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  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 available on recent clinical updates. Upcoming Victorian schedule changes are (March 2018):

    • Meningococcal ACWY vaccine will be added to the National Immunisation Program (NIP) schedule at 12 months of age (replacing Meningococcal C vaccine - this will also change the Hib dosing schedule, although catch-up less affected due to use of hexavalent vaccines).
    • 9-valent Human Papilloma Virus (HPV) vaccine and 2-dose schedule for age 12-13 years (replacing 4-valent HPV and 3-dose schedule in this age group).
    • Herpes zoster vaccine for people aged 70 years and a 5-year catch-up program for people aged 71-79 years.
    • Influenza vaccination is now recommended for age 6 months and older, and is funded for all children <5 years,  adults 65 years and older, and age 5 years and older with medical risk factors  - now included in the table below.

    Please see Victorian Immunisation Schedule. This guideline has been updated (March 2018) to include recent changes, and to cover all age groups. 

    Table 1. Catch-up vaccination guidelines

    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. 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)
    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.
    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), 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
    C (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. 
    Meningococcal ACWY

    15-16 years (year 10)    1 dose

    IM     0.5 ml - *4-valent meningococcal [ACWY] is provided for year 10 students (or age equivalent 15-16 years) in Victoria until end 2018 (State-based program, previous catch-up for 15-19 years to end 2017). MenACWY also provided for MSM population until 31 December 2018. Additional dosing of 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 <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.

    Pneumococcal conjugate (13vPCV)

    <7 months
    3 doses 

    7-11 months 
    2 doses 

    12-59 months 
    1 dose

    IM    0.5 ml

    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.

    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, 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 (0,6-12m) and *3-dose course 15 years and older or immunocompromised (0, 2, 6m). Also see Immunisation Handbook and  ATAGI information.

    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 for immunocompromised adults (including due to HIV infection) and in Victoria funded for MSM population until 31 December 2018. 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 or SC (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 - 0.25 ml age 6 months to <3 years; 0.5 ml age 3 years and older. Different formulations funded for adults 65 years and older. *If aged <9 years at the time of first administration - 2 doses minimum 1 month apart. Check Immunisation Handbook and ATAGI advice

    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 (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

    In 2016, there were significant changes 'No Jab, No Pay' legislation (see  backgroundDepartment of Health informationDepartment of Human Services informationDepartment of Social Services 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 BenefitChild Care Rebate and  Family Tax Benefit Part A-end of year supplement). In mid-2018 - the payments affected will change - families will lose part of the regular fortnightly family tax benefit payment if their children do not meet immunisation criteria.

    Centrelink uses the Australian Immunisation Register (AIR) 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 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 will need updating or families will lose these Centrelink payments

    • The Australian Immunisation Register (AIR)  expanded to include all children/young people <20 years, and 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). 
    • Additional catch-up vaccinations are now funded including for age 10-19 years catch-up vaccinations are free for all children and young people <20 years on an ongoing basis, and free for all refugee and humanitarian entrants 20 years and older  (see fact sheet).

    In Victoria, the state 'No Jab, No Play' legislation was introduced 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. 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 servicesUpcoming changes mean only the patient AIR record will be accepted as evidence of immunisation (not the health provider view). This is likely to lead to substantial difficulties and delays 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 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]
      • If written records are available in other languages - the Department of Social Services 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 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 (offered to refugees, but not all SHP entrants). Offshore vaccine information will be available on Department of Home Affairs HAPlite system (system roll out early 2018). 
    • From 11/2015, 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.
    • Asylum seekers who arrived by boat should have had vaccinations in Australian immigration detention. 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. The Community Detention Assistance Desk (CDAD) provides immunisation records for people in Community detention (but not others) - phone 1800 725 518.
      • Immunisation provision in detention was variable
      • 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 a GP, (can also be completed by paediatrician, public health physician or allergist).
    • 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 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, 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, HPV, hepatitis B, hepatitis A), people who have injected drugs (hepatitis A, hepatitis B).

    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 (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. It may be helpful to consider by antigen (DTPa/dTpa, polio, HBV, MMR, VV (all ages); MenC/MenACWY (children/adolescents); Hib, 13vPCV, influenza (<5 years); HPV (adolescents); Herpes zoster (70 years and older); 23vPSV and influenza (65 years and older) and then consider extra risk factors.
    • 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 cross-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, GPO Box M933, Perth WA 6843 or by fax on 08 9254 4810. 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 section above)
    • Current vaccinations should also be entered into AIR.
    • Document medical exemptions where relevant (i.e. medical contraindication or natural immunity) – GPs/other eligible professionals should complete an AIR 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: 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 - to 31 Dec 2018 - previous catch-up program for 15-19 year olds ceased December 2017

    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 (see fact sheet).
    • Catch-up immunisation has been funded for all refugees and asylum seekers in Victoria since 2015, and is now funded through federal initiatives (see 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 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

    References

    Immigrant health clinic resources. Initial: Georgie Paxton and Jim Buttery. Revisions: Georgie Paxton and Rachel Heenan. Updated March 2018. Contact: georgia.paxton@rch.org.au