Chapter 3 | Immunisation across the life course

• Review your state or territory immunisation schedule and ensure you understand which additional vaccinations are available (recommended and funded) for Aboriginal and Torres Strait Islander people.
• Contact your local public health unit for further advice on the immunisation schedule or catch-up vaccination.
• Ensure all clinic staff are aware of optimising immunisation coverage for Aboriginal and Torres Strait Islander children through appropriate in-service education or professional development.
• Aim to vaccinate at the earliest appropriate age for recommended immunisations to ensure on-time vaccination.⁶
• Do not delay immunisations due to mild illness without fever (temperature <38.5°C).²²
• Ensure all immunisations are recorded on the AIR in a timely manner. Failure to record childhood immunisations accurately may result in families losing their financial and/or childcare entitlements.²³
• Provide opportunistic information and education to guardians/parents about HPV and other school-based vaccinations, including regarding the benefits of vaccination to prepare families for when consent is requested through the school.
• Use the PneumoSmart vaccination tool to determine whether your patient is recommended to receive pneumococcal vaccination.
• The use of patient registries and the implementation of robust, culturally appropriate and locally relevant patient recall and reminder policies will assist in the follow up of patients who are due/overdue for vaccination.

• Australian immunisation handbook
• NIP schedule
• National Centre for Immunisation Research and Surveillance (NCIRS) immunisation schedules for Aboriginal and Torres Strait Islander people by jurisdiction
• PneumoSmart vaccination tool
• Australian immunisation handbook catch-up calculator
• Sharing Knowledge About Immunisation
• NCIRS Enhancing data quality of vaccination encounter records – tips and tricks
• RACGP: Pain management strategies for childhood immunisation, Handbook of non-drug interventions (HANDI)

Background

After European invasion and colonisation of Australia, Aboriginal and Torres Strait Islander people were exposed to many infectious diseases for which they had no immunity, including smallpox, influenza and measles. Major epidemics resulted in significant mortality, contributing to the profound loss of traditional knowledge, cultural practices and languages, which is still felt today.

While Aboriginal and Torres Strait Islander people continue to be disproportionately affected by infectious diseases, immunisation programs have successfully reduced this inequity for many vaccine-preventable diseases.²⁴ For example, hepatitis A notification rates declined sharply after the introduction of the hepatitis A immunisation program in 2005 for Aboriginal and Torres Strait Islander children aged under 5 years in the Northern Territory (NT), Queensland (Qld), South Australia (SA) and Western Australia (WA). Prior to the introduction of this program, hepatitis A notification rates were fourfold higher among Aboriginal and Torres Strait Islander people than among non-Indigenous Australians. This gap has now been closed.²⁵

Although immunisation is highly effective in preventing infectious diseases, other activities are also important to prevent both vaccine-preventable and other infectious diseases for which there is no vaccine available. These activities include:

• addressing social and environmental determinants of health, such as adequate housing and access to appropriate health hardware in the home
• health promotion activities targeted at increasing awareness of infection risks and preventive behaviours, including reducing exposure to tobacco smoke, covering coughs and sneezes, staying home when sick, hand hygiene and mask wearing in some settings
• the use of other therapeutics, such as oral antiviral medications, for the treatment and prevention of some infections.²⁶

The provision of comprehensive, culturally safe primary healthcare, with strong therapeutic relationships and continuity of care at the service provider level, helps ensure providers are aware of when patients are due for immunisations based on age, medical risk factors, previous immunisation history, locality or where missed at school, and can offer appropriate education and vaccination when these milestones are reached.

This chapter focuses on vaccine-preventable diseases and immunisation recommendations of particular importance for Aboriginal and Torres Strait Islander people.

