ARCHIVED - Canada Communicable Disease Report

1 December 2007

Volume 33

Number 13

Summary of the outcomes from the National Consensus Conference for vaccine-preventable diseases in Canada, Quebec, Quebec, June 12-14, 2005

Introduction

The first in a series of National Consensus Conferences for Vaccine-Preventable Diseases in Canada (NCC-VPD) was held in Quebec City from June 12-14, 2005. The Conference focused on setting national disease reduction and immunization coverage goals and targets for six vaccine-preventable diseases: invasive meningococcal disease (IMD), invasive pneumococcal disease (IPD), varicella, pertussis, influenza and rubella.

This article summarizes the outcomes from the consensus conference and is the second in a series of articles published in the Canada Communicable Disease Report (CCDR) on the consensus conference. The first was the comprehensive Final Report from the National Goals and Recommendations Consensus Conference for Vaccine Preventable Diseases, 2005⁽¹⁾ and the third and final article will describe the process of the conference from pre conference research and preparation, through establishing consensus at the conference to post conference follow-up and the adoption and implementation of conference outcomes.

Consensus conference summary

The objectives of the 2005 consensus conference were to:

• Review existing national goals and targets from previous consensus conferences (post-1990) and where necessary, agree upon new national goals and targets
• Achieve consensus on the new goals and recommendations; and
• Outline the essential steps to facilitate national adoption and implementation of the goals and recommendations.

Participants included representatives from all provinces and territories, including chief medical officers of health, provincial and territorial epidemiologists, and program experts, technical and program experts from the federal government, international experts, and key non-government groups.

Conference terms and definitions

For the purpose of conference deliberations, the definition of terms is as follows:

Goal: Is defined as a broad statement of a desired achievement over a specific time frame. Goals are not required to be quantitative or measurable.

Objectives/Recommendations: Are statements of intent that are more specific, measurable, achievable, realistic, and timed. An objective may include a target. At a subsequent meeting of the Canadian Immunization Committee (CIC) it was recommended that the term objective be reserved for use by the jurisdictions to determine individually how best to work towards nationally agreed upon goals, in a feasible timeframe, given their own unique requirements. Therefore throughout these documents the term objective has been replaced with recommendation.

Targets: Are measurable, they specify the amount of progress to be made and the time by which it is to be made.

Further, time lines for national goals and recommendations should be reasonable and feasible, with 5 years suggested as an appropriate planning horizon.

Vaccine eligibility: For the purpose of developing recommendations for national goals, participants agreed that vaccine eligibility should be based on the National Advisory Committee on Immunization (NACI) recommendations rather than jurisdictional public health programs.

Goals and recommendations

Consensus was reached on three goals and 52 updated or new recommendations. During the conference participants were assigned to disease specific working groups and asked to develop or update recommendations for disease reduction and immunization coverage. For some diseases, working groups proposed additional recommendations which were considered essential for achieving disease specific goals; these additional recommendations, which addressed issues of surveillance, laboratory diagnosis and vaccine program implementation, were also presented and voted on in plenary and are presented in this report. Goals for pertussis, IMD and varicella were not developed by the working groups at the conference, however they were subsequently proposed by the Public Health Agency of Canada (PHAC) for uniformity and approved by CIC following the conference, and are included in this report. The following is a summary of all goals and recommendations from the conference that achieved consensus and include changes and additions approved by CIC in December 2005. A more complete review of issues, rationales and discussions for each disease specific working group is included in the Final Report(1). A compact disk (CD) containing all reference material and copies of presentations for all diseases reviewed at the conference is available upon request from Programs IRID-DDIR@phac-aspc.gc.ca.

Rubella

Goal: Adopt the World Health Organization / Pan-american Health organization (WHO/PAHO) regional goal to eliminate indigenously transmitted cases of rubella and congenital rubella syndrome (CRS) from Canada by 2010.

Disease incidence
- Decrease the rate of rubella-negative primigravida women to < 4% by 2010, by ensuring that all women of childbearing age have a documented history of rubella immunization and, if not, that they are offered a rubella-containing vaccine.

