ARCHIVED - Canadian National Report on Immunization, 2006

Volume: 32S3 - November 2006

1. Canada's National Immunization Strategy: Progress Highlights

Developed and advocated by the Federal, Provincial and Territorial (F/P/T) Advisory Committee on Population Health and Health Security, the First Ministers' Accord on Health Care Renewal endorsed the National Immunization Strategy (NIS) in February 2003. In June 2003, the NIS was accepted by the Conference of F/P/T Deputy Ministers of Health. It was further supported in the 2003 Federal Budget through an allocation of $45 million over 5 years, to strengthen national collaboration on immunization.

The NIS is a collaborative approach to address immunization activities in Canada. The goals of the NIS are as follows:

• Provide high, achievable and measurable coverage of publicly funded immunization programs for all Canadians.
• Provide complete coverage of all children with routine childhood vaccines recommended by the National Advisory Committee on Immunization (NACI).
• Ensure that there is equitable access to routinely recommended vaccines - among jurisdictions and in special populations - while considering jurisdictional program implementation differences.
• Promote public and professional acceptance of recommended programs.
• Provide optimal vaccine safety, effectiveness and acceptance.
• Improve program coordination and efficiency.
• Provide optimal cost-effectiveness and affordability of programs.
• Establish security of vaccine supplies.
• Provide national intervention when required.

To achieve these goals, five components were identified for action, and specific objectives were developed for each component. These five components are the development of national goals and recommendations for immunization programs, immunization program planning, vaccine safety, vaccine supply and the immunization registry network. The five components are supported by interrelated activities, including immunization research, professional and public education, and vaccine-preventable disease surveillance. This section highlights the key accomplishments in each of these areas.

1.1 Development of national goals and recommendations for immunization programs

The first national consensus conference on national goals and recommendations for vaccine-preventable diseases was held in June 2005. Conference delegates included representatives from international, national, federal, P/T, non-governmental and professional agencies and organizations. The participants reviewed and assessed disease reduction and immunization coverage goals, recommendations, and targets for six vaccine-preventable diseases, namely rubella, varicella, pertussis, invasive pneumococcal disease, invasive meningococcal disease and influenza.

The Canadian Immunization Committee (CIC), which is responsible for providing advice and recommendations on the NIS implementation, will review these goals and recommendations and work with a task group to consolidate conference proceedings. A summary report of the conference will be released in 2006. Future consensus conferences are planned to review, develop and update recommendations for national goals for immunization coverage and disease reduction for all vaccine preventable diseases.

1.2 Immunization program planning

One of the goals of the NIS is to ensure that equitable access exists to NACI-recommended vaccines. This is a challenge, considering the differences in jurisdictional program implementation. After the NIS was approved in 2003, $300 million dollars was provided to the P/T to purchase four new vaccines: acellular pertussis, meningococcal C conjugate, pneumococcal conjugate and varicella vaccines. The majority of P/Ts now offer access to these newly funded vaccines, a significant increase from 2003 (Table 1). This means that approximately twice as many Canadian children can be protected from these childhood diseases in 2006 as compared with 2003. The current P/T immunization programs are listed in Annex 1 of the report.

Table 1. Impact of public funding on harmonized access: summary of provinces and territories with access to newly funded vaccines, 2003 vs. 2006

1.3 Vaccine safety

Vaccine safety is an integral component of the NIS. Objectives of this component are to optimize the vaccine safety system, maintain professional and public confidence in the safety of vaccines and address growing anti-immunization concerns. Several key accomplishments were identified for this component:

• The F/P/T Vaccine Safety Network was developed through on-site consultations with P/T jurisdictions to discuss priorities and develop an action plan for identified gaps, and through consultations with vaccine manufacturers to improve cooperation on and understanding of vaccine safety and obtain vaccine lot dose distribution data on a regular basis.
• Improvements have been made to the Canadian Adverse Event Following Immunization Surveillance System (CAEFISS) (previously called the Vaccine Associated Adverse Events Surveillance System, VAAES) to enhance the ability to produce timely reports from the CAEFISS database.
• The national guidelines for vaccine storage and handling for vaccine providers have been updated in collaboration with Canadian Nursing Coalition on Immunization (CNCI), the Vaccine Supply Working Group, jurisdictional representatives and manufacturers. The updated guidelines are expected to be published in late 2006.