As well as being included in recommendations for the whole population, the Australian immunisation handbook recommends additional specific vaccines for Aboriginal and Torres Strait Islander peoples.¹⁰ Many of these vaccines are funded under the NIP;⁹ others are funded by state or territory government programs, and others are recommended but not currently funded under any program. Recommendations for immunisations and funding arrangements are subject to change, and immunisation providers should consult the latest version of the NIP, state and territory immunisation schedules and the Australian immunisation handbook for the most up-to-date advice.^9,10

The current additional NIP vaccines for Aboriginal and Torres Strait Islander people are as follows:

• influenza: all people aged ≥6 months annually*
• hepatitis A: in the NT, Qld, SA and WA, two doses before five years of age
• shingles: all people aged 50 years and over
• meningococcal: three doses of MenB at 6–8 weeks, four months and 12 months of age, with an additional dose at six months for Aboriginal and Torres Strait Islander children with specified medical risk conditions*
• pneumococcal
  •  children: in the NT, Qld, SA and WA (and children aged ≤12 months in other jurisdictions with a risk condition):
    • additional dose of conjugate vaccine (13-valent pneumococcal conjugate vaccine [13vPCV]) at six months 
    • two doses of polysaccharide vaccine (23-valent pneumococcal polysaccharide vaccine [23vPPV]; first dose at age 4 years, followed by a second dose at least five years later)*
  • adults without a risk condition for pneumococcal disease: one dose of 13vPCV at age ≥50 years, one dose of 23vPPV 2–12 months after and a second dose of 23vPPV at least five years later*
  • children aged >12 months and adults diagnosed with a risk condition for pneumococcal disease: vaccinations according to the additional vaccination for people with medical risk conditions schedule at the time of diagnosis.*

Note, the number of lifetime doses of 23vPPV is now limited to two for all people who are recommended to receive 23vPPV.*

*Vaccination schedules or funding that have been updated under the NIP since the third edition of this guideline.

In addition to the vaccines included on the NIP, the Australian immunisation handbook recommends the following vaccines for Aboriginal and Torres Strait Islander people; however, these vaccines are not currently funded under the NIP. State and territory health authorities should be consulted to determine whether programs are funded and the exact geographic boundaries for relevant immunisations.

• Meningococcal: all Aboriginal and Torres Strait Islander people aged between 2 months and 19 years are strongly recommended to receive the Meningococcal ACWY (MenACWY) vaccine and a course of the Meningococcal B (MenB) vaccine (if these vaccines have not already been received under the NIP, noting that MenACWY is currently funded for all children at 12 months and 14–16 years of age and MenB is funded for infants on the NIP)
• Tuberculosis: one dose of the Bacillus Calmette–Guérin (BCG) vaccine for children aged <5 years in certain parts of Australia living in areas of high tuberculosis incidence (according to local public health guidelines)
• Pneumococcal disease: for people with underlying risk conditions for pneumococcal disease that are not funded under the NIP (see the Australian immunisation handbook for information on risk conditions, and which conditions are funded under the NIP)²⁷
• Japanese encephalitis: for those living and working in the outer Torres Strait islands. State and territory programs are also in place in several jurisdictions in response to Japanese encephalitis cases and detections in mainland Australia since early 2022
• Hepatitis B: for non-immune adults who have no history of a completed course of hepatitis B immunisation

Childhood immunisation

For many years, Aboriginal and Torres Strait Islander children have reached higher immunisation coverage rates at age five years (60 months) than all children of the same age (96.09% versus 94.27%, respectively, as of December 2022).^8,28 In contrast, the percentage of Aboriginal and Torres Strait Islander children fully immunised at 12 and 24 months of age as per the NIP schedule, is lower than for all children of the same age.^4,29,30 Although catch-up vaccination may help higher coverage rates to be attained at five years of age, on-time vaccination continues to be lower in Aboriginal and Torres Strait Islander children.^4–6,31 For example, in 2021, 67.1% of Aboriginal and Torres Strait Islander children received a first dose of the measles, mumps, rubella (MMR) vaccine on time (within 30 days of the recommended age), compared with 80.1% of all children.⁴

On-time vaccination in young Aboriginal and Torres Strait Islander children contributes to the prevention of vaccine-preventable disease in early childhood. Young Aboriginal and Torres Strait Islander children currently experience higher Haemophilus influenzae type b (Hib) and pertussis notifications, and higher rotavirus hospitalisations.^6,32 Although the incidence of Hib disease became very low in all children in Australia after the vaccination program was introduced in the 1990s, Aboriginal and Torres Strait Islander children aged under five years still experience a 12-fold greater burden of disease, largely due to social and environmental determinants of health.⁷

