Immigrant Health Service

Catch-up immunisation in refugees

  • Table 1.

    Vaccine type Age,
    Number of doses
    Route and dose Minimum dosing interval (months) Notes
    Diphtheria Tetanus
    Pertussis (DT)
    <4 years
    4 or 5 doses DTPa
    IM
    0.5 ml
    1,1*,6** 3 doses for primary series then **4th dose at 18 months of age or 6 months after primary course, and 5th dose at 4 years. If 4 doses of DTP given before age 18 months, give a 5th dose at 4 years. If the 4th dose is given after the child is 3.5 years the 5th dose is not required. A hexavalent vaccine is available in all jurisdictions, (combining DTPa with IPV/Hib/HepB). *If using the hexavalent vaccine combined with hepatitis B, the dosing interval changes (2 months between doses 2 and 3 and 4 months between dose 1 and 3).
    4-9 years
    4 doses DTPa
    IM
    0.5 ml
    1,1*,6** 3 doses for primary series then **4th dose 6 months after primary course. Hexavalent vaccine as above.
    Current recommendations are to separate DTPa/IPV/HiB/Hep B from MenC/Hib - this may extend catch-up immunisation to 4 visits, using MenC instead is therefore likely to be more convenient and reduce catch-up visits.
    10 years and older
    3 doses (dTpa, dT, dT)
    IM
    0.5 ml
    1,1 Insufficient safety data on 3 doses of dTpa, therefore recommend dTpa, dT, dT, then 10-year and 20-year booster dTpa. A single dose of dTpa is funded for refugees as the first dose of a primary course, and a single dose is funded for children aged 10-15 years. dTpa is now available combined with IPV – dTpa-IPV.
    Measles
    Mumps
    Rubella (MMR)
    (LAV)
    <10 years
    2 doses
    IM or SC*
    0.5 ml
    1 2nd dose due at 3.5 - 4 years if <3.5 years at first dose.
    MMR is now available combined with Varicella Vaccine (VV) as MMR-V (*given SC) - although MMR-V is not recommended as the first dose of MMR containing vaccine in children <4 years, due to increased risk of fever/febrile convulsions in this setting.
    10 years and older (born  >1966)
    2 doses
    IM or SC*
    0.5 ml
    1 Note: MMR now given as part of Departure Health Check for Offshore Humanitarian arrivals aged 9 months - 54 years, consider timing if administering TST for TB screening or live viral vaccines.
    MMR-V (*given SC) can be given as the first dose in children 4 years and older (followed by MMR alone), not recommended in those aged 14 years and older.
    Inactivated Poliomyelitis Vaccine (IPV)

    <4 years
    4 doses*


    4 years and older
    3 doses 

    Varies** 0.5 ml

    1,1, varies*


    1,1

    *4th dose required if aged <4 years for primary course. Different combination vaccines available, combined with DTPa/dTpa/HiB/Hep B. Hexavalent vaccine dosing as above. Also available as dTpa-IPV.
    **IPV in combination vaccines given IM, IPV alone given SC. Note: OPV and IPV are considered interchangeable (OPV may have been given prior to travel to Australia from certain countries)
    Hepatitis B <11 years
    3 doses
    IM
    0.5 ml
    1,2** Combination vaccines are available, *dosing intervals complex, minimal dosing intervals: 1 month between dose 1 and 2; 2 months between doses 2 and 3; and 4 months between dose 1 and 3.
    11-15 years
    2 doses (adult formulation)
    IM
    1 ml
    4 Alternate regimen is 3 doses paediatric formulation (0.5 ml) as above 
    16 years and older
    3 doses*
    IM
    varies**
    1,2** *Age 16 - 19 years 3 doses paediatric formulation (0.5 ml), 20 years and older 3 doses adult formulation (1 ml). Dosing intervals as above.
    Meningococcal
    C conjugate (MenC)
    Any*
    1 dose
    IM
    0.5 ml
    - *Normally given at age 12 months. Disease has bimodal peaks in incidence of <5 years and 15-24 years, catch-up previously funded to 19 years (born>1987). MenC available combined with Hib (MenC/Hib) - licensed to 9 years, MenC (all ages) also available. Current recommendations are to separate DTPa/IPV/Hib/Hep B from MenC/Hib; using MenC instead is therefore likely to be more convenient and reduce catch-up visits.
    Additional dosing (of the 4-valent meningococcal [ACWY] vaccine) recommended in asplenia, see Immunisation Handbook.
    Haemophilus influenzae
    type b (Hib)
    2-11 months
    2 or 3 doses, then booster*

