Equity Aspects of Canadian Immunization Programs Differences within and between countries

There is a global recognition that immunization is one of the most cost-effective public health interventions which should be available to everyone.  The equity approach to immunization provides a holistic and integrated framework for addressing inequalities and disproportions in the realization of human rights. The aim of this study is to review the performance of the immunization programs in Canada through an equity lens using two analytical frameworks for immunization programs. It focuses on four elements of the programs: a) the burden of disease; b) immunization strategy; c) ability to evaluate; and d) research questions.  To achieve universal access to vaccination, Canada should have a strong connection with human rights, where realities and outreach need to be prioritized. Preventable diseases such as influenza, H1N1, and varicella have been reported specifically in Aboriginal Canadians, immigrants and refugees. Our study seeks to demonstrate that access to vaccines should be considered one of the most vital human rights and as a matter of fundamental intervention to achieve health equity.


Differences within and between countries
Mirella Veras 1 & David Zakus 2

I. Introduction
Health equity is defined as an "absence of systematic disparities in health (or in the major social determinants of health) between groups with different social advantages/disadvantages (eg., wealth; power; prestige). 3" The concept of equity is consequently an ethical principle essential to human rights and its discoursesa principle bolstering contemporary strategies of national health and the possible future epistemological preoccupation 1 .Article 25 of the Universal Declaration of Human Rights, for example, affirms the rights (that is, the equal availability and access) of medical care and necessary social services for everyone.The United Nations Committee on Economic, Social and Cultural Rights further illustrates, and very much underlines, the importance of immunization accessibility in the attempt to reduce major infectious diseases in risk groups such as children and other vulnerable populations. 4;6 The first vaccine, we recall, was developed more than 200 years ago and since then millions of lives have been saved, with several infectious diseases being eradicated through vaccination strategies 7 .For example, smallpox was eliminated worldwide by 1977 and the threat of paralytic poliomyelitis has since diminished completely in most countries across the globe.Deaths caused by certain diseases including polio, measles, mumps, rubella, hepatitis A, hepatitis B, pneumococcal, meningococcal disease and tetanus have also significantly decreased in the wake of effective immunization programs. 8et although people living in developed countries are generally considered the healthiest in the world (owing to the structural and accessibility factors of systems), the opportunity and possibility to be healthy varies according to social class, geographic location, education level, socio-economic status, gender, ethnicity and other variables 9;10 .The idea of equal access to health is associated with the notion of equal human rights, which is a fundament to the concept of health equity amidst these very complex socio-economic, and at times, cultural, variables.Furthermore, equal opportunity and choice in the context of health implies that all people are able to achieve the highest possible level of physical and mental wellbeing within a given system, considering that many physical limitations can be overcome with appropriate resources and strategies which can properly consider, and steer through, these variables. 11 is presently estimated that 30,000 to 50,000 North Americans die each year from vaccine preventable illnesses. 12;14 Health disparities in Canada are presented among groups with particular characteristics such as socio-economic status (SES), aboriginal identity, geographic location and gender.For instance, Canadians who live in Northern remote communities have higher rates of smoking, obesity and heavy drinking when compared to the Canadian average.Such behavioral patterns result in the lowest life expectancy and the lowest disability-free life expectancy (DFLE) of the country.Moreover, First Nations on reserves have four times the rate of potential years of life lost caused by injuries, including suicides 15 .This, arguably, is not merely a question of behavior patterns and lifestyle habits, but equally one of access.It is further reported that Canadian women live six years longer than men even though they are more likely to have long term activity limitations and chronic conditions.
In Canada, it is nigh on a statistical given that many adults die of infectious diseases which could have been prevented through vaccination. 16In 2010, 428 Canadians died from H1N1 and a great many thousands were infected in spite of 41% (excluding those residing in the respective territories) having received immunization by April 2010. 17Regarding the Human Papillomavirus (HPV), the Society of Obstetricians and Gynecologists of Canada estimates that 10% to 30% of the Canadian adult population is infected with HPV and around 75% of Canadians will have at least one HPV infection in their lifetime.Additionally, each year, approximately 580 women die from cervical cancer, which is strongly associated with the HPV infection 18 .
