Canada Communicable Disease Report

 

Volume: 34S2
March 2008

Supplement

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56 Pages - 316 KB

Final Report of Outcomes from the National Consensus Conference for Vaccine-Preventable Diseases in Canada

June 2005

Appendix A

Abbreviations

Acronym Title
ACIP Advisory Committee on Immunization Programs (US)
CDC Centers for Disease Control and Prevention, US
CDCEG Communicable Disease Control Expert Group
CDCN Communicable Disease Control Network
CIC Canadian Immunization Committee
CPS Canadian Paediatric Society
CRS Congenital Rubella Syndrome
CVS Congenital Varicella Syndrome
Tdap Diphtheria, tetanus, acellular pertussis vaccine adult formulation
Td-IPV Diphtheria, tetanus, acellular pertussis and inactivated polio virus vaccine
F/P/T Federal/Provincial/Territorial
HC Health Canada
HIV/AIDS Human Immunodeficiency Virus / Auto Immune Deficiency Syndrome
iDIEM Institute for Directed Influenza Evaluation and Management
IgM Immunoglobulin M
IMD Invasive Meningococcal Disease
ImG Immunoglobulin G
IMPAct Immunization Monitoring Program Active
IPD Invasive Pneumococcal Disease
IPV Inactivated Polio Virus vaccine
Men-C-C Meningococcal C Conjugate Vaccine
MHSc Master's degree in Health Science
MSc Master's degree in Science
NACI National Advisory Committee on Immunization (Canada)
NCC-VPD National Consensus Conference for Vaccine-Preventable Diseases
NCS National Centre for Streptococcus Alberta Canada
NICS National Immunization Coverage Survey
NIS National Immunization Strategy
N. meningitidis Neisseria meningitidis
NML National Microbiology Laboratory
PAHO Pan American Public Health Organization
PCR Polymerase Chain Reaction
PHAC Public Health Agency of Canada
Pneu-C-7 Heptavalent pneumococcal conjugate vaccine
Pneu-P-23 (23) Polyvalent pneumococcal polysaccharide vaccine
Td Tetanus and diphtheria adult vaccine formulation
US United States
VZV Varicella Zooster Virus
WHO World Health Organization

Appendix B

Discussion Guides

Goals and Objectives for Vaccine-Preventable Diseases in Canada
Consensus Conference, 2005 (GOCC-VPD)
Rubella Discussion Guide

Original Objectives and Targets
Consensus Conference 1994*

Goal: Eliminate indigenous rubella infection during pregnancy and thus prevent fetal damage, congenital rubella syndrome (CRS) and other negative outcomes of infection by the year 2000.

Targets
Vaccine Coverage:
  • Achieve and maintain 97% vaccine coverage at 2 years of age by the year 1997.
  • Achieve and maintain 99% age-appropriate vaccine coverage at school entry by the year 1997.
  • Achieve and maintain 99% age-appropriate vaccine coverage of 14 to 15-year-olds by the year 1997.
Immunization of Women:
  • Screen serology and/or obtain date of immunization of ALL pregnant women seen prenatally for rubella susceptibility by 1995.
  • Achieve and maintain postpartum immunization for rubella of 99% of all susceptible women prior to hospital discharge by year 1995.
  • Ensure that all women of childbearing age have a documented history of rubella immunization and, if not, that they are offered rubella vaccine to decrease the rate of rubella-negative primigravida women to < 4% by the year 1997.
  • Ensure that all vaccines administered have been appropriately transported, stored and delivered.
  • Review the goal and all targets again in 1997.

* Mumps and Rubella Consensus Conference 1994.
PAHO/WHO: 44th Directing Council, 55th Session of the Regional Committee September 2003.

Revised Objectives and Targets

Context: Adopt WHO/PAHO recommendation to establish the goal of rubella and congenital rubella syndrome elimination from the Americas by the year 2010.

