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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Immunisation

Author Dr Jenny James
Expert reviewer Dr Hasantha Gunesekara

Background

Immunisation has had a powerful impact in preventing disease in Aboriginal and Torres Strait Islander children.1,2 However, Aboriginal and Torres Strait Islander children still have higher rates of vaccine preventable diseases1,3–6 and decreased rates of vaccination coverage when compared to non-Indigenous children.2,7–12 Coverage rates from universally funded vaccines are similar in Aboriginal and Torres Strait Islander children and non-Indigenous children by 24 months of age,1 but delayed vaccination is more common in Aboriginal and Torres Strait Islander children and fewer are fully vaccinated at 12 months of age.1,2,7–12 Recent data from the Australian Childhood Immunisation Register showed 91% of children Australia wide were fully vaccinated at 12 months of age, while only 83% of Aboriginal and Torres Strait Islander children were fully vaccinated at the same age.1

The Australian Childhood Immunisation Register coverage estimates are reliable with regards to identifying Aboriginal and Torres Strait Islander status of children,11 however, routine reports on immunisation coverage allow for significant lags in immunisation. The Australian Childhood Immunisation Register’s reporting of coverage rates at 1 year of age are based on completion of vaccinations scheduled at age 6 months or earlier,11,12 so data on delays in vaccination in Aboriginal and Torres Strait Islander children may underestimate the magnitude of the problem.

Some vaccination programs are not universally applicable to all Australian children and target Aboriginal and Torres Strait Islander children only. Comparison of rates of immunisation coverage from universally applicable versus targeted vaccination programs show the latter are sometimes associated with lower rates of immunisation coverage in Aboriginal and Torres Strait Islander children. This is reflected in low rates of coverage for hepatitis A vaccine and 23vPPV, both of which are vaccinations recommended for Aboriginal and Torres Strait Islander children only.1,2,5,6 There is also evidence that non-vaccine serotypes cause a disproportionate amount of disease in Aboriginal children compared to non-Aboriginal children with regards to some vaccine preventable diseases. This has been seen with mumps, invasive pneumococcal disease and meningococcal disease.1,6,13 Therefore, it is likely that factors other than immunisation coverage, such as heavy nasopharyngeal colonisation, poorer immunologic responses and persistent nasopharyngeal carriage continue to contribute to higher rates of vaccine and non-vaccine preventable disease in Aboriginal and Torres Strait Islander children.6

Young Aboriginal and Torres Strait Islander adults experience a much higher rate of invasive pneumococcal disease due to non-7vPCV serotypes.1,5 Coverage rates for influenza and pneumococcal vaccination 23vPPV in eligible Aboriginal and Torres Strait Islander people aged 15–49 years are low.1

The National Health and Medical Research Council Australian Immunisation Handbook,14 9th edition, identifies no diseases in New South Wales, Victoria, the Australian Capital Territory or Tasmania requiring specific immunisation coverage for Aboriginal and Torres Strait Islander people up to and including the age of 14 years. In other states and territories (health authorities should be consulted to determine exact geographic boundaries) the following diseases have vaccination requirements specific to Aboriginal and Torres Strait Islander children:

  • hepatitis A
  • tuberculosis
  • pneumococcal disease (requiring a booster dose at 18–24 months of age with 23vPPV)
  • Hib infections requiring PRP-OMP vaccine.

They have also identified two diseases requiring immunisation coverage in Aboriginal and Torres Strait Islander people aged from 15–49 years:

  • influenza with yearly vaccination recommended for all Indigenous adolescents (and adults) in that age group
  • pneumococcal disease with 23vPPV recommended for Aboriginal and Torres Strait Islander adolescents (and adults) with a chronic disease.14

A large number of interventions can improve immunisation coverage. They can be summarised under three categories: provider/system based interventions, enhancing access to vaccination services, and increasing community demand for vaccination. Effects may be increased if the interventions are administered in combination rather than as single interventions.15

Resources

Catch-up immunisation calculator
www.health.sa.gov.au/ immunisationcalculator/

Australian Immunisation Handbook
www.health.gov.au/ internet/immunise/publishing.nsf/ content/handbook-home.

Recommendations: Immunisation
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation* All children Conduct regular postnatal review of all infants and offer vaccination As per Australian standard vaccination schedule IA14
Use the catch-up schedule for all children behind in their vaccination schedule Opportunistic IA14
Environmental
  Implement provider/system based interventions: review vaccination status at each clinic visit and make a documented plan for the next vaccination Every visit IA16,17
Ascertain local clinic vaccination rates via audits of health records and Australian Childhood Immunisation Register records N/A IA16,18–20
Implement recall and reminder systems and computer prompts for staff and patients to address immunisation gaps, particularly in the first 12 months N/A IA16–22
Implement an adverse events reporting system N/A IA16–22
Increase access to vaccinations via:
  • fast tracking children presenting for immunisation
  • training and reminders for staff to screen and offer vaccinations
  • providing home visits and mobile clinics for immunisation
If resources are limited, focus particularly on vaccinations due in the first 12 months
N/A IA16–20,22,23
Increase community demand for vaccinations by:
  • promoting vaccination to parents, child care staff, and community workers such as Aboriginal and Torres Strait Islander liaison officers
  • using posters and other visual materials in public places
  • personalising health records
  • giving all parents/carers a record in card or book form of their child’s immunisation status
  • commencing promotional activities for parents of neonates early and in places where parents of very young babies attend
Ongoing IA15,16,18,20–24
* Vaccination should be implemented according to best practice recommendations in the Australian Immunisation Handbook and state and territory immunisation schedules

