the app is people will know exactly what the requirements are ahead of schedule.”

Ontario, he said, is one of two provinces that require immunization records for school entry; the other is New Brunswick. “The entire responsibility is on the parent to report,” said Wilson. “That has to change.”

Despite the attempt at modernization, Dr. Hirotaka Yamashiro, president of the Pediatrician Alliance Ontario, says the system continues to be “a real mess.”

“We still right now are relying on people having a yellow card that is kept up to date,” he said, adding that only works if the yellow card is never lost and kept on the person at all times. But that’s not always the case.

“It’s so cumbersome,” he said. “It’s laughable in 2018 that we can’t keep track of people’s vaccines. It’s crazy.”

Yamashiro, too, has noticed many parents receiving suspension letters for their kids and finds that it is often the only way they are motivated to update immunization records.

While he sees the government trying to centralize the vaccination system, the responsibility is still on the parents to deal with a system that “is frustrating for everybody.”

“(The system) is pretty complicated,” said Yamashiro. “Parents, without any medical knowledge, have to update (their kids’ records online) based on what’s on their yellow card…people will make mistakes, and Public Health will get mistaken information.”

Yamashiro would instead like to see the government have more conversations with family doctors and pediatricians, who do the vaccinations, and first fix the central database.

“Pediatricians are always ready to meet them if they want to,” he said. “If that central database is poor, it doesn’t solve the basic problem.”

Wilson too notes that even if the Digital Yellow Card becomes fully operational, “(the Ministry of Health) have to develop a system whereby the system can easily flow and move that data” from parent to doctor to public health to school.

At present, Toronto Public Health is assessing the vaccine records for students from 143 public high school students. Suspension for high school students will begin in the spring.

“There’s negligence and a lack of understanding of vaccines,” said Kamalia. “And gaps in the system.”

Yamashiro agrees. ““It’s too bad because it’s the kids and parents that are caught in a 1970s-style cumbersome process.”