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Recommendations from the National Varicella Consensus Conference: RESEARCH NEEDS

Consensus Conference: RESEARCH NEEDS

Participants identified a number of research needs and pri­orities related to varicella, outlined below. It was also recom­mended that these priorities be brought to the attention of appropriate funding bodies so that research funds can be made available to address them.
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  • General immunization issues such as the need for booster doses and waning immunity should be addressed.
  • Studies should be done to assess the molecular epidemiology of VZV strains in Canada.
  • Mechanisms of and susceptibility to VZV embryopathy should be defined.
  • Models should be used to predict when surveillance systems should shift from aggregate to case-by-case reporting and when special studies should be done for case investigation. Surveillance data should be periodically fed back into the models to improve their predictive capacity.
  • Appropriate and safe immunization strategies should be determined for immunocompromised patients, including HIV-infected persons; cancer patients in remission; solid organ transplant recipients; bone marrow transplant recipients; patients with hypogammaglobulinemia; leukemia patients (eg, whether to immunize three months after treatment, and the role of acyclovir); persons with chronic lung disease (eg, cystic fibrosis); and other immunocompromised individuals such as those receiving cyclosporine treatment.
  • Studies should be done to determine the potential for early use of vaccine in anatomically compromised individuals (eg, persons with pulmonary conditions or skin disease); persons with chronic heart disease; and preoperative cases (for elective surgeries).
  • History and serologic status of health care workers should be investigated to establish

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Recommendations from the National Varicella Consensus Conference: SURVEILLANCE NEEDS

Additional/improved data needs

Recommendation 5.1: All provinces should have a surveil­lance system that can provide information on the number and age distribution of cases of both varicella and herpes zoster. Recommendation 5.2: Canadian data should be gathered on the epidemiology and burden of illness in pregnancy. This should include gestational varicella and herpes zoster; perinatal varicella (maternal and infant); and congenital varicella syndrome (add to the Canadian Paediatric Sur­veillance Program as active surveillance). Recommendation 5.3: National population-based data should be gathered on the incidence of severe disease, particu­larly in adults, including hospitalizations and deaths.

Recommendation 5.4: Varicella and herpes zoster should be added to the Vital Statistics List of Rare and Infrequent Causes of Death.

Surveillance goals

Recommendation 5.5: A goal should be adopted to detect changes in the age-specific incidence of varicella.

The specific strategies/methods to achieve the specified goal are as follows:

  • Implementation phase: aggregate reporting, using sources such as schools, nurseries, daycare centres, emergency departments, walk-in clinics, sentinel physicians and health claims data.
  • Control phase: case-by-case reporting, including enhanced sentinel surveillance and outbreak investigation and control (with laboratory confirmation of cases, differentiation of wild versus vaccine virus strains, and serological testing).

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Recommendations from the National Varicella Consensus Conference: PROMOTION OF VARICELLA VACCINATION PROGRAMS

Recommendation 4.1: Information regarding varicella (in­cluding the burden of illness and complications; health care costs; vaccine efficacy and safety; the NACI recommendations for vaccine use; and the National Consensus Conference rec­ommendations) should be presented at the upcoming meeting of the Deputy Ministers of Health, and this information should be made available for presentation to other key policy makers. Recommendation 4.2: The Canadian Immunization Aware­ness Program should make available to provincial/territorial authorities and other jurisdictions responsible for vaccination programs information packages, for distribution to health care providers (public health, non-public health, pharmacists) at the appropriate time. The packages should include the NACI statement on varicella; the Varicella Consensus Conference recommendations; a Q&A format indicating incidence and complications of varicella disease and the benefits and risks of vaccine; information available on Health Canada’s web site; a bibliography; and other web site links. Recommendation 4.3: The Canadian Infectious Disease Soci­ety, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Paediatric Society, the Canadian Public Health Association, and other professional associations should raise the profile of varicella disease/vaccine through the inclusion of 1. articles in their professional publications and 2. presentations at professional meetings (continuing education units/continuing medical education credits). Recommendation 4.4: The Canadian Paediatric Society should take a lead role in coordinating the promotion of varicella vacci­nation by 1. providing a speaker list regarding varicella immu­nization, for continuing education events and media interviews; 2. developing an educational package (slides, hand-outs) for use in presentations at the local level; and 3. in­corporating information on varicella vaccine in Your Child’s Best Shot: A Parent’s Guide to Vaccination and other educa­tional materials.

