Adult & At-Risk Immunisation, Catch-Up Schedules

Assessing and completing an adult’s vaccination status, and the groups needing vaccines beyond the routine schedule. See National Immunisation Schedule for the routine age-based schedule, and The Travel Consultation for travel vaccination.

Assessing vaccination status

Take every opportunity — an unrelated consultation, a health assessment, a new patient — to review vaccination history and offer catch-up.

The Australian Immunisation Register (AIR) is the primary source: an Immunisation History Statement can be pulled via Health Professional Online Services or the AIR enquiries line. For adults ≥20 years, records from before September 2016 may be incomplete on the AIR.

If the AIR cannot confirm a vaccine and no written record exists, treat it as not given and offer age-appropriate catch-up. For most vaccines, there is no harm in an extra dose given to someone already immune — the exceptions are more frequent injection-site reactions after repeated diphtheria/pertussis/tetanus-containing doses, and Q fever, where prior infection or vaccination must be excluded serologically before vaccinating (anaphylaxis risk from an undetected prior exposure).

Catch-up principles

• Never restart a schedule. Count previous documented doses, regardless of the interval since the last one — oral cholera vaccine is the only exception.
• Give every overdue vaccine at the first catch-up visit rather than deferring any of them; schedule the next doses at the minimum acceptable interval.
• The number of doses needed can fall as a person ages — for example, a child starting Hib vaccination at 15 months needs only one dose, where an infant needs four.
• Inactivated vaccines can be given at any time relative to other vaccines. Live parenteral vaccines must be given simultaneously or at least 4 weeks apart.
• Combining two different combination vaccines that share an antigen is not routinely recommended but is acceptable if no alternative is available.

The Handbook’s Catch-up schedule for people ≥10 years of age table gives doses and intervals for anyone needing catch-up for a particular antigen. It covers only vaccines recommended at a population level — antigens such as hepatitis A that are only funded for specific risk groups are worked out from that group’s own schedule instead.

Complex catch-up — multiple overdue antigens, uncertain history, immunocompromise — is worth a call to the state or territory immunisation program or a specialist immunisation clinic rather than guessing.

Migrants, refugees and people seeking asylum

Migrants from resource-poor settings — especially refugees or people seeking asylum — may be incompletely vaccinated according to the Australian schedule and may have incomplete records of vaccination. Check any overseas documentation for validity (oral polio and tetanus doses are the ones most often given at intervals too short to count), and start a standard catch-up schedule if there is none.

Adult migrants, refugees and people seeking asylum may need vaccination, especially with MMR vaccine — this matters particularly for women of child-bearing age, for rubella protection. Pre-vaccination serology is worth doing for hepatitis B (in people from hepatitis B–endemic countries) and rubella susceptibility in women of child-bearing age, but is not otherwise routine before catch-up. Report every dose given to the AIR, including any documented overseas vaccination.

Aboriginal and Torres Strait Islander adults

For adults, the extra vaccines are against hepatitis B, influenza, pneumococcal disease and respiratory syncytial virus — funded in addition to the standard adult schedule. Practically: non-immune adults get hepatitis B vaccination, annual influenza from 6 months of age, one dose of 21-valent pneumococcal vaccine from age 25, and RSV vaccination from age 60. See Aboriginal and Torres Strait Islander Health & the 715 Check for the health-assessment item this sits alongside.

Immunocompromised patients

People who are immunocompromised have an increased risk of severe illness or death from many vaccine-preventable diseases, and often need extra doses of some vaccines to optimise protection. Live vaccines (MMR, MMRV, varicella, zoster [Zostavax], yellow fever, oral typhoid, BCG) are generally contraindicated in people who are moderately-to-severely immunocompromised — check the degree of immunocompromise and the specific agent before giving any live vaccine, and seek specialist immunisation advice if uncertain. Non-live vaccines are generally safe in people who are immunocompromised, since the antigens carry no infection risk, but they are often less immunogenic and extra doses may be needed. Where possible, complete vaccination before starting an immunosuppressive treatment or transplant workup rather than during it.

Occupational risk groups

Certain occupations carry an increased risk of some vaccine-preventable diseases — healthcare workers, childcare/early childhood workers, laboratory workers, and people who work with animals are the main groups seen in general practice.

All healthcare workers, including all workers and students directly caring for patients, or handling human tissue, blood or body fluids, are recommended vaccines against hepatitis B, measles/mumps/rubella, pertussis (dTpa), varicella and annual influenza — check local health-service policy for mandatory vs. recommended status, since this varies by employer and state. Add hepatitis A for workers in remote Aboriginal and Torres Strait Islander communities, and consider BCG for workers at high risk of drug-resistant tuberculosis exposure.

Pre-vaccination screening

Screen every adult before vaccinating: current illness, immunocompromise, pregnancy, prior vaccine reactions, allergies, recent blood products or immunoglobulin, and any occupational or lifestyle risk factors.

Only two absolute contraindications apply across all vaccines: anaphylaxis to a previous dose of that vaccine, or anaphylaxis to a vaccine component. Two further contraindications apply to live vaccines specifically: significant immunocompromise, and pregnancy — advise against pregnancy for 28 days after any live vaccine. Defer vaccination (not necessarily cancel) for acute febrile illness with systemic symptoms; a minor illness without fever is not a reason to delay.

After vaccination

The most serious immediate AEFI is anaphylaxis; severe reactions usually happen rapidly, within 15 minutes of vaccination — keep every vaccinated adult under observation for at least 15 minutes. Rapid intramuscular adrenaline is the cornerstone of anaphylaxis treatment: 0.5 mL of 1:1000 adrenaline IM into the anterolateral thigh for an adult, repeated every 5 minutes until improvement, with transfer to hospital in every case. Antihistamines and hydrocortisone are not first-line treatment. A vasovagal episode is distinguished from anaphylaxis by a strong central pulse and the absence of respiratory or skin signs.

Documentation of National Immunisation Program, COVID-19 and influenza vaccines on the Australian Immunisation Register (AIR) is mandated for every immunisation provider. All immunisation providers should report AEFIs, particularly serious or unexpected ones. Report to the state or territory health department (NSW: local public health unit, 1300 066 055) or directly to the TGA. Reporting does not imply the vaccine caused the event.

Advice for the patient: mild fever, injection-site soreness and malaise are expected for 1–2 days and settle with paracetamol or ibuprofen. Anything more severe, an unusual or prolonged reaction, or symptoms suggestive of anaphylaxis after leaving the clinic needs urgent review or an ambulance.