Consensus Conference 2005

Goal: To establish the goal of rubella and congenital rubella syndrome elimination in Canada by the year 2010.

Targets
Vaccine coverage:
  • Achieve and maintain 97% one-dose coverage with rubella containing vaccine at 2 years of age by the year 2010.
  • Achieve and maintain 97% two-dose coverage with rubella containing vaccine at school entry by the 2010.
  • Achieve and maintain 97% age-appropriate vaccine coverage of 8 to 16-year-olds by the year 2010.
Immunization of women:
  • Screen serology and/or obtain date of immunization of ALL pregnant women seen prenatally for rubella susceptibility by 2010.
  • Achieve and maintain postpartum immunization for rubella of 99% of all susceptible women prior to hospital discharge by year 2010.
  • Ensure that all women of childbearing age have a documented history of rubella immunization and, if not, that they are offered rubella vaccine to decrease the rate of rubella-negative primigravida women to < 4% by the year 2010.
  • Ensure that all vaccines administered have been appropriately transported, stored and delivered.
  • Review the goal and all targets again in 2010.

Goals and Objectives for Vaccine-Preventable Diseases in Canada
Consensus Conference, 2005 (GOCC-VPD)
Varicella Discussion Guide

The 1999 Objectives and Targets*

VZV = Varicella Zoster Virus
National Varicella Consensus Conference (NVCC)

Disease reduction
  • By 2005, an F/P/T forum should establish reduction goals for VZV-associated morbidity
Vaccine coverage

Vaccination should be offered to susceptible persons in the following groups, in descending order of priority: health care workers and other special groups, selected immunocompromised groups, preteens at the time of other vaccination programs, children at 1 year of age, catch-up of children aged 1 year to preteens, and other adults.

  • By 2003, 100% of health care workers should have known positive varicella serology, or a reliable history of disease, or documentation of varicella vaccination, or an acceptable medical contraindication to varicella vaccination.
  • By 2005, all provinces/territories should have a routine childhood immunization program for varicella, with initiation and completion of catch-up programs for susceptible children <13 years of age.
  • Primary immunization of children <13 years of age should be done with one dose, pending evidence-based assessment of this policy.
  • There should be no booster dose, pending further research to measure the need and appropriate timing for a booster to prevent of varicella and zoster.
  • By 2010, varicella vaccination coverage targets should be tied to measles vaccination coverage targets** to be achieved by the 2nd birthday and by the 7th birthday.

* Proceedings of the National Varicella Consensus Conference - Montreal, Quebec, May 5-7, 1999
CCDR Supplement Volume 25S5, August 1999

** Note: The coverage targets voted on were 95% and 97% by the 2nd and 7th birthday, respectively. However, the discussion was to link the varicella coverage targets to those for measles, which are 97% and 99%, respectively. The actual measles targets should be taken into consideration in program implementation and evaluation.

Issues for Evidence-Based Decision

Summarize NACI recommendations for varicella vaccine.

  • Summarize varicella vaccination programs across Canada as well as any international programs in existence.
  • How has the disease burden* of varicella (V) and/or herpes zoster (HZ) changed since the introduction of the universal P/T immunization program?
  • Does the epidemiological surveillance data accurately reflect the disease burden? Are increases artefact (laboratory testing, increased diagnosis) or real? Is there an age group who is systematically under-diagnosed (i.e., adolescents and adults)?
  • Have there been any unexpected adverse events related to varicella vaccination?
  • Is there evidence of waning immunity? Consider the need for booster programs.

