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Immigrant Health Service

Catch-up immunisation in refugees

  • Background

    Vaccine preventable diseases (VPD) 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 Handbook 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, and pre-vaccination screening checklist (includes translated versions).

      Major recent changes include: reduction to single dose HPV vaccine for immune competent adolescents/adults 9-25 years (Feb 2023) and updated (2023) Covid booster advice. The table below has been compiled from Handbook catch-up guidelines, including the NIP for comparison. Please see links to individual VPD for full recommendations, including for special risk groups and Aboriginal populations. Eligibility for free vaccines under the NIP is linked to eligibility for Medicare. Catch-up is free for refugees and humanitarian entrants of any age.

      Table 1. Catch-up vaccination guidelines

      Vaccine type Age,
      Number of doses             		Route and dose Minimum dosing interval (months) Notes

      Diphtheria Tetanus 
      Pertussis (DTPa, dTpa)

      NIP: 3-dose primary at 2,4,6 months, booster doses at 18 months, 4 years, 12-13 years. Pregnant women - single dose dTpa each pregnancy. 

      		 <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. If the 4th dose is given after the child is 3.5 years the 5th dose is not required, and in this case the next dose is the early adolescent booster. A hexavalent vaccine (DTPa-IPV-Hib-HepB) is available in all jurisdictions. *Use of the hexavalent vaccine in catch-up requires attention to intervals for hepatitis B vaccination (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 be used (previously dTpa, dT, dT). dTpa is available combined with IPV (dTpa-IPV). 

      dTpa recommended for pregnant women 20-32 weeks gestation in every pregnancy (can be given any time up to delivery). Tetanus and diphtheria (as dTPa) recommended in adults 50 years and older if last dose more than 10 years ago, dTpa booster recommended in adults 65 years and older if last dose more than 10 years ago. Adults (any age) wanting to reduce their risk of pertussis should have pertussis-containing vaccine.

      Measles
      Mumps
      Rubella (MMR)
      (LAV)

      NIP: 2 doses at 12 months (as MMR) and 18 months (as MMR-V).

      		 <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.

      Changes in 2019 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

      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. 

      Note: MMR given as part of offshore medical examinations for humanitarian arrivals aged 9 months - 54 years (from 2016). Consider timing in relation to live viral vaccines or TB screening. Women of childbearing age who are seronegative for rubella should receive rubella-containing vaccine (MMR contraindicated during pregnancy).

      Inactivated Poliomyelitis Vaccine (IPV)

      NIP: 4 doses at 2,4,6 months and 4 years.

      <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. If 3rd dose given at <3.5 years give 4th dose at 4th birthday (and 4th dose needs to be recorded on AIR after age 3.5 years). Different combination vaccines available, including hexavalent vaccines and dTpa-IPV.
      **IPV in combination vaccines given IM, IPV alone given SC. Note: OPV and IPV are considered interchangeable. 

      Note: Polio vaccination (IPV or OPV) also given as part of offshore medical examinations for humanitarian arrivals (from 2016). Also consider OPV in relation to other live vaccines or TB screening.

      Hepatitis B

      NIP: 4 doses at birth, 2,4,6 months.

      		 <11 years
      3 doses       		IM 
      0.5 ml      		 1,2** Combination vaccines are available, *minimal 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

      Meninogoccal ACWY

      NIP: single dose at 12 months, also funded for single dose at 14-16 years (year 10 equivalent).

      Meningococcal B

      NIP: funded for risk groups only.

      MenACWY        Any* 
      1 or 2 doses** 

      		 IM 
      0.5 ml         		  (2)**

      *MenACWY given at age 12 months, and year 10 equivalent (in Victoria at 15-19 years). Disease has bimodal peaks in incidence (<5 years and 15–24 years). Catch-up dosing reflects routine dosing for age (1-19 years), although MenACWY also recommended for any person who wants to reduce their risk of meningococcal disease.

      MenC catch-up previously funded to 19 years (born>1987). Consider providing MenACWY if previous vaccination was MenC. **Nimenrix = 1 dose, Menveo/Menactra = 2 doses, 2 months apart. Additional doses of MenACWY recommended in asplenia and conditions increasing risk of meningococcal disease.

      MenB - not included in catch-up


      		 IM      0.5 ml   2 or 6*

      MenB recommended for <2 years of age, adolescents 15-19 years and any person who wants to reduce their risk of meningococcal disease.

