This briefing provides an assessment of various policy options that could be used to improve childhood immunization rates in British Columbia based on a review of immunization coverage strategies utilized in other jurisdictions. The implications of implementing a mandatory immunization law for all school-aged children is analyzed and discussed, among other policy options aimed at increasing childhood immunization rates as part of a strategy to combat preventable diseases. The Province’s existing policy in this area, summarized in the Strategic Framework for Immunization in B.C., has failed to ensure immunization coverage targets for major vaccine-preventable diseases are met.

1. POLICY BRIEF
Childhood immunization: What can British Columbia do to
improve immunization rates?
By: Richard Horne

2. 2
1. INTRODUCTION
This briefing provides an assessment of various policy options that could be used to improve
childhood immunization rates in British Columbia based on a review of immunization
coverage strategies utilized in other jurisdictions. The implications of implementing a
mandatory immunization law for all school-aged children is analyzed and discussed, among
other policy options aimed at increasing childhood immunization rates as part of a strategy
to combat preventable diseases. The Province’s existing policy in this area, summarized in
the Strategic Framework for Immunization in B.C., has failed to ensure immunization
coverage targets for major vaccine-preventable diseases are met.
2. PROBLEM
British Columbia is failing to meet provincial and national immunization targets and is
falling behind international standards in regards to coverage for vaccine-preventable diseases
(Busby & Chesterley, 2015, p.1). Provincial coverage falls short of national targets of 85-
97%, depending on disease (Winsa, 2015, para.2). While 2014-15 coverage rates in British
Columbia have not been released, the recent trend suggests that the province will not reach
its target coverage rate of 95%, set in 2007 under the Strategic Framework for Immunization
in B.C. (Ministry of Health, 2007, p.6). The B.C. Centre for Disease Control (BCCDC)
estimates that only 65% of two-year-old children in 2014 maintained up-to-date
immunizations, down from 75% in 2007 [see Figure 1] (Provincial Health, 2014, p.4).
While a high proportion of children entering kindergarten maintained up-to-date
immunizations compared to two-year old children, the numbers have remained relatively
stagnant over time (Provincial Health, 2012, p.4).
In addition, a 2013 report from
UNICEF on child well-being
placed Canada among the
worst of 29 developed
countries in terms of coverage
for measles, polio and DPT3
for children aged 12 to 23
months [see Figure 2]
(Adamson, 2013, p.14).
Notably, if we compared
British Columbia to the other
developed countries on the
list, the province would rank
28th
of 29 (p.14). The problem
therefore is clear: too few
children in British Columbia have up-to-date immunizations to protect themselves and others
from major vaccine-preventable diseases.
As Busby & Chesterley (2015) argue, “vaccination has proved a valuable tool in limiting the
incidence of infectious diseases, including measles, smallpox and whooping cough, among
others” (p.2); however, recent outbreaks of vaccine-preventable diseases in B.C., including
the 2014 measles outbreak which affected 422 people, and the 2011 mumps outbreak that
Figure 1 - Immunization Rates B.C. 1
Source: BCCDC 2014

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affected 77 people, and the noted rise in anti-vaccination sentiment among parents are cause
for concern and highlight the need for
more effective vaccination programs,
especially those aimed at children who
are most susceptible (Fraser Health, 2015,
p.vi; Busby & Chesterley, p.1).
When children are not vaccinated against
major vaccine-preventable diseases they
place themselves and others at serious
risk of infection or even death (Public
Health, 2015). Almost all of the cases in
the mumps outbreak of 2011 and the
measles outbreak of 2014 in B.C. were
associated with individuals not
immunized against the disease (Fraser
Health, 2015, p.vi).
When immunization coverage rates fall
below the 95% percent threshold
vulnerable populations in the province are
placed at an increased risk of sickness or
even death (Tolsma, 2015, p.334).