Immunization coverage
- Achieve and maintain age-appropriate immunization coverage for rubella-containing vaccine in 97% of children by their 2^nd birthday (1 dose) by 2010.

- Achieve and maintain age-appropriate immunization coverage with rubella-containing vaccine in 97% of children by their 7^th birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with rubella-containing vaccine among 97% of adolescents 14 to 16 years of age by 2010.

- Achieve and maintain rubella post-partum immunization coverage in 99% of susceptible women prior to hospital discharge by 2010.

Other
- Screen serology and/or obtain date of immunization of ALL pregnant women seen prenatally for rubella susceptibility by 2010.

Varicella

Goal: Reduce illness and death due to complications from varicella through immunization.

Disease incidence
- Achieve a sustained reduction of 70% and 90% in the incidence of varicella by 2010 and 2015 respectively.

Immunization coverage
- Achieve and maintain age-appropriate immunization coverage with varicella vaccine in 85% of children by their 2^nd birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with varicella vaccine in 85% of susceptible children by their 7^th birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with varicella vaccine in 85% of susceptible adolescents by their 17^th birthday by 2010.

Other
- Decrease varicella-related hospitalization rates by 80% by 2010.

- Decrease the number of varicella-related deaths by 80% by 2010.

- Achieve and maintain 100% demonstrated varicella immunity in health care workers, by either history of disease, positive serology or prior immunization; and vaccinate if not immune, unless contraindicated, by 2010.

- Screen 100% of pregnant women annually for immunity to varicella, by either history of disease, prior immunization or positive serology, by 2010.

- Achieve and maintain immunization coverage with varicella vaccine in 100% of post-partum women without evidence of immunity, unless contraindicated, by 2010.

Invasive pneumococcal disease (IPD)

Goal: Reduce illness and death due to pneumococcal disease through immunization.

Disease incidence
- Achieve a sustained reduction of 80% in the incidence of IPD in children < 2 years of age compared with pre-conjugate vaccine incidence by 2010.

- Achieve a sustained reduction of 40% in the incidence of IPD in adults ≥ 65 years of age compared with 1998 incidence by 2010.

Immunization coverage
- Achieve and maintain age-appropriate immunization coverage with pneumococcal conjugate vaccine in 90% of children by their 2^nd birthday by 2008.

- Achieve and maintain age-appropriate immunization coverage with a single dose of pneumococcal polysaccharide vaccine in 80% of adults ≥ 65 years of age by 2010.

- Achieve and maintain age-appropriate immunization coverage with pneumococcal polysaccharide vaccine in 95% of residents of long-term care facilities by 2008.

Other
- Achieve a sustained reduction of 20% in mortality rates due to IPD in adults ≥ 65 years of age compared with 1998 baseline rates by 2010.

- All provinces and territories should continue to optimize their pneumococcal immunization programs for individuals at high risk for IPD as defined by NACI guidelines.

- Serotype determination should be made on a representative sample of invasive Streptococcus pneumoniae isolates starting in 2006.

Invasive meningococcal disease

Goal: Reduce illness and death due to Neisseria meningitidis (N. meningitides) serogroup C through immunization (proposed by CIC).

Disease incidence
- Prevent N. meningitidis serogroup C outbreaks in those < 25 years by 2012.

- Achieve a sustained reduction of 90% in the incidence of N. meningitidis serogroup C in children < 5 years of age by 2010.

- Achieve a sustained reduction of 95% in the incidence of N. meningitidis serogroup C in adolescents 12 to 19 years of age by 2010.

- Achieve a sustained reduction of 70% in the incidence of N. meningitidis serogroup C by 2010.

Immunization coverage
- Achieve and maintain age-appropriate immunization coverage with meningococcal C conjugate vaccine in 100% of N. meningitidis serogroup C close contacts⁽²⁾ of cases by 2010.

- Achieve and maintain age-appropriate immunization coverage with meningococcal C conjugate vaccine in 95% of high-risk groups⁽²⁾ for N. meningitidis serogroup C disease.

- Achieve and maintain age-appropriate immunization coverage with meningococcal C conjugate vaccine in 97% of children by their 2^nd birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with meningococcal C conjugate vaccine in 90% of adolescents by their 17^th birthday by 2012.

