ARCHIVED - Canada Communicable Disease Report

1 December 2007

Volume 33

Number 13

The process to establish and implement national goals and recommendations for vaccine preventable diseases in Canada under the National Immunization Strategy

Introduction

The first in a series of National Consensus Conferences for Vaccine-Preventable Diseases in Canada (NCC-VPD) was held in Quebec City from June 12-14, 2005. The purpose of the conference was to review existing national goals and targets for disease reduction and immunization coverage and make new recommendations for six vaccine-preventable diseases: invasive meningococcal disease (IMD), invasive pneumococcal disease (IPD), varicella, pertussis, influenza and rubella. This is the third in series of three articles published in the Canada Communicable Disease Report (CCDR)^{(1, 2)} regarding this conference. It describes the process of the conference from pre conference research and preparation, through to conference consensus rules and conduct, and post conference follow-up leading towards the adoption and implementation of conference outcomes.

Background

The National Immunization Strategy (NIS), approved in 2004, is a means for the federal provincial and territorial jurisdictions to work in partnership to improve the effectiveness and efficiency of immunization programs in Canada. One of the key components of the NIS is the development of national goals and targets for disease prevention and immunization coverage.

The Canadian Immunization Committee (CIC) was established in 2004 to coordinate all NIS related activities including the establishment of national goals. As one of their first national initiatives, the Committee requested the Immunization and Respiratory Infections Division (IRID) of the Public Health Agency of Canada (PHAC) to coordinate a series of national consensus conferences to establish national goals and targets for the prevention and control of all vaccine-preventable diseases. The following describes the evidence based process used for this first consensus conference. This process was approved by CIC and will be reviewed prior to the next conference.

Pre conference preparation

The CIC recommended six vaccine-preventable diseases for review in this first consensus conference. Four diseases, invasive meningococcal disease (IMD), invasive pneumococcal disease (IPD), pertussis and varicella were selected as public funding in the amount of 300 million dollars (Cdn) was given to provinces and territories by the federal government for the purchase of vaccines after the approval of the NIS in 2004. Rubella was included in support of the Pan-American Health Organization (PAHO) regional goal for indigenous rubella and congenital rubella syndrome elimination in the Americas⁽³⁾. Influenza was included as it was thought to be timely.

A conference planning committee was formed 6 months prior to the conference. The task of the committee was to create an evidence-based review process for each of the six diseases and to oversee the review of the technical content and participant list for the conference. The planning committee included members from CIC, PHAC, the National Advisory Committee on Immunization (NACI), other federal agencies, and provincial and territorial representatives. Due to the limited time allotted for the actual conference and the large number of diseases to be reviewed, extensive preparatory research was required. Members of the planning committee were asked to select and lead teams of three to four subject matter experts from academia, public health and laboratories. These expert groups spent 3 months working in preparation for the conference. Each group reviewed current evidence, existing national and international goals, recommendations and targets. They identified and discussed the most germane issues, and created bibliographies of the relevant documents. Each group also developed a preliminary set of recommendations for new or revised national goals and targets. These components were compiled in disease-specific discussion guides to help lead the working group discussions during the conference.

Sixty-two representatives from national, international, federal, non-governmental, professional agencies and organizations including at least two representatives from each of the 13 provincial and territorial Ministries of Health were invited to the consensus conference. Participants included representatives from all provinces and territories, including chief medical officers of health, provincial and territorial epidemiologists, and program experts, technical and program experts from the federal government, international experts, and key non-government groups. In all, 82 people participated in this consensus conference.

Prior to the conference, each participant was asked to identify the three disease-specific working groups in which they wished to participate. Preferences were respected when possible while ensuring equitable representation on all disease-specific working groups. Subject matter experts and were assigned to working groups and chairpersons were selected from members of the planning committee.

The discussion guides and relevant literature were shared with participants for their disease-specific working group prior to the conference. A CD-ROM containing the reference material and presentations for all diseases was shared with conference participants after the conference and is available upon request through the IRID Program Section email [Programs.IRID-DDIR@phac-aspc.gc.ca].

Terms and definitions

For the purpose of conference deliberations, the definition of terms is as follows:

Goal: Is defined as a broad statement of a desired achievement over a specific time frame. Goals are not required to be quantitative or measurable.