Measles for example, is one of the leading
causes of death among children globally despite widespread availability of the measles
vaccine (World Health, 2015). Vaccine coverage rates that dip below 95% percent, as they
have in B.C., significantly reduce the likelihood that vulnerable populations, namely
pregnant women, the elderly, children below the age of immunization and the
immunocompromised, will be protected through ‘herd immunity’ (p.334). As Tolsma
explains, “herd immunity occurs when a critical portion of a community is immunized
against a contagious disease….because the majority of those within the population are
immunized, those that are not, or those that cannot be immunized are protected” (p.334).
The Ministry of Health (MOH) should be concerned with finding ways to protect the health
and well-being of those who cannot protect themselves (p.334).
As Compton (2009) explains, “widespread use of vaccines can reduce pressures on the
healthcare system through averted hospitalizations and long-term disability, along with
decreased reliance on antibiotics to treat vaccine-preventable diseases” (p.4). Stagnating
immunization coverage rates among school-aged children in British Columbia should
therefore be viewed as a problem that needs to be addressed.
3. POLICY IMPLICATIONS
Immunization programs in Canada have been responsible for the elimination and control of
infectious diseases once common in this country and have saved more lives in the past 50
years than any other health intervention (Public Health, 2013, para.1). Stagnant or declining
Figure 2 – Global Immunization Rates
Source: UNICEF
Source: Adamson, 2013 (UNICEF Report)

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vaccination coverage for diseases rarely seen in Canada could result in their reappearance,
resulting in potentially serious future public health epidemics (Public Health, 2013, para.1).
While reports vary in regards to B.C.’s actual coverage rates among children for measles,
diptheriea, tetanus toxoid, pertfussis, poliovirus, hepatitis B and varicella, all major reports
indicate coverage is well under the 95% threshold, which leaves a significant portion of the
population at risk. Ultimately, the lower the vaccination coverage the greater the risk
becomes of a major public health epidemic. With that comes increased health care costs,
and if the recent UNICEF report on Canada is any indication, reputational damage in regards
to the Province’s commitment to child health and well-being (Busby & Chesterley, 2015,
p.4). The Public Health Agency of Canada (PHAC) estimates that each dollar spent on
immunization creates $16 in cost savings from “reduced visits to healthcare providers, fewer
hospitalizations and premature deaths, as well as reduced time off by parents to care for sick
children” (Busby & Chesterley, 2015, p.3). The cost of inadequate immunization coverage,
both financial and reputational, serve to act as a political impetus for the MOH to find ways
to improve coverage rates across the province.
4. RESEARCH FINDINGS
i. Jurisdictional Overview
British Columbia is not the only jurisdiction that has failed to meet immunization targets
“necessary to avert disease transmission” (Compton, 2009, p.xiv). While vaccination polices
vary considerably between national and sub-national governments the majority can be placed
in one of two broad categories: countries that promote parental choice, leaving vaccination
decisions to parents, and countries that limit parental choice, making vaccinations for certain
vaccine-preventable diseases mandatory unless a formalized exemption is obtained on
medical, religious or ideological grounds. Based on the UNICEF report, one cannot
conclude that mandatory or voluntary systems produce higher immunization coverage levels
(Adamson, 2013, p.14). Compton’s (2015) evaluation of global immunization programs
emphasizes the importance of centralized immunization registries; local coverage targets;
clear public messaging; and financial incentive programs for physicians and parents (p.xiv).
Policymakers must be aware of these best practices in making decisions about the future
direction of immunization policy in B.C.
In Canada, only Manitoba, Ontario and New Brunswick maintain mandatory vaccination
policies that apply strictly to children entering school (Walkinshaw, 2011a, para.1).
Ontario’s immunization coverage rates are the only one of the three that fare better than
British Columbia’s (Busby & Chesterley, 2015, p.6). However, even with Ontario’s
mandatory vaccination program for school-aged children, which includes penalties such as
school suspension for non-compliance, the system comes with its own set of shortfalls
(Walkinshsaw, 2011a, para.9). As Compton (2009) explains, even relatively high provincial
coverage rates mask regional disparities, as well as local program delivery (p.xiv). In
Toronto, there are certain schools with coverage rates below 50%, well below the provincial
average (Gordon, 2014, para.10). British Columbia’s voluntary system of immunization has
produced similar results. For example, only 51% of children in 2014 in the Kootney region
maintained up-to-date immunizations versus 67% provincially (BCCDC, 2014, p.6-7). For
policymakers, regional disparity should be viewed as a serious concern given, as Busby &
Chesterley (2015) explain, “immunity is a local effect” (p.3).