Other
- Enhance epidemiological, clinical and laboratory surveillance of invasive meningococcal C disease to include immunization status and uniform polymerase chain reaction technology for all jurisdictions.

- Provinces and territories should evaluate N. meningitidis serogroup C immunization programs including, but not limited to, immunization coverage, vaccine effectiveness, vaccine safety and epidemiological changes.

Influenza

Goal: The goal of the annual influenza immunization program is to prevent serious illness caused by influenza and its complications, including death.

Disease incidence
- National disease reduction goals should be established for influenza.

Immunization coverage
- The following 2001 national immunization coverage targets should be maintained until a task group has been convened and made updated recommendations:

• 95% coverage of residents of long-term care facilities and staff who have extensive contact with residents
• 80% coverage of persons aged ≥ 65 years of age
• 80% coverage of persons < 65 years of age with high risk conditions
• 80% coverage of health care workers
• 100% coverage of vaccinators
• 80% coverage of household contacts of people at high risk

Other
- Governments should work collaboratively to ensure that a safe and immunogenic vaccine is available for annual influenza immunization programs.

- Governments should work collaboratively to efficiently deliver influenza immunization to eligible persons each year.

- Governments should work collaboratively to establish a mechanism for strategic design of influenza immunization programs, including applied public health research and program evaluation of:

• basic science
• surveillance
• evaluation of interventions
• knowledge, attitudes and behaviours
• mathematical and economic modeling

Pertussis

Goal: Reduction of disease incidence through routine immunization and increased access to immunizations in populations with low coverage (proposed by CIC).

Disease incidence
- Achieve a sustained reduction in the reported incidence of pertussis among persons 10 to 19 years of age to at least the levels present in persons 1 to 4 years of age by 2010.

- Reduce the reported incidence of pertussis in persons 30 to 39 years of age to the same levels as in persons 20 to 29 and 40 to 59 years of age by 2015.

Immunization coverage
- Achieve and maintain age-appropriate immunization coverage with acellular pertussis vaccine in 95% of infants by 3 months of age by 2010.

- Achieve and maintain age-appropriate immunization coverage with acellular pertussis vaccine in 95% of infants/children by 7 months of age by 2010.

- Achieve and maintain age-appropriate immunization coverage with acellular pertussis vaccine in 95% of children by their 2^nd birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with acellular pertussis vaccine in 95% of children by their 7^th birthday by 2010.

- Achieve and maintain age-appropriate immunization coverage with the Adacel adult vaccine (Tdap) vaccine in 85% of adolescents by their 18^th birthday by 2010.

- Provinces/territories should replace diphtheria-tetanus adult vaccine (Td) with the Adacel adult vaccine (Tdap) for the adult population by 2010.

Other
- Decrease the number of deaths from pertussis to zero in the target population of ≤ 3 months of age by 2010.

- The Canadian Public Health Laboratory Network should reaffirm the laboratory recommendations from the 2002 Pertussis Consensus Conference.

Conclusion

The rubella goal has been approved by CIC for national endorsement through the Pan-Canadian Public Health Network. CIC approved the remaining goals and recommendations from the consensus conference as “gold standards” to be used by provinces and territories to guide the development and refinement of provincial and territorial programmatic objectives.

The 2005 national goals and recommendations will be re-evaluated in 2010, and future consensus conferences are planned to review, develop and update national goals and recommendations for immunization coverage and disease reduction for all remaining vaccine-preventable diseases.

References

1. Final Report of Outcomes form the National Consensus Conference for Vaccine-Preventable Diseases in Canada. CCDR In Press.

2. National Advisory Committee on Immunization (NACI). Canadian Immunization Guide. 6^th ed.,Ottawa ON, Health Canada, 2002. http://www.phac-aspc.gc.ca/ publicat/cig-gci/index.html.

Acknowledgements

We would like to thank the national and international experts and program specialists who participated in the consensus conference, the conference co-chairs, the planning committee members, those who donated their time to ensure that the evidence presented in the discussion guides was the most current and relevant, and staff of the Immunization and Respiratory Infections Division for making the conference a success.