Objectives/Recommendations: Are statements of intent that are more specific, measurable, achievable, realistic, and timed. An objective may include a target. At a subsequent meeting of the CIC it was recommended that the term objective be reserved for use by the jurisdictions to determine individually how best to work towards nationally agreed upon goals, in a feasible timeframe, given their own unique requirements. Therefore throughout these documents the term objective has been replaced with recommendation.

Targets: Are measurable, they specify the amount of progress to be made and the time by which it is to be made.

Further, time lines for national goals and recommendations should be reasonable and feasible, with 5 years suggested as an appropriate planning horizon.

Vaccine eligibility: For the purpose of developing recommendations for national goals, participants agreed that vaccine eligibility should be based on NACI recommendations rather than jurisdictional public health programs.

Conference process

The conference took place over 2 days. Following introductory remarks and presentations on the first day, participants remained in plenary session to consider and vote on recommendations for rubella elimination. Participants then spent the rest of day-one in their assigned disease-specific working groups. Presentations on surveillance, epidemiology, laboratory issues and immunization programs and coverage were given in each group. Led by a chairperson and assisted by subject-matter experts, a rapporteur and a note-taker, working group members reviewed disease-specific evidence, identified key issues, and developed and provided rationales for all recommendations.

On the second day, recommendations from the working groups from the five remaining diseases were presented in plenary by panels selected by each disease-specific working group. After presenting the recommendations and rationales, participants asked questions for clarification and then voted using an electronic voting system provided by the National Microbiology Laboratory (NML) in accordance with the rules outlined below. Once the initial level of agreement was determined, the floor was opened for comment and discussion. If consensus was not achieved in the first vote or achieved through a minority vote, a second vote was held after the comment and discussion period.

Participants with voting rights included: provincial/territorial representatives including chief medical officers of health, epidemiologists, and program experts; experts from IRID and the NML; CIC members not functioning in an alternate role; members of the conference planning committee; representatives of non-governmental organizations and health professional associations; and conference co-chairs (in situations where results would be otherwise inconclusive). Voting rights did not extend to international experts, PHAC staff working as rapporteurs and conference support, industry representatives, or participants with a conflict of interest.

The process for voting on consensus recommendations was supported by the assurance that all participants would have an opportunity to express their views in either plenary or working group sessions.

• Options for voting include “agree”, “agree with reservations” and “disagree”.
• At least 66% of participants eligible to vote must be present to have quorum.
• Consensus was achieved when at least 75% of participants eligible to vote either “agreed” or “agreed with reservations” to a recommendation. The election of a recommendation with 50% to 74% of eligible participants agreeing without reservation constituted a majority vote, while a vote achieving consensus with only 25% to 49% agreeing without reservation represented a minority vote.
• A recommendation was not considered supported if the combined number of participants “agreeing” or “agreeing with reservation” represented < 75% of eligible participants or if > 33% of eligible participants were absent from or declined to take part in a vote.

Consensus conference outcomes

Consensus was reached on three goals and 52 recommendations. Due to time constraints national goals were not developed by the working groups for varicella, IMD and pertussis, and therefore were not voted on in plenary. For influenza, it was agreed by consensus to adopt the 2001 national immunization coverage targets and to postpone the development of recommendations for disease reduction for a future conference. The goals and recommendations were reported in the first⁽¹⁾ and second⁽²⁾ article of this series on the NCC-VPD.

At the end of the conference, participants evaluated the process and recommendations were made for consideration for subsequent consensus conferences

Post conference process and follow-up

Outcomes from the 2005 Consensus Conference were revised for consistent wording and to adhere to national coverage reporting standards⁽⁴⁾. National goals were proposed for the remaining three diseases (varicella, IMD and pertussis) to standardize content. These revisions and additions were approved by CIC in December 2005.

Following approval, CIC requested each jurisdiction to assess the feasibility, measurability and to prioritize each outcome of the conference within their own jurisdiction. A questionnaire was distributed and feedback was reviewed by CIC prior to determining next steps. The purpose of this survey was to evaluate the impact of the outcomes from the consensus conference on immunization programs and to identify gaps and needs in the provinces and territories.