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ii. Political Landscape
The immunization political landscape is a controversial one that the Ministry must be aware
of in determining the most appropriate response to the immunization coverage shortfall. On
the surface, most agree that vaccination is an important component of maintaining public
health. Nationally, the PHAC has stated that they “support immunization as an effective
means to protect Canadians from infectious diseases, and encourages all Canadians to keep
their immunizations up-to-date” (Walkinshaw, 2011a, para.20). This despite the fact that
“the federal government doesn’t appear inclined to step into the fray” given immunization
administration is a provincial responsibility (para.19).
While the majority of individuals agree that vaccination programs must allow for medical
exemptions, more than 75% British Columbians would support mandatory vaccination
according to a recent (2015) poll by Insights West (Walkinshaw, 2011b, para.2; Johnson,
2015, para.1). Provincially, both the Liberals and the NDP have shied away from notions of
mandatory vaccinations despite noted concerns “about the propensity of some regions of BC
to have a low vaccination rate” (Drews, 2015; para.11; CKWN, 2015, para.4).
Policymakers must be aware that vaccination skeptics and organizations like the Vaccination
Risk Awareness Network (VRAN) will be critical of moves to limit opt-out opportunities for
parents. Policies that seek to reduce parental freedoms will likely be met with much
criticism.
iii. Parental Acceptance and Coverage
Immunizations through vaccines are one of the most effective disease prevention tools;
however, as Omer, Salmon, Orenstein, deHart & Halsey (2009) explain, “the success of an
immunization program depends on high rates of acceptance and coverage” (p.1981).
For policymakers, understanding why acceptance and coverage rates are not at a sufficient
level across all regions is an important question that must be answered to ensure policy is
appropriately tailored to address these issues. Busby and Chesterley’s (2015) evaluation of
immunization policy in Canada offers several reasons that may offer an explanation for
B.C.’s poor performance (p.6-7):
- Parental concerns over vaccine safety supported by misinformation;
- Parental complacency;
- Parental free-riders that benefit from high immunization rates without the perceived
need to have their own children vaccinated;
- Cost and access, in terms of time and resources; and
- Religious beliefs
Tailoring B.C.’s immunization strategy around these issues while respecting the diversity of
stakeholder interests will be paramount to ensure a successful outcome.
5. STAKEHOLDER ANALYSIS
As Compton (2009) asserts, “the relationship between parents – the primary gatekeepers of
childhood immunization – and the public health system’s role in providing and monitoring
immunizations, is particularly important in developing policies to empower both groups
towards responsible and informed decision-making (p.3). In the broadest sense, parents of
vaccine-eligible children and the government agencies responsible for public health can be

6. 6
viewed as the main contributors to the problem as well as the main stakeholders required to
solve it.
Children without up-to-date immunizations, to protect themselves and others from major
vaccine-preventable diseases, are a problem that largely affects vulnerable populations.
Each of the following stakeholders play an important role in solving the immunization
coverage shortfall:
i. Vulnerable populations (indirect stakeholder):
Individuals born between 1970-1992, children below the age of immunization, and the
immunocompromised are particularly at-risk of mortality, morbidity and the negative health
outcomes that can result from the spread of preventable diseases when vaccine coverage
rates fall below 95% of the population (Tolsma, 2015, p.334). Those born between 1970-
1992 are “too old to have received a second dose of measles, mumps and rubella (MMR) as
a child, but too young to have gained natural immunity through exposure to the disease in
the pre-vaccine era” (Buck & Gatehouse, 2015, para.13). Vulnerable populations can be
viewed as supporters of policy initiatives aimed at improving vaccination coverage and herd
immunity.
