Immigrant Health Service

Catch-up immunisation in refugees

  • 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

      Vaccine type Age,
      Number of doses
      Route and dose Minimum dosing interval (months) Notes
      Diphtheria Tetanus 
      Pertussis (DTP, dTp)
      <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. If 4 doses of DTP given before age 18 months, give a 5th dose at 4 years, reflecting the NIP which includes dose 4 at 18 months and dose 5 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.   
      10 years and older 
      3 doses (dTpa)
      IM 
      0.5 ml
      1,1

      Up to 3 doses of dTpa may now be used (previously dTpa, dT, dT), then 10-year and 20-year booster dTpa. dTpa is now available combined with IPV (dTpa-IPV).

      dTpa is also recommended for pregnant women from 28 weeks gestation in every pregnancy; partners of women who are at least 28 weeks gestation if no booster for 10 years, and parents of children <6 months if no booster for 10 years.

      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 (*given IM) 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.

      Recent changes (April 2019) have lowered the recommended age at which infants can receive MMR in special circumstances - from 9 months to 6 months. Infants 6 months and older can receive MMR as post-exposure prophylaxis, or during outbreaks (or for travel to endemic areas). 

      10 years and older (born  1966 or later) 
      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 tuberculosis (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), but is 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 ACWY    Any* 
      1 or 2 doses** 
      IM 
      0.5 ml   
       (2)

      *Normally given at age 12 months, disease has bimodal peaks in incidence of <5 years and 15-24 years, MenC catch-up previously funded to 19 years (born>1987). Consider providing MenACWY if previous meningococcal vaccination was provided as MenC. 

      **Nimenrix = 1 dose, Menveo/Menactra = 2 doses, 8 weeks apart. 

      15-19 years (year 10 or equivalent)  1 dose

      IM     0.5 ml -

      Also provided for year 10 students (and available in Victoria for those aged 15-19 years, State-based program).

      Additional doses of meningococcal ACWY vaccine recommended in asplenia

      Haemophilus influenzae
      type b (Hib)
      2-17 months 
      1-3 doses then booster* 
      18-59 months 
      1 dose 
      IM 
      0.5 ml
      1 or 2* 
      varies* 2  

      Required in children <5 years of age. Not required 5 years and older, unless special circumstances, including asplenia  but may be given as part of combination vaccines. Children <10 years generally receive multiple doses of Hib through the use of combination vaccines (e.g. hexavalent DTPa/IPV/HiB/HepB). 

      Refer to Immunisation Handbook for catch-up schedule in younger children - <7 months - 3 doses then booster at 18 months, 7-11 months 2 doses then booster at 18 months, 12-17 months 1 dose then booster at 18 months or 2 months after last dose (whichever is later). If a child has received PRP-OMP Hib vaccine for the first 2 doses, they do not require a 3rd dose but should still have a booster at 18 months.

      Pneumococcal conjugate (13vPCV)

      <12 months
      3 doses 

      12-59   months 
      1 dose

      IM    0.5 ml

      1,1 

       

      -   

      Now given at 2,4 and 12 months of age in NIP, with an extra dose at 6m for children with medical risk factors. 

      Required in all children <5 years of age, and 5 years and older if medical risk factors. If providing catch-up for children who have medical risk factors: <12 months - 4 doses required, and 12-59 months - 2 doses required. 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.

      Pneumococcal polysaccharide (23vPSV) 65 years IM    0.5 ml -

      Age 65 years and older

      People with medical risk factors as above. See Immunisation Handbook.

      Varicella (VV)
      (LAV)

      18 months - 13 years 
      1 dose 

      14 years and older* 
      2 doses

      SC 
      0.5 ml

      -

       


      All children <14 years should have at least one dose of VV (and preferably two doses 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, 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.

      Herpes zoster (LAV)

      70-79 years    1 dose

      SC 
      0.5 ml
      - Recommended at age 70 years, 5-year catch-up program available for those age 71-79 years (starting 2018). Exclude previous dosing and contraindications, and check decision aid.
      Human Papilloma Virus (HPV)

      12-14 years
      2 doses

      15 years and older*            3 doses

      IM 
      0.5 ml

      6

       

      2,6

      From 2018, 9-valent HPV given to all year 7 students (or age equivalent 12-13 years). 2-dose course <15 years (0,6-12 months) and *3-dose course 15 years and older or immunocompromised (0, 2, 6 months). Also see Immunisation Handbook .

      9-valent HPV funded up to and including age 19 years. HPV vaccines not recommended during pregnancy, can be given during breastfeeding. 4-valent HPV recommended and funded in Victoria funded for MSM population until 31 October 2019. Licensed for females age 9-45 years and males 9-26 years.

      Influenza    (seasonal and annual)

      <9 years          1 or 2 doses*

      9 years and older 1 dose

      IM (dose varies)

      1

       

      -  

      Now recommended annually for all people 6 months and older. In Victoria, funded for children <5 years (from 2018), adults 65 years and older, and age 5 years and older with medical risk factors.

      Dose and formulation vary with age and formulation - 0.25 ml age 6 months to <3 years (FluQuadri Junior); 0.5 ml age 6 months and older (Fluarix Tetra), 0.5 ml 3 years and older (FluQuadri), 0.5 ml 18 years and older (Afluria Quad, Influvac Tetra). Different formulations funded for adults 65 years and older (Fluad, Fluzone High-Dose, both 0.5 ml). *If aged <9 years at the time of first administration - 2 doses minimum 1 month apart. Check Immunisation Handbook

      Rotavirus
      (LAV)
      <6 months,
      2 doses*

      Oral       1.5 ml

      1 Not usually given as catch-up due to strict age restrictions. Rotarix (1.5 ml): 2 doses at 2 and 4 months of age, 1st dose must be given <15 weeks, 2nd dose must be given <25 weeks. 
      Bacillus Calmette Guerin (BCG)
      (LAV)
      <16 years*,
      1 dose  
      ID, 
      varies**
      - Recommended in:1,2 
      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 (also consider cumulative travel). 
      Neonates with family history of leprosy. 
      *Consider in:
      Exposure to active pulmonary TB where preventive therapy not possible/after completion preventive therapy. 
      Travel to high prevalence area >6 weeks if aged <5 years, >3 months aged >5 years[2]. 
      Only give if no record/scar, no immunosuppression, no evidence TB infection (requires TST if previous travel, usually no TST if age <2 years and no travel) and no other contraindications. **Dose is 0.05ml age <12 months, 0.1ml 12 months and older. Only available through RCH and Monash currently.

      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

      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 3rd doses of dTpa-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
      • 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:

      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

      References

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