Re: US Experience and lessons learned

  • Summarize vaccine coverage and V and HZ incidence rates in the US since the introduction of the universal varicella immunization program?
    1. National averages
    2. Regional variation
  • Did the US develop national goals and objectives (targets) for varicella vaccine coverage and V and HZ disease reduction when the universal immunization program was initiated?
    1. If yes, have they been revised recently
    2. If no, have any been developed since initiating the program?
  • How has the disease burden** of V and HZ changed since the introduction of the universal immunization program in the US?
  • How has variation in vaccine coverage impacted on the disease burden** of V and HZ?
  • Have there been any changes in disease burden** of V and HZ, specific to the following groups, since the initiation of the universal immunization program?
    1. Age groups
    2. At risk groups such as the immunocompromised, women of childbearing years and other at adult at risk groups (southern hemisphere immigrants, healthcare workers)
  • What has been the impact (good and bad) of varicella "breakthrough" cases in terms of vaccine coverage rates, disease burden** (severe complications, severity of illness, etc.) and public confidence in the varicella immunization program?
    1. Is there any evidence to suggest that breakthrough cases boost immunity to V and/or HZ?
  • Have observations in the US to date confirmed or refuted mathematical modelling predictions suggesting an association between immunization coverage and V and HZ incidence and disease burden** and/or the impact of waning immunity?
  • What lessons can we learn from the US experience with the varicella universal immunization program?

** Disease burden = disease incidence, hospitalizations and mortality

Cost effectiveness
  • What studies have been done on cost effectiveness of varicella vaccination? Summarize the key findings.
Revised Goals' Objectives and Targets
Disease reduction
  1. Disease incidence targets (Establishment of disease reduction goals recommended in 1999 NVCC)
    • To achieve a XX% reduction in the incidence of varicella in children aged 12 months to 13 years by the year XXXX.
    • To achieve a XX% reduction in the incidence of zoster in adults by the year XXXX.
    • To (decrease/eliminate - 1 or 2 dose respectively) the number of varicella outbreaks in schools Canada (alternate: give target).
  2. Hospitalization targets
    • Decrease rates of hospital and ICU admission among children aged 12 months to 13 years by XX% by the year XXXX.
  3. Mortality targets
    • Decrease the number of deaths from varicella to 0 in the target population of children aged 12 months to 13 years by the year XXXX.
Vaccine coverage
  • At least XX% of children should have received age-appropriate immunization with varicella vaccine by 2(3) years of age by the year XXXX.
  • At least XX% of adolescents should have received immunization with varicella vaccine by 13 years of age by the year XXXX (or by the end of secondary school).
  • By 2010, varicella vaccination coverage targets should be tied to measles vaccination coverage targets to be achieved by the second birthday and by the 7th birthday. Actual measles targets should be taken into consideration in program implementation and evaluation.
Other
  • 100% of susceptible health care workers should have received immunization with varicella vaccine by the year XXXX.
  • Pre-teens at the time of other vaccination programs (captured above in bullet 2?).
  • Catch-up children 12 months to 13 years, susceptible adults?
  • Susceptible women considering pregnancy.
Questions for Next Steps - Implementation
  1. Have jurisdictions implemented any of the recommendations from the August 1999 NVCC?
  2. How can we identify correlates of immunity with more precision?
  3. How can we optimize the use of immunization registries in linking vaccine status to disease?
  4. Would we want to consider public awareness campaigns and what would we hope to achieve?
  5. Others
  6. What type of information is needed (surveillance, targeted research) and how do we go about collecting information to inform decision- making regarding?
    1. Need and timing of booster immunization with varicella vaccine
    2. Changing epidemiology e.g., age-specific shift or increase in incidence of varicella zoster
    3. Incidence, impact and any factors related to breakthrough disease
  7. Is there a need for further information on cost-benefit, especially with respect to potential future decision-making on two-dose/booster programs.
  8. What are the laboratory diagnostic issues, e.g., when/who to test [before/after vaccination/post-rash onset] and testing recommendations for wild type versus vaccine virus strains?