ii. Immunization Providers (indirect stakeholder):
Physicians and nurses play an important role as primary service providers of immunizations
in the province. As Compton (2009) explains, physicians and nurses are important
stakeholders to consider given their responsibility for “endorsing and operationalizing
immunization policy” (p.61). Their role as primary overseers of patient health provides
significant opportunities to educate parents and prompt decision-making. Changes to the
province’s immunization strategy must include consultation with physicians and nurses
because of the significant power and influence they have on parental decisions. Given the
widespread acknowledgment of the safety and benefits of early childhood vaccination, and
their role as vaccination service providers, physicians and nurses can be viewed as both
supporters and partners.
iii. Government Agencies Responsible for Public Health (direct stakeholders):
While the B.C. MOH is responsible for the development of immunization policies in the
province, Regional Health Authorities (RHA) and the B.C. First Nations Health Authority
(FNHA) provide direct immunization services and support for families through their network
of local public health units on the Ministry’s behalf (Government of BC, 2013). In addition,
the PHAC, provides
mechanisms for enhanced collaboration on issues such as vaccine safety,
surveillance, immunization registries, research, vaccine supply and immunization
program planning, and enables bridging of policy recommendations made at the
national level with immunization program development at the provincial/territorial
level (PHAC, 2013, para.6).
The PHAC, and the RHAs and their respective local health units, can be viewed as partner
stakeholders based on their involvement in the administration of immunization programs.

7. 7
iv. Parents of Vaccine-Eligible Children (indirect stakeholders):
Parents of vaccine-eligible children are key stakeholders to consider in the development of
solutions to address the inadequate rates of immunization in B.C. given parental decisions
have a direct and consequential impact on vaccination rates. This group can be viewed as
both supporters and opponents of policy initiatives aimed at improving vaccination
coverage, depending on the strategy that is pursued. Parents of vaccine-eligible children can
be broken down into four main categories:
 Vaccine-Supportive Parents (VSP) – those who strongly support vaccination and
have/will ensure their children receive up-to-date immunizations. VSPs can be
viewed as supporters;
 Vaccine-Hesitant Parents (VHP) - those “who might feel ill-equipped to make the
decision to vaccinate their children or are uncertain about what is best” (Busby &
Chesterley, 2015, p.10). This group also includes “unconvinced-objectors” who
“might be actively seeking more information” (p.10). Children from parents in this
group may not maintain up-to-date vaccinations or may have never received
vaccinations of any kind. Depending on the approach that is taken, VHPs can be
viewed as supporters or opponents;
 Free-Rider Parents (FRP) - those “who are broadly supportive of vaccines, but who,
for reasons of time, energy or complacency, do not see that their children are fully
immunized” (Busby & Chesterley, p.10). Children from parents in this group may
not have up-to-date vaccinations or may have never received vaccinations of any
kind. FRPs can be viewed as supporters;
 Vaccine-Objector Parents (VOP) – those who strongly oppose vaccination for
religious or ideological reasons (p.10). Children of these parents are least likely to
have been vaccinated (p.10). VOPs can be viewed as opponents.
As Busby and Chesterley (2015) argue, vaccine hesitant parents and free-rider parents are
the most ideal stakeholders to tailor policy interventions (p.10).
6. PUBLIC ENGAGEMENT
Given the polarizing views toward immunization, the MOH should commit to an open
public consultation to solicit feedback from the general public and targeted stakeholder
groups on the proposed policy recommendations, once developed. Doing so will help draw
out issues the government may have failed to consider; it will provide an important measure
of public support for the proposed initiatives; it will help draw attention to the problem; and
it will demonstrate that the government is committed to engaging the public in an open and
transparent manner by considering all viewpoints on the issue.