Added to these disparities and the dissymmetry of the national picture, access to vaccines varies among different groups within the population, among the ten provinces and three territories of Canada.In many provinces the distribution of vaccines is based on location of residence (geo-demographic data) instead of scientific evidence (epidemiological research data).People living in some Canadian provinces therefore have access to vaccines that people in other provinces frankly do not have, 19 further evidencing a problem of availability, access and disproportion.What's more, internal migration in Canada results inadequate immunization because the vaccination schedules among the provinces differ significantly and are not necessarily synchronized. 20In 2008/2009, almost 400,000 Canadians moved between provinces 21 .A person who moves to another province is at risk to missing important doses of specific vaccines because of differences in these provincial schedules.
Our article focuses on the equity aspects of the immunization programs within Canada and how equity in immunization initiatives can be assessed from a population health perspective (considering the problems of dissymmetry and access).Four elements of immunization in Canada will be presented following a brief summary of the Canadian immunization system and its inequalities.The first element of the immunization program focuses on the burden of vaccine preventable diseases.The second focuses on the immunization strategies themselves, the third on evaluation and, finally, the fourth element on the need to develop research to enhance equity in immunization programs in Canada as well as to better understand the main determinants and variables of immunization inequalities of the country (Figure1).

II. The Canadian Immunization System
Immunization programs in Canada vary between the ten provinces and three territories with each constitutionally mandated to determine and deliver their own health services. 22The responsibility for immunization is shared between federal, provincial and territorial (FPT) governments. 23The development of a national immunization strategy was initiated in 1999 by the FPT Deputy Minister of Health 24 .In 2003 a National Immunization Strategy was published as proof and consequence to developments in the discourse of population health.This document sets out the major elements and supporting activities related to a national immunization strategy, its broader protocols, remit of application and outreach capability.According to the National Strategy, FPT jurisdictions should work "in partnership" to improve the consistency and synchrony of immunization programs.A mechanism to thus achieve a national collaboration between jurisdictions was implemented to support equitable access to recommended vaccines; improve the efficiency of public health human resources; engage in global immunization initiatives; ably introduce new immunizations; and facilitate inter-sectoral collaboration related to immunization issues. 25spite recognition of the National Immunization Strategy, many provinces and/or territories lacked the required funding to implement the strategy outlined in the report. 26Each jurisdiction independently planned and delivered their immunization programs, which ultimately led to health disparities in access to vaccines.The result was that a complicated dissymmetry and disproportionate national picture emerged.
Our investigation draws upon equity aspects of the Canadian immunization system using the analytical framework for immunization programs in Canada developed by Erickson, DeWals and Farand 27 and the Global Framework for Immunization Monitoring and Surveillance (GFIMS) of the World Health Organization. 28The Erickson framework allows for a comparison and examination of immunization programs in Canada, with 58 criteria classified into 13 categories.The categories included are: burden of disease; vaccine characteristics; immunization strategy; cost-effectiveness; acceptability; feasibility; evaluability of programs; research questions; equity; ethical legal considerations; and political considerations.This framework has been specifically employed to structure immunization program reports in consensus building and prioritization conferences.We focus our analysis on four categories using an equity lens for the following aspects of the immunization programs: a) burden of disease; b) immunization strategy; c) ability to evaluate; and d) research questions.Although we acknowledge the importance of the other elements, we did not encounter sufficient literature to analyze them.The GFIMS framework provides elements to assess immunization strategy and the ability of the governments to evaluate their programs, describing key components of a functioning system and its essential requirements.The GFIMS focuses on two strategic areas: (1) surveillance of vaccine preventable diseases and, (2) immunization program monitoring. 29

