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Sunday, 11 December 2011

Immunization – who does it better? Public Health Nurses or Physicains?

It is the question that remains unanswered and one that brings out the biases amongst public health professionals.  is it not clear that Public Health Nurses provide a better childhood vaccine delivery system than through private physician’s offices?
Of course what is “better”.   Higher coverage rates?  Fewer vaccine errors?  Less vaccine wastage? Better documentation?  Less expensive?  Fewer delayed immunizations? 
If the answer was apparent then we have enough experience to be able to distinguish which is better and we would not have the mixed system that exists.   Newfoundland, PEI, Saskatchewan, Alberta, the territories - childhood vaccines are predominately delivered by PHNs.  BC and Quebec have mixed systems, with BC split geographically and Quebec intermixed.  Manitoba, Ontario, Nova Scotia and New Brunswick are predominately delivered by physicians.   Should this not be enough to demonstrate variance and a clear best practice?  apparently not. Or at least if someone has the data comparing the different systems, they have not released it.  
A few things that probably need confirmation, but likely could be substantiated.  PHNs are more likely to have a structured approach to timely immunization, physicians more opportunistic. As such, it would make sense that there may be less delayed infants with a public health system right?   Well some work suggests otherwise as accessing public health for a clinic appointment can be more of a problem than a physician office visit.  Vaccine wastage is likely lower in Public health systems.  Vaccine safety reporting is definitely higher in public health systems. Documentation is not great anywhere, but better where public registries exist - although Manitoba has an excellent system based on physician delivered vaccines demonstrating that it can work as well.  Clearly, no clear winner based on what we currently know.
As for vaccine coverage, it should be simple to compare something like 2 year old immunization rates, right?   Well, try to find two provinces that actually use the same measure let alone publish any data.   2 year old MMR versus just measles, or all age appropriate vaccines by 2 years of age, or even every antigen specific rate.
The best data that was located in reviewing the question was for the four Western provinces.   Manitoba suggesting rates from 2003 in the 72% range for all 2 year old age appropriate vaccines, Saskatchewan claiming near 80% for each antigen in 2008/09, Alberta holding bragging rates to 84% for Penta, and 89% for MMR in 2008, and BC suggesting 66% for all age appropriate vaccines in 2010 (however this excludes one of the largest geographic areas where physicians provide vaccine).   Again, no clear winner based on very crude assessment.  I’d welcome some data from the other provinces if it is available and this site will be updated. (drphealth at gmail.com).
The point of this exercise is that we spend hundreds of millions of dollars each year on vaccination programs in Canada, yet we have not yet defined which model of care is the best at delivery.  Parallel systems have redundancies and inefficiencies.  Resolving these may lead to  better outcomes at a lower cost – so is exploration of the question justified?
There are other factors at play.  It seems that there is a high correlation with immunization rates by the density of physicians.  A definite but lower correlation also exists by density of PHNs.  This makes inherent sense.  Where there is a physician oversupply, ensuring routine preventative care is undertaken is integral to staying in business.   PHN distribution is more equitable within provinces and should not be a major accessibility issue, and hence a better distribution system for rural and smaller communities in the country.
So, the simple question remains unanswered, but may be a key question for public health to determine.  Policy forces may push vaccination out of the public health realm and into primary health care settings if the evidence is not amassed and communicated. 

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