CPHA Canvax

Immunizing kids is important. Helping them overcome pain and fear of immunization is important too.

Lucie Marisa Bucci - Senior Manager (Immunize Canada)

Immunizing school children is an effective way to increase coverage. Most public health jurisdictions in Canada have school immunization programs, which roll out meningococcal, hepatitis B and HPV vaccines, among others. The positive outcomes of these programs are numerous. Yet, we are just beginning to learn that a substantial number of children who receive vaccines at school have negative experiences (1). Often these negative experiences are attributed to pain and fear of needles. For some children, injection needles conjure anxiety and distress that can perpetuate into episodes of fainting, and eventually to vaccine refusals (2).  

In 2015, a research team (HELPinKIDS&ADULTS) led by a University of Toronto Professor, Dr. Anna Taddio, published (an update to) a Clinical Practice Guideline (CPG) on the management of pain and fear during vaccination (3). Recognition of the extensive knowledge synthesis and evidence-based interventions published in the CPG is on the rise, and public health has noticed. The World Health Organization (WHO), and more recently in Canada, the Public Health Agency of Canada (via the National Advisory Committee on Immunization (NACI) and the Canadian Immunization Guide (CIG)), and the Chief Medical Officer of Health of Ontario have all recognized the need to focus on improving the experience of vaccination by addressing pain and fear (4,5,6).

With this recognition, why has there not been widespread change?

It is no surprise that implementing broad stroke changes in public health takes time. Many of the cost-neutral interventions recommended in the CPG are already in use, albeit informally, by public health nurses, and there are efforts to incorporate these practices into policy. For example, the BC Center for Disease Control is the first provincial health authority to change its immunization policy and to recommend local units use interventions to reduce pain and fear during immunizations (7). Further exploratory work in this area reveals that public health units in Ontario also have local policies that address pain and fear management. However, the implementation of these policies is hampered by lack of processes for school clinic planning and execution that consider pain and fear mitigation (8).

Improvement requires commitment from everyone

Improving the immunization experience at school requires re-examination of current school vaccination clinic processes and collaboration among all important stakeholders (public health, students, parents and school staff). We know that children benefit from an environment that supports their needs, and recent research shows that both school children and teachers are open to what they can do to help (9).

Therefore, it was no surprise that a child was the first to suggest transforming the pain and fear interventions into a tool that both children and public health can use. This idea, the first of its kind, easily incorporates the interventions into a game that children can play to support what they want to do to improve their immunization experience. This choice also provides a framework for delivering vaccinations that is followed by public health and school staff. Information on this new tool and its implementation in public health will be featured in an upcoming edition of CANVax In Brief.

  1. Taddio A, Chambers C, Halperin S, Ipp M, Lockett D, Rieder MJ, Shah V. Inadequate pain management during childhood immunization: the nerve of it. Clin Ther 2009; 31(Suppl 2):S152-S167.
  2. Taddio A, Ipp M, Thivakaran S, Jamal A, Parikh C, Smart S, Sovran J, Stephens D, Katz J. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine 2012:30(32):4807-4812.
  3. Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, et al. HELPinKids&Adults. Reducing pain during vaccine injections: clinical practice guideline. CMAJ 2015; 187(13):975-982.
  4. World Health Organization (WHO). Meeting of the Strategic Advisory Group of Experts on Immunization, April 2015: Conclusions and recommendations. Reducing pain and distress at the time of vaccination. Wkly Epidemiol Rec (WER) 2015;90:261–77.
  5. Public Health Agency of Canada. Canadian Immunization Guide, Part 1, Key Immunization Information, Vaccination Administration Practices [Internet]. Ottawa (ON): Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-8-vaccine-administration-practices.html#t4 (Accessed January 12, 2019).
  6. Ontario Ministry of Health and Long-Term Care (MOHLTC). Vaccines: The best medicine: 2014 Annual Report of the Chief Medical Officer of Health of Ontario to the Legislative Assembly of Ontario. 2014. www.health.gov.on.ca/en/common/ministry/publications/reports/cmoh_14_vaccines/docs/cmoh_14_vaccines.pdf (Accessed January 15, 2019).
  7. BC Centre for Disease Control. Section IVB: Reducing Immunization Injection Pain. Communicable Disease Control Manual, Chapter 2 Immunization. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%202%20-%20Imms/SectionIVB_RIIP.pdf (Accessed January 15, 2019).
  8. Bucci LM, Taddio A, MacDonald NE, Segall R, Freedman T. Staying clear of pain and fear: A survey of policies and practices in Ontario public health school immunization clinics. Poster Presentation. Canadian Immunization Conference, December 4-6, 2018, Ottawa.
  9. Bucci LM, MacDonald NE, Sondagar C, Taddio A. Taking the sting out of school-based immunizations. Pediatrics & Child Health, 2017, 41-42.