Guidance on the use of COVID-19 vaccines for 2025 to summer 2026

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Organization: Public Health Agency of Canada

Date published: 2025-01-10
Cat.: HP40-376/2025E-PDF
ISBN: 978-0-660-74983-9
Pub.: 240716

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Preamble

The National Advisory Committee on Immunization (NACI) is an External Advisory Body that provides the Public Health Agency of Canada (PHAC) with independent, ongoing and timely medical, scientific, and public health advice in response to questions from PHAC relating to immunization.

In addition to burden of disease and vaccine characteristics, PHAC has expanded the mandate of NACI to include the systematic consideration of programmatic factors in developing evidence based recommendations to facilitate timely decision-making for publicly funded vaccine programs at provincial and territorial levels.

The additional factors to be systematically considered by NACI include: economics, ethics, equity, feasibility, and acceptability. Not all NACI statements will require in-depth analyses of all programmatic factors. While systematic consideration of programmatic factors will be conducted using evidence-informed tools to identify distinct issues that could impact decision-making for recommendation development, only distinct issues identified as being specific to the vaccine or vaccine-preventable disease will be included.

This statement contains NACI's independent advice and recommendations, which are based upon the best current available scientific knowledge. This document is being disseminated for information purposes. People administering the vaccine should also be aware of the contents of the relevant product monograph. Recommendations for use and other information set out herein may differ from that set out in the product monographs of the Canadian manufacturers of the vaccines. Manufacturer(s) have sought approval of the vaccines and provided evidence as to its safety and efficacy only when it is used in accordance with the product monographs. NACI members and liaison members conduct themselves within the context of PHAC's Policy on Conflict of Interest, including yearly declaration of potential conflict of interest.

Background

The endemic circulation of SARS-CoV-2 has allowed public health programs to shift toward longer-term planning for a more sustainable approach to managing COVID-19 disease. Internationally, strain selection assessments for COVID-19 vaccines have been occurring on a regular basis, with the COVID-19 vaccines being updated once a year, prior to the fall/winter respiratory season. Surveillance activities and programs for SARS-CoV-2 are evolving to meet information needs within the context of the ongoing circulation of the virus. At the national level, Canadian SARS-CoV-2 surveillance has been integrated into the longstanding Respiratory Virus Detection Surveillance System (RVDSS). However, there continue to be uncertainties around ongoing disease epidemiology to which immunization programs will have to adapt.

Canadian provinces and territories have been accessing supply of COVID-19 vaccines that were procured and paid for by the federal government since they first became available in December 2020. Compared to other routine immunization programs which are paid for by provinces and territories, this has been unique to the COVID-19 pandemic. A significant anticipated change is that jurisdictions will be responsible for the costs of buying COVID-19 vaccines for implementation starting in the fall of 2025. The KP.2 mRNA COVID-19 vaccines used in the 2024 to 2025 respiratory season are the last COVID-19 vaccines covered under the advance purchase agreements put in place by the federal government during the pandemic. This change has provided an opportunity for NACI to reassess key COVID-19 immunization program considerations, as well as the overall framing and approach to advice for COVID-19 vaccines going forward.

There have been several COVID-19 vaccine products authorized for use in Canada, and NACI has previously issued guidance to recommend that either mRNA or protein subunit COVID-19 vaccines can be used in the authorized age groups for protection from SARS-CoV-2. This statement is intended to assist with COVID-19 vaccine program planning for 2025 and until the summer of 2026. It is uncertain what products will be available during this period of time; the COVID-19 chapter of the Canadian Immunization Guide will be updated to reflect the available products as appropriate. NACI will continue to monitor the evolving COVID-19 epidemiology and vaccine information and will provide updated guidance if necessary.

Methods

The NACI COVID-19 Working Group (COVID-19 WG) reviewed the available information pertaining to XBB.1.5 vaccines including vaccine effectiveness and duration of protection. The NACI COVID-19 WG also reviewed available evidence on SARS-COV-2 epidemiology as well additional considerations related to COVID-19 immunization programs, including cost-effectiveness and the timing and feasibility of COVID-19 vaccine administration.

On September 19 and November 19, 2024, NACI reviewed the evidence presented to the COVID-19 WG. Following a thorough review of the evidence and consultation at NACI meetings, the committee voted on specific recommendations. The statement was approved on December 6, 2024.

Further information on NACI's process and procedures is available elsewhereFootnote 1Footnote 2.

