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As outbreaks of preventable infectious diseases such as measles continue to increase, there have been growing cries to make vaccination mandatory in Canada. The get-tough approach has broad public support. According to a recent Angus Reid poll, 70 per cent of Canadians believe vaccination should be a prerequisite to admission to school.

But, practically, what does mandatory mean? How do you ensure compliance from the more than five million babies, children and youth who attend daycare, primary and secondary school? And what do you do if they don’t comply? After all, the Angus Reid poll shows that 20 per cent of parents say that vaccination should be their choice, not mandatory.

Currently, only two provinces – Ontario and New Brunswick – have mandatory-vaccination policies. Under Ontario’s Immunization of School Pupils Act, children attending school in the province must be vaccinated against diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, rubella, meningococcal disease and varicella (chickenpox, if born after 2010.)

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And under Ontario’s Child Care and Early Years Act, children attending child care must also get shots to protect against invasive pneumococcal disease (IPD) and rotavirus. The rules are similar in New Brunswick, while in Manitoba only measles vaccination is mandatory. Other provinces tend to ask parents for proof of vaccination, but don’t act on it.

So let’s stick to Ontario, which has the most extensive rules and actually enforces them. Crunch time tends to come in kindergarten. When parents submit proof of vaccination, they often learn that their child is not up to date. There are nine mandatory vaccines, but some require multiple shots, and the schedules are different in every province.

Many parents are surprised they have to provide this information themselves. Most have a little yellow personal immunization record. Until recently, the pages had to be copied and mailed, faxed (!) or phoned in to the school and/or public health officials.

Recently, Ontario unveiled Immunization Connect Ontario (ICON), a $160-million system that allows parents to enter data online; they can also use the increasingly popular CANImmunize app.

The extra parental work is required because Canada is a laggard in creating electronic health records. Legislation that would have made it mandatory for physicians and nurses to report vaccination records directly to public health is on hold, too.

Checking compliance is a massive job for public health and, in Canada, public health is a municipal responsibility. So let’s take Ottawa as an example. There are roughly 150,000 students enrolled in Ottawa-area schools, and 8,000 new ones annually. Last year, 25,781 of those students did not have all their mandatory vaccines. About 85 per cent of those cases were missing paperwork. But still, thousands of students were missing vaccines, so Public Health Ottawa staged catch-up clinics. All told, about 12,000 students were threatened with suspension, but only about 300 students were actually suspended.

The vast majority of parents support vaccination, but many don’t have a family physician, or aren’t the world’s best record-keepers. Mandatory vaccination laws should not punish the willing because they are unable.

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Exemptions from the law are also permitted for medical, religious or philosophical reasons. Some children cannot receive vaccines because their immune systems are compromised, such as children with cancer. For them, it is essential that everyone else be vaccinated to create herd immunity.

Those who make a statement of "conscience or religious belief” have to undertake a mandatory education course and, in the end, less than 2 per cent of students (about 3,000 in Ottawa) are granted exemptions.

Those who refute the law outright because they are fiercely anti-vaccine – only a few dozen in Ottawa – face fines of up to $1,000. How many are actually fined is unclear.

The key to good legislation is balance respecting individual rights and the collective good. Exemptions must exist, but they need to be hard to obtain. And you don’t want to punish students unduly for the sins of their parents.

The biggest challenge for provinces – both those who have mandatory vaccination and those considering it – is to make it easier to do the right thing.

Right now, excessive redundancy and bureaucracy, along with the abysmal state of electronic record-keeping, places too much of a burden on law-abiding parents.

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If we’re serious about mandatory vaccination, we need to put our money where our mouth is. We need to fund public health properly to do a job that requires an army of nurses and enormous resources. If we’re serious about keeping our children safe from the growing threat of infectious diseases, we will make that investment.

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