Goals and Objectives for Vaccine-Preventable Diseases in Canada
Consensus Conference, 2005 (GOCC-VPD)
Invasive Pneumococcal Disease Discusion Guide

Original Objectives and Targets*
Disease reduction
  • To achieve a 40% reduction in the incidence of invasive pneumococcal disease in vaccine-eligible groups by the year 2005.
  • To achieve a 40% reduction in the rate of death due to invasive pneumococcal disease in vaccine-eligible groups by the year 2005.
Vaccine coverage
  • To achieve and maintain 95% vaccine coverage for residents of long-term care facilities by the year 2003.
  • To achieve and maintain 80% vaccine coverage in all other groups for whom vaccine is recommended by the year 2003.
Issues for Evidence-Based Decision
  1. Summarize NACI recommendations for pneumococcal immunization programs in Canada.
  2. Summarize pneumococcal vaccination programs across Canada and international programs in existence.
  3. How has the disease burden (i.e., disease incidence, hospitalizations and mortality) of IPD changed since the introduction of the universal P/T immunization programs?
    1. Have there been any age-specific changes in disease burden of IPD since the initiation of the P/T immunization programs?
    2. Do 7-valent vaccine programs and 23-valent vaccine programs have an additive impact on IPD in some target populations?
  4. What is the impact of the vaccine on herd immunity?
  5. Is there evidence of waning immunity?
  6. Is there evidence of replacement serotypes causing invasive disease as a result of immunization programs?
  7. What is the impact of immunization programs on antibiotic resistance?
  8. What lessons can we learn from the US experience with universal pneumococcal immunization programs?
  9. Have there been any unexpected adverse events related to pneumococcal conjugate vaccine?
  10. Discuss cost effectiveness.

* Preventing Pneumococcal Disease: A Canadian Consensus Conference, Feb. 16-18, 1998. Can J Infect Dis 1999; 10(Suppl A).

Revised Objectives and Targets
Disease reduction
  1. Disease incidence targets
    • To achieve a XX% reduction in the incidence of invasive pneumococcal disease in vaccine-eligible serotypes in children < 2 years (alternative: 5 years) of age by the year XXXX.
    • To achieve a XX% reduction in the incidence of invasive pneumococcal disease in vaccine-eligible serotypes in adults > 65 years of age by the year XXXX.
    • To achieve a XX% reduction in the incidence of invasive pneumococcal disease in vaccine-eligible serotypes in highrisk groups by the year XXXX.
  2. Hospitalization targets
    • To decrease rates of hospital and ICU admission among children < 2 year of age by XX% by the year XXXX.
    • To decrease rates of hospital and ICU admission among high-risk children by XX% by the year XXXX.
    • To decrease rates of hospital and ICU admission among adults ≥ 65 years of age by XX% by the year XXXX.
  3. Mortality targets
    • Decrease the number of deaths from invasive pneumococcal disease to X in children 2 months to 2 years of age by year XXXX.
    • Decrease the number of deaths from invasive pneumococcal disease to X in adults ≥ 65 years of age by year XXXX.
Vaccine Coverage
  • At least XX% of children should have received age-appropriate immunization with pneumococcal conjugate vaccine by 2 years of age by the year XXXX.
  • At least XX% of adults > 65 years of age should have received a single dose of pneumococcal polysaccharide vaccine by the year XXXX (alternate wording: "by X years of age" for measurement purposes).
  • To achieve and maintain XX% vaccine coverage for residents of long-term care facilities by the year XXXX.
  • At least XX% of high-risk people should receive age-appropriate immunization with pneumococcal vaccine by the year XXXX (alternate wording: have separate conjugate and polysaccharide coverage targets for high risk).
Questions for Next Steps
  1. Have jurisdictions implemented any of the recommendations from the February 1998 National Consensus Conference on Preventing Pneumococcal Disease?
  2. How adequately do we capture age-specific disease incidence, hospitalization and mortality through surveillance, hospital discharge data and Statistics Canada deaths registry?
  3. Do any jurisdictions have enhanced surveillance for invasive pneumococcal disease?
  4. Which provinces and territories routinely collect serotype data on invasive pneumococcal isolates?
  5. Are the serotype data currently collected adequate to determine targets and measure progress towards reducing vaccine-eligible disease outcomes?
  6. How can disease outcomes and vaccine coverage be measured for high-risk groups?
  7. How can we optimize the use of immunization registries in linking vaccine status to disease?
  8. What are the barriers in improving implementation of adult immunization programs and how can we overcome them? How can we address missed opportunities for pneumococcal vaccination among older adults (e.g., during annual influenza vaccinations)?
  9. Would we want to consider professional education and public awareness campaigns and what would we hope to achieve?

