Question Period Note: Impact of COVID-19 on children's vaccination

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• The COVID-19 pandemic and associated public health measures that aim to limit transmission of the virus have adversely impacted the availability and accessibility of prevention and health services at all levels, including routine childhood vaccinations.
• Routine vaccination programs remain one of the most effective measures to protect Canadians against vaccine-preventable diseases (VPDs), such as measles, mumps and tetanus. Many common infectious diseases that were once a major cause of morbidity and mortality in Canada are now preventable with vaccines. Nevertheless, VPDs remain a public health concern in Canada, and it is important to achieve the highest possible levels of vaccination.
• Due to the ongoing pandemic, a decrease in routine childhood vaccination coverage is being reported by provinces and territories (PTs) due to the reduction of in-person primary care visits, disruptions in school-based vaccination programs, as well as healthcare workers being mobilized to respond to COVID-19. Decreased confidence in vaccines stemming from widespread and growing mis- and dis-information may also be widening gaps in vaccine acceptance as parents hesitate to get their children fully vaccinated.
• Disruptions to routine childhood immunization services leading to decreased vaccine coverage are concerning for the possible resurgence of VPDs, including measles.
• There is currently limited data to quantify the impact of the pandemic on pediatric immunization coverage in Canada, and any differential impacts on specific groups of children.
• Routine immunization programs prevent illness, save lives and are critical in maintaining the health of Canadians and healthcare system capacity.
• When enough people are vaccinated against vaccine-preventable diseases, we protect ourselves and those around us. Children, immunocompromised individuals, the elderly, and those who do not have up-to-date vaccinations are at greater risk of contracting vaccine-preventable diseases.
• We are working with provinces and territories to monitor routine childhood immunization coverage, including disparities in coverage across key groups.
• We are also working to ensure that public health and primary care services support parents and families in catch-up of delayed/missed childhood immunizations in order to prevent potential outbreaks of vaccine-preventable diseases and to support population protection in Canada against many vaccine-preventable diseases that continue to circulate internationally.

Global estimates of vaccination coverage in 2020 suggested that 23 million children did not receive basic vaccines through routine immunization services, which is 3.7 million more than in 2019. Disruptions to routine childhood immunization services during the COVID-19 pandemic leading to decreased vaccine coverage are concerning for possible resurgence of vaccine-preventable diseases (VPDs), including measles.

International and Canadian public health authorities continue to recommend that routine immunizations are essential health services that should not be deferred.

Vaccine Surveillance
High levels of vaccination coverage for VPDs are required to help ensure the ongoing health and safety of Canadians, particularly children, people who are immunocompromised (who have weakened immune systems), and the elderly. The Public Health Agency of Canada (PHAC) monitors and leads surveillance of national vaccination coverage and effectiveness for the general population, as well as populations at greater risk of disease and/or severe outcomes. Updated vaccination coverage goals and VPD reduction targets were agreed to by PTs in 2017, in line with current evidence. Coverage goals range from 80-95% depending on the age group and the VPD. The Childhood National Immunization Coverage Survey (2019) showed that while vaccination coverage in Canada is good, Canada is not reaching national coverage goals except for the rubella vaccine among 7-year-olds and the tetanus-diphtheria-pertussis (Tdap) vaccine booster dose among 17-year-olds. Further, due to the ongoing pandemic, a decrease in vaccination coverage is being reported by PTs due to the closure of some primary care offices as well as healthcare workers being mobilized to respond to COVID-19.

There is currently limited data to quantify the impact of the pandemic on pediatric immunization coverage in Canada, and any differential impacts on specific groups of children. An Ontario study showed that childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic especially in children aged 15 to 18-months old. The coverage rates recovered in the second half of 2020 but remained lower overall compared to pre-pandemic rates. PHAC and Statistics Canada are currently administering the Childhood National Immunization Coverage Survey to provide an updated national picture of childhood vaccination coverage in Canada.

