This report describes the first URVP implemented in Canada and compares and contrasts the success of two different vaccine delivery systems (public health clinics and family physicians’ offices). In PEI, where rotavirus vaccine was delivered primarily by public health nurses in province-wide public health offices and satellite locations, implementation proceeded smoothly and vaccine uptake was rapid, quickly achieving coverage rates in excess of 90% for both the first and second doses. In contrast, in CDHA/NS where vaccine was administered in family physician offices, program implementation was plagued by lack of awareness by physicians and care-givers, despite extensive efforts to engage their participation, inform them about the program, and provide them with the necessary tools to provide the vaccine to their patients. As a result, vaccine uptake was suboptimal and, at the end of the two-year program, still lagged far below other routine pediatric immunizations. A potential contributing factor to the better vaccine coverage in PEI compared to CDHA/NS is that the program in PEI was province-wide whereas in NS it was limited to a single district. However, CDHA/NS is home to nearly 50% of the provincial population in NS and the implementation methods employed mirrored those methods routinely used for province-wide programs. Although the vaccine was provided to physicians at no cost, there were concerns about inadequate compensation to the physicians for vaccine administration. Because rotavirus vaccine was the first orally delivered vaccine available in NS, there was no established reimbursement rate for this activity. In consultation with local physician leaders, a rate of 50% of the rate provided for injectable vaccines was established; however, this may not have been deemed sufficient by some practicing physicians.
In comparing the implementation successes of the two programs, it may be that, despite the logistical barriers, the vaccine coverage achieved in CDHA/NS may be typical for new vaccine programs in a physician-delivered or mixed public health/physician-delivered system. In the United States, rotavirus was recommended for universal infant programs in 2006 . In 2009, the first year for which data are available in the National Immunization Survey, vaccine coverage was only 43.9% among children 19–36 months of age, rising to 59.2% in 2010, 67.3% in 2011, and 68.6% in 2012 . This slow rate of increase in vaccine coverage is typically observed in the US. Human papillomavirus vaccine (HPV) was recommended for universal immunization of pre-adolescent girls in the US in 2007  and in 2008, vaccine coverage for the first dose was 37.2% and the third dose 17.9%. Coverage rates rose by 5–10% per year and by 2011 coverage was reported as 53.0% for dose 1 and 34.8% for dose 3; no further increase in coverage was reported in 2012 . Similar coverage rates for the first and subsequent years of universal programs have been reported in the US for other vaccines including pneumococcal conjugate and varicella vaccines . In contrast, in Finland, vaccinations are given by public health nurses in public health clinics or in schools . Rotavirus vaccine was offered to all infants beginning in September 2009 and achieved vaccine coverage rates in excess of 95% during the first two years of the program, comparable to other vaccines in their universal infant program .
In Nova Scotia where human papillomavirus vaccine is administered by public health nurses in school-based programs, vaccine coverage rates after the first three doses was 85.3%, 81.2%, and 77.1%, respectively in 2008, one year after implementation of the program . Three years later in 2011, coverage rates had risen to 92.3%, 83.4%, and 76.1% for the three doses. No data are available about the coverage rates in Nova Scotia of other recently introduced physician-administered publicly funded vaccine programs (conjugate meningococcal vaccine, varicella vaccine, pneumococcal conjugate vaccine). In PEI, vaccine coverage with the rotavirus vaccine is similar to their success with other recent universal vaccine programs, all of which are administered by public health nurses. For example, with meningococcal conjugate vaccine given to infants at 12 months of age, vaccine coverage was 93% in the year following implementation of the program and has maintained a level of at least 90% since that time. With HPV vaccine, coverage rates after the first three doses was 87.6%, 84.9%, and 81.1%, respectively, one year after implementation of the program. Four years later, coverage rates had risen to 90.7%, 90.3%, and 87.3% for the three doses.
Rapid uptake of vaccines in publicly funded programs can be successfully accomplished in physician office-delivered programs. In the United Kingdom where childhood vaccines are provided by general practitioners, pneumococcal conjugate vaccine was introduced into the universal vaccination program in 2006 and vaccine coverage of 83.7% was achieved for the primary series by 12 months of age after the first year, rising to 91% in the second year . The nature and perception of the infection, disease, and vaccine may play a role in how rapidly vaccine coverage is achieved. Vaccine coverage targets for practices and financial incentives for meeting those targets may also contribute to the success observed in the UK . Rotavirus vaccine was introduced into the UK publicly funded vaccine program in 2013; first-year coverage data won’t be available until late 2014.
Although high rates of vaccine coverage can be achieved in physician-delivered programs, as we found in this study, the rise in vaccine coverage rates appears to be more uniformly rapid in public health nurse-delivered programs. An additional benefit of public health delivered programs is the precision of vaccine coverage estimates, particularly in the absence of vaccine registries. In CDHA/NS, the rotavirus vaccine coverage rates achieved are bracketed between vaccine doses that were reported as given and vaccine doses that were provided to physicians. In contrast, the coverage rates provided by PEI are precisely as reported.
As a result of the high coverage rates achieved in PEI, hospitalizations related to rotavirus virtually disappeared from the province. In contrast, there was a less dramatic effect of the URVP in CDHA/NS (unpublished data, manuscript submitted). This may be a contributing factor to the decision by the PEI Department of Health and Wellness to continue the URVP after completion of this project. In contrast, NS remains one of 5 Canadian provinces without a URVP.