1.4 Vaccine supply

Vaccine supply is one of the main pillars of the NIS. The goal is to establish the long-term security of high-quality vaccine supply at the best international price for Canada. To facilitate achievement of this goal, the F/P/T Vaccine Supply Working Group (VSWG) was formed. Some of the achievements of the VSWG are as follows:

• Facilitated participation of almost all P/Ts in bulk purchasing for routine childhood vaccines through a centralized bulk purchasing agreement.
• Facilitated long-term contracts for the four newly funded vaccines (Table 1) introduced in Canada.
• To support security of supply, collaborated with P/Ts, other government departments and the vaccine manufacturers for split contracts for supply of vaccines.
• Provided support and facilitated distribution of the annual influenza vaccine and also provided input and feedback for the pandemic influenza vaccine contract.
• Responded to shortage issues of pertussis containing vaccines, pneumococcal polysaccharide vaccine and botulism antitoxin, and facilitated equitable distribution of supply to P/Ts without disruption to the programs.
• Established protocols with the Special Access Program of Health Canada to permit access to diphtheria antitoxin.
• Initiated a comprehensive study to examine the feasibility of a vaccine supply strategy for Canada.

1.5 Immunization registry network

The Canadian Immunization Registry Network (CIRN) is a network of representatives from all Canadian jurisdictions committed to developing a virtual national network of immunization registries. Since its inception in 2001, it has provided a forum for the creation of national data standards and functional standards and the centralized coordination necessary to ensure that compatible electronic immunization registries are developed across Canada.

In 2002, only three jurisdictions had fully functional registries. Of fourteen jurisdictions surveyed in 2004, including the First Nations and Inuit Health Branch (FNIHB) of Health Canada:

• five have fully functioning registries, which they plan to continue using (Manitoba, New Brunswick, Saskatchewan, Prince Edward Island and British Columbia);
• four are in the process of implementing a registry (Alberta, Ontario, Newfoundland and Labrador and FNIHB);
• two are evaluating options for a new registry (Quebec and Northwest Territories);
• and three have no registry (Nova Scotia, Yukon and Nunavut).

CIRN continues to be actively involved in revising and developing tools, technology and standards for immunization registries in Canada. It is currently working with the INFOWAY Pan-Canadian Health Solution to ensure that the immunization registry module under development is compliant with existing national standards for immunization registries in Canada. By 2009, all jurisdictions will have access to immunization registry technology through this project.

CIRN also acts as the advisory group for the Automated Identification of Vaccine Products (AIVP) project, which evaluated the feasibility and user acceptance of bar coding vaccine products to improve immunization record-keeping and inventory management, as recommended by NACI in 1999. The AIVP project was implemented in collaboration with a wide range of stakeholders, including the vaccine industry, Canadian therapeutic product labelling regulators, vaccine providers, standards committees and international standard-setting organizations.

The feasibility study was completed in 2004, and the pilot evaluation was performed in 2005 in a public health unit and in a physician's office. On the basis of the positive results of the pilot evaluation, standards to label vaccine products with bar codes were proposed. The next steps in the project include working with the vaccine industry to come to agreement on bar coding standards and an implementation time-frame; establishing plans for implementing bar coding technology across all Canadian jurisdictions; and further enhancing the Vaccine Identification Database System (VIDS) used to transfer vaccine-specific data from a central Web-based repository to the client immunization record.

