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The Canadian Pandemic Influenza Plan for the Health Sector

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Annex D
Recommendations for the Prioritized Use of Pandemic Vaccine

Date of Latest Version: October 2006

Summary of Significant Changes:

New terminology has been developed to improve clarity and facilitate consistent application of the recommended priority groups.
Definitions for these new occupation-related terms are located in the Glossary for the Plan.

1. Priorities for Vaccination
2. New Terminology for the Classification of Workers
3. Recommended Priority Groups for Pandemic Vaccination Program Implementation
Group 1: Health Care Workers, Public Health Responders and Key Health Decision Makers
Group 2: Pandemic Societal Responders and Key Societal Decision Makers
Group 3: Persons at High Risk of Severe or Fatal Outcomes Following Influenza Infection
Group 4: Healthy Adults
Group 5: Children, 24 Months to 18 Years of Age

1. Priorities for Vaccination

Priorities for vaccination have been established to facilitate planning for the implementation of an efficient and consistent pandemic immunization strategy across Canada. Although enough vaccine will be made to immunize all Canadians, it is anticipated that the new pandemic vaccine will become available in batches, necessitating prioritization within the population as the initial doses become available. In keeping with the goal of pandemic response, the prioritization process must consider the impact that the vaccine will have on (i) reducing morbidity and mortality by maintaining the health services response and the protection of high-risk groups, and (ii) minimizing societal disruption by maintaining the essential services necessary for public health, safety and security. The pandemic vaccine will become available in lots; depending on the size of these lots and overall production capacity, prioritization of vaccine recipients will likely be necessary. Furthermore, it is likely that two doses of vaccine will be required to achieve a protective response in the vaccinee. Therefore when vaccine becomes available, it is essential that it be distributed in a predefined, equitable and consistent manner in all provinces and territories.

The Vaccine Working Group has developed the following recommendations for the prioritized use of a pandemic vaccine in order to provide guidance to Pandemic Influenza Committee (PIC) and those involved in pandemic planning at the federal, provincial, territorial (F/P/T) and local levels. The priority groups will need to be reassessed and possibly altered to ensure that they are consistent with the overall goal of the pandemic response, as soon as epidemiologic data on the specific pandemic virus becomes available. When data on the epidemiology of the pandemic becomes available, PIC will be the lead in the final identification and prioritization of groups to receive influenza vaccine. These recommendations will be distributed as national guidelines as soon as possible and with the expectation that they will be followed by all jurisdictions in order to ensure a consistent and equitable program. The lists provided in this document are intended to be illustrative not exhaustive in nature.

2. New Terminology for the Classification of Workers

Since the last edition of the Plan, new terminology has been developed to improve clarity, develop estimates for, and facilitate consistent application of the recommended priority groups. These new terms have been defined and included in the Glossary. Provinces and Territories as well as local public health authorities will need to consider how these terms apply to their own populations.

Vaccine eligibility criteria should be defined on the basis of the work, duties and role that the individual performs rather than the position label. For example, a fire fighter who would be expected to respond to house calls related to illness should probably be considered a "health care worker" rather than a "pandemic societal responder."

National estimates of the population sizes for most of the priority groups were developed on the basis of census data and data available from professional organizations and other NGOs. These estimates have been distributed to each P/T, and the First Nations and Inuit Health Branch, Health Canada, to facilitate planning. However, each jurisdiction is encouraged to develop more refined estimates of these populations, i.e. estimates that would be more applicable to the pandemic planning activities in their jurisdictions.

3. Recommended Priority Groups for Pandemic Vaccination Program Implementation

Group 1:

Health Care Workers, Public Health Responders and Key Health Decision Makers

Rationale: The health care and public health sectors will be the first line of defence in a pandemic. Maintaining the health service response and the vaccine program is central to the implementation of the response plan in order to reduce morbidity and mortality. Members of this group may be considered in the following work settings for vaccine program planning:

acute care hospitals
long-term care facilities and nursing homes
private physician offices
home care and other community care facilities
public health offices
ambulance and paramedic services
pharmacies
laboratories
government offices

Group 2:

Pandemic Societal Responders and Key Societal Decision Makers

Rationale: The ability to mount an effective pandemic response may be highly dependent on persons, within the groups listed below, being in place to maintain key community services. Those individuals that are essential to the response or to maintaining key community services may vary among jurisdictions. Local plans will likely reflect these differences, however they are likely to include:

police
fire fighters
armed forces
key emergency response decision makers (e.g. elected officials, essential government workers, disaster services personnel)
utility workers (e.g. water, gas, electricity, nuclear power, essential communications systems)
funeral service and mortuary personnel
people who work with institutionalized populations (e.g. corrections)
persons who are employed in public transportation and the transportation of essential goods (e.g. food)
key government employees/elected officials (e.g. ministers, mayors)

Group 3:

Persons at High Risk of Severe or Fatal Outcomes Following Influenza Infection

Rationale: To meet the goal of reducing morbidity and mortality, persons most likely to experience severe outcomes should be vaccinated. For planning purposes, this priority group has been based on the high-risk groups identified by the National Advisory Committee on Immunization (NACI) for annual vaccine recommendations. Additional groups have also been included based on evidence indicating an elevated risk (e.g. during the annual epidemics, young infants experiencing rates of hospitalization similar to the elderly).

If necessary, prioritization of the following subgroups within Group 3 would depend on the epidemiology of influenza disease at the time of a pandemic.

A:	Persons living in nursing homes, long-term care facilities, homes for the elderly (e.g. lodges)
B:	Persons with high-risk medical conditions living independently in the community
C:	Persons over 65 years of age living independently and not included in 3A and 3B
D:	Children, 6 to 23 months of age (current vaccines are not recommended for children under 6 months of age)
E:	pregnant women

Currently, NACI does not consider pregnant women as a high-risk group in its recommendations for annual influenza vaccination. However, pregnant women have been at elevated risk during past pandemics.

Group 4:

Healthy Adults (i.e., all individuals, 18-64 years of age, who do not have a medical condition that would qualify them for inclusion in the "high risk"; group and who do not fall into one of the other occupation-based priority groups)

Rationale: This group is at lower risk of developing severe outcomes from influenza during annual epidemics, but this group comprises the major work force and represents the most significant segment of the population from an economic impact perspective. Vaccination of healthy adults would reduce the demand for medical services and allow individuals to continue normal daily activities. Simultaneous absence of large numbers of individuals from their places of employment, even for non-essential personnel, could produce major societal disruption. Medical facilities could also be overwhelmed by health care demands, even for outpatient services. This might compromise the care of those with complications.

Group 5:

Children, 24 Months to 18 Years of Age

Rationale: This group is at the lowest risk of developing severe outcomes from influenza during annual epidemics, but this group plays a major role in the spread of the disease. While children's absence from school might not have the direct economic and disruptive impact of illness in adults, it could have an indirect effect because of adults having to care for ill children.

Consideration was given to prioritizing the family members of health care workers, however it was decided that singling out these individuals would not be logistically feasible or ethically justifiable.