    12-59 months
    1 dose then booster*
    IM
    0.5 ml
    1 or 2*
    varies* 2  
    Not required 5 years and older, but may be given as part of combination vaccines. Children aged <10 years will now receive multiple doses of Hib through the use of combination vaccines (e.g. hexavalent DTPa/IPV/HiB/HepB and also MenC/Hib). Current recommendations are to separate DTPa/IPV/Hib/Hep B from MenC/Hib; using MenC instead is therefore likely to be more convenient and reduce catch-up visits. Hexavalent dosing as above.
    *Refer to Immunisation Handbook for catch-up schedule in younger children - different vaccines require different catch-up schedules with different dosing intervals.
    13-valent Pneumococcal conjugate
    (13vPCV)
    <7 months
    3 doses

    7-11 months
    2 doses

    12-59 months
    1 dose
    IM
    0.5 ml
    1,1

    1

    Required in children < 5 years of age, additional doses for children with medical risk factors, including prematurity. 
    *Dosing interval is 1 month for <12 months age or 2 months for 12 months of age and older. 
    People with medical risk factors require extra doses of 13vPCV and 23vPPV (minimum 8 weeks apart) see Immunisation Handbook.
    Varicella (VV)
    (LAV)
    18 months-13 years
    1 dose

    14 years and older*
    2 doses
    SC
    0.5 ml
    1 All children <14 years should have at least one dose of VV, usually given as either VV or MMR-V at 18 months. Prior varicella infection is not a contraindication. If varicella containing vaccine is given <12 months of age, the dose should be repeated at 18 months. MMR-V is not recommended as the first dose of MMR containing vaccine in children <4 years, due to increased risk of fever/febrile convulsions in this setting, and  is not recommended in those aged 14 years and older.
    *VV is recommended in non immune adolescents/adults 14 years and older (no clinical history and negative serology). People 14 years and older with a reliable history of varicella should be considered immune; check serology if no clinical history of varicella infection.
    Human Papilloma Virus (HPV) 12-18 years
    3 doses
    IM
    0.5 ml
    1, 3 Complete doses within 12 months. 4-valent vaccines licensed for use in females aged 9─45 years, males aged 9─26 years. Not recommended during pregnancy, can be given during breastfeeding. Recommended for immunocompromised adults (including due to HIV infection) and men who have sex with men (MSM). From 2015, HPV given to all year 7 students.
    Rotavirus
    (LAV)
    <6 months,
    2 or 3 doses*
    Oral, varies* 1 Not usually given as catch-up due to strict age restrictions. *Dosing depends in vaccine type. Rotarix (1 ml): 2 doses at 2 and 4 months of age, 1st dose must be given <15 weeks, 2nd dose must be given <25 weeks. Rotateq (2 ml): 3 doses at 2, 4, and 6 months of age, 1st dose must be given <13 weeks of age, 3rd dose must be given <33 weeks of age.
    Bacillus Calmette Guerin (BCG)
    (LAV)
    <16 years*,
    1 dose  
    ID,
    varies**
    - Recommended in:[1,3]
    Children <5 years in households with immigrants/unscreened visitors from high prevalence countries.
    Children <5 years travelling to high prevalence countries (i.e.>40 cases per 100 000 population per year) for >3 months.
    Neonates with family history of leprosy.
    *Consider in:
    Exposure to active pulmonary TB where preventive therapy not possible or after completion preventive therapy.
    Travel to high prevalence area > 6 weeks if aged <5 yrs,>3 months aged >5 years[2].
    Only give if no record/scar, no immunosuppression, no evidence TB infection, and no other contraindications. **Dose is 0.05ml age <12 months, 0.1ml 12 months and older.

    IM = intramuscular, SC = subcutaneous, ID = intradermal, LAV = Live Attenuated Vaccine (marked in red - consider pregnancy, and dosing interactions)

    Background

    Vaccine preventable diseases are endemic and/or epidemic in countries of origin of refugee families, and disruptions to health care may affect vaccine quality and access to immunisation. Information on vaccination coverage and disease status in country of origin is available from the WHO website, including immunisation schedules by country. See the Australian Immunisation Handbook[1] for specific information on catch up vaccination, and the Australian immunisation schedule. Information is also available on recent clinical updates.

    Recent changes - federal 'No jab, no pay' and Victorian 'No jab, no play' legislation and policy.

    From 2016, there have been significant changes in immunisation policy related to the federal 'No Jab, No Pay' legislation (see background, Department of Health information, and summary information ). Children and young people (<20 years) need to be up to date for their immunisations  OR be on a vaccine catch-up schedule OR have a medical exemption to be eligible to receive certain family assistance payments from Centrelink (Child Care Benefit, Child Care Rebate and Family Tax Benefit Part A-end of year supplement).  

