Given that there is no pre-COVID-19 world to go back to, now is the time to determine how to go forward more effectively. Routine immunization programs need to be reinforced while ensuring physical distancing and other measures for minimizing COVID-19 spread (Canadian Patient Safety Institute 2011) (Health Canada 2020). With data analysis, delivery gaps must be detected and addressed, consequently making it easier for those who need catch-up to get caught up. Going forward, it will be important to:
Recognize that no one size will fit all, but at the same time make efforts to decrease fragmentation of the immunization system.
Adjust public health clinics and physician routine immunization times, and sites, to better meet patient needs.
Make efforts to grow opportunities for routine immunization, such as standing orders for immunization when patients come in contact anywhere in the health system, e.g., visits to emergency rooms or clinics as well as admissions, for instance post splenectomy (Tahir et al. 2020).
Additionally, pharmacies can help if the types of immunizations and the age groups in their scope of practice are expanded. Finally, consider whether special catch-up clinics are needed and if so, how best to organize them in order to maximize attendance but minimize risk of COVID-19 transmission. Creativity and innovation are the watch words.
For all Canadian jurisdictions, the 2020/2021 fall school immunization programs will have overlapping cohorts as schools were closed in the spring of 2020 to mitigate COVID-19 spread. Plan now on how best to make the 2020/2021 immunization program effective, efficient and, to the degree possible, a positive experience for the students, teachers and the schools. Program revisions will vary by district as contexts differ. More resources will be needed due to the “double” cohort and additional measures required to limit potential COVID-19 transmission. Given the larger numbers of students, extra efforts are needed to mitigate student stress in order to minimize immunization stress-related responses (ISRRs) (Gold et al. 2020). Added stressors are in play; catching up on missed schooling in the previous spring, changed living with COVID-19 and the added pressure of more disinformation, including anti-vaccine rhetoric, ramped up with COVID-19 (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200202-sitrep-13-ncov-v3.pdf ). Making the immunization experience as positive as possible is critical for program success. The CARD (Comfort, Ask, Relax, Distract) program has been shown to help (Taddio et al. 2019). Additionally, because school programs are “mass” campaigns, public health programs need to be prepared for potential crises if any serious adverse events occur—including clusters of ISRRs. Chapter 7 in the 2019 WHO report on Immunization Stress-related Responses outlines approaches (World Health Organization 2019).
Given the potential for further waves of COVID-19 that may occur concurrently with influenza this upcoming winter, access and uptake of influenza vaccine this fall must be optimized to help mitigate the health system capacity crunch if both viruses strike concurrently or overlap (National Advisory Committee on Immunization 2020). Given that influenza campaigns may be delivered in mass settings with stress levels increased if COVID-19 resurges, public health needs to be very prepared to address cases and/or clusters of adverse events following immunization. Not doing this well could undermine the whole immunization program.
Whether catch-up, routine, or mass immunization is being done, in all settings, steps need to be taken to minimize risk of acquisition of communicable infections, including COVID-19 (Canadian Patient Safety Institute 2011) (Health Canada 2020). Measures may differ by setting but must be adequate to allay concerns among healthcare workers and the public. Measures may include but are not limited to, appropriately timed appointments to minimize waiting, appropriate space in waiting rooms for physical distancing, use of personal protective equipment according to local guidance, and frequent, meticulous hand hygiene.