Years old in Ontario, Canada: A retrospective cohort study ... - medRxiv

medRxiv preprint doi: ; this version posted October 29, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

Impact of the COVID-19 pandemic on routine immunization coverage in children under 2 years old in Ontario, Canada: A retrospective cohort study

Authors: Catherine Ji, MD, MSc, CCFP a,b Pierre-Philippe Pich?-Renaud, MD c, d Jemisha Apajee, MSc a Ellen Stephenson, PhD a Milena Forte, MD, CCFP, FCFP a, e Jeremy N. Friedman, MB.ChB, FRCPC d, f Michelle Science, MD, MSc, FRCPC c, d Stanley Zlotkin, MD, PhD, FRCPC d, f, g, h Shaun K. Morris, MD, MPH, FRCPC c, d, g Karen Tu, MD, MSc, CCFP a,b,i

Affiliations: a. Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario, Canada, M5G 1V7 b. Toronto Western Family Health Team, University Health Network, 440 Bathurst Street, 3rd Floor, Toronto, Ontario, Canada, M5T 2S6 c. Division of Infectious Diseases, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8 d. Department of Paediatrics, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8 e. Mount Sinai Academic Family Health Team, 60 Murray Street, 4th Floor, Toronto, Ontario, Canada, M5T 3L9 f. Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8 g. Centre for Global Child Health and the SickKids Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, Ontario, Canada, M5G 0A4 h. Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, Canada, M5T 3M7 i. North York General Hospital, 4001 Leslie Street, Toronto, Ontario, Canada, M2K 1E1

Corresponding author: Catherine Ji, catherine.ji@uhn.ca, 440 Bathurst Street, 3rd floor, Toronto, Ontario, Canada, M5T 2S6

1 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

medRxiv preprint doi: ; this version posted October 29, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

Abstract Background: The COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the pandemic. Methods: We conducted an observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, Pneu-C-13, Rot, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15 and 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3). Results: 12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic. Conclusion: Childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

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medRxiv preprint doi: ; this version posted October 29, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

Introduction The coronavirus disease 2019 (COVID-19) pandemic and associated public health measures aiming to limit its transmission have had an unprecedented impact on healthcare services at all levels, including on routine childhood immunizations [1-3]. Multiple jurisdictions worldwide have reported significant declines in childhood vaccines administered and immunization coverage in the months following the pandemic declaration [4-12]. Disruptions to routine childhood immunization services leading to decreased coverage are concerning for possible resurgence of vaccine-preventable diseases (VPDs), including measles [13-15].

In response to these concerns, international and Canadian public health and governmental institutions have recommended that routine immunizations are essential health services that should not be deferred, especially the primary series and booster doses for children aged less than two years [16-18]. Some studies have nonetheless reported on parents avoiding medical care facilities, clinics not providing in-person services due to the perceived risk of COVID-19 transmission, and school immunization programs being suspended [19, 20]. There is currently limited data to quantify the impact of the pandemic on pediatric immunization coverage in Canada, and whether the pandemic has impacted access to vaccination differentially for specific groups of children. The objective of this study was to compare the immunization coverage for children under two years old before and during the first waves of the COVID-19 pandemic by using primary care electronic medical records (EMR) data in the province of Ontario.

Methods Study design

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medRxiv preprint doi: ; this version posted October 29, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

We conducted an observational retrospective open cohort study using EMR data from family medicine practices included in the University of Toronto Practice-Based Research Network (UTOPIAN) to assess immunization coverage from January 2019 to December 2020.

Data source We used data from the UTOPIAN Data Safe Haven, which is a secure research database comprised of de-identified patient records extracted from EMRs of contributing family medicine practices associated with the University of Toronto, with more than 70% of these family physicians practicing in the Greater Toronto Area (GTA) in Ontario [21]. From the UTOPIAN database, we extracted the sociodemographic characteristics (date of birth, sex and postal code) and immunization records (name of vaccine and date given) of the children included in the study population. Measures of socioeconomic status (SES) and marginalization based on neighborhood income, material deprivation and ethnic concentration quintiles were derived based on the children's postal code using the Statistics Canada Postal Code Conversion File [22-24].

Study population We created an open cohort of children using the following eligibility criteria: 1) were aged 0-2 years old during the study period, 2) had a valid sex and date of birth recorded in their EMR, 3) had at least two visits recorded in their EMR during the study period, with at least one visit after the second week of life to ensure continuity of care.

Setting

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medRxiv preprint doi: ; this version posted October 29, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

Ontario is Canada's most populous province, with nearly 40% of the country's population [25]. Early in the COVID-19 pandemic, Ontario declared a state of emergency on March 17, 2020 and entered its first "lockdown" [26]. As the first wave of the pandemic improved, restrictions were progressively lifted throughout the province with Toronto being one of the last regions to enter the final stage of reopening on July 31, 2020 [27]. Ontario experienced a second wave of COVID-19 cases and deaths from September 2020 to February 2021 [28]. At the end of the study period, Ontario had experienced the second highest number of COVID-19 cases and number of deaths in Canada [29]. Within the province, 30% of all cases have been detected in Toronto and the GTA [28].

In Ontario, immunizations for children under two years old are usually administered by primary care providers, including family physicians, during regular well-baby visits [20, 30] and documented in the children's medical record. EMR data from family physicians' clinics has been previously used and validated to study childhood immunization coverage in Ontario [30-32]. Ontario's Publicly Funded Immunization Schedule [33] recommends six different vaccines in the first 24 months of life (Table 1), including diphtheria, tetanus, pertussis, polio, haemophilus influenzae type b (DTaP-IPV-Hib) vaccine, pneumococcal conjugate (Pneu-C-13) vaccine, rotavirus (Rot) vaccine, meningococcal conjugate (Men-C-C) vaccine, measles, mumps, and rubella (MMR) vaccine, and varicella (Var) vaccine.

Table 1. Ontario's Publicly Funded Immunization Schedule for children under 2 years old

Age milestones

Vaccine

2 months 4 months 6 months 12 months 15 months 18 months

DTaP-IPV-Hib

X

X

X

X

Pneu-C-13

X

X

X

Rot

X

X

X*

5

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