title: Seasonal variation in rates of emergency room visits and acute admissions following recommended infant vaccinations in Ontario, Canada: a self-controlled case series analysis.
abstract: OBJECTIVE
  To determine if birth month has an effect on the incidence of adverse events following the 2- and 12-month recommended vaccinations.
  
  
  METHODS
  Using health administrative databases, we conducted a population-based retrospective cohort study and employed a self-controlled case series analysis approach. We included children born in Ontario, Canada between April 1st 2002 and March 31st 2010 who received the diphtheria, tetanus, pertussis, inactivated poliovirus and Haemophilus influenzae type b (DTaP-IPV-Hib) vaccine recommended at 2 months and/or the measles, mumps, and rubella vaccine recommended at 12 months. We calculated the relative incidence (RI) of hospitalizations and emergency room visits within a pre-specified risk period compared to a control period following vaccination. We measured the effect of birth month using relative incidence ratios (RIRs) to compare the RI for infants born in each month to that for the month having the lowest RI.
  
  
  RESULTS
  For the 2-month vaccination, we observed the lowest and highest RIs for infants born in October and April, respectively. The RIR (95% CI) for April compared to October was 2.06 (1.59-2.67, p<0.0001), consistent with a strong seasonal effect. For the 12-month vaccination, November births had the lowest RI, whereas August births had the highest. The RIR (95% CI) for August compared to November was 1.52 (1.30-1.77, p<0.0001).
  
  
  CONCLUSIONS
  Our findings suggest a seasonal effect on susceptibility to adverse events following vaccination exists. Further study will be important to elucidate potential biological and/or behavioral explanations for the seasonal effect we observed.
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, University of Ottawa, Ottawa, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Hawken
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, University of Ottawa, Ottawa, Canada.
authors.forename: Beth K
authors.initials: BK
authors.lastname: Potter
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, University of Ottawa, Ottawa, Canada; Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Eric I
authors.initials: EI
authors.lastname: Benchimol
authors.affiliation: Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Julian
authors.initials: J
authors.lastname: Little
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, University of Ottawa, Ottawa, Canada.
authors.forename: Robin
authors.initials: R
authors.lastname: Ducharme
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: kwilson@ohri.ca.
authors.forename: Kumanan
authors.initials: K
authors.lastname: Wilson
mesh_terms: D015331:Cohort Studies; D015721:Diphtheria-Tetanus-Pertussis Vaccine / Q000008:administration & dosage / Q000009:adverse effects*; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D018073:Haemophilus Vaccines / Q000008:administration & dosage / Q000009:adverse effects*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D022542:Measles-Mumps-Rubella Vaccine / Q000008:administration & dosage / Q000009:adverse effects*; D009864:Ontario / Q000453:epidemiology; D011054:Poliovirus Vaccine, Inactivated / Q000008:administration & dosage / Q000009:adverse effects*; D012189:Retrospective Studies; D012411:Rubella Vaccine / Q000008:administration & dosage / Q000009:adverse effects*; D012621:Seasons; D018074:Vaccines, Conjugate / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D015721:Diphtheria-Tetanus-Pertussis Vaccine; D018073:Haemophilus Vaccines; D022542:Measles-Mumps-Rubella Vaccine; D011054:Poliovirus Vaccine, Inactivated; D012411:Rubella Vaccine; D018074:Vaccines, Conjugate; C541234:diphtheria-tetanus-five component acellular pertussis-inactivated poliomyelitis -Haemophilus influenzae type b conjugate vaccine
keywords: Adverse events following immunization; Health services research; Seasonality; Self-controlled case series