1.6 Immunization research

Immunization research is one of the cross-cutting activities of the NIS. Since the NIS was established, there have been notable accomplishments in a number of key areas:

• A meeting with researchers and academia was held in October 2004 to define immunization research questions, set priorities and develop mechanisms for cooperation.
• The Public Health Agency of Canada (PHAC) and Canadian Institutes of Health Research (CIHR) jointly supported an Influenza Research Priorities Workshop in August 2005. The objective was to develop recommendations on national research priorities that will enhance pandemic and interpandemic influenza prevention and control strategies. The final report identifies the top 10 priorities for influenza research. Since that time the CIHR has disseminated its first request for applications for pandemic preparedness, and further analysis of funding opportunities for identified priorities will be carried out.
• The Human Papillomavirus (HPV) Vaccine Research Priorities Workshop was held in November 2005. The objective was to develop national research priorities for optimal Canadian HPV vaccine use. Results point to the development of 49 research questions and the identification of 21 infrastructure gaps with the three most highly ranked research questions relating to program delivery issues. The final report is currently being finalized.
• The Influenza Immunization Program Evaluation Study was carried out, comparing the universal influenza program in the province of Ontario with influenza immunization programs targeting populations at high risk of complications in Canada. Phase I of the study is now complete. Phase II will be carried out in partnership with the Canadian Institutes of Health Research during 2006-09.

1.7 Professional and public education

The goal of this cross-cutting activity of the NIS is to provide high-quality educational material and information to both health professionals and the public; several initiatives have taken place to this end:

• The Professional EducationWorking Group was formed. A comprehensive, detailed list of core competencies for immunization was developed that is national in scope, multi-disciplinary in focus and applicable to both formal and continuing professional education. In addition, a training package in a modular format is being prepared for the education of health professionals.
• The Immunization and Respiratory Infections Division (IRID) of the PHAC, in partnership with the Canadian Paediatric Society (CPS), hosted the 6th Canadian Immunization Conference in December 2004, which had over 970 participants. The 7th conference will be held in December 2006.
• IRID, in collaboration with P/Ts and nongovernmental organizations, is working on the development of public awareness through a marketing strategy for immunization. The Canadian Coalition for Immunization Awareness Program, in cooperation with IRID, developed and implemented the Annual Influenza Immunization Awareness Program and the National Immunization Awareness campaign. A public Web site was created to include immunization related topics: http://www.immunize.cpha.ca/.

1.8 Vaccine-preventable disease surveillance

The Vaccine-Preventable and Respiratory Infections Surveillance (VPRIS) working group was established in December 2005 as a national mechanism for working with stakeholders to improve surveillance systems for vaccine-preventable diseases and respiratory infections. The mandate of the VPRIS Working Group is to identify gaps and needs, set priorities and provide advice, direction and coordination on the development, ongoing enhancement and evaluation of surveillance activities/systems for respiratory infections and vaccine-preventable diseases, as well as the use of surveillance methods and/or special studies to identify and assess relevant issues. Members of the VPRIS Working Group include representatives from the PHAC (IRID, National Microbiology Laboratory, Centre for Emergency Preparedness and Response), experts from F/P/T surveillance programs, Canadian Public Health Laboratory Network and other disease-specific and epidemiology experts. One of the priorities of the VPRIS Working Group for 2006 is the completion of the surveillance annex to the Canadian Pandemic Influenza Plan.

IRID also continues to provide ongoing support to and participation in several national surveillance systems that monitor vaccine-preventable diseases. These surveillance systems are described in Section 3 of this report.

1.9 Conclusions

The NIS is a work in progress. Its development and implementation is a long-term commitment that will improve our ability nationally to ensure that new immunization programs across Canada are introduced in a timely fashion and that there is equitable access to recommended vaccines. It will help improve efficiencies of programs, affordability of vaccines, security of vaccine supply and vaccine safety monitoring and response, as well as restore public confidence in vaccines. Ultimately the NIS will enhance our ability to reduce the impact of vaccine preventable disease. Provinces and territories will continue to be responsible for planning, funding and delivering immunization programs to their respective populations and to contribute to shared activities that support the NIS.

A full progress report on the implementation and evaluation of the NIS strategy will be published in 2007. Additional information on the NIS can be found on the PHAC Web site:
http://www.phac-aspc.gc.ca/publicat/nis-sni-03/index-eng.php.