Modernization of Canada’s Yellow Fever Vaccination Program

1. Modernization of Canada’s Yellow Fever Vaccination Program Manitoba 6th Annual Travel Health Conference Dr. Denise H. Werker Migration and Travel Health

2. Modernization of Canada’s 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/prophylaxis 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 Canada’s 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 N=241 *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* *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@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