Immunization in Canada: Canadian Immunization Guide
Introduction
The objectives of immunization programs are to prevent, control, eliminate or eradicate vaccine-preventable diseases by directly protecting vaccine recipients and indirectly protecting vulnerable individuals who may not respond to vaccines or for whom vaccines may be contraindicated. These objectives are dependent upon the epidemiology of the diseases, the effectiveness of available vaccines, and the ability to achieve . In Canada, the low incidence of vaccine-preventable diseases and their associated morbidity and mortality have been a result of comprehensive Federal, Provincial and Territorial (F/P/T) immunization policies, and the ongoing monitoring and evaluation of vaccines and immunization programs. Refer to the  in Part 1 for information about the impact of immunization on the epidemiology of vaccine preventable diseases and the benefits of immunization.
This chapter provides an overview of immunization programming in Canada and discusses the various F/P/T immunization committees and mechanisms that support policy development. In doing so, it describes the National Immunization Strategy which serves as the principle framework that guides the work of F/P/T advisory bodies, stakeholders, networks and key decision-making processes.
Immunization policy and program development
In Canada, the responsibility for health care, including immunization, is shared by the F/P/T governments. While each jurisdiction has a distinct mandate and unique operating context, their activities are complementary and collaborative. Collaboration is a key component of immunization policy and program development as F/P/T governments benefit from sharing data, knowledge, expertise and best practices that help provide the necessary information for their respective programs.

# National Immunization Strategy
Since its adoption in 2003, the  (NIS) has been a platform for collaboration between F/P/T stakeholders and has facilitated the development of consistent and equitable approaches to immunization planning, vaccine purchasing, program delivery and education. The NIS provides mechanisms for enhanced collaboration on issues such as vaccine safety, surveillance, immunization registries, research, vaccine supply and immunization program planning. The NIS enables collaboration of policy recommendations made at the national level with immunization program development at the provincial/territorial level. NIS priorities and developments in immunization were reviewed in 2016 in order to develop key objectives and activities to be carried out for the next five years. For more information, refer to .

# Key federal/provincial/territorial stakeholders
Through health departments, advisory bodies and other public authorities, all F/P/T governments engage in different aspects of immunization program planning, delivery and evaluation. Key stakeholders are described below.
Federal Government
The  (PHAC) is the federal agency responsible for immunization activities such as the , , vaccine recommendations, , as well as . The Public Health Agency of Canada is also involved in the national monitoring and assessment of vaccine preventable diseases.
To help provide leadership, advice and support for timely vaccine recommendations and sustainable immunization programs, PHAC is supported by two scientific advisory committees whose members are recognized experts in multiple fields including pediatrics, infectious diseases, immunology, medical microbiology, internal medicine, nursing and public health.
National Advisory Committee on Immunization (NACI)
Created in 1964, the  (NACI) provides PHAC with expert and evidence-based recommendations regarding the use of vaccines authorized for use in Canada, advises on the need for national vaccination strategies, and makes recommendations for vaccine development research. NACI's mandate was expanded incrementally from 2016-2019 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. NACI uses the EEFA Framework, a published and peer-reviewed framework that considers programmatic factors including: economics, ethics, equity, feasibility, and acceptability (EEFA) to ensure comprehensive and transparent immunization program decision-making. However, not all NACI Statements will require an in-depth analysis of all programmatic factors. For more details on the development and application of NACI's EEFA Framework, please refer to . NACI knowledge syntheses, analyses and recommendations on vaccine use in Canada are published in literature reviews, statements and updates. NACI recommendations are also published in the Canadian Immunization Guide. Refer to  for additional information about the immunization guideline development process.
Committee to Advise on Tropical Medicine and Travel (CATMAT)
The  (CATMAT) provides evidence-based recommendations relating to prevention and treatment of infectious diseases and other health hazards that may be encountered by Canadian travellers outside of Canada, suggests mechanisms for the widespread dissemination and utilization of such information, and advises on priorities for epidemiological research and other activities related to travel or tropical medicine. Some CATMAT recommendations for the use of authorized immunization products for travellers may extend beyond recommendations developed by NACI for Canada due to differences in disease prevalence internationally. Refer to  for publications.