7. POLICY OPTIONS
Option 1: Prompted Informed Choice Model
While many developed nations maintain mandatory vaccination programs for children, more
than half of EU countries utilize voluntary, prompted informed choice models that have been
shown to result in high immunization coverage rates (Haverkate et al, 2012, p.2). Informed
choice has been shown to be effective in Canada as well. Immunization models, such as
those found in Newfoundland and Alberta, prompt parents to voluntarily make a decision
regarding immunization after birth (Busby & Chesterley, 2015, p.13). Nurses enter all
newborn information into a provincial registry and schedule an appointment, if the parents
agree, to discuss the risks and benefits of immunization, and to answer any questions (p.13).

8. 8
Throughout adolescence, a child’s immunizations are tracked in a provincial registry with
automatic reminders sent to parents to remind them about pending or late immunizations;
this is particularly important for Free-Rider Parents who support vaccination but fail to
ensure their child maintains up-to-date immunizations (p.13). As Busby and Chesterley
(2015) explain, the advantage of this model “is that it has one point of contact for parents
with notable expertise and specialization in delivering messages and information” (p.13).
While Alberta’s immunization rates mirror British Columbia’s for children at 2 years of age,
Alberta fares far better for children entering kindergarten, with rates of over 90%, compared
to 76% in B.C. (Walkinshaw, 2011a, para.11; BCCDC, 2012, p.4). Meanwhile,
Newfoundland’s informed consent model boasts the highest immunization rates in Canada
and is the only province that has met national targets (Busby & Chesterley, 2015, p.13).
As Jacobson-Vann & Szilagyi (2009) note, based on their study of immunization programs
in developed countries, “in virtually all settings in which patient reminder and recall
interventions were rigorously evaluated the reminder and recall systems were found to be
effective in improving immunization rates” (p.12). The lack of a centralized and integrated
immunization registry in B.C. will create an implementation challenge if this model is
pursued. However, this concern can be addressed if the province can follow through on its
commitment to develop an integrated registry (BCMOH, 2007, p.57).
While the province would incur additional costs to implement and maintain such a system--
including IT, staffing and software expenses, this could be potentially offset in the medium-
long term through health care savings achieved by an increase in immunization coverage.
PHAC estimates that $16 dollars in health care costs are saved from every $1 spent on
immunization programs (Busby & Chesterley, 2015, p.3).
Given this option preserves parental choice it is unlikely to garner any significant opposition
from Vaccine-Opposed Parents. Similarly, Vaccine-Hesitant Parents may be more inclined
to immunize their children given the single point of contact, which provides several
opportunities for dialogue and education between parents and their primary health care
provider.
Option 2: Incentive Model
A number of countries use an incentive based system to encourage parents and health care
providers to consider immunization. While the introduction of physician remuneration
provided B.C. doctors with some form of compensation for the administration of vaccines,
this “should not be confused with pay-for-performance incentives” used in jurisdictions such
as Australia (Compton, 2009, p.44). Interviews from Compton’s (2009) study revealed
existing remuneration rates for doctors in B.C., $8 per vaccination, to be insufficient at
covering the costs of administration let alone create an incentive to immunize (p.45).
Australia’s model provides performance-based remuneration for health care providers as
well as “nontaxable payments of AUS$129 for each child who meets immunization
requirements between 18 and 24 months of age, and again if the child meets requirements
between four and five years of age” (Walkinshaw, 2011b, para.7).

9. 9
The majority of jurisdictions that employ incentive based immunization systems also
maintain no-fault compensation programs for individuals injured from vaccines
(Walkinshaw, 2011b, para.16). Neither B.C. nor any other Canadian province offer this type
of compensation (p16). Policymakers should view no-fault insurance cautiously as
programs designed to compensate victims of vaccines may exasperate questions about
vaccine safety.
Implementing an incentive-based immunization model for parents and health care providers
could mobilize Free-Rider Parents to immunize their children. Tying immunizations to
financial incentives may also provide additional incentives for physicians to fully educate
parents about immunization, which could lead to more Vaccine-Hesitant Parents agreeing to
have their children immunized. Australia’s immunization coverage has increased
dramatically since the incentive program was introduced, with rates at over 90% for major
vaccine-preventable diseases (Busby & Chesterley, 2015, p.13).
