Doctors fail to report on vaccines, audit says
By Stanley Tromp, Vancouver Sun, 14 Aug 2006
Many B.C. doctors are not reporting on the children they immunize, and children could be at risk of an "outbreak of vaccine preventable diseases" if immunization rates drop too low due to health workers who disparage vaccinations to parents, a government audit says.
A November 2005 audit by the B.C. comptroller general's office says some doctors are failing to provide the proper paperwork necessary to track vaccinations, an issue that makes it difficult to know whether enough children are receiving key vaccinations in large enough numbers.
"There is concern that the partners may not be coordinating their activities sufficiently to ensure success of the program," notes the audit, obtained through the Freedom of Information Act.
"There is concern that B.C. could experience an outbreak of vaccine preventable diseases, if two-year-old immunization rates are too low."
The B.C. Centre for Disease Control recently completed an immunization survey for two-year-olds, and found that the immunization rates were lower than agreed performance targets, the audit said.
In fact, the audit warns that two of the province's five health authorities -- Vancouver Coastal Health Authority and the Fraser Valley Health Authority -- didn't provide adequate immunization records for children under two.
"At the time of the fieldwork," the audit says, "two of the HAs in B.C. did not monitor and report their two-year-old immunization rates, mainly due to non-reporting physicians."
"The [three other] health authorities that were able to report immunization data were not meeting their performance agreement target of 85 per cent, and rates reported had declined from prior years," the audit said
In the Fraser Valley and Vancouver Coastal health authorities, a significant proportion of immunizations are not captured in B.C.'s central registry, causing immunization rates to be inaccurate and often understated.
"Non-reporting physicians maintain that they are too busy and find the process for reporting to the PH [public health] unit time- consuming."
But Dr. John Blatherwick, chief medical health officer for the Vancouver Coastal Health Authority, and Dr. Perry Kendall, B.C. provincial health officer, disagree with the audit's conclusions. They say database systems are being upgraded and the overall vaccination program is working well, with the child immunization rate in B.C. -- for diseases such as polio, measles, rubella, influenza, chickenpox, and others -- stable or rising.
"I do not think this is true," Blatherwick said of the audit's findings, adding that he believes children are getting vaccinated even if reporting is poor.
"The level of children with all but one booster shot does not put us at a risk of these vaccine preventable diseases breaking out and the track record in B.C., Vancouver and North America shows this to be true."
Blatherwick said doctors have occasionally been required to fill out paperwork about immunization only to see the data unused.
"We've collected that data before, and let it sit -- and, by the way -- with no major outbreaks because of not having data in the past 22 years."
The audit even cautioned that demanding VCHA physicians to report on their work could lead to their stopping immunization entirely: "The VCHA has not required physicians to report immunization records to PH units because of concerns that mandatory reporting would result in physicians withdrawing immunization services."
The Vancouver Coastal Health Authority is moving to a new database system, and Blatherwick said the VCHA will probably require reporting when the new system is fully running, "but I'm not spending scarce resources on clerical staff to input data that won't really be used."
Asked if there was any risk to the public of the rates being under-reported, Blatherwick replied: "None that I am too concerned about. . . . Registers are for the bureaucrats -- immunizations are what public health people are interested in."
Kendall said in an interview that under-reporting true immunization rates is relatively less harmful than over-reporting them, although it could result in vaccines being sent to areas where they really aren't needed.
Kendall said possible payment for reporting is now being discussed among doctors and government for the B.C. Medical Association's updated master agreement with physicians.
Blatherwick said if reporting immunized patients' names is important, the government could set a Medical Service Plan fee for immunizations and collect the patient's data through MSP, but "MSP has repeatedly said no." He added that the new B.C. Health Act, now in draft discussion stage, might deal with the reporting issue.
Kendall said another effective way to gather the rates is through the random surveys of children that health authorities have been doing regularly for years.
Yet he said the reporting system has become more complex with the recent addition of four new vaccines. For that reason, the federal government has provided $100 million for a national health Infoway database, which would include immunization records. The B.C. Health Ministry is working to integrate its own health databases, then perhaps merge them with the Infoway, Kendall said.
The audit also noted there is poor sharing of immunization records between provinces and their databases.
"This can lead to potentially significant omissions from and duplications of records in the registries," the audit said.
"For example, new residents to B.C., or B.C. residents that obtain immunization services from the First Nations and Inuit Health Branch, may be excluded from the registries."
The audit also noted several other factors that could impair immunization rates.
"We were also advised that other health care providers displayed a negative approach to immunization or did not appear to fully support immunization. These attitudes displayed by health care providers may discourage parents, causing them to delay their child's immunization schedule or choose not to immunize their child at all."
Kendall explained that a minority of B.C. health providers, such as some nurses, naturopaths and chiropractors, do not believe in vaccines.
As one example, "B.C.'s rate of flu uptake vaccinations is much lower than it ought to be. We hope there aren't any physicians out there who have doubts about it. If we hear about providers who give out misinformation about vaccines, we try to educate them."
The audit said some parents object to immunizing their children for moral or cultural reasons.
"While PH units and physicians may offer immunizations, families are not forced to participate. The ministry and its partners generally feel that resources would be better sent elsewhere, than trying to persuade conscientious objectors of the benefits of immunization," the audit said.
"However, the ministry and its partners can still track identified conscientious objectors through their registry systems so that if an outbreak occurs, the information is available to identify the areas at greatest risk."
Kendall also said the vaccination rate might be slowed down slightly by the fact that the newly formed College of Registered Nurses requires nurses to be certified to provide vaccines to children. "My personal opinion is that nurses who were perfectly capable of giving shots before then had to re-train and be re- certified, which I think was unnecessary bureaucratization."
"Overall, the child immunization rates in B.C. are stable or rising, but there are still too many non-immunized children today," said Kendall.
"That's partly because people have lost confidence in some of the vaccines, and partly because we haven't seen many of these illnesses appear."
The audit also said that health authorities with large immigrant populations are facing additional challenges, including translating foreign immunization records and entering them into their registry systems.
"As there is no requirement for new immigrants to provide immunization records until their child enters the school system, some of the new immigrants may not be vaccinated in compliance with B.C.'s recommended immunization schedule. Further, new immigrants may not be aware of opportunities to access immunizations in B.C. They may also be excluded from the immunization registry system if they have not contacted a PH unit."
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