Immunisation coverage in Australia is calculated from the AIR and measures the proportion of children in certain age cohorts that are fully immunised according to the universal NIP schedule.³³ For example, coverage rates at age five years (60 months) are calculated based only on a child receiving their fourth or fifth dose of DTPa and fourth dose of polio vaccine at 48 months of age.⁴

The calculation of coverage rates does not take into consideration NIP vaccines that are funded for Aboriginal and Torres Strait Islander children only. Immunisation coverage for these targeted vaccines, such as MenB, are considerably lower than those for vaccines funded for all children.⁴ Coverage rates also allow for significant lags in immunisation, with the AIR reporting of coverage rates at 12 months of age based on completion of vaccinations scheduled at age six months or earlier, contributing to an underestimation of the problem of vaccine delay in Aboriginal and Torres Strait Islander children.⁴ Although immunisation coverage rates presented by the Australian Department of Health and Aged Care are useful indicators, they are likely to under-represent important problems of late and missed vaccination in Aboriginal and Torres Strait Islander children and mask these coverage deficits.¹ On-time vaccination for all NIP-scheduled vaccines must be a key priority for primary healthcare providers.

Invasive meningococcal disease (IMD) continues to result in a disproportionate number of deaths among Aboriginal and Torres Strait Islander people.³⁴ Notification rates of IMD due to serogroup B are higher in Aboriginal and Torres Strait Islander people than in non-Indigenous Australians, and are increasing, with MenB being the most common cause of IMD in children, adolescents and young adults.^34–36 Coverage rates for MenB immunisation in Aboriginal and Torres Strait Islander children are well below the 95% target for childhood vaccinations, with only 63.8% of the first eligible cohort of children for MenB immunisation under the NIP completing the three-dose schedule by 31 December 2021.⁴

Catch-up vaccination for MenB is currently only funded up to two years of age, even though it is recommended for all Aboriginal and Torres Strait Islander people aged between two months and 19 years. MenB disease is seen predominantly in those aged under five years and between 15 and 19 years,³⁵ making this a critical vaccine for timely delivery in line with the NIP schedule before the age of one year.

The contributing factors for late and under-vaccination in childhood are complex and are discussed below. Disruptions due to the COVID-19 pandemic appear to have had an impact on childhood vaccination coverage globally and in Australia, particularly for Aboriginal and Torres Strait Islander children.⁴

Adolescent immunisation

The incidence of cervical cancer is over twice as high among Aboriginal and Torres Strait Islander women than among non-Indigenous Australian women, and the associated mortality rates are more than three-fold higher for Aboriginal and Torres Strait Islander women.³⁷ HPV is the cause of almost all cervical cancers, and causes some cancers of the vulva, vagina, penis, anus and oropharynx.³⁸ Vaccination against HPV prior to exposure is an important opportunity for reducing the higher incidence of cervical cancer among Aboriginal and Torres Strait Islander women through primary prevention.

From 2023, the dose schedule for the 9-valent HPV vaccine has changed to a single dose (from the previous two-dose schedule), given primarily through school immunisation programs, at age 12–13 years.³⁹ People who are significantly immunocompromised still require three doses. The move to a one-dose schedule followed global evidence that there is comparable efficacy and effectiveness between single- and multidose schedules in preventing persistent HPV infection.⁴⁰ Prior to the COVID-19 pandemic, one-dose HPV vaccine coverage was high in Australia, including among Aboriginal and Torres Strait Islander adolescents.^8,41 However, coverage fell globally, including in Australia, during the pandemic, particularly among Aboriginal adolescents who may have missed vaccination at school.^40,42,43 Catch-up vaccination for Aboriginal and Torres Strait Islander adolescents is critical, and a catch-up program is funded under the NIP up to the age of 25 years for delivery by primary care providers. The benefit from HPV immunisation decreases with increasing age,⁴⁴ highlighting the importance of timely vaccination in accordance with the NIP schedule into adolescence.

