The past year has seen confirmed outbreaks of measles across in British Columbia, Alberta, Saskatchewan and Ontario.

Measles is highly contagious, and can lead to serious complications and death for children under the age of five. It is strongly recommended by the Public Health Agency of Canada that children are routinely vaccinated against measles through two doses of the MMR (measles-mumps-rubella) vaccine.

While vaccines protect the individuals who have been vaccinated, they can also help protect a community from the spread of infectious diseases when over a certain threshold of the population has been vaccinated. This concept is known as ‘herd immunity’, and provides protection for those who are not yet vaccinated.

The routine vaccination schedule varies among provinces and territories, with children receiving vaccinations from the age of about 2 months up until six years.

However, not all children are vaccinated. Some have medical conditions, such as allergies to some vaccine components or immune disorders. However there are growing numbers of parents choosing not to vaccinate their children for ideological or religious reasons.

A 2010 Ontario study found that the rate of students with exemptions for school entry vaccination is less than 2 percent, although it noted rising rates of non-medical exemptions amongst children born since 1998. This was the year that the Lancet published a (now refuted) study linking the MMR vaccine to autism. Although the study was based on fraudulent data, it received widespread media attention and publicity, and is described as sparking “an international crisis of confidence in the safety of the MMR vaccine”

Only three Canadian provinces have mandatory school entry vaccination laws

Schools are a particularly important setting where infectious diseases can be passed among children.

In Canada only Ontario, Manitoba and New Brunswick have legislation that mandates children be vaccinated in order to attend school. The Ontario and New Brunswick legislation, both of which have been in place since 1982, are quite extensive and require school children to be vaccinated against diseases like diphtheria, tetanus, polio, pertussis (whooping cough), measles, rubella, mumps, varicella (chicken pox) and meningococcal disease. The Manitoba legislation only requires school children be vaccinated against measles.

However, in each province with mandatory school entry laws there are exemption clauses for children who are not vaccinated due to medical, religious or ideological reasons. To opt out, parents must sign and notarize an affidavit with a statement of these beliefs. Statements of medical exemptions must be provided to schools by a physician or nurse practitioner.

Judy MacDonald, Medical Officer of Health for Calgary notes that Alberta has no legislation in place to mandate that children show proof of vaccination to enter school. However, she highlights that the province’s Public Health Act requires that in an outbreak “the Medical Officer of Health must exclude children at schools if they aren’t immune to measles [have not received the measles vaccine].”

The Alberta approach is in line with the Public Health Agency of Canada’s guidelines around managing a measles outbreak. The guideline states that during a measles outbreak, those who refuse or cannot receive the MMR vaccine “may be excluded from childcare facilities, schools and post secondary educational institutions at the discretion of the Medical Office of Health.” This exclusion period is meant to quarantine the non-vaccinated child and to reduce the chances that she or he will catch or transmit the infection to others.

However, given recent measles outbreaks there has been debate – and demand from some parents – that school entry vaccination requirements should be put in place in those provinces and territories that do not have them.

Kumanan Wilson, a general internist and Chair in Public Health Policy at the Ottawa Hospital Research Institute, notes that there tend to be two groups of parents who are choosing not to vaccinate their children.

The first are those who have a belief strongly opposing vaccinations, and who will seek out exemptions to the mandatory requirements. He says that the second group is best described as ‘vaccine hesitant’ parents who either “delayed or forgot about their children’s vaccination” and suggests that it is among these parents “where mandatory policies can have an influence.”

‘Vaccine hesitancy’ among Canadian parents

A 2011 report to the Canadian Public Health Agency of Canada surveyed parents’ attitudes towards vaccines. It found that while nine in ten parents believe childhood vaccinations in general are effective and important for their child’s health, 35% expressed concerns about the safety of vaccines and half of parents reported speaking to a health care provider regarding their worries about vaccination.

In 2013, the Canadian Pediatric Society released guidelines to help clinicians have evidence-based conversations with parents who are hesitant or have safety concerns about vaccines.

A Healthy Debate series published in September 2012 noted that these concerns have translated into decreasing vaccination rates for Canadian children with public health officials finding communicating the benefits of vaccines to parents a challenge. The series also highlighted that there are significant information gaps about vaccination rates, and outbreaks of vaccine-preventable infectious diseases in Canada.