Introducing an incentive-based model will come at a cost to the province. Given the
projected surpluses for the next three fiscal years, the province could likely afford to
introduce a like-model, if so desired (Government of BC, 2015). Full costing and a more
detailed proposal would need to be developed before this is pursued. Given the widespread
commitment to health care by the government and the official opposition, it is unlikely this
plan would receive significant opposition on intent alone. However, Vaccine-Supportive
Parents could view this as an unnecessary cost to government. Notwithstanding that
potential, it is unlikely that vaccine supporters would oppose this type of model.
Option 3: Compulsory, School-Age Requirements Model, with Penalties
Similar to the models used in Ontario and New Brunswick, the majority of compulsory
immunization systems require parents to provide proof of immunization upon entry into
school or request a formal exemption based on medical, religious or ideological grounds
(Carman & Kirkey, 2015, para.2). The results from these systems are mixed. In the
Canadian context, neither Ontario nor New Brunswick has significantly higher rates than
provinces that maintain voluntary systems (Busby and Chesterley, 2015, p.6). However,
European countries have fared much better; 4 of the 5 countries with the highest
immunization coverage rates utilize systems of mandatory vaccination (Haverkate et al,
2012, p.4; Adamson, 2013, p.14). Penalties in these systems range from school suspensions
for children without up-to-date immunizations or an approved exemption, as is the case in
Ontario, to requiring non-immunized students to stay home in the event of a vaccine-
preventable disease outbreak, as is the case in many European countries (Busby &
Chesterley, p.12; Carman & Kirkey, para.2)
The literature suggest that mandatory immunizations are most conducive in jurisdictions
where voluntary compliance is failing to meet immunization targets and where the social
climate is amenable to such requirements (Government of AB, p.23). In B.C., the social
climate appears to be warming and immunization targets are failing to meet provincial and
national targets. 78% of respondents from a recent Insights West poll expressed support for
mandatory vaccinations while 17% believe it should be left to the parent’s discretion.
(Johnson, 2015, para.1). In addition, the Provincial Health Officer recently supported the
call from the Canadian Medical Association (CMA) to “require parents to provide proof

10. 10
their child has received up-to-date immunizations for school entry” (Carman & Kirkey,
2015, para.1).
While the social climate in B.C. appears to be warming, dangers exist if the province moves
too aggressively with this approach, particularly given its lack of success in Canada.
Vaccine-Hesitant Parents may not respond well to stringent policies that provide a default
choice and may be swayed by the negative backlash that would likely ensue from Vaccine-
Objector Parents and organizations such as the Vaccination Risk Awareness Network
(VRAN). Groups like VRAN will continue to defend the position that “parents should be
allowed to determine whether they are willing to take the risk that their children get that
disease, get through it and develop long-term, lifelong immunity” (Walkinshaw, 2011a,
para.12-13).
8. RECOMMENDATIONS
The lack of a centralized, integrated immunization registry in British Columbia creates
challenges in identifying vulnerable populations within regions. As such, B.C. must fulfill
its long-standing commitment to introduce a fully integrated, centralized immunization
registry and ensure that it is accessible to all immunization providers. Previous
commitments made by the province to implement an integrated, centralized registry did not
include access for physicians and nurses (Compton, 2009, p.44). To establish the most
complete and accurate registry all health care providers, including physicians, nurses and
public health immunizers, must have access to the system in recognition of the various
immunization delivery models in the province. Furthermore, to maximize the success of
Recommendation 2, all health care providers should be instructed to create an immunization
record at birth, regardless of whether the parents of the child have opted to not pursue
immunization or are undecided at the time of birth. Currently, some local health units only
establish records for children who seek out immunization (p.44); which “limits the ability to
create a complete and comprehensive registry for the province” (p.44).
To help ensure all parents are aware of the benefits and risks of immunization, are made
aware of recommended immunization schedules for their children, and are provided an
opportunity to engage in dialogue with a knowledgeable health care provider, B.C. should
pursue implementation of a Prompted, Informed Choice Model based off the successful
model adopted in Newfoundland.