Overview of evidence and considerations

Epidemiology

Figure 1. Percentage of SARS-CoV-2 tests positive by surveillance week, season in Canada (from 2022 Week 35 to 2024 week 48, RVDSS)
Figure 1. Text version below.
Figure 1: Descriptive text
Figure 1. Percentage of SARS-CoV-2 tests positive by surveillance week, season in Canada (from 2022 Week 35 to 2024 week 48, RVDSS)
Surveillance week 2022-23 2023-24 2024-25
35 13.4% 14.4% 17.9%
36 13.1% 15.9% 18.4%
37 12.7% 16.5% 18.7%
38 13.6% 18.6% 18.9%
39 14.4% 19.6% 17.0%
40 15.1% 19.8% 16.1%
41 16.6% 17.5% 15.0%
42 15.4% 17.8% 15.6%
43 15.8% 17.9% 15.1%
44 13.9% 17.7% 13.8%
45 12.4% 18.2% 12.5%
46 12.0% 18.8% 11.0%
47 11.8% 19.3% 10.2%
48 12.1% 18.0% 9.6%
49 12.6% 17.5% no data
50 13.1% 17.8% no data
51 14.1% 16.8% no data
52 15.5% 15.4% no data
1 15.0% 14.5% no data
2 13.4% 13.0% no data
3 12.2% 11.4% no data
4 11.3% 10.2% no data
5 11.5% 9.3% no data
6 11.9% 8.8% no data
7 11.8% 8.1% no data
8 11.7% 7.5% no data
9 11.2% 7.0% no data
10 11.4% 6.2% no data
11 11.6% 6.1% no data
12 11.3% 5.2% no data
13 10.8% 4.9% no data
14 10.9% 4.7% no data
15 11.4% 4.9% no data
16 10.9% 4.8% no data
17 10.1% 5.5% no data
18 9.8% 6.5% no data
19 9.6% 7.4% no data
20 9.3% 8.2% no data
21 9.2% 7.9% no data
22 8.5% 8.5% no data
23 7.4% 9.7% no data
24 6.7% 10.0% no data
25 6.2% 10.6% no data
26 5.8% 11.5% no data
27 5.7% 12.2% no data
28 6.1% 12.9% no data
29 6.9% 14.0% no data
30 7.7% 14.2% no data
31 8.4% 15.8% no data
32 9.4% 14.8% no data
33 11.6% 15.6% no data
34 13.4% 17.9% no data

Vaccine effectiveness and duration of vaccine protection

Vaccine safety

For more information, please see the section on Safety and adverse events in the COVID-19 chapter of the CIG.

Economics

Ethics, equity, feasibility, and acceptability

Timing of immunization programs and vaccination

Other considerations

For further information on NACI's recommendations on the use of COVID-19 vaccines, please refer to NACI: Statements and publications and the COVID-19 vaccine chapter of the CIG.

Choice of COVID-19 vaccine

Recommendations

Please see Table 1 for an explanation of strong versus discretionary NACI recommendations.

The following recommendations apply for all of 2025 and up to the summer of 2026.

Recommendations 1A and 1B pertain to both those previously vaccinated and unvaccinated, while Recommendations 2A and 2B pertain only to those previously vaccinated.

For those previously vaccinated:

Recommendation 1A. NACI recommends a COVID-19 vaccine for previously vaccinated and unvaccinated individuals at increased risk of SARS-CoV-2 exposure or severe COVID-19 disease, which includes the following individuals:

(Strong NACI recommendation)

Recommendation 1B. NACI recommends that all other previously vaccinated and unvaccinated individuals (6 months of age and older) who are not at increased risk for SARS-CoV-2 exposure or severe COVID-19 disease (i.e., not on the list above in Recommendation 1A) may receive a COVID-19 vaccine.

(Discretionary NACI recommendation)

Considerations:

In addition to Recommendation 1A, some previously vaccinated individuals at increased risk of severe COVID-19 disease are recommended a second dose of COVID-19 vaccine per year.