    Centrelink uses ACIR to establish whether vaccinations are up to date (by antigen). The vaccines that are linked to family assistance payments are: DTPa/dTpa, IPV, MMR and hepatitis B. When the first dose of vaccines covering all the overdue antigens is entered into ACIR, the child is recorded as being up to date until the next set of vaccines becomes overdue (usually 3 months later). Medical exemptions (i.e. for immunity) on ACIR are also factored into establishing whether vaccinations are up to date. 

    All children and young people (<20 years of age) need an assessment of their immunisation status to: clarify their immunisation history, enter information into ACIR if it has not been recorded, and provide catch-up vaccines if needed. ACIR information will need updating or families will lose these Centrelink payments

    In Victoria, the state 'No jab, No Play' legislation has also been introduced, where children need to be up to date with vaccinations or have commenced an immunisation catch-up plan to enrol in childcare or kindergarten. Children who arrived in Australia as a refugee or asylum seeker are eligible for a 16-week grace period to start catch-up vaccinations after they enrol in childcare. See further information, and resources for early childhood services.

    General principles

    No-one arriving as a refugee or asylum seeker will be vaccinated and up to date according to the Australian immunisation schedule, due to differences in country of origin schedules and/or issues with health service access. 

    Refugees and asylum seekers should be vaccinated so they are up to date according to the Australian immunisation schedule; equivalent to an Australian-born person of the same age.

    1. Assess any existing immunisation records

    • Written records are considered reliable evidence of vaccination status if available; however most refugees do not have documentation of immunisation. There is often a clear verbal history of vaccinations, although there is debate on the validity of parental/self recall of vaccination status[4, 5].
    • Offshore Humanitarian Programme arrivals may have had vaccines as part of the Departure Health Check (DHC). The DHC includes MMR in people aged 9 months - 54 years, Yellow Fever (YF) and Polio Vaccine (OPV or IPV) depending on area, although the DHC is voluntary and uptake is incomplete.
    • From 2016, additional immunisation will be implemented for the Syrian and Iraqi cohorts, with MMR, polio vaccination and diphtheria-tetanus-pertussis vaccination – in the form of hexavalent or pentavalent vaccine in children <10 years – check available paperwork.
    • Asylum seekers arriving by boat may have had immunisations in Australian immigration detention. Check their health summary or health discharge assessment (they should have a copy). They may also have a photocopy of a vaccination card - there are often differences between the health summary and card. The Community Detention Assistance Desk (CDAD) should be able to provide immunisation records for people in Community detention (but not others) - phone 1800 725 518.
      • Immunisation provision was variable over the first half of 2013 on Christmas Island, and improved from around August 2013.
      • Asylum seeker children aged <7 years should have had their immunisation information entered into ACIR - although this frequently has not occurred (either in detention or subsequently in the community), and alternative/changes in name spelling (if there is no Medicare) can make this information difficult to find.
    • Clarify any vaccinations given in Australia and check ACIR for those aged <20 years.

    2. Consider relevant clinical information

    • Hepatitis B serology is part of post arrival screening, if there is documented immunity (sAb >10 mIU/mL)  hepatitis B vaccination is not required and a medical exemption form should be completed.
    • Rubella serology is recommended in women of childbearing age. 
    • Varicella serology should be checked in those aged 14 years and older with no clinical history of varicella infection.
    • Otherwise, routine serologic testing for immunity to vaccine-preventable diseases is not recommended in refugee/asylum seeker health screening.
    • Check for a history of varicella and the presence of a BCG scar (deltoid, forearm, scapula, both sides and may be elsewhere). BCG vaccination has been found to leave a scar in between 75%[3] - 99%[6] of recipients.
    • Assess for any contraindications to vaccination, completing the pre-vaccination screening checklist and relevant responses (Table 2.1.1 and Table 2.1.2 in the Australian Immunisation Handbook). 
      • Consider recent vaccines (including offshore vaccines) and/or tuberculin skin tests (TST). The DHC includes live viral vaccines (LVV). There should be a minimum 4-week interval between vaccine dosing, and TST should be administered before, or 4 weeks after LVV. 
      • Consider pregnancy, including in adolescents. In general LVV (MMR, MMR-V, VV) and HPV are contraindicated during pregnancy and should not be given for 28 days prior to pregnancy.
    • Consider medical conditions requiring extra vaccine protection including asplenia, HIV infection/other immunosuppression, severe or chronic medical conditions or hepatitis B (where hepatitis A vaccination is recommended in the absence of immunity).
    • Consider any occupational risk factors requiring extra vaccine protection (e.g. healthcare workers (hepatitis B vaccine, influenza vaccine) or occupational animal exposure/abattoir workers (Q fever).