The MenACWY (protecting against meningococcal disease caused by serogroups A, C, W and Y) and dTpa vaccines are listed on the NIP to be given during adolescence, commonly through school-based programs. Primary care providers should check the AIR, offer catch-up vaccination if missed at school and any other recommended vaccinations for Aboriginal and Torres Strait Islander adolescents, including meningococcal (MenB), pneumococcal (for those with specified medical risk conditions) and influenza (for all Aboriginal and Torres Strait Islander adolescents under the NIP) vaccination.¹⁰

Adult immunisation

The importance of immunisation extends into adulthood. Key life stages in adulthood to consider vaccinations include pregnancy, older age and the onset/presence of risk factors such as smoking, chronic disease and other medical comorbidities.

Reported immunisation coverage rates for adult NIP-funded vaccines are known to be much lower than childhood immunisation coverage rates.⁴⁵ Although under-reporting has likely contributed to these rates in the past, it is now mandatory for all NIP vaccinations to be reported to the AIR, so data quality since mid-2021 is expected to improve.⁴⁶

In 2021, 26.5% of Aboriginal and Torres Strait Islander people aged 70 years had received the zoster vaccine (versus 30.6% of all Australian adults of the same age).⁴

Low pneumococcal immunisation coverage rates in older adults are of particular concern, with Aboriginal and Torres Strait Islander adults scheduled to receive an age-based course at 50 years of age, or earlier if risk factors are present, to protect against pneumococcal disease caused by Streptococcus pneumoniae.¹⁰ Rates of invasive pneumococcal disease are at least fourfold higher and mortality rates at least 1.6-fold greater among Aboriginal and Torres Strait Islander people than non-Indigenous Australians, with greatest risk in older adults (age 50 years and older) and children aged <5 years.^24,34,47 In addition to invasive pneumococcal disease, which includes severe presentations such as meningitis, septicaemia and pneumonia (with bacteraemia or empyema), S. pneumoniae can cause non-invasive disease, such as otitis media.

In 2021, 10.8% of Aboriginal and Torres Strait Islander adults aged 50–69 years were recorded as having received 13vPCV, despite it being funded under the NIP for all adults in this age group since July 2020.⁴ Further to this, many Aboriginal and Torres Strait Islander people may be eligible for additional doses of pneumococcal vaccination at a younger age due to the presence of medical risk factors; however, vaccination coverage for this cohort is known to be particularly low. ATAGI advises that ‘clinicians should ensure careful screening of all patients to determine if they have either risk conditions for pneumococcal disease or identify as Aboriginal and/or Torres Strait Islander’, because this means they should receive additional vaccine doses.⁴⁷

The list of conditions associated with an increased risk of pneumococcal disease was updated and simplified in 2020.⁴⁷ Pneumococcal vaccination is funded under the NIP for some, but not all, of the risk conditions on this long list. Some of the key conditions where vaccination is recommended, but not funded, include diabetes, smoking and chronic obstructive pulmonary disease.²⁷ Clinicians should ensure they are familiar with this list of risk conditions, and offer pneumococcal vaccination as per the Australian immunisation handbook¹⁰ at the time of diagnosis of the risk condition. One of the major contributing factors to the low rates of pneumococcal vaccination for at-risk individuals is likely to be the complicated nature of assessing eligibility and the doses required. The online PneumoSmart vaccination tool is an easy-to-use calculator to assist clinicians in determining eligibility and pneumococcal vaccination course⁴⁸ (see Useful resources).

Another priority is hepatitis B. Despite higher acute hepatitis B notification and hospitalisation rates among Aboriginal and Torres Strait Islander people aged 15–49 years,²⁴ there is no nationally funded vaccination program for adults. Universal immunisation for hepatitis B in childhood was introduced in Australia in 2000, with relatively high coverage achieved since then among Aboriginal and Torres Strait Islander infants. However, coverage among adolescents and adults is lower.⁴⁹ The Australian immunisation handbook recommends that all Aboriginal and Torres Strait Islander people have their risks and vaccination status for hepatitis B reviewed, receive testing for previous hepatitis B virus infection and receive vaccination if they are not immune.⁵⁰ Several individual states and territories currently offer funded hepatitis B vaccination for at-risk groups (refer to state and territory health department websites for eligible groups)⁵¹ and, with ongoing advocacy, hepatitis B vaccination is likely to become fully funded for non-immune adults.