Recommendation 2A. NACI recommends the following individuals should receive a second dose of COVID-19 vaccine per year:

(Strong NACI recommendation)

Recommendation 2B. NACI recommends the following individuals may receive a second dose of COVID-19 vaccine per year:

(Discretionary NACI recommendation)

Considerations:

Summary of evidence and rationale:

Research priorities

Table 1. Strength of NACI recommendations
Strength of NACI recommendation (based on factors not isolated to strength of evidence, such as public health need) Strong Discretionary
Wording "should/should not be offered" "may/may not be offered"
Rationale Known/anticipated advantages outweigh known/anticipated disadvantages ("should"), or Known/Anticipated disadvantages outweigh known/anticipated advantages ("should not") Known/anticipated advantages are closely balanced with known/anticipated disadvantages, or uncertainty in the evidence of advantages and disadvantages exists
Implication A strong recommendation applies to most populations/individuals and should be followed unless a clear and compelling rationale for an alternative approach is present. A discretionary recommendation may be considered for some populations/individuals in some circumstances. Alternative approaches may be reasonable.

Abbreviations

ACIP
Advisory Committee on Immunization Practices (United States)
CAR
Chimeric antigen receptor
CI
Confidence interval
CIG
Canadian Immunization Guide
CMC
Chronic medical condition
COVID-19 WG
COVID-19 Working Group
HCW
Health care worker
HSCT
Hematopoietic stem cell transplantation
ICER
Incremental cost-effectiveness ratio
ICU
Intensive care unit
JCVI
Joint Committee on Immunisation (United Kingdom)
NACI
National Advisory Committee on Immunization
NITAG
National Immunization Technical Advisory Group
PCR
Polymerase chain reaction
PHAC
Public Health Agency of Canada
QALY
Quality-adjusted life year
RSV
Respiratory syncytial virus
RVDSS
Respiratory virus detection surveillance system
UNDRIP
United Nations Declaration on the Rights of Indigenous Peoples
US CDC
United States Centres for Disease Control and Prevention
VE
Vaccine effectiveness

Acknowledgments

This statement was prepared by: E Wong, B Warshawsky, A Tuite, A Simmons, S Wilson, and R Harrison, on behalf of NACI.

NACI gratefully acknowledges the contribution of: J Daniel, R Miranda, M Salvadori, A Howarth, and the NACI Secretariat.

NACI

NACI members: R Harrison (Chair), V Dubey (Vice Chair), M Andrew, J Bettinger, N Brousseau, A Buchan, H Decaluwe, P De Wals, E Dubé, K Hildebrand, K Klein, M O'Driscoll, J Papenburg, A Pham-Huy, B Sander, and S Wilson.

Liaison representatives: L Bill/ M Nowgesic (Canadian Indigenous Nurses Association), S Buchan (Canadian Association for Immunization Research, Evaluation and Education) E Castillo (Society of Obstetricians and Gynaecologists of Canada), J Comeau (Association of Medical Microbiology and Infectious Disease Control), M Lavoie (Council of Chief Medical Officers of Health), J MacNeil (Center for Disease control and Prevention), M McIntyre (Canadian Nurses Association), D Moore (Canadian Paediatric Society), M Osmack (Indigenous Physicians Association of Canada), J Potter (College of Family Physicians of Canada), A Pucci (Canadian Public Health Association), D Singh (Canadian Immunization Committee), and A Ung (Canadian Pharmacists Association).

Ex-officio representatives: E Ebert (National Defence and the Canadian Armed Forces), P Fandja (Marketed Health Products Directorate, Health Canada), E Henry (Centre for Immunization Surveillance and Programs (CISP), PHAC), M Lacroix (Public Health Ethics Consultative Group, PHAC), J Stothart (Centre for Immunization Surveillance, PHAC), J Kosche (Centre for Vaccines and Therapeutics Readiness (CVTR), PHAC), C Pham (Biologic and Radiopharmaceutical Drugs Directorate, Health Canada), M Routledge (National Microbiology Laboratory, PHAC), M Su (COVID-19 Epidemiology and Surveillance, PHAC), and T Wong (First Nations and Inuit Health Branch, Indigenous Services Canada).

NACI COVID-19 Vaccine Working Group

Members: S Wilson (Chair), M Andrew, H Decaluwe, P De Wals, D Moore, B Sander, A Buchan, Y-G Bui, M Miller, L Panagiotakopoulos, D Singh, L Roper, and M Willcott.

PHAC participants: H Birdi, P Doyon-Plourde, C Jensen, R Krishnan, M Salvadori, A Tuite, A Simmons, A Howarth, MC Tunis, B Warshawsky, E Wong, L Lee, E Kovacs, G Gebretekle, N Forbes, and J Zafack.