Nine provinces and territories and the First Nations and Inuit Health Branch responded. While goals for rubella and IPD were thought to be feasible (8/10) and measurable (7/10), goals in general were not seen as a priority by the jurisdictions (2/10). Disease reduction and immunization coverage recommendations were given slightly higher priority than goals, (3/10 and 4/10 respectively). Both disease reduction and immunization coverage recommendations were seen as somewhat feasible (5/10) and slightly more difficult to measure (4/10). Responses demonstrated inadequate surveillance data and resources to develop new data collection tools and monitoring systems to monitor the new goal and recommendations. Respondents also noted that some of the recommended targets and timelines were unrealistic within their jurisdiction.

CIC recommendations on outcomes

The goal to eliminate indigenously transmitted cases of rubella and congenital rubella syndrome (CRS) from Canada by 2010 is the only goal approved by CIC for national endorsement by the Pan-Canadian Public Health Network. Feedback from the survey and discussions with provincial and territorial representatives revealed that the limitations noted by each province and territory would clearly affect their ability to fully implement the 2005 national goals and recommendations. Therefore, CIC agreed to approve the remaining outcomes from the consensus conference as “gold standards” to be used by provinces and territories to guide the development and refinement of provincial and territorial programmatic objectives.

Recommendations to improve the conference process

Recommendations to improve the process were collected during and after the conference from participants and provincial and territorial representatives respectively. The most common recommendation from the conference was that future consensus conferences should focus on fewer diseases, to allow sufficient time to consider evidence and make informed decisions. Recommendations from the above provincial and territorial survey were reviewed by CIC and while wording changes were incorporated, those that would change the content of the consensus statements were not. These recommendations along with others from conference participants and members of the conference planning committee will be put forth to the planning committee of subsequent consensus conferences.

Next steps

The national goals and recommendations from the consensus conference 2005 will be re-evaluated in 2010, and future consensus conferences are planned to review, develop and update national goals and recommendations for immunization coverage and disease reduction for the remaining vaccine-preventable diseases. To ensure that best practices are implemented, evaluation reports have been summarized and a “Lessons Learned” exercise will be held prior to the planning of subsequent conferences.

Some of the activities that will be undertaken by CIC in consultation with NACI and other stakeholders in anticipation of subsequent conferences will be: to determine the number of diseases appropriate for a single consensus conference and to evaluate the challenges of considering several diseases concurrently to ensure sufficient time is available to consider all of the evidence and make informed decisions. As well, CIC will determine criteria for the prioritization and selection of which vaccine-preventable diseases are included in future consensus conferences. In some cases, it may be appropriate to devote an entire conference to one disease, with influenza cited as an example.

With regard to the goal and recommendation setting process, CIC will make recommendations on whether the consensus conferences should focus on developing “ideal” or “practical” goals.

Conclusions

Despite current limitations there are clear benefits to developing national goals and recommendations for vaccine-preventable diseases. As provinces and territories aspire towards the national vision, their immunizations programs will invariably improve, resulting in increased coverage. These improvements can in turn be used to justify additional funding for their immunization programs. As well, establishing national goals and recommendations provides a method of accountability at the jurisdictional level. Ultimately, the goals and recommendations from the NCC-VPD 2005 are not binding for provinces and territories. Rather, they provide members of the Pan-Canadian Public Health Network and provincial and territorial partners with a common foundation from which to initiate discussions leading to the adoption and implementation of goals at the jurisdictional level. While provincial/territorial programs and objectives may still vary at the conclusion of this process, they will now be guided by a common vision.

References

1. Summary of Outcomes form the National Goals and Recommendations Consensus Conference for Vaccine- Preventable Diseases in Canada. CCDR In Press.

2. Final Report of Outcomes form the National Goals and Recommendations Consensus Conference for Vaccine-Preventable Diseases in Canada. CCDR In Press.

3. 44^th PAHO-WHO Directing Council 55^th Session of the Regional Committee. Resolution CD44.R1 Sustaining Immunization Program – Elimination of Rubella and Congenital Rubella Syndrome (CRS). Sept. 22-26, 2003.

4. National Standards for Immunization Coverage Assessment: Recommendations from the Canadian Immunization Registry Network. CCDR 2005;31(9):93-97.

Acknowledgements

We would like to thank the national and international experts and program specialists who participated in the consensus conference, the conference co-chairs, the planning committee members, those who donated their time to ensure that the evidence used for the decision making guides was the most current and relevant, and staff of the Immunization and Respiratory Infections Division for making the conference a success.