    3. Develop a catch-up vaccination plan

    • Determine which vaccines have already been given and if there is immunity to hepatitis B or varicella. Complete, but do not restart, immunisation schedules if there is written documentation of previous vaccine doses. Clarify if there is a plan in place; in which case opportunistic immunisation is not appropriate, unless specifically requested by the primary care provider.
    • Aim for minimum number of visits, and minimum dosing schedules. In general, catch-up immunisation can be provided over three visits across 4 months in adolescents and adults (i.e. by giving the 3rd doses of DT containing and hepatitis B vaccine at the same visit). Children 4-9 years of age will require a 4th dose 6 months after the primary course. Younger children will also require 4 or 5 doses (see resources). 
    • Give combination vaccines where possible (to reduce the number of needles). Consider formulations, age restrictions and schedule changes.
    • See Table 1 for dose number, interval and practice points. The SA Immunisation Calculator can be used to calculate catch-up schedules for children <10 years. 
    • Be opportunistic. For most vaccines, there are no adverse events associated with additional doses in immune individuals, and the benefits of immunisation are substantial. Extra doses of DT (or dT) containing vaccines and pneumococcal polysaccharide vaccines may be associated with increased local reactions[1].

    4. Document vaccinations that have been given (in Australia and overseas)

    • Provide a written record and a clear plan for ongoing immunisation. It is useful to document which dose of vaccine has been given (e.g. MMR dose 1 of 2)
    • Vaccination information for children and young people aged <20 years should be entered into the Australian Childhood Immunisation Register (ACIR) which can also be cross-checked for previous vaccines.
    • Vaccinations given overseas or in immigration detention should be recorded onto ACIR online or by completing an Immunisation History Form and returning the form to the Department of Human Services, GPO Box M933, Perth WA 6843 or by fax on 08 9254 4810. ACIR is currently is experiencing significant delays with entering hard-copy information – use on-line entry to ensure vaccination information is updated promptly. 
    • Previous vaccination in Australia may also need to be entered into ACIR (for those arriving >2004 - see No Jab No Pay section above)
    • Current vaccinations should also be entered into ACIR.
    • Document medical exemptions where relevant (i.e. medical contraindication or natural immunity) – GPs should complete an ACIR Medical Exemption Form and return the form to the Department of Human Services, GPO Box M933, Perth WA 6843 or by fax on 08 9254 4810.

    5. Ensure catch-up vaccination is completed

    • Make sure children/families/adults understand they will need 3-4 visits for vaccination.
    • Where possible, immunise family members simultaneously to reduce the total number of visits.
    • Provide information about immunisation and family assistance payments. For patients with low-English proficiency, translated immunisation information is available on the Health Translations Directory
    • Use a recall and reminder system to support completion of immunisation schedules (e.g. NSW refugee health service appointment reminder tool)

    For families outside the initial stage of settlement - remind them to plan early for travel immunisations. Many families subsequently travel and may be at increased risk when visiting friends/relatives in their area of origin. 

    Additional notes

    The current National Immunisation Program Schedule in Victoria for secondary students includes:

    • Year 7: Varicella, and HPV (now for both males and females). Universal Hepatitis B vaccine was introduced in Victoria in May 2000, so the cohort vaccinated as babies reached year 7 in 2012 and the catch-up program ceased in 2013.
    • Year 7-10: dTPa (Boostrix).

    Vaccines for refugees/asylum seekers are supplied though several government immunisation initiatives:

    2015 vaccine funding changes for refugees and asylum seekers in Victoria

    Details of government funded vaccines are available at: Criteria for eligibility for free vaccines in Victoria. Criteria introduced in January 2015 state: 'Age appropriate vaccines are supplied for vulnerable citizens who meet eligibility criteria and who were age appropriate at the time a vaccine was available.' (see below)

    Eligibility criteria: 

    • Hold a Medicare care (or be eligible to hold a Medicare card)
    • Hold Australian citizenship 
    • Hold Australian permanent residency, or have applied for permanent residency
    • All asylum seekers, regardless of Medicare status.

    Age appropriate at the time a vaccine was available: (the following list has been compiled based on vaccine programs in Victoria, and calculates the birth year for Victorian-born people accessing the relevant recent programs)

    • Hepatitis B vaccine - born 1989 onwards (2000 infant immunisation, 2001 catch-up year 7 program, ceased 2013 when birth cohort reached year 7)
    • Human Papilloma Virus vaccine - females born 1981 onwards and males born 1999 onwards (2007 immunisation for females aged 13-26 years, 2013 immunisation for males in year 9 or aged 14-15 years) 
    • Meningococcal C vaccine - born 1987 onwards (2003 immunisation at 12 months, 2003 - 2006 immunisation provided for age 1-19 years)
    • Varicella vaccine - born 1993 onwards (2005 immunisation at 18 months and catch-up year 7 program). 

    Resources

    References

    Immigrant health clinic resources. Initial: Georgie Paxton and Jim Buttery. Revisions: Georgie Paxton. Updated May 2016. Contact: georgia.paxton@rch.org.au