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 vaccination. Information on vaccination coverage and disease status in country of origin is available from the World Health Organization (WHO), including  immunisation schedules by country. See the Australian Immunisation Handbook¹ for specific information on catch-up vaccination, vaccine preventable diseases (VPD), the Australian National Immunisation Program (NIP) Schedule, and guidance on catch-up for <10 years and 10 years and older.

Please also see the Victorian Immunisation Schedule. 

Table 1. Catch-up vaccination guidelines

IM = intramuscular, SC = subcutaneous, ID = intradermal, LAV = Live Attenuated Vaccine (consider pregnancy, and dosing interactions), MSM = men who have sex with men

Policy and legislation

Federal

• In 2016, the 'No Jab, No Pay' legislation was introduced (see background,  Department of Health (DH) information,  Department of Human Services (DHS) information,  Department of Social Services (DSS) summary)
• 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 (CCB)  Child Care Rebate (CCR) and the full amount of Family Tax Benefit Part A - FTB-A) - if children do not meet the immunisation requirements FTA-B payments reduce by $28.28 per fortnight, per child
• Centrelink uses the Australian Immunisation Register (AIR) to establish whether vaccinations are up to date. 
  • The vaccines that are linked to family assistance payments are those given in early childhood: DTPa/dTpa, IPV, MMR and hepatitis B, and for younger children, pneumococcal and meningococcal vaccinations
  • When the first dose of vaccines covering all the overdue antigens is entered into AIR, the child is recorded as being up to date until the next set of vaccines becomes overdue (usually 3 months later).  Medical exemptions can be completed by relevant health professionals (i.e. for immunity) and are 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 AIR if it has not been recorded, and provide catch-up vaccines if needed. AIR information needs to be up to date or children/families may lose Centrelink payments. 

• The Australian Immunisation Register (AIR) became a 'whole of life' register from 2016. Previously, AIR was the Australian Childhood Immunisation Register (ACIR) and could only be used for children <7 years, meaning any child who arrived aged 7 years and older (i.e. arriving from 2004 onwards) or, who received early childhood catch-up vaccines past the age of 7 years, did not have their immunisation information entered into AIR
• Specialist and other health providers can register to enter information onto AIR (GP and paediatrician registration is automatic, although paediatricians may not be able activate their individual registration and as of 2017, advice from Victorian Department of Health and Human Services (DHHS) is to use a service log-on)
• Catch-up vaccinations are funded including for age 10-19 years  and all refugee and humanitarian entrants 20 years and older.

State

• In Victoria, the 'No Jab, No Play' legislation (2015) came into effect in 2016 - children need to be up to date with vaccinations or have commenced an immunisation catch-up plan to enrol in childcare or kindergarten in Victoria - see resources
• 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 
• Only AIR records are accepted as evidence of immunisation for childcare/kindergarten enrolment (either individual or health provider view), which may be difficult for people without Medicare, recent arrivals, or children waiting for overseas records to be entered onto AIR. 

General principles

No-one arriving as a refugee or asylum seeker will be vaccinated and up to date according to the Australian National Immunisation Program (NIP) Schedule, due to differences in country of origin schedules and/or issues with health service access.

All refugees and asylum seekers will require catch-up vaccinations - they 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.^3,4 In the absence of written documentation, full age appropriate catch-up immunisation is recommended
  • If written records are available in other languages - the DSS provides a free document translating service for Australian citizens and new migrants settling permanently in Australia. Within the first two years of arriving in Australia, eligible individuals can have up to 10 key personal documents (including vaccination records) translated into English, free of charge
    
• Offshore Humanitarian Programme arrivals may have had vaccines as part of the Departure Health Check (DHC). The DHC occurs in the week prior to travel, this assessment is voluntary, and uptake is incomplete. The DHC includes MMR in people aged 9 months - 54 years, and Yellow Fever (YF) and Polio Vaccine (OPV or IPV) depending on area. Check available information (e.g. on Department of Home Affairs HAPlite system, any patient-held records, case worker, refugee nurse). 
  • From 2016, additional vaccinations were implemented for the Syrian and Iraqi cohorts, with MMR, polio vaccination and DTP/dT vaccination – in the form of pentavalent vaccine in children <10 years – check available paperwork and the HAPlite system as above, and ensure these vaccinations are entered onto AIR
• Asylum seekers who arrived by boat should have had vaccinations in Australian immigration detention, although in practice, immunisation provision was variable. Check their health summary or health discharge assessment (they should have a copy) or request IHMS information. They may also have a photocopy of a vaccination card - there are often differences between the health summary and card. Asylum seeker children aged <7 years should have had their immunisation information entered into AIR - 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 AIR (all ages).