Since November 2023, all Aboriginal and Torres Strait Islander people aged 50 years and older are eligible for fully funded zoster virus vaccination with a 2-dose course of the recombinant vaccine Shingrix, which replaces the live-attenuated vaccine Zostavax, a, on the NIP.^52–55

Influenza

Influenza is the most common vaccine-preventable disease in Australia.^24,56 Hospitalisation rates in Aboriginal and Torres Strait Islander people are significantly higher across all age groups, with the highest rates seen in those aged 0–4 years.^6,34

All Aboriginal and Torres Strait Islander people aged ≥6 months are recommended and funded to receive the influenza vaccine each year due to an increased risk of complications of influenza.⁵⁷ Older adults, pregnant women and people with comorbidities are also recognised to be at particularly high risk.⁵⁷

In 2019, influenza vaccination coverage was higher among Aboriginal and Torres Strait Islander people than other Australians across all age groups.⁷ Coverage among Aboriginal and Torres Strait Islander people dropped in 2020, with rates below those for all people, particularly in those aged under 50 years, but is steadily increasing in subsequent years across all age groups .⁵⁸ Influenza vaccination in pregnancy is particularly important because, in addition to reducing influenza in the mother, it provides protection for the infant for up to six months after birth due to the transplacental transfer of antibodies.^57,59 Given the high levels of severe illness and comorbidity in Aboriginal and Torres Strait Islander people, the influenza vaccination should be promoted in all age groups and coverage in children increased to a level closer to that achieved for other NIP-funded vaccines.⁶ ATAGI publishes annual seasonal influenza vaccine statements, which should be reviewed each year for information on specific vaccines and age eligibilities.⁶⁰

Emerging and re-emerging diseases

Despite these achievements, Aboriginal and Torres Strait Islander people have experienced higher mortality rates from COVID-19 (4.5-fold higher for people age 55–64 years compared with non-Indigenous Australians of the same age), contributed to by pre-existing chronic disease and less access to appropriate and culturally safe primary healthcare.^63,64 COVID-19 vaccination rates among Aboriginal and Torres Strait Islander people have lagged behind vaccination rates in non-Indigenous Australians throughout the vaccination rollout. COVID-19 vaccination continues to be recommended by ATAGI to prevent severe illness, and clinicians should refer to up-to-date ATAGI clinical advice to counsel patients regarding recommended vaccination.¹¹

Lower immunisation coverage rates, disruption to routine primary healthcare and vaccination programs during the COVID-19 pandemic, a return of international travel following border openings and the ongoing impacts of climate change have likely contributed to the increase or new presence of other emerging and re-emerging diseases in Australia.

Vaccination programs for the mosquito-borne Japanese encephalitis virus are being rolled out through state and territory health departments in response to human cases and animal detections in mainland Australia since early 2022. Increasing tuberculosis transmission among Aboriginal and Torres Strait Islander people in several jurisdictions has resulted in the need for increased public health action, and jurisdictional childhood immunisation recommendations should be adhered to.

Increasing notifications of measles and diphtheria are concerning. Maintaining high rates of childhood vaccination and confirming the receipt of two doses of a measles-containing vaccine for those born during or since 1966 remains vital.¹⁰ Offering adults requiring a tetanus booster vaccination with dTpa (rather than diphtheria–tetanus [ADT] booster) will also help protect against pertussis.

Improving immunisation coverage and timeliness

Improving immunisation coverage and timeliness for Aboriginal and Torres Strait Islander people across the life course must be an area of focus for all primary healthcare services. Vaccination at the earliest appropriate age for recommended vaccinations for all Aboriginal and Torres Strait Islander people should be a public health goal, both as an issue of equity and in recognition of the higher burden of severe disease experienced.⁶

Barriers to vaccination can include those affecting the patient and the health service. Service-level barriers include low levels of awareness among staff of the high vaccine-preventable disease burden in Aboriginal and Torres Strait Islander people across the life course and the importance of timely vaccination to prevent disease.¹ Primary care providers are often faced with time pressures, which means there is not adequate time or funding available to follow up children who are overdue for vaccinations.¹ Not having systems in place to routinely ascertain Aboriginal and/or Torres Strait Islander status of the patient, to check the AIR prior to each consultation, to recall patients and to remind staff (eg through practice software) regarding any immunisations that are due are also barriers to vaccination.^1,6,16,18