Footnotes

Footnote a

There is limited evidence on clinical risk factors for severe COVID-19 disease in pediatric populations. Children at increased risk for severe outcomes may include children who are medically fragile/have medical complexities, children with more than one comorbidity, children with neurological disorders, children with chronic lung disease, and children with Down syndrome (Trisomy 21), and other immunocompromising conditions.

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Footnote b

Autonomous decisions should be made by Indigenous Peoples with the support of healthcare and public health partners in accordance with UNDRIP.

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Footnote c

For the purposes of this statement, health care workers (HCWs) and other care providers in facilities and community settings refers to HCWs, care providers, emergency response workers (i.e., first responders including fire, police, and ambulance), those who work in continuing care or long-term care facilities or residences, those who provide home care for people at high risk, and students of related health care services. HCWs include any person, paid or unpaid, who provides services, works, volunteers, or trains in a hospital, clinic, or other health care facility.

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Footnote d

Social inequities have contributed to increased risk of exposure to and severe disease from SARS-CoV-2. Throughout the pandemic, NACI has acknowledged that racialized, marginalized and other equity-denied populations in Canada were disproportionately affected by COVID-19. Systemic barriers to accessing necessary supportive care for COVID-19 included factors such as poverty, systemic racism and being unhoused. These groups remain populations recommended for vaccination to recognize the health inequities these individuals may continue to face in the post-pandemic context.

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References

Footnote 1

Ismail SJ, Langley JM, Harris TM, et al. Canada's National Advisory Committee on Immunization (NACI): evidence-based decision-making on vaccines and immunization. Vaccine. Apr 19;28 Suppl 1:A58-63. http://doi.org/10.1016/j.vaccine.2010.02.035. https://www.ncbi.nlm.nih.gov/pubmed/20412999.

Return to footnote 1 referrer

Footnote 2

Ismail SJ, Hardy K, Tunis MC, et al. A framework for the systematic consideration of ethics, equity, feasibility, and acceptability in vaccine program recommendations. Vaccine. Aug 10;38(36):5861-5876. http://doi.org/10.1016/j.vaccine.2020.05.051.

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Footnote 3

Public Health Agency of Canada. Respiratory virus detections in Canada. Ottawa (ON). Public Health Agency of Canada; 2024 Jul 10 [cited 2024 Dec 9]. Available from: https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada.html.

Return to footnote 3 referrer

Footnote 4

COVID-19 Immunity Task Force (CITF). Seroprevalence in Canada. Data cut-off December 31, 2023 [Internet]. Montreal (QC). COVID-19 Immunity Task Force; [cited 2024 Dec 9]. Available from: https://www.covid19immunitytaskforce.ca/seroprevalence-in-canada/.

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Footnote 5

Kwong JC. Personal communication: COVID-19 XBB vaccine effectiveness against Omicron severe outcomes – preliminary results. 2024 Oct 7 and 2024 Dec 4.

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Footnote 6

Carazo S, Skowronski DM, Brousseau NM, et al. Monovalent mRNA XBB.1.5 vaccine effectiveness against COVID-19 hospitalization in Quebec, Canada: impact of variant replacement and waning protection during 10-month follow-up. medRxiv. 2024:2024.11.13.24317190. http://doi.org/10.1101/2024.11.13.24317190.

Return to footnote 6 referrer

Footnote 7

Link-Gelles R. Effectiveness of COVID-19 (2023-2024 Formula) vaccines [slides presented at the Advisory Committee on Immunization Practices meeting on June 26, 2024] [Internet]. Atlanta (GA): CDC; 2024 Jun 26 [cited 2024 Dec 9.] Available from: https://www.cdc.gov/acip/downloads/slides-2024-06-26-28/03-COVID-Link-Gelles-508.pdf.

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Footnote 8

Link-Gelles R. Effectiveness of COVID-19 vaccines [slides presented at the Advisory Committee on Immunization Practices meeting on October 23, 2024] [Internet]. Atlanta (GA): CDC; 2024 Oct 23 [cited 2024 Dec 9]. Available from: https://www.cdc.gov/acip/downloads/slides-2024-10-23-24/04-COVID-Link-Gelles-508.pdf.

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Footnote 9

Altarawneh HN, Chemaitelly H, Ayoub HH, et al. Effects of previous infection and vaccination on symptomatic Omicron infections. N Engl J Med. 2022 Jun 15;387(1):21-34. http://doi.org/10.1056/NEJMoa2203965.

