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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). |
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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.
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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.
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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.
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