Catherine Mah, a pediatrician and Assistant Professor at the University of Toronto Dalla Lana School of Public Health says that “more surveillance data breaking down the populations who are not getting vaccinated, or opting out of vaccination policies would be helpful for prevention and planning.” She notes that in the United States there is a centrally coordinated national immunization registry through the US Centre for Disease Control that tracks vaccination data of children across the country.

Experts have highlighted that unlike Canada, all American states have laws (with some variation around specific vaccinations) that mandate children entering school to provide proof of vaccinations. However, studies have shown that there has also been an increase in non-medical exemptions from vaccination requirements in the United States.

In spite of growing exemption rates – seen among populations with strong ideological or religious beliefs – Wilson still sees these laws as an effective tool, in particular for vaccine hesitant parents, or those who forgot or neglected to vaccinate their children according to the schedule. He notes that for some, the mandatory school entry vaccination policies can be “a fail safe mechanism for those who fell through the cracks.”

Can exclusion policies effectively contain outbreaks?

Wilson also questions the value of exclusion policies in curbing the spread of infectious diseases. He says that for measles in particular “which is among the most infectious of the vaccine preventable diseases, it is too little too late, and by the time children are taken out of the school they would have already spread the disease.”

There are significant logistical challenges associated with enforcing exclusion policies and accessing documentation during an outbreak to demonstrate that children have received the two doses of the MMR vaccine. Judy MacDonald says that trying to ascertain proof of vaccination for all students in a school is “very labour intensive and time sensitive.”

Mah highlights that when an outbreak occurs, and responsibility to manage outbreaks and enforce exclusion policies is “decentralized to local authorities such as public health units” as is the case in Alberta, strong communication is needed to coordinate and manage the situation.

In Alberta there has been a great deal of media and public attention around the recent measles outbreak with regular updates on the location of measles cases and outbreaks.

Raphael Sharon, an Edmonton pediatrician notes that he speaks to parents “everyday about the safety and efficacy of these vaccines.” He suggests that growing public concern and conversation about measles has influenced parents who are vaccine hesitant. He suggests that “because of the measles outbreak, more parents are bringing in their kids to get vaccinated.”

Concerns about the ability of exclusion policies to contain outbreaks have motivated some parents to call on provincial governments to add mandatory vaccine legislation.

The ethics of mandatory vaccinations for children

In British Columbia, a group of parents have received media attention for starting a petition calling on Premier Christy Clark to introduce mandatory school entry vaccination requirements.

The petition argues that “as of right now schools do not ask if your child is vaccinated. Which means they have no idea how many are covered in their school …If they have this information they will know if someone is putting everyone (including their own child) at risk by ignoring the policy to stay home during an outbreak.”

Perry Kendall, the Chief Medical Officer of Health in BC has been quoted in the media that while he “supports the intentions of the petition” he does not believe that “making vaccinations mandatory is a way to achieve that aim.” Kendall notes that outbreaks in BC have been concentrated amongst certain congregations of anti-vaccination religious communities, and that these communities would be best served by education around the benefits of vaccination, rather than mandatory laws.

Healthy Debate has covered the issues of the ethics and politics of mandatory vaccinations for health care workers. In the case of children, there are challenging and value-based issues related to who has the right to decide whether children should be vaccinated – parents or the state.

Parents who are hesitant about vaccinations are often “trying to balance a decision between perceived risks of harm of a vaccine, and the risks of the actual disease” says Mah. She notes, however that this “very personal set of choices does influence other people’s children.”

Studies have found that children with non-medical exemptions are at increased risk of acquiring and transmitting vaccine preventable diseases. Measles outbreaks tend to occur in schools with more unvaccinated children, and unvaccinated children are 35 times more likely to contract measles as their vaccinated peers.

Kumanan Wilson says “there is no easy answer here and you have to respect an individual’s rights – however, when it is in relation to children, and other children are being put at risk, that is when tension arises.”

“Vaccination is a moral and social obligation on all of us so that we can protect those who can’t” says Raphael Sharon. When speaking to parents about vaccinating their children, he stresses that “not vaccinating doesn’t just pose potential health risks to your child, but also to those who can’t defend themselves from infectious diseases – in particular children under 12 months who haven’t yet received the MMR vaccine, and immunocompromised patients of any age. These vulnerable people count on the so-called herd immunity for protection.”

Should all provinces and territories have mandatory school entry vaccination laws? Yes

No