References

  1. Menzies R, Turnour C, Chiu C, McIntyre P, Department of Health and Ageing. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2003–2006. Communicable Diseases Intelligence, National Centre for Immunisation Research and Surveillance of Vaccine preventable diseases, 2008.
  2. Menzies RI, Singleton RJ. Vaccine preventable diseases and vaccination policy for indigenous populations. Pediatr Clin North Am 2009;56(6):1263–83.
  3. Australian Institute of Health and Welfare. Comparative snapshot of Indigenous child health and wellbeing: a picture of Australia’s children. Canberra: AIHW, 2009.
  4. Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander health performance framework. Canberra: DoHA, 2008. Cited October 2011. Available at www.health.gov.au/ internet/main/publishing.nsf/Content/ health-oatsih-pubs-framereport.
  5. Lehmann D, Willis J, Moore HC, Giele C, Murphy D, Keil AD, et al. The changing epidemiology of invasive pneumococcal disease in Aboriginal and non-Aboriginal Western Australians from 1997 through 2007 and emergence of nonvaccine serotypes. Clinical Infectious Disease 2010;50(11):1477–86.
  6. Menzies R, McIntyre P. Vaccine preventable diseases and vaccination policy for indigenous populations. Epidemiol Rev 2006;28:71–80.
  7. O’Grady KA, Krause V, Andrews R. Immunization coverage in Australian Indigenous children: Time to move the goal posts. Vaccine 2009;27(2):307–12.
  8. Hull B, Deeks S, Menzies R, McIntyre P. Immunization coverage annual report 2007. Communicable Diseases Intelligence, National Centre for Immunisation Research and Surveillance of Vaccine preventable diseases, 2007.
  9. Hull B, Deeks S, Menzies R, McIntyre P, Department of Health and Ageing. What do we know about 7vpcv coverage in Aboriginal and Torres Strait Islander children? A 2007 update. Short report Communicable Diseases Intelligence, National Centre for Immunisation Research and Surveillance of Vaccine preventable diseases, 2007.
  10. Hull BP, McIntyre PB. Timeliness of childhood immunisation in Australia. Vaccine 2006;24(20):4403–8.
  11. Rank C, Menzies RI, Department Health and Ageing. How reliable are Australian Childhood Immunisation Register coverage estimates for Indigenous children? An assessment of data quality and coverage. Commun Dis Intell 2007;31(3):283–7.
  12. Baillie RS, Si D, Dowden MC, Selvey CE. A systems approach to improving timeliness of immunization. Vaccine 2009;27(27):3669–74.
  13. Bangor-Jones RD, Dowse GK, Giele CM, van Buynder PG, Hodge MM, Whitty MM. A prolonged mumps outbreak among highly vaccinated Aboriginal people in the Kimberley region of Western Australia. Med J Aust 2009;191(7):398–401.
  14. National Health and Medical Research Council. The Australian Immunisation Handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/internet/ immunise/publishing.nsf/content/ handbook-home.
  15. Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countires. Cochrane Database Syst Rev 2011;Jul 6;(7):CD008145.
  16. Pickering LK, Baker CJ, Freed GL, Gall SA, Grogg SE, Poland GA, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2009;49(6):817–40.
  17. National Institute for Health and Clinical Excellence. Reducing the differences in the uptake of immunisations. PH21. London: National Institute for Health and Clinical Excellence, 2009. Cited October 2011. Available at http://guidance.nice.org.uk/ PH21/Guidance/pdf/English.
  18. Community Guide Branch Epidemiology and Analysis Program Office. The community guide vaccinations to prevent diseases: universally recommended vaccinations. An evidence based guideline Atlanta: Centers for Disease Control, 2009. Cited October 2011. Available at www.thecommunityguide.org/ vaccines/universally/index.html.
  19. American Academy of Pediatrics. Policy statement on increasing immunization coverage. Pediatrics 2003;112(4).
  20. Centers for Disease Control and Prevention. Immunization strategies for healthcare practices and providers. In: Atkinson W, Wolfe S, Hamborsky J, editors. Epidemiology and prevention of vaccine–preventable diseases, 12th edn. Washington DC: Public Health Foundation, 2011.
  21. Jacobsen VJ, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database Syst Rev 2005;Jul 20;(3):CD003941.
  22. Committee on practice and ambulatory medicine and council on community pediatrics. Policy statement increasing immunization coverage. Pediatrics 2010;125:1295–304.
  23. Queensland Government Department of Health. Child and youth health practice manual for child and youth health nurses and Iindigenous child health workers: Section 2 key prevention, early detection and early interventions. Brisbane: Queensland Government Department of Health, 2007. Cited October 2011. Available at www.health.qld.gov.au/ child-youth/docs/CYH_Manual_2.pdf.
  24. Central Australian Rural Practitioners Association. CARPA standard treatment manual, 5th edn. Alice Springs, NT: CARPA, 2009.
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