Recommendation 1: Introduce a fully integrated, centralized immunization registry
accessible to all immunization providers
Recommendation 2: Introduce a Prompted Informed Choice Model

11. 11
Model components that should be considered:
- registration of all children into an immunization database at birth by a health care
provider, likely a nurse or a midwife, regardless of whether the parents wish to
immunize;
- attempt to achieve written consent or refusal to schedule an immunization
appointment. Hesitant parents will not be required to state their approval or
opposition if they so choose but will be followed up with at a later date;
- require written consent be re-obtained for scheduled vaccinations in kindergarten and
grades 4, 6 and 9 to ensure consent throughout the vaccination schedule;
- ensure the provincial registry can facilitate automatic reminders for parents to ensure
vaccinations are up to date.
A full public consultation should be pursued to ensure health care providers and the public
support the above recommended changes. MOH staff will need to decide whether the above
approach can be accommodated through existing acts, regulations and guidelines or if new
ones need to be written before the province should proceed with public consultations.

12. 12
Further Research
Constable, C., Blank, N.R., & Caplan, A.L. (2014). Rising rates of vaccine exemptions:
Problems with current policy and more promising remedies. Vaccine, 32(2014),
1793-1797.
Delamonica, E., Minujin, A., & Gulaid, J. (2005). Monitoring equity in immunization
coverage. Bulletin of the World Health Organization, 83(5), 384-391.
Guttmann, A., Shulman, R., & Manuel, D. (2011). Improving accountability for children’s
health: Immunization registries and public reporting of coverage in
Canada. Paediatrics & Child Health, 16(1), 16-18.
Mah, C.L., Gutmann, A., McGeer, A., Krahn, M., & Deber, R.B. (2010). Compulsory
school-entry vaccination laws and exemptions: Who is opting out in Ontario and why
does it matter? Healthcare Policy, 5(4), 37-46.
Merilind, E., Salupere, R., Västra, K., & Kalda, R. (2015). The influence of performance-
based payment on childhood immunisation coverage. Health Policy (Amsterdam,
Netherlands),119(6), 770.
References
Adamson, P. (2013). Child well-being in rich countries: A comparative overview.
Florence, Italy: UNICEF Office of Research.
BC Centre for Disease Control (2014). Immunization Coverage: Children at the 2nd
Birthday. Retrieved from http://www.bccdc.ca/resourcegallery
/Documents/Statistics%20 and%20Research/ Statistics%20and%20Reports/
Immunization/Coverage /2_Year_Old_Coverage_20082012_Birth_Cohorts.pdf
BC Centre for Disease Control (2012). Immunization coverage: Kindergarten. Retrieved
from http://www.bccdc.ca/NR/rdonlyres/507BAC70-B95C-4278-9E76-
4F7D7A859202/0/_KindergartenResults.pdf
BC Ministry of Health (2007). Immunize BC: A strategic framework for immunization in
B.C. (Report No. C2007-960072-7). Retrieved from the British Columbia Ministry
of Health website: http://www.health.gov.bc.ca/library/publications/year/
2007/immunizebc.pdf
Busby, C., & Chesterley, N. (2015). A shot in the arm: How to improve vaccination
policy in Canada. Toronto, Ontario: C.D. Howe Institute.

13. 13
Carman, T., & Kirkey S. (2015, August 26). Should proof of vaccinations be required for
school entry in B.C.? The Vancouver Sun. Retrieved from
http://www.vancouversun.com/health/Should+proof+vaccinations+required+school+
entry/11319594/story.html
CKNW News (2015). BC health minister says no plans to make vaccination mandatory
in schools. Retrieved December 5, 2015, from http://www.cknw.com/2015/02/10/
65009/
Compton, J.E. (2015). Canada’s Best Shot: Policies to Improve Childhood Immunization
Coverage. Retrieved November 27, 2015, from http://summit.sfu.ca/item/15379
Drews, J. (2015). Mandatory childhood vaccination policies don’t work: BC’s top doc.