Practical barriers that can impact Aboriginal and Torres Strait Islander patients and families can include costs associated with vaccination, having to make appointments, access to transport, the mobility of families, school attendance (for school-based programs) and other urgent competing priorities taking precedence over preventive healthcare.^3,15–17,41 A lack of access to culturally safe health services is also an important barrier to vaccination, with culturally safe services and providers recognised to be trusted sources of information by Aboriginal and Torres Strait Islander people.^{1,3,20,21,65,66}

Not being aware of the most up-to-date immunisation schedule and eligibility for government-funded vaccinations is a barrier that can affect both service providers and patients. Misperceptions about vaccination may also contribute to lower immunisation coverage. For example, perceptions that influenza presents a low risk to the individual or that the influenza vaccine can cause influenza have been identified in the literature as common misperceptions affecting vaccination uptake.³

Enablers of vaccination are summarised in Box 1. Implementing a variety of evidence-based strategies is required to increase the coverage and timeliness of vaccination.¹⁵

A key benefit of vaccination identified by Aboriginal and Torres Strait Islander people in qualitative literature is the protection of others, such as family, Elders and unborn babies.^3,17,67 Providing information about the wider family and community benefits of vaccination align with cultural values and a strengths-based approach to vaccination education. Furthermore, AHPs are Australian Health Practitioner Regulation Agency registered and are specialised health professionals who are experts delivering culturally appropriate, holistic and community-orientated health care. AHPs also play an important role through cultural brokerage, which improves communication within the health setting. Where AHPs deliver immunisation services (where state or territory regulations allow), immunisation coverage has been shown to increase.²¹

An example of an initiative that has successfully contributed to closing the gap in immunisation coverage and timeliness is the Aboriginal Immunisation Health Care Worker (AIHCW) Program in NSW, where AIHCW positions were funded in public health units across the state. ¹⁹ AIHCWs contact families of all Aboriginal and Torres Strait Islander infants prior to the due date for their first scheduled vaccination to provide the rationale for timely immunisation and to facilitate contact with culturally safe local immunisation services if required (pre-call notices).^5,19 AIHCWs also follow up Aboriginal and Torres Strait Islander children recorded as not up to date with vaccinations on the AIR and promote vaccination in their communities (the program does not directly provide vaccination services).¹⁹ The program demonstrated cultural safety and improved immunisation coverage and timeliness, helping overcome barriers to timely vaccination.^5,19,69 An Australian population-based cohort study has demonstrated that delayed receipt of the first DTPa vaccine due at 6–8 weeks of age is a key driver of subsequent delayed vaccine doses.³¹ Therefore, programs such as the AIHCW Program and the use of ‘pre-call’ strategies, such as those implemented in NSW, are likely to benefit the timeliness of later vaccine doses in addition to the first vaccination visit.³¹ It should be noted that the pre-call strategy relies on telephone contact, and in other parts of Australia this type of strategy may be less feasible, although other methods for contacting families to remind them of vaccinations that are due and to offer support to attend health services (eg door-to-door) may be appropriate.

The issues affecting vaccine uptake are many and complex. Although concerns about vaccines seem to have increased globally during the COVID-19 pandemic, vaccine hesitancy among Aboriginal and Torres Strait Islander parents/caregivers in regard to childhood vaccination has not previously been identified as a major driver of suboptimal immunisation coverage.¹ For Aboriginal and Torres Strait Islander people, barriers to COVID-19 vaccination can include a distrust in government, which stems from the long history of systemic racism and maltreatment towards Aboriginal and Torres Strait Islander people by government policies and institutions.¹⁷ Concerns surrounding the COVID-19 vaccination are likely to have been heightened by misinformation, such as that accessed via social media.^17,20,70 Most barriers to vaccination, including COVID-19 vaccination, can be addressed by governments with equitable policy and action, and by ensuring access to culturally appropriate and safe health services for all Aboriginal and Torres Strait Islander people. ⁷⁰