The Burden of vaccine preventable diseases and equity
Immunization is one of the most cost-effective public health interventions curtailing disease (cost per life saved or disability prevented), saving millions of lives around the word annually 30 .In Canada, however, many continue to suffer and die from vaccine-preventable diseases. 31ricella (commonly called chickenpox), for example, is a vaccine-preventable viral disease.However, this infection is significantly under-reported in Canada.The percentage of Canadians aged between 18 and 64 who reported having had varicella currently stands at 84%.Each year, around 350,000 cases are expected to occur and it is estimated that 90% of Canadians will have contracted varicella before they reach 12 years old. 32The infection, moreover, is associated with significant mortality, morbidity and as having an economic impact. 33e incidence of chickenpox presents geographic and gender differences in Canadian provinces and territories Tables 2 and 3 included in our sudy evidence the incidence and occurrence of chickenpox in FPT jurisdictions.For both sexes, the province of Newfoundland and the Yukon and Northwest Territories had the highest incidence of Chickenpox in 2004, with these territories being hit by the highest incidence of chickenpox in women compared to men. 34  According to the National Advisory Committee on Immunization (NACI), the varicella vaccine (Var) should be administered to children aged between 1 and 12 years old.Susceptible individuals, 13 of years' or more, should receive two doses at least 28 days apart.NACI recommends an emphasis on promoting varicella immunization within immigrant and refugee populations from tropical countries, as well as women of childbearing age; health and child care workers; people in contact with immuno-compromised persons; those with cystic fibrosis, and those susceptible adults exposed to a case of varicella. 36Outbreaks of varicella in immigrant populations have been reported in developed countries and for reasons that remain unclear, immigrant adults are disproportionately 36   susceptible to the infection.37;38A cost-effectiveness study was conducted to identify the best vaccination strategy for adult immigrants and refugees arriving in industrialized countries with the results highlighting the importance of screening adult immigrants and refugees. 39other study conducted in Canada to determine the susceptibility of newly arrived immigrants and refugees to measles, mumps and rubella showed that 36% of the immigrant populations were not immune to at least one of the three diseases.The study demonstrated in a multivariable analysis adjusted for demographic and socioeconomic covariates, that immigrant women are more susceptible to measles (odds ratio, 2.1 [CI,1.2 to 3.8]) and rubella (odds ratio, 1.7 [CI, 1.2 to 2.6]) but not to mumps (odds ratio, 1.1 [CI, 0.8 to 1.5]) when compared to immigrant men. 40e medical examinations which are required by Canadian immigration policy are urinalysis, a serological test for syphilis, an HIV test, a chest X-Ray and serum creatinine if the applicant suffers with hypertension.However, there are no requirements for a vaccine-record and no policy is in place to specify immunization before arriving to Canada or, in fact, how to be immunized once on Canadian soil.
Inequalities related to Aboriginal identity were demonstrated in the 2009 UNICEF report: First Nation children under one year of age are 80 times more likely to have chickenpox compared to non-Aboriginal children.They are also more likely to have a higher incidence of vaccine-preventable diseases, in particular those living on reserves. 44A study focusing on the mothers' perception of childhood immunizations in First Nation communities of the Sioux Lookout Zone in Northwestern Ontario identified several key factors that negatively influence immunization uptake: knowledge barriers; the influence of others; vaccine barriers; and missed opportunities.Mothers claimed that they had limited knowledge of preventable diseases and how vaccines can indeed act as prevention.In addition, they reported negative side affects attributed to the vaccine related by others, such as fever, pain and swelling.Another barrier to immunization uptake was illness of the children at the time of immunization, even if illness was relatively minor 45 (tables 2 and 3 respectfully).
