Monthly Archives: March 2017

Mumps boosters: A quality improvement challenge

By now most of the public is aware of multiple mumps outbreaks taking place across Canada. Manitoba, Toronto, and even the Vancouver Canucks hockey team have been affected by outbreaks. Some public health officials have urged the public through the media to ask their doctor about their status, or to get a mumps booster, or some muddled message combining both.

This issue, potentially affecting millions of Canadians, deserves more clarity and organization in how we approach this problem.

Let me share my experience in my practice this week, which may shed some light on some possible solutions and pitfalls to address.

To begin, I ran a search of my EMR for patients born after 1970 AND 4 years of age and over AND with fewer than 2 mumps vaccines given. Of a roster of 2,200 patients, this yielded a list of 400 patients (I will refer to this list of those needing vaccination as the “cohort”). A couple of them were children who will be coming in soon for their MMRV (measles/mumps/rubella/varicella) vaccine. I ran another search for those in the cohort who have ever had a mumps blood test done. I had to go through these charts manually to see whether they were immune to mumps, because prior to OLIS, mumps bloodwork results coming from the lab was sent via fax, and entered manually as “reactive” or “immune”, so I could not rely on a keyword search to be accurate. A few dozen patients were found to be immune, mainly students and those working in health care, and they were eliminated from the cohort. Still close to 350 patients left to sort through.

But we had a major speed bump. Of the remaining cohort, there was no reliable way to distinguish which of these patients had complete childhood immunization records in their charts and truly required a mumps booster, and those that simply had incomplete records, without going through each individual chart. When I transitioned to my EMR in 2012 and took over from a retiring physician, I went through every sliver of paper in their paper chart and ensured that all vaccines were documented in the EMR. (6 months of 6-hour nighttime horror sessions with me and the EMR was certainly gruelling.) But many of these patients were not part of our practice as children, and their records were not always reliably part of their medical record.

Sifting through every electronic chart took a couple of hours, and I found around 60 charts that had no childhood immunization data. The London Middlesex Health Unit was kind enough to let us send faxes with the patient labels attached of the patients whose records we needed. (Usually they require individual patients’ names left on an answering machine). Some of our patients were not raised in the area, and the health unit did not have records on them.

Next speed bump. The health unit doesn’t have immunization data on anyone over the age of 35. And my electronic records have virtually no childhood immunization data from those over 35.

So here’s what I’ve done in my practice. We now have a list of around 200 patients between 24-35 who definitively require a mumps vaccination, and we have scheduled four walk-in vaccination clinics next week. My staff has called all of the patients to notify them of their status and the clinic availability. We have ordered around 100 doses of MMR from the health unit, and will likely require more in the coming weeks. In case the patients don’t attend the clinics, there are reminders in the patients’ charts for the next time they are seen for an unrelated reason.

But the 35yo+ group of around 150 patients? I haven’t decided yet. My options are to, a) call each of them and see if they can track down their immunization records (likely will be futile), b) have them get mumps titres done, or c) just go ahead and vaccinate them, or a combination of a), b), and c).

Most physicians are likely reading this, thinking that either the data quality in their EMRs is not reliable enough for this type of work, or that they are simply not interested in an undertaking of this magnitude for no monetary compensation.

This is where we need leadership from public health, especially provincially and locally. The message of “talk to your doctor about the mumps vaccine” is simply not adequate. We need guidance on many issues, including what to do about the 35yo+ cohort. Will there be enough vaccine supply if every practice is administering 200+ doses? Will health units across the province support physicians’ requests for immunization records?

And finally, this situation has underscored the desperate need for a provincial electronic immunization solution. I understand that Panorama is set to be released soon, but I think the province needs to give physicians an idea of its timeframe, and any available details on what Panorama will be able to achieve, and what gaps will remain.

I would propose that the proposed section 10 (2) of Bill 87, that states

“Every physician, nurse or prescribed person who administers an immunizing agent to a child in relation to a designated disease shall provide the prescribed information to the medical officer of health for the public health unit in which the immunizing agent was administered.”

be removed from the legislation until Panorama is fully functional. As someone who has spent an entire week cultivating electronic vaccination records and communicating with my local health unit, it is simply not practical or reasonable to expect physicians to fax isolated records after each administered vaccination. An open exchange of information is important, but this needs to wait until the proper electronic infrastructure is in place.

So before these mumps outbreaks get any worse, we need urgent guidance from public health with specific guidelines and processes on how to best approach this issue.