B.2 Immunization Program Planning

a) Objectives

Immunization program planning is a key component of the proposed National Immunization Strategy. The goal of this NIS component is to support collaborative, national assessment and prioritization of new vaccines, using common criteria.

b) Existing System

Currently, immunization programs are planned and delivered primarily at the provincial/territorial level, so decisions are independently taken by 13 individual jurisdictions. In planning an immunization program, most jurisdictions have advisory bodies that adapt NACI recommendations on the use of specific vaccines to local situations, based on epidemiological, program, and financial considerations¹⁰. In planning their immunization programs, provinces and territories may also consider the advice and input from various national groups, such as the Council of Chief Medical Officers of Health, the Canadian Nursing Coalition on immunization, the Canadian Paediatric Society, and the Canadian Public Health Association.

c) Gaps/Limitations of Existing System

Within the current system, expert recommendations on immunization are made, but there is no coordinated, national mechanism for assessing and prioritizing new vaccines, from a policy perspective. It is therefore difficult to move from discussion and scientific recommendations on immunization program planning, to national collaboration and coordinated provincial/territorial policy decisions within a comprehensive national plan. This can lead to the following issues:

• Differences in vaccine programs across jurisdictions
  
  Most jurisdictions have a recommended schedule of routine childhood immunization programs similar to that recommended by NACI, for the older vaccines¹⁰. However, there are some notable differences in other, special immunization programs. For instance, publicly-funded influenza and pneumococcal immunization programs have varied by jurisdiction in terms of the risk groups covered. Differential schedules, such as the hepatitis B immunization programs in Canada, which target school-aged children of different ages/grades, can have an impact when an individual moves from one jurisdiction to another.
  
  Furthermore, we are in a time of rapid technological advances, which have the potential to further diversify vaccine programs across the country. Certain new vaccines (e.g., varicella, pneumococcal conjugate, acellular pertussis vaccine for adolescents and adults, meningococcal conjugate vaccines) are available on the Canadian market, but have yet to be added to the publicly-funded immunization programs of many provinces or territories, as they consider both the implications and cost of doing so. During the next few years, there will continue to be many new vaccines, new combinations of vaccines, and improved formulations of old vaccines (see text box below). These new products will share the ability to prevent or ameliorate serious diseases but at increased cost.

New Vaccines on the Horizon Mid-Term (3-6 years): nasal influenza vaccine, rotavirus vaccine, other meningococcal vaccines, Group A streptococcus, Group B streptococcus, respiratory syncytial virus (RSV) for the elderly, human papillomavirus (HPV). Long-Term (7-10 years): RSV for infants, human papillomavirus (HPV), parainfluenza virus (PIV), non-typeable Haemophilus influenzae and other otitis media pathogens, herpes simplex virus (HSV), hepatitis C virus, human immunodeficiency virus (HIV).

• Use of public health human and other resources
  
  Each jurisdiction conducts its own reviews of vaccine recommendations and policy analyses before making recommendations on new and existing immunization programs. Furthermore, jurisdictions spend considerable time and resources (e.g., materials, communications) in activities related to the other components of the NIS, such as vaccine procurement and safety. Efficiencies could be realized through national collaboration on these issues.
• Timing of introduction of vaccine programs across jurisdictions
  
  The introduction of new vaccine programs occurs in some jurisdictions in advance of others. The two-dose measles immunization program is one such example. Although the incidence of measles declined substantially after introduction of a one-dose measles program in the mid-late 1960s (reducing the annual number of reported cases from an estimated 300,000 cases per year before immunization to less than 2000 per year in 1995¹¹), outbreaks persisted, mostly in school-aged children, even in populations with virtually 100% documented one-dose coverage¹¹. It became increasingly clear, both from Canadian and international evidence, that a routine one-dose program would not achieve the goal of measles elimination9. Recommendations for a routine second dose of measles vaccine were made at Canadian consensus conferences, the Pan American Health Organization, and NACI between 1992 and 1995. Introduction of a routine two-dose program occurred in all provinces/territories between 1996 to mid-1997, and various catch-up programs were completed in eight provinces and territories.
  
  As another example, all provinces and territories in Canada currently have a universal childhood hepatitis B immunization program in place. The grade levels which are targeted for immunization vary by jurisdiction, with the most common being Grade 4¹³. The school vaccination programs in Canada have been very successful, reaching over 90% of eligible children¹³. These programs were introduced over a number of years across the country, resulting in some delays in access to this vaccine program.

• Intersectoral collaboration on immunization issues could be improved
  
  Vaccine-preventable diseases and immunization programs can have major impacts on areas other than health, such as education, labour and productivity, and early childhood development. The impact of influenza on workplace productivity¹⁴ and school attendance¹⁵ are two cases in point. Influenza immunization has been shown to lead to significant reductions in the frequency of absenteeism from work due to respiratory illness, as well as to reductions in school absenteeism. Efforts to collaborate with other departments and agencies in the area of immunization could be enhanced with a national strategy.

d) Proposed Approach

To address the gaps and limitations described above, it is proposed that an analytical framework/common criteria be used for the assessment and prioritization of new vaccines by all F/P/T governments. Such a tool would ensure that important, agreed-upon factors and criteria are considered in the decision-making process.

A draft analytical framework/tool was developed by Erickson, De Wals and Farand (unpublished document) for information and consideration by F/P/T jurisdictions. The criteria for decision making, adapted from this framework, are classified into the following broad categories:

• Disease characteristics and burden
• Vaccine characteristics
• Alternative immunization strategies and programs
• Social and economic costs and benefits of alternate programs
• Feasibility and acceptability of alternative programs
• Ability to evaluate programs
• Research questions
• Other considerations

The draft framework is meant to be practical and to facilitate rather than replace existing decision-making processes, allowing for more efficient long-term planning and information sharing between F/P/T stakeholders in the area of immunization. National participation will be required to develop further and to refine this draft framework and to move from theory to practice; however, it represents a potentially valuable tool to assist with immunization program planning. The long-term vision of this component of the NIS is to develop an approach that would involve all F/P/T jurisdictions in collaborative decision making on all new vaccines, using common criteria.