Yet another example of the vulnerability of specific groups to infection by preventable diseases is the H1N1 influenza pandemic of 2009.;48 According to the 2010 Canadian Community Health Survey (CCHS), immigrants were less likely to have been vaccinated compared to non-immigrants: 38% versus 42%.The survey covered household populations aged from 12 upwards in all Canadian provinces, excluding members of the Canadian Forces; residents of Indian reserves; institutions; certain remote areas, and civilian residents of Canadian military bases. 49 June 2009, an outbreak of H1N1 in a northern First Nation community in Manitoba was documented by the Public Health Agency of Canada.In spite of 8% of the population of Manitoba being First Nation peoples, 17% of the H1N1 cases that required hospitalization in the province belonged to the First Nation demographic. 50Overall in Canada, 3% of the population is Aboriginal, which accounted for 11% of the H1N1 cases requiring hospitalization.Statistically, Aboriginal people are more susceptible to being exposed to poverty; environmental contamination; poor health status; a high incidence of hepatitis B and C, 51 and inadequate access to healthy food. 52This vulnerability has also been reported in other countries.In 1918, the mortality rate in Aboriginal communities across North America was significantly higher compared to non-Aboriginal peoples (9% to 3%). 53In Australia, 2.5% of the population constitutes Aboriginal and Torres Strait Islanders, though they accounted for 9.7% of patients hospitalized with H1N1 in 2009. 54sparities in Human Papilloma Virus (HPV) related diseases are an additional example of inequity in preventable diseases worldwide. 55HPV is considered the most preventable sexually transmitted infection known. 56he global burden of cervical cancer is approximately 500,000 new cases each year and around 274,000 deaths. 57It is further estimated that 75% of all sexually active women will have at least one HPV infection in their life time. 58 meta-analysis study revealed that what we commonly call "social class" is a factor associated with invasive cervical cancer, appearing to be higher in North America and low/middle income countries than in Europe.Women from low social class have an increased risk of approximately 100% to develop invasive cervical cancer when compared to those of higher social class.59 In Canada, the highest rates of cervical cancer are among women belonging to socially disadvantaged groups such as those of lower income; low literacy; recent immigrant and aboriginal ethnicity (this underlying the importance of education, awareness and access).60 Each year, these women represent an unequal burden of the 1,300 cases of cervical cancer.61 There are nearly twice as many cases of HPV in Nunavut compared to other Canadian provinces and territories 62 and studies have shown that Canadian Aboriginal women are three times more likely to develop cervical cancer than non-Aboriginal women.63 Prevention of the HPV infection encompasses three strategies: sexual behavior modification, screening and vaccination.64 .Sexual behavior modification is a strategy that involves upstream determinants of this sexually transmitted disease.On the other hand, screening (Papanicolaou) and immunization programs focus on the biomedical causes of HPV infection.65 The Papanicolaou smear pap test has significantly reduced the incidence and mortality of cervical cancer.In spite of the success of the strategy, in 2006 approximately 1,350 new cases of cervical cancer and 390 cervical cancer-related deaths were reported.Sixty percent of those diagnosed women had not been screened or had received inadequate treatment.The infection mostly affects women from socially and diverse disadvantaged groups that face barriers to screening or treatment.66 The vaccine to prevent HPV meet Canadian approval in 2006, and was consequently recommended for girls aged 9-13 years in 2007 by the National Advisory Committee on Immunization (NACI). Th vaccine protects against two high risk types of HPV (16 and 18) responsible for approximately 70% of cervical cancers and two lowrisk types (6 and 11), responsible for 90% of anogenital warts.67 In 2007, the Federal government allocated $300 million to support a national HPV vaccination in all jurisdictions of Canada.68 Although all the provinces and one territory do provide HPV vaccination, the strategies of access and implementation vary across the jurisdictions.The HPV vaccine is provided free to all females in at least one of the educational clusters (grades 4 to 9) through school programs.Some provinces only cover one age group of females, while other provinces cover a second age group including all females under 18 years old.Quebec has the most inclusive program, providing vaccination for girls in grades 4 and 9girls up to the age of 18 can also be vaccinated upon request.For those under 14, a consent form must be signed by the parent or guardian.69;70 The most restrictive programs are in Nova Scotia, Prince Edward Island, Ontario and Manitoba where the HPV vaccination is restricted to one school grade.Additionally, the strategies for immunization programs seem to be unassociated with the incidence of cervical cancer in each jurisdiction since many jurisdictions have a high incidence and low vaccine coverage.71 In addition to the preventive benefits of the HPV vaccine in women, the risk of anogenital warts and precancerous lesions in men is said to be effectively reduced by 90%. Helth Canada approved the HPV vaccine for use in men in 2010, yet this move was not publicly funded.Men who are interested in being vaccinated are advised to purchase the vaccine through prescription from a doctor, pharmacist or travel clinic.72 An international comparison between member countries of the Organization for Economic Co-operation and Development (OECD) shows that Canada has the lowest coverage for the third dose of diphtheria toxoid, tetanus toxoid and pertussis vaccine (DTP3) (table 3).Likewise, poor coverage for the almost standard third dose of polio vaccine (POL3) and measles' immunization means that Canada's overall ranking among OECD nations is dismal: 11 th out of 12 in the ranking for DTP3 vaccine; 10 th out of 11 for POL3 and 6 th out of 13 for measles.Indeed, although polio has been eliminated from the Americas and the number of polio cases worldwide has been drastically reduced, the risk remains for imported cases of polio from countries where the virus still circulates. Th Pan-American Health Organization (PAHO) recommends maintaining 95% vaccine coverage.Canada, meanwhile, has 80% vaccine coverage for POL3 73 (table 4 74 ).

