Vaccines - Part II: The requirement to vaccinate children attending school

In my last post, I wrote about the origins of vaccines and the risk-benefit comparison between them and other types of medications. This post will focus on the requirement for children to be vaccinated before attending public school in Ontario.

In Ontario, the Immunization of School Pupils Act ("IPSA") requires proof of immunization against "designated diseases" before being admitted to elementary or high schools, unless they are exempt.

The designated diseases are (IPSA s. 1 “designated diseases” + O Reg 261/13):

• Diphtheria;
• Measles;
• Mumps;
• Poliomyelitis;
• Rubella;
• Tetanus;
• Meningococcal disease;
• Pertussis;
• Varicella.

There are exemptions for:

• Statement of conscientious or religious objection provided by the parents;
• Statement of medical exemption provided by a physician or RN;
• Evidence of immunity.

In Toronto, the average exemption rate is 2%, however, the Toronto Star reported in 2014 that some Toronto schools have vaccination exemption rates as high as 40%, well below the level required for herd immunity.

Risk of Outbreak

If a child has been exempt from the immunization requirements and there is a "risk of outbreak", public health can exclude people who are not vaccinated from school unless they have lab evidence of immunity.

Amending the Immunization of School Pupils Act

Ontario plans to amend IPSA, as described in this excellent Ontario Bar Association article:

• Clause 2(3) of the Immunization Bill would require a parent who seeks to exempt his or her child from an immunization to attend “an immunization education session” in addition to filing a statement of conscience or religious belief with the appropriate medical officer.
• Notably, clause 2(4) grandfathers in those parents who filed the statement of conscience or religious belief 
• Clause 4 would render the delivery of the immunization statement far more straightforward.  Instead of merely providing the parent with a statement that the immunization has been administered, “[e]very physician, nurse or prescribed person who administers an immunizing agent” would in addition directly report this information to the medical officer of health.
• The reporting mechanism in the province would thereby become considerably more efficient, as the medical professional involved rather than the parent would shoulder the responsibility of reporting the child’s immunization.

When I was on the board of directors at my daughter's daycare there was a measles outbreak in Toronto. Toronto Public Health sent letters to all of the parents saying that if our children were not yet vaccinated (either due to an exemption or because they were too young for their second dose) against measles, they could be prohibited from attending the daycare until the risk abated.

The board of directors considered implementing a policy that would require all children to be vaccinated (at the time daycares were covered by legislation similar to IPSA). I suggested that to do so without any exemptions would potentially put the daycare into conflict with the Ontario Human Rights Code. For example, if a parent decided not to vaccinate their child for religious reasons, the daycare could be held liable for discrimination on the grounds of religion due to adverse effect that the policy had.

As I previously wrote about the Human Rights Code, the Code prohibits discrimination on a number of grounds. The two that could be at issue here are religion and disability. Another potential issue would be discrimination on the grounds of conscience, however, this is not a protected ground under the Ontario Human Rights Code, as seen in this case at the Human Rights Tribunal of Ontario, which found that a paramedic was not discriminated against for refusing to get vaccinated because it was against his firmly held but non-spiritual beliefs: Ataellahi v. Lambton County (EMS), 2011 HRTO 1758 (CanLII). It is a protected ground under s. 2(a) of the Canadian Charter of Rights and Freedoms.

All of this is to say that for a private organization, the concerns are for those that cannot be vaccinated due to a medical condition or due to religious reasons, but if the government is changing the law, they would need to consider conscious as a potential ground of discrimination.

Ultimately, the daycare decided to take my recommendations under consideration, but my daughter was no longer attending the daycare by the time the decision to change the policy was made. My recommendation was to demonstrate that there would be undue hardship to accommodate religious exemptions in the form of unacceptable compromise in safety if herd immunity were diminished. 

My recommendation was to implement the following policy:

All children, staff, and volunteers (“Person” / “People”) at the Daycare must be immunized against the diseases listed in the most recent version of Immunization of School Pupils Act, RSO 1990, c I.1 (“Designated Diseases”).

Currently, the Designated Diseases that must be immunized against are:

1. Diphtheria
2. Tetanus
3. Polio
4. Measles
5. Mumps
6. Rubella
7. Meningococcal Disease
8. Pertussis (whooping cough)
9. Varicella (chickenpox)

Any Person that does not show proof of immunization against the Designated Diseases will not be permitted to attend the Daycare unless they provide a “Statement of Medical Exemption” as described in Section 1 of the Immunization of School Pupils Act. The only exceptions to this policy are for religious or conscientious objection. Even then the Daycare will only permit such a Person to attend if allowing the exemption will result in a total number of unvaccinated People of fewer than 5% of all of the People attending the Daycare. For greater clarity, no exemption will be made if it would result in the number of vaccinated People being below the 95% required for herd immunity.

If a Person has been granted a religious or conscientious exemption, and

• An outbreak of one of the Designated Diseases for which the person is not immunized against occurs, or is imminent,
• Within a 100 km radius of the Daycare,
• The Person can, at the sole discretion of the Daycare, be excluded from attending the Daycare. This policy exists notwithstanding the ability of the Medical Officer of Health to order a Person to not attend the Daycare, even if no such order has been made.

Note to the Board of Directors

This policy is meant to:

1. Encourage a 100% vaccination rate for children, staff, and volunteers.
2. Provide a complete exemption to vaccination for those who are unable to be vaccinated due to health reasons or who are already immune. The Statement of Medical Exemption means a statement signed by a nurse or doctor when the vaccine:

a.     May be detrimental to the health of the person named in the statement, or

b.     Is unnecessary in respect of the person named in the statement by reason of past infection or laboratory evidence of immunity.

1. Protect everyone at the daycare by limiting the religious or conscientious exemptions, such that there will always be herd immunity by having no fewer than 95% of people vaccinated, unless we have an influx of people with verified Statements of Medical Exemption.
2. Comply with the Human Rights Code regarding non-discrimination on the grounds of creed (religion) and disability.