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Footnote 10

Bobrovitz N, Ware H, Ma X, et al. Protective effectiveness of previous SARS-CoV-2 infection and hybrid immunity against the omicron variant and severe disease: a systematic review and meta-regression. Lancet Infect Dis. 2023 May;23(5):556-567. http://doi.org/10.1016/S1473-3099(22)00801-5.

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Footnote 11

Carazo S, Skowronski DM, Brisson M, et al. Protection against omicron (B.1.1.529) BA.2 reinfection conferred by primary omicron BA.1 or pre-omicron SARS-CoV-2 infection among health-care workers with and without mRNA vaccination: a test-negative case-control study. Lancet Infect Dis. 2023 Jan;23(1):45-55. http://doi.org/10.1016/S1473-3099(22)00578-3.

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Footnote 12

Carazo S, Skowronski DM, Brisson M, et al. Prior infection- and/or vaccine-induced protection against Omicron BA.1, BA.2 and BA.4/BA.5-related hospitalisations in older adults: a test-negative case-control study in Quebec, Canada. medRxiv. 2022:2022.12.21.22283740. http://doi.org/10.1101/2022.12.21.22283740.

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Footnote 13

Cerqueira-Silva T, de Araujo Oliveira V, Paixao ES, et al. Vaccination plus previous infection: protection during the omicron wave in Brazil. Lancet Infect Dis. 2022 Jul;22(7):945-946. http://doi.org/10.1016/S1473-3099(22)00288-2.

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Footnote 14

Chin ET, Leidner D, Lamson L, et al. Protection against Omicron from vaccination and previous infection in a prison system. N Engl J Med. 2022 Nov 10;387(19):1770-1782. http://doi.org/10.1056/NEJMoa2207082.

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Footnote 15

Spreco A, Dahlstrom O, Joud A, et al. Effectiveness of the BNT162b2 mRNA vaccine compared with hybrid immunity in populations prioritized and non-prioritized for COVID-19 vaccination in 2021-2022: A naturalistic case-control study in Sweden. Vaccines (Basel). 2022. Aug 7;10(8). http://doi.org/10.3390/vaccines10081273.

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Footnote 16

Vicentini M, Venturelli F, Mancuso P, et al. Risk of SARS-CoV-2 reinfection by vaccination status, predominant variant, and time from previous infection: A cohort study in Italy. SSRN Electronic Journal. 2022 Jun. http://doi.org/10.2139/ssrn.4132329.

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Footnote 17

Lind ML, Robertson AJ, Silva J, et al. Effectiveness of primary and booster COVID-19 mRNA vaccination against Omicron variant SARS-CoV-2 infection in people with a prior SARS-CoV-2 infection. medRxiv. 2022:2022.04.19.22274056. http://doi.org/10.1101/2022.04.19.22274056.

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Footnote 18

Joint Committee on Vaccination and Immunisation. JCVI statement on COVID-19 vaccination in 2025 and spring 2026. United Kingdom. 2024 Nov 14 [cited 2024 Dec 9]. Available from: https://www.gov.uk/government/publications/covid-19-vaccination-in-2025-and-spring-2026-jcvi-advice/jcvi-statement-on-covid-19-vaccination-in-2025-and-spring-2026.

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Footnote 19

Keeling MJ, Hill EM, Petrou S, et al. Cost-effectiveness of routine COVID-19 adult vaccination programmes in England. medRxiv. 2024:2024.11.08.24316972. http://doi.org/10.1101/2024.11.08.24316972.

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Footnote 20

University of Michigan COVID-19 Vaccination Modelling Team. Economic analysis of an additional dose of the 2024-2025 COVID-19 vaccine [slides presented at the Advisory Committee on Immunization Practices meeting on October 23, 2024] [Internet]. Atlanta (GA): CDC; 2024 Oct 23 [cited 2024 Dec 9]. Available from: https://www.cdc.gov/acip/downloads/slides-2024-10-23-24/05-COVID-Prosser-508.pdf.

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Footnote 21

Simmons AE, Miranda RN, Li MWZ, et al. Cost-utility analysis of current COVID-19 vaccination program recommendations in Canada. [manuscript]. medRxiv. 2024:2024.12.13.24318988. https://doi.org/10.1101/2024.12.13.24318988.

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Footnote 22

Miranda RN, Simmons AE, Li MWZ, et al. Cost-utility analysis of COVID-19 vaccination strategies for endemic SARS-CoV-2 circulation in Canada. medRxiv. 2024:2024.12.06.24318620. http://doi.org/10.1101/2024.12.06.24318620.

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