Health Canada
Other Federal Departments and Agencies
Other federal departments and bodies with immunization related interests and activities (that is, research, policy and operational considerations) include: , , , , , , , , , , , and .
Provincial and Territorial Governments
The provincial and territorial (P/T) governments are responsible for the administration and delivery of health care services, including immunization-related programs. Immunization policies and schedules are developed by P/T governments or their expert immunization advisory committees, based on jurisdiction-specific needs, other immunization recommendations (such as NACI), program resource availability and constraints, and identified priorities. In addition, P/T governments are responsible for: purchasing vaccines for publicly funded programs; the design and maintenance of immunization registries; disease and safety surveillance and program monitoring; and public and professional education and engagement (such as immunization campaigns, information services, and professional training, education and guidance). Each jurisdiction has its own process and mechanism for setting immunization targets and planning, designing, implementing and evaluating immunization programs. Evidence and recommendations developed by NACI are referenced by P/T governments to inform their local immunization policy and program decisions.
Pan-Canadian Public Health Network
The  (PHN) was established by Canada's F/P/T Ministers of Health in 2005 as a key intergovernmental mechanism to:
- strengthen and enhance Canada's public health capacity,
- enable F/P/T governments to enhance day-to-day business of public health, and
- anticipate, prepare for, and respond to public health events and threats.
The work of the PHN is governed by a 17-member Pan-Canadian Public Health Network Council (PHNC) composed of senior F/P/T government officials responsible for public health, including the  and senior government officials from all jurisdictions who are responsible for public health. The PHNC is accountable to the Conference of F/P/T Deputy Ministers of Health, which provides direction and approves public health policy priorities for Canada. The PHNC has three Steering Committees reporting under it: the Healthy People and Communities Steering Committee, the Public Health Infrastructure Steering Committee, and the Communicable and Infectious Diseases Steering Committee. 
Canadian Immunization Committee
The Canadian Immunization Committee (CIC) was established in 2004 to provide a national forum to implement the objectives of the National Immunization Strategy (NIS), improve the effectiveness and efficiency of immunization programs, address emerging immunization issues, and foster F/P/T cooperation, collaboration and engagement of non-governmental stakeholders. Under the direction of the Communicable and Infectious Diseases Steering Committee of the PHNC, the CIC consists of F/P/T government representatives who review and provide strategic operational and technical advice and recommendations on issues related to immunization policies and programs. 
Council of Chief Medical Officers of Health
The Council of Chief Medical Officers of Health (CCMOH) may provide further guidance and recommendations on technical issues relating to immunization. Its members are the Chief Medical Officers of Health from each P/T, the most senior public health physician of the  of Indigenous Services Canada, and the Chief Public Health Officer of Canada. The CCMOH reports to the Conference of F/P/T Deputy Ministers of Health through the PHNC.
Development of recommendations by NACI
A new statement with recommendations will be developed when certain circumstances arise such as a new vaccine or indication, anticipated public health emergency or programmatic concerns for instance. For more information, refer to .
In developing recommendations, NACI relies on its working groups. The working groups consist of NACI members, liaison members, ex-officio representatives and other vaccine experts who systematically review and synthesize the available scientific and other technical information (i.e., disease burden, vaccine characteristics, unpublished study data) pertaining to specific questions or issues raised by NACI. Recommendations from other groups (e.g.,  ,  . NACI recommendations are summarized for easy use by vaccine providers in the  (CIG).
Chapter revision process
The CIG Part 1 Working Group updated this chapter to include additional information on immunization programs in Canada and to reflect the current responsibilities of F/P/T immunization committees, advisory bodies, stakeholders, and networks in immunization policy and program development.