      *Bexsero = 2 doses, 8 weeks apart (2 months and older) or Trumenba = 2 doses, 6 months apart (10 years and older). No preference for type if age 10 years and older, vaccines are not interchangeable. Additional doses of MenB vaccine recommended in asplenia and conditions increasing risk of meningococcal disease. 

      Haemophilus influenzae
      type b (Hib)

      NIP: 4 doses at 2,4,6,18 months.

      		 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)

      NIP: 3 doses at 2,4,12 months, then single dose at 70 years and older. Additional doses (13vPCV and 23vPPV) for specified medical risk conditions.

      <12 months
      3 doses 

      12–59 months 
      1 dose

      70 years               1 dose

      		 IM      0.5 ml

      1,1 

      –

      –


       

      Required in all children <5 years of age, and 5 years and older if medical risk factors. Also recommended for adults 70 years and older. If providing catch-up for children with 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. Note: 15- and 20-valent conjugate vaccines are now registered for use in Australia (age 18 years and older).

      Pneumococcal polysaccharide (23vPPV)

      NIP: only for medical risk and Aboriginal populations.

      (medical risk factors, age 2 years and older)

      		 IM      0.5 ml   – 

      Additional doses in people with medical risk factors. See Immunisation Handbook.

      Varicella (VV)
      (LAV)

      NIP: single dose at 18 months.

      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 (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)

      NIP: single dose at 70-79 years.

      50 years and older*
      1 or 2 doses**

      		 SC 
      0.5 ml       		– or 2 *Recommended for all people 50 years and older and for age 18 years and older if immunocompromised (or expected to become immunocompromised). NIP - funded for age 70-79 years (until 31/10/23). **Zostavax (NIP) - registered age 50 years and older, single dose, Shingrix registered age 18 years and older, 2 doses, 2-6 months apart. Exclude contraindications, and check Immunisation Handbook.

      Human Papilloma Virus (HPV)

      NIP: single dose at 12-13 years.

      9-25 years (suggest 12-25y)   1 dose*

      		 IM 
      0.5 ml


      *Changed to single dose regimen Feb 2023 for immune competent people aged 9-25 years (reducing lower age and raising upper age for catch-up from 19 years), however included at 12-13 years in NIP. Also recommended in all MSM (any age - consider past/future exposure, only funded to 25y), not recommended adults 26 years and older otherwise. Recommended for immunocompromised (suggest 9 years and older) - 3-dose schedule, 0,2,6 months (also noting licensing below).  See Immunisation Handbook.

      From Feb 2023 - 9-valent HPV funded 9-25 years inclusive. HPV vaccines not recommended during pregnancy, can be given during breastfeeding. Licensed for females age 9–45 years and males 9–26 years.

      Influenza    (seasonal and annual)

      NIP: annual dose 6 months - <5 years, 2 doses in 1st year of administration age 6 months - 9 years. Annual dose 65 years and older, medical risk factors (all ages) and occupational groups. Also funded for  pregnant women.

      <9 years
      1 or 2 doses*

      9 years and older 1 dose

      		IM (dose varies)

      1

       

      –

      Recommended annually for all people 6 months and older, including pregnant women. Victorian funding reflects NIP.

      Dose and formulation vary with age and formulation – 0.5 ml age 6 months and older (Fluarix Tetra, Vaxigrip Tetra, Influvac tetra, FluQuadri), 0.5 ml 2 years and older (previous and also FlucelvaxQuad), 0.5 ml 5 years and older (previous and also Afluria Quad). Different formulations funded for adults 60 years and older (Fluzone 60y+ and Fluad Quad 0.5 ml 65y+). *If aged <9 years at the time of first administration – 2 doses minimum 1 month apart. Check Immunisation Handbook and MVEC information .

      Covid

      (Separate to NIP).

      For age 6 months - 11 years - use age-approved original (ancestral) vaccines for primary and any booster doses (no bivalent vaccines for this age group).

      For age 12 years and older, use bivalent vaccines for primary course and booster doses (from May 2023).

      6 months - 4 years with risk factors - 2 or 3 doses*

      5-17 years - 2 doses* + consider booster as recommended

      18 years and older - 2 doses* + boosters as recommended

      		 IM (dose varies)

      2 months, if 3rd primary  recommended also 2 months

      Boosters 6 months after last dose or last infection

      *6 months - 4 years with immunocompromise*, disability, complex/multiple health conditions - 2 doses. *Severely immunocompromised 3 doses. From June 2023, only Pfizer vaccine for this age group (3 mcg dose). No booster doses.