III. Immunization Strategy
Erickson's Framework emphasizes the importance and indispensability of having a guideline for vaccine use.Although Canada boasts a National Immunization Strategy, published in 2003, and a National Advisory Committee on Immunization (NACI), all jurisdictions have varying, autonomous strategies and schedules for immunization. 75he NACI recommends, for example, Hepatitis B vaccine for infants (three doses) or pre-adolescents (two or three doses).In the province of Alberta, hepatitis B administers three doses in grade 5 while in Ontario two doses are administrated in grade 7, and in Quebec two doses of hepatitis A and B are administrated in grade 4.And while some provinces have a catch-up program for the HPV vaccine in teenage girls, others do not.The differences between doses and the age of administration, however, repeat in all provinces and territories. 76ternationally, many countries have advanced to develop harmonized and well synchronized immunization programs.The United States has a harmonized immunization schedule for children 0 to 6 years, 7 to 18 years, as well as a catch-up and adult immunization schedule. 77Australia has an integrated and harmonized national system across three levels of government.It has also a huge Aboriginal population living in remote areas and vaccine recommendations highlight the need to target Aboriginal people and other vulnerable populations if disease risk is to be reduced and wellbeing both developed and maintained.The GFIMS and Erickson Frameworks highlight the role of an immunization strategy to ensure program efficiency.Programs should have a specific strategy in terms of reduction of morbidity and mortality as well as an objective in terms of coverage for target groups.;80 The WHO emphasizes use surveillance and data monitoring to promote improved access.Documenting the short and long term effects of vaccination strategy on disease burden as well as monitoring program effectiveness are two of the main purposes of a surveillance system. 81The WHO provides online information related to planning and management, system performance and surveillance among other indicators for each country. 82Canada, however, does not provide information related to work-plan costing for immunization strategies.Additionally there is a visible lack of information regarding surveillance and system performance. 83Although there is no national level information available, some provinces have documented their experience.In Quebec, results of surveys, consultations and discussions with different stakeholders are used to refine decision making processes before implementing a new program, tailored education and promotion programs. 84The province of Alberta, moreover, developed a strategic plan for 2007-2017 in order to address barriers through an evidence-based strategy. 85The strategy includes collaboration with other ministries and the federal First Nations and Inuit Health Branch.It recognizes that low socio-economic status is the major barrier for immunization in adults and children. 86British Columbia, also, had developed a strategic framework that underlines the need to identify barriers and improve access to immunization services.This involved consultation with British Columbia health and correction authorities, family physicians, as well as Citizenship and Immigration Canada, BC Corrections, First Nations and Inuit Health (Health Canada). 87erall, in the case of Canada, there is a visible and felt need to further develop immunization strategies and programs in order to meet FPT goals, and the program objectives which aim to reduce morbidity and mortality, increase coverage for different target groups, and achieve harmonized program delivery.

