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
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

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
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.

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 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

15. 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

16. 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

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. 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

21. 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 International Travel and Health

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

23. 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!

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

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 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