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

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

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 Completely revised in 2005 Purpose is basically the same but Scope is broader to include any public health event of international concern Came into effect June 15, 2007 All signatory countries to IHR(2005) must comply

International tourist arrivals by region, 1950-2006

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

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

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

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 A country where the vectors of yellow fever are present, may require a traveller coming from an area where the WHO has determined that a risk of yellow fever transmission is present to be quarantined: 1) If the traveller is unable to produce a valid certificate of vaccination against yellow fever; 2) Until the certificate becomes valid, or; 3) Until a period of not more than six days, from the date of last possible exposure to infection, has elapsed. Should the travellers not be quarantined, they may be required to report any feverish or other symptoms to the competent authority and be placed under surveillance.

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

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

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

Canadian tourists returning from countries other than the United States, 1972-2006

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

Designation of Yellow Fever Vaccination Centres in Canada Interim 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

Designation of Yellow Fever Vaccination Centres in Canada Interim 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

Yellow Fever Vaccination Centres in Canada by Province/Territory Yellow Fever Vaccination Centres in Canada by Province/Territory* March 2008 N=241 *Excludes DND clinics

International Certificate of Vaccination or Prophylaxis

Certificate of Medical Contraindication to Vaccination

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

Challenges Country 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

Yellow Fever Vaccination Requirements 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

Map: Countries at risk for yellow fever transmission Risk of Transmission of Yellow Fever WHO. 2008. International Travel and Health

Simplified Risk Analysis* RISK OF YELLOW FEVER YES NO COUNTRY ENTRY REQUIREMENT Benefit of vaccine outweighs risk Risk of vaccine outweighs benefit Vaccine recommended Vaccine not recommended *Individual risk assessment always needed!

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)

Contact: yfinfofj@phac-aspc.gc.ca Need more information? Contact: yfinfofj@phac-aspc.gc.ca

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

Reported Adverse Events Following Yellow Fever Vaccine in Canada January 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