Vaccine Confidence
Vaccine hesitancy has been a longstanding challenge to reducing the burden of childhood illness around the world and was identified as a top threat to global health by the World Health Organization in 2019. The rapid spread of mis- and dis-information on COVID-19 vaccines is challenging confidence in all vaccines, including routine childhood vaccinations. PHAC is working with provinces, territories, Indigenous organizations and a range of trusted partners and stakeholders in public health to address vaccine hesitancy by enhancing capacity building, information resources, culturally appropriate vaccination approaches, and supporting community-led approaches to build vaccine confidence and reduce access barriers. The Agency is also working to support health care providers with reliable information on vaccines, and evidence-based strategies and resources to effectively discuss vaccines with their patients and clients, including to support discussions and decisions about childhood vaccination.

COVID-19 Vaccination
Health Canada has approved certain COVID-19 vaccines for infants, children and youth aged 6 months to 5 years and older.

Infants and young children (6 months to 4 years)
Health Canada has approved the:
• Moderna Spikevax (25 mcg) vaccine as a two-dose primary series for infants and young children aged 6 months to 5 years
• Pfizer-BioNTech Comirnaty (3 mcg) vaccine as a 3-dose primary series for infants and young children aged 6 months to 4 years

NACI recommends that a primary series with an mRNA COVID-19 vaccine may be offered to children 6 months to 4 years of age who are not moderately to severely immunocompromised and who do not have contraindications to the vaccine, with a dosing interval of at least 8 weeks between doses. The same mRNA vaccine is recommended for all doses of a primary series, if possible. A primary series plus an additional dose of an mRNA COVID-19 vaccine may be offered to children 6 months to 4 years of age who are moderately to severely immunocompromised, with an interval of 4 to 8 weeks between each dose (Discretionary NACI Recommendations). NACI preferentially recommends a 3-dose primary series of the Moderna Spikevax vaccine for children who are moderately to severely immunocompromised.

Concurrent administration with other vaccines is not recommended at this time in this age group. This is a precautionary measure to help determine if a potential side effect is due to a COVID-19 vaccine or a different vaccine. However, concurrent administration or a shortened interval between a COVID-19 vaccine and other vaccines may be warranted on an individual basis in some circumstances at the clinical discretion of the healthcare provider.

Children (5 to 11 years old)
For a primary series, Health Canada has approved the:
• Pfizer-BioNTech Comirnaty (10 mcg) vaccine for children 5 to 11 years old
• Moderna Spikevax (50 mcg) vaccine for children 6 to 11 years old
• Moderna Spikevax (25 mcg) vaccine for children 5 years old

For a booster dose, Health Canada has approved the:
• Pfizer-BioNTech Comirnaty (10 mcg) vaccine for children 5 to 11 years old

The mRNA COVID-19 vaccines for children use a smaller dosage than the mRNA vaccines for those who are 12 years of age and older. This is because, in clinical trials, lower doses provided children under 12 years of age with very good protection against COVID-19. How long protection lasts in children and youth is still being evaluated.

NACI strongly recommends that children 5 to 11 years old receive 2 doses of an mRNA vaccine with the second dose given at least 8 weeks after the first dose. Children 5 to 11 years of age who are moderately to severely immunocompromised should receive 3 doses of an mRNA vaccine as their primary series with an interval of 4 to 8 weeks between each dose (Strong NACI Recommendation).

Children who turn 12 before their second dose should receive an adult dose for their second dose.

The Pfizer-BioNTech Comirnaty (10 mcg) vaccine is preferred for children 5 to 11 years old. This is because more data are available from the real-world use of this vaccine. Millions of children have safely received this vaccine in Canada and around the world.