      5-11 years - 2 doses. From June 2023, only Pfizer (1/3 adult dose, orange vial - 10mcg). *Severely immunocompromised 3 doses. Booster: consider if medical comorbidities increasing risk of severe Covid-19 or disability with significant/complex health needs.

      12-17 years - 2 doses, using BA.4/5 containing bivalent vaccines (for both doses, or for 2nd if commenced with original vaccine - either Pfizer or Moderna). *Severely immunocompromised 3 doses. Booster: consider if medical comorbidities increasing risk severe Covid-19 or disability with significant/complex health needs.

      18 years and older - 2 doses, using BA.1- or BA.4/5-containing bivalent vaccines (either Pfizer or Moderna). *Severely immunocompromised 3 doses. Novovax can be used age 18 years and older. Boosters: regardless of prior doses, if 6-months after last covid vaccine or confirmed infection (bivalent vaccines preferred) 

      • Recommended all adults 65 years and older and adults 18-64 years with medical comorbidities or disability with significant/complex health needs.
      • Consider all adults 18-64 years.

      Rotavirus
      (LAV)

      NIP: 2 doses at 2 and 4 months

      		 <6 months,
      2 doses*

      Oral       1.5 ml

      		 1 Not usually given as catch-up due to strict age restrictions. Rotarix (1.5 ml): 1st dose must be given <15 weeks, 2nd dose must be given <25 weeks.  

      Bacillus Calmette Guerin (BCG)
      (LAV)

       NIP: not included.

      		 <5 years with risk factor*,
      1 dose         		ID, 
      varies**       		  – Recommended:  i) children <5 years travelling to high prevalence countries (>40 cases per 100,000 population per year - see WHO data) based on individual risk assessment. BCG should be given at least 3 months prior to travel (also consider cumulative travel); ii) neonates with family history of leprosy.  
      Consider: children <5 years in households with immigrants/unscreened visitors from high prevalence countries.
      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

      • In 2016, the 'No Jab, No Pay' legislation was introduced (see background and Department of Social Services (DSS) summary) - requiring children and young people (<20 years) to meet immunisation requirements for Centrelink family tax benefit part A (FTB-A) and childcare fee assistance.
        • Children/young people need to be up to date for their childhood immunisations OR be on a vaccine catch-up schedule OR have a medical exemption to receive:
          • The full amount of FTB-A - payments reduce by up to $30.66 per fortnight per child (applies to age <20 years)
          • Childcare Subsidy - if a child stops meeting the immunisation requirements, payments stop after 63 days (applies to age <13 years)
        • Centrelink uses the Australian Immunisation Register (AIR) to establish whether vaccinations are 'up to date'. AIR became a 'whole of life' register from 2016. Use of AIR expanded rapidly with Covid vaccination at all ages. AIR can be accessed through HPOS.
          • Early childhood vaccines are linked to Centrelink payments (DTPa, IPV, MMR, hepatitis B, pneumococcal and meningococcal vaccinations) - see due-overdue rules.
          • When the 1st dose of vaccines covering all overdue antigens is entered on AIR, the child is recorded as being 'up to date' until the next vaccines becomes overdue (usually 3 months later). 
          • Medical exemptions (i.e., for immunity) can be completed by eligible health professionals (or their HPOS delegate) and included in up to date calculations. Eligible health professionals include GPs/GP registrars, paediatricians, public health/infectious diseases physicians, and clinical immunologists. 
          • Catch-up vaccinations are funded including for children <10 years, age 10–19 years and all refugee and humanitarian entrants 20 years and older.

      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, check 'catch-up' on AIR, and provide catch-up vaccines if needed. AIR information needs to be up to date or children/families may lose Centrelink payments. 