Goals and Objectives for Vaccine-Preventable Diseases in Canada
Consensus Conference, 2005 (GOCC-VPD)
Invasive Meningococcal Disease (IMD) Discusion Guide

Original Objectives and Targets*

There are no original goals and objectives available since the implementation of the serogoup C vaccination programs.

Questions/ISSUES for Evidence- Based Decision
  1. Summarize NACI recommendations for serogroup C IMD.
  2. Summarize IMD serogroup C vaccination programs across Canada. Summarize international programs in existence.
  3. How has the disease burden* of IMD serogroup C changed since the introduction of the universal P/T immunization program?
  4. Have there been any age specific changes in disease burden* of IMD serogroup C since the initiation of the P/T immunization program?
    1. Has the disease burden changed differentially in P/Ts providing infant immunization versus those providing immunization at 1 year of age.
  5. What is the impact of the UK Vaccine effectiveness study and dosage schedules?
  6. What is the impact of vaccine on herd immunity?
  7. Is there evidence of replacement serogroups occurring as a result of the immunization programs?
  8. Is there evidence of waning immunity? Consider the need for re-vaccination programs.
  9. Have there been any unexpected adverse events related to meningococcal C conjugate vaccine?
  10. Evidence for meningococcal C vaccine in control of outbreaks.
  11. Discuss cost effectiveness.

* Disease burden = disease incidence, hospitalizations and mortality

Objectives and Targets
Disease reduction
  1. Disease incidence targets
    • To achieve a XX% reduction in the incidence of N. meningitidis serogroup C in children < 5 years of age by the year XXXX.
    • To achieve a XX% reduction in the incidence of N. meningitidis serogroup C in adolescents 15 to 19 years of age by the year XXXX.
    • To reduce the reported incidence of N. meningitidis serogroup C among adolescents to at least the levels present in preschool- aged children by the year XXXX.
    • To achieve a XX% reduction in the incidence of N. meningitidis serogroup C in Canada by XXXX.
    • To eliminate meningococcal serogroup C outbreaks in Canada by XXXX.
  2. Mortality targets
    • Decrease the number of deaths from invasive meningococcal disease to X in children < 5 years of age by year XXXX (or serogroup C specific).
    • Decrease the number of deaths from invasive meningococcal disease to X in adolescents 15 to 19 years of age by year XXXX (or serogroup C specific).
    • Overall target?
Vaccine coverage
  • At least XX% of children should have received age-appropriate immunization with meningococcal conjugate vaccine by 2 years of age by XXXX.
  • At least XX% of adolescents should have received age-appropriate immunization with meningococcal conjugate vaccine by 17 years of age by XXXX.
Questions for Next Steps
  1. How adequately do we capture age-specific disease incidence, hospitalization and mortality through surveillance, hospital discharge data and Statistics Canada deaths registry?
  2. Which provinces and territories routinely report complete laboratory data on invasive meningococcal isolates?
  3. Are the serotype data currently collected adequate to determine targets and measure progress towards reducing vaccine-eligible disease outcomes
  4. Are disease sequelae currently being measured for meningococcal diseases?
  5. The need for revaccination/booster dose needs to be assessed by NACI.
  6. How can we optimize the use of immunization registries in linking vaccine status to disease?
  7. Would we want to consider professional education and public awareness campaigns and what would we hope to achieve?
  8. Once approved for use in Canada, what will be the impact of the quadrivalent conjugate vaccine?

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