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 (by GP, paediatrician, clinical immunologist, infectious disease physicians, public health physician)
• 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 
• 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
  • Consider recent vaccines (including offshore vaccines) and/or tuberculin skin tests (TST). The DHC includes LAV. There should be a minimum 4-week interval between vaccine dosing, and TST should be administered before, or 4 weeks after LAV
  • Consider pregnancy in all females of child bearing age, including in adolescents. In general LAV (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, hepatitis B or hepatitis C (where hepatitis A vaccination is recommended in the absence of immunity)
• Consider any other/occupational risk factors requiring extra vaccine protection(e.g. healthcare workers (hepatitis B vaccine, influenza vaccine), occupational animal exposure/abattoir workers (Q fever), men who have sex with men (meningococcal ACWY, HPV, hepatitis B, hepatitis A), people who have injected drugs (hepatitis A, hepatitis B) - use the HALO approach (health, age, lifestyle, occupation).

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 3^rd doses of dTpa-containing and hepatitis B vaccine at the same visit). Children 4-9 years of age will require a 4^th dose 6 months after the primary course. Younger children will also require 4 or 5 doses
• 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 for catch-up schedules for children <10 years, and the Victorian DHHS provides a catch-up tool for 10 -19 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 all ages should be entered into the AIR which can also be checked for previous vaccines
  • Vaccinations given overseas or in immigration detention should be recorded onto AIR online or by completing an Immunisation History Form and returning the form to the Department of Human Services, Australian Immunisation Register, PO Box 7852, Canberra BC ACT 2610, or fax 08 9254 4810 (Note: WA number). AIR has 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 AIR (for those arriving after 2004 - see No Jab No Pay above)
• Current vaccinations (all ages) should also be entered into AIR
• Document medical exemptions where relevant (i.e. medical contraindication or natural immunity) – medical exemption form and return the form to the Department of Human Services, Australian Immunisation Register, PO Box 7852, Canberra ACT 2610 or fax 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: dTpa (Boostrix), HPV (2-dose course age <15 years - 0, 6-12 months; 3 dose course age 15 years and older - 0, 2 and 6m). Hepatitis B year 7 catch-up program ceased in 2013, varicella year 7 catch-up program ceased in 2017.
• Year 10: Meningococcal ACWY - also funded for 15-19 year olds

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

• Catch-up immunisation arrangements in relation to 'No Jab, No Pay' provide free catch-up vaccinations for all children/young people <20 years (ongoing from 2017, regardless of Medicare) and also for refugees and humanitarian entrants 20 years and over.
• BCG vaccine is provided (to authorised providers) for use in children <5 years travelling to high incidence areas. See information on BCG clinics.
• Hepatitis B vaccine is provided free for named 'at-risk' groups in Victoria, including household contacts.

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 - to help calculate vaccinating refugee/asylum seeker arrivals equivalent to an Australian-born person of the same age.

• 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 until end 2017). 

Resources

• AIR - medical exemption forms, accepted providers, immunisation history form
• ASID/RHeaNA guidelines (2016)
• Australian Immunisation Handbook
• Foreign vaccine products/naming (Centers for Disease Control)
• Foundation House - Immunisation resources
• Health Translations Catch up vaccinations for refugees and asylum seekers in Victoria fact sheets English, Amharic, Arabic, Burmese, Chin Hakha, Dari, Farsi, Karen, and Tamil
  
• Immunisation: Victorian Department of Health and Human Services
• Melbourne Vaccine Education Centre (MVEC) (including fact sheets)
  
• National Centre for Immunisation Research and Surveillance (NCIRS) – Fact Sheets 
• National Immunisation Program - Expansion
  
• Immunisation calculator (SA Health) provides catch-up schedules for <10 years of age)
• Translated immunisation resources
• Vax on time app
• Victorian Immunisation Schedule
• WHO immunisation schedules - to identify routine vaccines in a country select the country from the drop down list, select all vaccines and select OK.

References

• References
  

_{Immigrant health clinic resources. Initial: Georgie Paxton and Jim Buttery. Revisions: Georgie Paxton. Updated April 2019. Contact: georgia.paxton@rch.org.au}