Retrieved December 5, 2015, from http://www.news1130.com/2015/02
/23/mandatory-childhood-vaccination-policies-dont-work-bcs-top-doc/
Fraser Health (2015). Immunizations and vaccine preventable diseases 2014-2015.
Retrieved from the Fraser Health website: http://www.fraserhealth.ca/media/2015-04-
23_FHA_Annual%20Report_FINAL_Lowres.pdf
Gordon, A. (2014, October 30). The vaccination gap: Who is up to date with shots and
how do we know? The Toronto Star. Retrieved from http://www.thestar.com/life
/2014/10/30/the_vaccination_gap_who_is_up_to_date_with_shots_and_how_do_we_k
now.html
Government of Alberta (2007). Alberta immunization strategy: 2007-2017. Retrieved from
the Alberta Ministry of Health website: http://www.health.alberta.ca/
documents/Immunization-Strategy-07.pdf
Government of BC (2013). About Immunize BC. Retrieved from the Immunize BC
website: http://www.immunizebc.ca/search?keys=regional+health+authority
Government of BC (2015). Balance budget 2015 maintains discipline, supports economic
growth and job creation. Retrieved from the Government of BC website:
http://bcbudget.gov.bc.ca/2015/newsrelease/2015_News_Release.pdf
Haverkate, M., D’Ancona, F., Giambi, C., Johansen, K., Lopalco, P.L., Cozza V., &
Applegren E. (2012). Mandatory and recommended vaccination in the EU, Iceland
and Norway: Results of the VENICE 2010 survey on the way of implementing
national vaccination programmes. Euro Surveill, 17 (22), 1-6. Retrieved from
http://www.eurosurveillance.org/ViewArticle.aspx?Articleld=20183.

14. 14
Jacobson Vann, J. C., & Szilagyi, P. (2005). Cochrane database of systematic reviews:
Patient reminder and patient recall systems to improve immunization rates. Cochrane
Database of Systematic Reviews 2005, Issue, (3), 1-70. Retrieved from
http://web.a.ebscohost.com.ezproxy.library.uvic.ca/ehost/pdfviewer/pdfviewer?sid=2
097bbc7-7b59-4224-bc54-a490a1da8136%40sessionmgr4003&vid=2&hid=4214
Johnson, L. (2015). Mandatory childhood vaccinations supported by majority in B.C. and
Alberta: Poll. CBC News. Retrieved from http://www.cbc.ca/news/canada/british-
columbia/mandatory-childhood-vaccinations-supported-by-majority-in-b-c-and-
alberta-poll-1.3106259
Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., & Halsey, N. (2009).
Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable
diseases. The New England Journal of Medicine, 360(19), 1981-1988.
doi:10.1056/NEJMsa0806477
Public Health Agency of Canada (2013). Canadian Immunization Guide. Retrieved
October 15, 2015, from http://www.phac-aspc.gc.ca/publicat/cig-gci/p01-02-eng.php
Tolsma, E. C. (2015). Protecting our herd: How a national mandatory vaccination
policy protects public health by ensuring herd immunity. Journal of Gender, Race
and Justice, 18(1), 313. Retrieved from http://uvic.summon.serialssolutions.com/
Walkinshaw, E. (2011a). Mandatory vaccinations: The Canadian landscape. Canadian
Medical Association Journal, 183(16), 1165-1166. Retrieved from
http://doi.org/10.1503/cmaj.109-3992
Walkinshaw, E. (2011b). Mandatory vaccinations: The international landscape.CMAJ :
Canadian Medical Association Journal, 183(16), 1167–1168. Retrieved from
http://doi.org/10.1503/cmaj.109-3993
Winsa, P. (2015, March 12). Ontario failing to meet national vaccination targets. The
Toronto Star. Retrieved from http://www.thestar.com
World Health Organization (2015). Measles. Retrieved October 15, 2015, from
http://www.who.int/mediacentre/factsheets/fs286/en/