Evaluation of immunization programs in Canada
Safety of vaccines and population effectiveness are the most important elements to be evaluated in an immunization program or strategy. 88Regular monitoring regarding the coverage, access to vaccines and safety are crucial to program evaluation through an equity lens. 89Furthermore, information systems play an important role in monitoring the burden of diseases, adverse events associated with vaccines and respective coverage. 90 Canada, FPT governments share responsibility in delivering immunization programs.Each jurisdiction is responsible for planning, funding and delivering immunization program packages.The federal government holds responsibility for monitoring national coverage rates, adverse events following immunization and the incidence of vaccine preventable diseases. 91The National Advisory Committee on Immunization (NACI) publishes recommendations for all vaccines that are approved for use in Canada which are included in the Canadian Immunization Guide. 92The recommendations are based on disease risk; vaccine efficacy; safety, and targeting healthcare providers.Some aspects such as feasibility, acceptability and cost are, however, not considered. 93e Quebec immunization program is considered effective.It targets 15 diseases and only 20 injections are offered up to 15 years of age.Quebec is one of the few provinces that reserves a fraction of its budget for program evaluation and monitoring. 94The evaluation process is mainly based on a complete report of available vaccines, potential vaccine strategies, and schedules approved by the Quebec Immunization Committee.Existing evidence is utilized, and sometimes experts are consulted, as well as surveys conducted to evaluate disease burden when and where necessary.The committee estimates cost-effectiveness ratios for several strategies and identifies barriers for program implementation.In addition, the recommendations of the NACI and Advisory Committee on Immunization Practices are a constant point of reference and guideline. 95Paralleling the example of Quebec is that of British Columbia which developed an assessment program for delivery effectiveness, including information on coverage, disease epidemiology and vaccine safety.The BC framework also aims to assess if its immunization program works within the guidelines established in the Canadian Immunization Guide 96 .
Accessing coverage data allows for the identification of social, geographic, cultural and ethnic barriers to vaccination. 97The evaluation of Aboriginal, immigrant and refugee coverage rates serve to implement strategies to improve vaccine uptake in remote areas and in territories where the coverage is lower than the national average.Little information, however, is available regarding how provinces and territories evaluate their immunization programs, and a risk rather than a virtue to jurisdictional autonomy is presented.The monitoring of indicators that focus on health equity should be disaggregated and accessible for monitoring over time at the geographic level.A set of indicators is needed to show the links between health and main determinants. 98An equity analysis can assess the interaction between inequities and evaluate the gaps and dissymmetry in immunization programs over time.These aspects are fundamental to tailoring strategies to specific geographic areas, regions and populations where uptake is low, barriers are substantial and disease is prevalent. 99Further evidence indicates that appropriately targeted incentives can reduce inequalities in health outcomes. 100.

Research questions regarding Immunization
Research is an important tool for tackling the negative impact of health interventions, the programs and policies on equity as well as the disparity between population groups.Beyond the description of health inequalities and measuring immunization disparities, equity-oriented research has the potential to identify which interventions, programs or practices reduce inequities. 101According to the Public Health Agency of Canada (PHAC) the immunization research community in Canada is small, focusing on the development and pre-licensure testing of new vaccines, with funding mostly from private industry or government grants. 102There is a lack of research not only regarding program implementation and monitoring, but also regarding models which predict the effect and impact of new vaccines, of cost-effectiveness as well as the evaluation of the specialization needs of professionals.Furthermore, in order to protect health and decrease existing inequalities, it is crucial to prioritize immunization research in Canada as well as to identify and document the needs of immunization research,103 including research on sociological and demand issues at the community level.