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Recommendations from the National Varicella Consensus Conference: VARICELLA VACCINE USE IN SPECIAL POPULATIONS

VARICELLA VACCINE USE IN SPECIAL POPULATIONS

Recommendation 3.1: All healthy, susceptible non-pregnant adults should be targeted for vaccination. However, priority for active targeting should be given to health care workers; house­hold contacts of immunocompromised individuals; child care workers; and primary and secondary school teachers. Recommendation 3.2: Active targeting plan: All jurisdictions and employers with an existing responsibility (such as Occu­pational Health/Public Health/obstetric care workers/primary care physicians, etc) are to direct campaigns of screening (his­tory of varicella with or without serology) and offer vaccine to the active targets.

Health care workers

Recommendation 3.3: Susceptible health care workers should be immune prior to employment or should be immu­nized according to a two-dose schedule to be completed within two months, to minimize outbreaks and loss of time due to varicella in health care settings. All susceptible health care workers currently in the system should be immunized. Initial priority should be given to immunizing health care workers on wards or in patient care settings that contain susceptible high-risk patients (eg, settings with immunocompromised pa­tients, intensive care units, and emergency rooms). Recommendation 3.4: Identifying susceptibles: Before an employee begins employment, a varicella history should be obtained. If there is any doubt about previous disease or vaccination, or the history is negative or unknown, sero- logical testing should be performed. If the result is negative, the employee should be immunized. If the individual re­ceives the vaccine, (s)he should be furloughed or reassigned only if there is a varicella-like rash.

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Recommendations from the National Varicella Consensus Conference: DEVELOPMENT AND IMPLEMENTATION OF VARICELLA VACCINATION PROGRAMS

Recommendation 2.1: A universal immunization program for young children should be implemented within two years of the availability of a refrigerator-stable vaccine. Recommendation 2.2: Systematic immunization should be­gin as soon as possible for susceptible preteens less than 13 years of age with whatever vaccine is available, preferably through a school-based program. Immunization of prioritized at-risk persons (as defined in the recommendations under Special Populations) should be initiated at the same time. Recommendation 2.3: As soon as a universal program is in place, a catch-up program for susceptible persons less than 13 years of age should be initiated and completed within five years. Recommendation 2.4: Primary immunization of children less than 13 years of age should be done with one dose. Surveillance must be planned in order to permit reassessment of this policy. Recommendation 2.5: There should be no booster dose planned in the vaccination program. Research is required to measure the need for booster vaccination to prevent varicella and herpes zoster, and for timing of boosters if needed. Recommendation 2.6: Vaccine should be administered to children as early as recommended (by the manufacturer) for a given vaccine. When possible, it should be linked with a vaccination visit already in place.

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Recommendations from the National Varicella Consensus Conference: CONFERENCE RECOMMENDATIONS

A definition of health care workers was recommended, based on the national Infection Control Guidelines for Occupa­tional Health in Health Care Facilities. General Recommendation: The definition of health care worker should include all individuals, including trainees, in health care settings (eg, hospitals, ambulatory care settings, long-term care facilities) who may have the potential for ac­quiring or transmitting infectious agents during the course of their work. Volunteers who have direct patient contact should be considered as health care workers.

PUBLIC HEALTH GOALS AND OBJECTIVES FOR VARICELLA CONTROL AND VACCINE COVERAGE

Recommendation 1.1: The criteria for embarking on a routine varicella vaccination program should be as follows:

  • Primary decisions: the vaccine is safe, effective and beneficial to the individual; and the burden of disease justifies program consideration.
  • Absolute criterion: feasibility to deliver the vaccine to more than 90% of the targeted population in each province/territory.
  • Relative criteria: availability of a refrigerator-stable vaccine product; availability of a combination product; vaccine cost comparable with existing routine childhood vaccines; and 100% accessibility to a vaccination program.

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Recommendations from the National Varicella Consensus Conference

Recommendations from the National Varicella Consensus Conference

The National Varicella Consensus Conference was spon­sored by the Laboratory Centre for Disease Control (LCDC), Health Canada, and held from May 5 to 7, 1999, in Montreal, Quebec. The first varicella vaccine in Canada, a live attenuated Oka strain vaccine, was licensed in December 1998 and is recommended by the National Advisory Committee on Immunization (NACI) for primary immunization of healthy persons aged 12 months or older.

Currently, varicella vaccine is not universally accepted by all health care professionals or the public. Multiple competing priorities for public health resource allocation at the provin­cial/territorial or local level increase the likelihood that the timing of implementation of varicella vaccination programs will differ widely among provinces and territories. In addition, a number of logistic challenges to the implementation of rou­tine vaccination programs exist with the currently licensed freezer-stable vaccine, which is the most heat-sensitive of all vaccine products currently available. The primary challenges are the cost of the vaccine, and the storage and handling re­quirements (specific issues include inadequate freezer capac­ity, cost of freezer space for both public health delivery and physicians’ offices, and potential difficulties with delivery of the vaccine to remote areas).

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