NACI recommends that children 5 to 11 years of age who have an underlying medical condition that places them at high risk of severe illness due to COVID-19, including children who are immunocompromised, should be offered a booster dose of the Pfizer-BioNTech Comirnaty (10 mcg) COVID-19 vaccine at least 6 months after completion of a primary series. (Strong NACI recommendation)

For all other children 5 to 11 years of age, NACI recommends that a booster dose of the Pfizer-BioNTech Comirnaty (10 mcg) COVID-19 vaccine may be offered at least 6 months after completion of a primary series in the context of heightened epidemiological risk. (Discretionary NACI recommendation)

Health Canada, PHAC and NACI continue to monitor the safety and effectiveness of the mRNA COVID-19 vaccines in children 5 to 11 years of age and will provide updates if needed.

Youth (12 to 17 years old)
Health Canada has approved the following mRNA COVID-19 vaccines for a primary series for people 12 years of age and older:
• Pfizer-BioNTech Comirnaty (30 mcg) COVID-19 vaccine
• Moderna Spikevax (100 mcg) COVID-19 vaccine

NACI recommends youth 12 to 17 years of age should be offered 2 doses of an mRNA vaccine with a dosing interval of 8 weeks. Youth 12 to 17 years of age that are moderately to severely immunocompromised should receive 3 doses as their primary series with a recommended interval of 4 to 8 weeks between each dose (Strong NACI Recommendation).

The use of the Pfizer-BioNTech Comirnaty (30 mcg) vaccine is preferred for use in youth 12 to 17 years of age for the primary series due to the lower risk of myocarditis/pericarditis.

Health Canada has approved the following mRNA COVID-19 vaccines for a booster dose for people 12 years of age and older:
• Pfizer-BioNTech Comirnaty (30 mcg) vaccine is authorized as a first booster dose for individuals 16+
• Pfizer-BioNTech Comirnaty bivalent BA.1 (30 mcg) vaccine is authorized as a booster dose for people 12+
• Pfizer-BioNTech Comirnaty bivalent BA.4/5 (30 mcg) vaccine is authorized as a booster dose for people 12+

NACI recommends that individuals 12 years of age and older who are at increased risk of severe illness from COVID-19 should be offered a fall 2022 COVID-19 booster dose, regardless of the number of booster doses previously received (Strong NACI Recommendation). All other individuals 12 to 64 years of age may be offered a fall 2022 COVID-19 vaccine booster dose, regardless of the number of booster doses previously received (Discretionary NACI Recommendation). NACI recommends that bivalent Omicron-containing mRNA COVID-19 vaccines are the preferred vaccine products for booster doses this fall (Strong NACI Recommendation).

NACI recommends that fall booster doses may be offered at an interval of 6 months after a previous COVID-19 vaccine dose or SARS-CoV-2 infection. A shorter interval of at least 3 months may be considered, particularly in the context of heightened epidemiological risk, evolving epidemiology and operational considerations for the efficient deployment of fall immunization programs. Based on what is known at this time, it is not expected that a booster dose will be routinely provided every 3 months.

Youth may receive a COVID-19 vaccine at the same time, or any time before or after, other vaccines.

• Vaccines can protect children against 16 serious diseases, including polio, mumps, diphtheria, chicken pox, measles, whooping cough (pertussis), and tetanus, among others. Many vaccines for VPDs are offered early in life (i.e., to infants, children and youth), based on evidence of the optimal timing and protection of the vaccinations, as reflected in PTs’ recommended immunization schedules. Most of the vaccines recommended in early life provide over 90% protection against the disease, with protection being lifelong for some vaccinations.
• The best way to protect children's health is to prevent these diseases in the first place by keeping their vaccinations up-to-date.
• Multiple countries worldwide have reported significant declines, delays and disruptions in the administration of routine childhood vaccines and VPD immunization coverage starting in the months following the pandemic declaration.
• The highly infectious nature of many VPDs, the fact that the majority of the vaccine coverage estimates are below the set goals in Canada, and the low vaccine coverage estimates in some other countries elevate the risk of outbreaks of potentially serious VPDs domestically and globally.