      State

      • In 2016, the 'No Jab, No Play' legislation (2015) came into effect in Victoria – 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. In practice, loss of Centrelink childcare fee assistance (i.e., No Jab, No Pay) is typically the more immediate barrier.
        • Refugee and asylum seeker children (and certain other groups) are eligible for a 16-week support period to start catch-up vaccinations after they enrol in childcare. 
        • AIR records are the only accepted evidence of immunisation for childcare/kindergarten enrolment, 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 seeking asylum will be vaccinated and up to date by the Australian 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; however many refugees do not have immunisation documentation. There is often a clear verbal history of vaccinations, although there is debate on the validity of parental/self recall of vaccination status. If there is no written documentation, full age appropriate catch-up immunisation is recommended
        • Ask about any overseas records - if overseas written records are available in other languages – the Department of Home Affairs (DHA) provides a free document translating service for new migrants (up to 10 documents within the first two years). 
        • Offshore humanitarian arrivals have vaccines as part of their offshore medical examinations, including MMR (9 months – 54 years) and Yellow Fever (YF) and Polio Vaccine (OPV or IPV) depending on port of departure. These vaccines are often given at the Departure Health Check (DHC) in the week before travel. Check available information (e.g. DHA HAPlite system, case worker, refugee nurse) and ensure these vaccines are entered on AIR. 
        • Asylum seekers who spent time in detention should have had vaccinations in 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. Lack of or intermittent Medicare and alternative/changes in name spelling can make this information difficult to find.
      • Clarify any vaccinations given in Australia and check AIR (all ages). Check 'catch-up plan in place' on AIR - this effectively allows 6-months grace before Centrelink payments are reduced.

      2. Consider relevant clinical information

      • Serology
        • Hepatitis B serology is part of post arrival refugee health screening. If there is documented immunity (sAb >10 mIU/mL) hepatitis B vaccination is not required and a medical exemption should be recorded on AIR (or submitted by form) by eligible medical professionals as above.
        • Rubella serology is recommended in women of childbearing age (age <18 years usually more practical to vaccinate with MMR)
        • Varicella serology should be checked in those aged 14 years and older with no clinical history of varicella infection. 
        • The Immunisation Handbook recommends considering serology (MMR, varicella, hepatitis A, hepatitis B, Q fever) when planning catch-up for adolescents and adults. 
        • Refugee guidelines do not recommend routine serology for MMR (due to cost, delays/extra steps, lack of combination vaccines overseas (until recently often measles vaccine) and use of combination vaccines in Australia).
      • Assess for any contraindications to vaccination, completing the pre-vaccination screening checklist (includes translated). 
        • Consider recent vaccines (including offshore vaccines) and/or tuberculosis (TB) screening. Offshore vaccines include LAV, there should be a minimum 4-week interval between vaccine dosing, and TB screening should be administered before, or 4 weeks after LAV.
        • Consider pregnancy in all females of child bearing age, including adolescents. 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, influenza, covid), childcare workers (hepatitis A, influenza, covid), aged care workers (influenza, covid), disability support workers (hepatitis A, hepatitis B, influenza, covid)  occupational animal exposure/abattoir workers (Q fever, influenza), 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, but will often then slot into the routine early childhood visit schedule.
        • Give combination vaccines where possible (to reduce the number of needles). Consider formulations and age restrictions.
        • See table 1 for dose number, interval and practice points. An online catch-up calculator is available for children <10 years, and Victorian DH catch-up guidelines for 10 years and older.
        • 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.

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

      • Provide a written record and a clear plan for ongoing immunisation. It is often 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, including any previous (overseas or in Australia) or current vaccines - either using AIR online or by completing an Immunisation History Form
        • Document medical exemptions where relevant (i.e. medical contraindication or natural immunity) – either using AIR online, or using a medical exemption form.

      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. Translated immunisation information is available on Health Translations.
      • Use a recall and reminder system to support completion of immunisation schedules.

      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

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

      • Catch-up immunisation arrangements in relation to 'No Jab, No Pay' as above
      • 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 'at-risk' groups in Victoria, including household contacts – see Better Health information

      Pharmacies in Victoria can now provide most vaccinations (not hepatitis B). This program has expanded since April 2020 and was used for covid vaccination – see guidelines.  Vaccines can now be provided from age 5 years, and include: 

      • 5 years and older - Influenza vaccine, Covid vaccine, JE, MPX (with training). 
      • 12 years and older – dTpa (with provisions), HPV.
      • 15 years and older – MMR, dTpa, and MenACWY.
      • 50 years and older - pneumococcal, zoster.

      Resources

      Immigrant health clinic resources. Initial: Georgie Paxton and Jim Buttery. Revisions: Georgie Paxton. Updated Sep 2023. Contact: georgia.paxton@rch.org.au