There is a lack of information about inequalities in immunization programs.Priority questions for immunization research should be based upon the identification of the most relevant gaps in current knowledge 97 World Health Organization -WHO.Global framework for immunization monitoring and surveillance .Department of Immunization, Vaccines and Biologicals Switzerland 1-56.2007. 98Braveman P. Monitoring equity in health: a policy-oriented approach in low-and middle-income countries.WHO/CHS/HSS/981, Equity Initiative Paper No 3 .1998. 99 regarding access to vaccines and should have a framework with an equity lens to guide the design and analysis of research.Many questions need to be answered in order to enhance health equity: are the vaccines available for those who are in need?Is there a difference in incidence of vaccine preventable disease between non-Aboriginal and Aboriginal Canadians?Is there a difference in immunization levels between girls and boys?Have immigrant and refugee children the same access to vaccines as Canadian children?How can immunization evaluation be incorporated most effectively into the design of immunization programs?Why is the incidence of chickenpox higher in females compared to males in Northwest Territories?What are the reasons for Canada having a lower coverage rate when compared to other countries constituting the OECD?
Research can provide evidence and influence policymakers as well as inform the production or reduction of health inequalities in immunization strategies. 104Equity is thus an important component in the formulation of research question and strategy.An equity lens adopted in research can identify vulnerable populations that should be targeted by a program or given strategy, and indeed pinpoint the weaknesses and virtues of such programs and strategies.105;106 .

V. Conclusion
Achieving equity and fostering human rights in immunization programs is the sine qua non condition for enhancing equity in health care.Immunization is a right that should be respected and protected by government to ensure that vaccines will be accessible to all populations in need.It must be accomplished independently of geographical place, gender, socioeconomic condition, ethnicity, education level and religion, thereby enabling diverse groups to have equal access.
Universal access to vaccination in Canada will remain a distant almost unachievable reality if human rights remain unaddressed.Morbidity and mortality due to vaccine preventable diseases have been reported specifically in Aboriginal Canadians, immigrants and refugees.Disparities in influenza, H1N1 and varicella have also been reported.These conditions signal inequalities and disproportions.An increase in health care costs results in the decline of population health as well as impacting on other areas of social reality.
Reducing barriers to improve equity in immunization coverage-rates requires a commitment to enhancing the opportunity for all people to be vaccinated.It requires that health professionals must provide appropriate care in a culturally sensitive way and that populations be informed to increase demand for these services.It requires planning and delivering programs based on an awareness of such differences.
It is important to achieve equity in preventing diseases and in immunization strategy, evaluation and research.The implementation and monitoring of strategies should themselves be evaluated to further ensure that goals will be achieved and that equity is included as a key criterion.The development of evaluation tools based on equity to monitor coverage rates, safety, and access to vaccines, is essential for decision making at the national and provincial/territorial levels.Furthermore, research using an equity lens can furnish information regarding interventions that can increase vaccination coverage, evaluate program impact and identify barriers to access of vaccines for different populations in order to enhance health equity.These elements are key to eliminating immunization inequalities and to ensuring that all Canadians will have protection against vaccine-preventable diseases independently of their geographic location and/or social, economic and ethnic identity.
The improvement of immunization research capacity in Canada must establish a strong partnership between the research community, industry and funding agencies, such as the Canadian Association for Immunization Research and Evaluation (CAIRE), the Canadian Institutes of Health Research (CIHR), Canadian Population Health Institute (CPHI), and the Canadian Network for Vaccines and Immunotherapeutics (CANVAC). 107search designs should monitor the indicators of vulnerable populations that will be targeted.The data on incidence of vaccine-preventable disease must be disaggregated by gender, ethnicity, socioeconomic status, language, age, Aboriginal status, disability and immigration status by the respective provinces and territories.This can constitute an equity-sensitive framework for monitoring Canadian immunization programs.

Figure
Figure 1: Elements for assessing equity within the Canadian Immunization Program All Canadian jurisdictions implemented a universal, publicly-funded childhood varicella program between 2000 and 2007.The last jurisdictions to establish this program were Quebec and Yukon Territory, which implemented their programs in 2006 and 2007, respectively. 3529 Ibid., 26 30 F/P/T Advisory Committee on Population Health and Health Security -ACPHHS.National Immunization Strategy.Final Report.2003 31 Statistics Canada.Annual Demographic Estimates: Canada, Provinces and Territories -2008.
National Advisory Committee on Immunization.Canadian Immunization Guide 2006.7th edition .2006.