A guide for health professionals working with
immigrant and refugee children and youth

Immunizations: Bringing Newcomer Children Up-to-date

Key points

  • Confirming or updating immunizations is not part of the immigration medical examination. Do not assume that newcomer children are completely immunized as per the Canadian schedule.
  • Only accept written documentation as evidence of previous immunizations.  Do not rely on parental recall of their child’s immunization or illness history. 
  • Even written documentation is not always reliable.
  • A ‘catch-up’ schedule is available from the National Advisory Committee on Immunization, and should be used for children who are not fully immunized in accordance with current guidelines.
  • Newcomer families and their health care providers need easy-to-follow instructions for future vaccinations.

Introduction

Ensuring that a child new to Canada is ‘up-to-date’ with all immunizations poses unique challenges. Confirming or updating childhood immunizations is not a part of the immigration medical examination, and it cannot be assumed that newly arrived children are completely immunized. Even if they were ‘caught up’ in their country of origin, they are probably under-immunized by Canadian standards. Careful examination of any vaccine records a child does have is important, but remember: such documents are often written in a foreign language and may be inaccurate or even falsified.

When a little vaccine history is as good as none

A family from the Congo has recently arrived in Canada as refugees. They have 4 children. They have spent the last few years in various refugee camps in Tanzania and Kenya, and speak little English. The father only speaks and understands Swahili. You request the assistance of an interpreter, who is able to tell you that the children are 4 months, 26 months, 6 years and 14 years of age. The parents have a paper indicating that their 4-month-old girl received 4 doses of DPT, 3 doses of OPV and 3 doses of hepatitis B vaccine. They have no vaccine records for the other children. The parents recall being told that their two eldest children had measles when they were young. As far as the parents know, all their children are healthy now, although they had several episodes of diarrheal illness and respiratory infection while living in the camps.

Learning points:

  • Accurate and reliable information on the immunization status of children who are new to Canada is not always available.
  • Involving an interpreter when there is a language difficulty can greatly enhance communication between the family and health care professionals.
  • While the youngest child has an immunization document, her age and the number of doses of vaccine she has reportedly received suggest that doses have been given too close together in some cases (i.e., less than 4 weeks apart for DPT) or that the documentation itself is inaccurate.
  • All the children will need to be started on a catch-up schedule appropriate for their age. Although the parents were told that two of their children had measles, this does not necessarily mean they are immune: many rashes might be called ‘measles’. All the children will need to be immunized against measles.

STEP 1: Which immunizations has this child received?

Childhood immunization schedules differ considerably according to the country of origin. Immigrant and refugee children may have been immunized according to the World Health Organization’s (WHO’s) Expanded Program of Immunization (EPI) Plus schedule (see Table 1).

Vaccine Birth 6 wks 10 wks 14 wks 9 to 12 mos
Table 1: The WHO’s Expanded Program of Immunization (EPI) Plus* schedule
BCG

 

 

 

 

DPT

 

 

OPV

[●]

 

Measles

 

 

 

 

HBV

 

 

Yellow Fever (YF)

 

 

 

 

*YF and HBV added in 1994 for endemic countries

[ ] added during epidemics

† alternative schedules for HBV include: at 6 wks, 10 wks and 14 wks OR at birth, 6 wks and 9 to 12 mos.

BCG Bacillus Calmette-Guérin vaccine; DPT diphtheria-pertussis-tetanus vaccine; OPV Oral polio vaccine; HBV hepatitis B vaccine

Source: Adapted from the WHO’s Expanded Program of Immunization (EPI) Plus* schedules.

The EPI Plus schedule is followed by many developing countries when vaccine supplies are available. Also, there are country-specific immunization protocols which vary based on local epidemiology and policies. Vaccination information by country can be found on the WHO website.

When immunization records are available

Health care providers cannot rely on a newcomer parent’s recollection of their child’s immunization history, and should only rely on written documentation when certain basic criteria are met. A newcomer child’s written vaccine record is considered to meet minimum acceptable standards when the following variables are all consistent with current guidelines:1

Criteria

  • vaccine type
  • number of doses
  • intervals between doses
  • age of the patient at the time of immunization

Even when such requirements are met on paper, a child’s immunization records still may not accurately reflect the child’s immune status.2,3 Studies in international adoptees have shown that children who have an immunization record are more likely to have seroprotection than those with no records at all. However, there is poor agreement between the number of doses documented and likelihood of immunity.2 The reasons for this discrepancy are multifactorial and likely to include:3

  • product quality
  • cold chain breaches
  • health status of the child at the time of vaccination
  • inaccurate  documentation

Moreover, the product types and/or names may differ from vaccines used in Canada, thus leading to further confusion. The U.S. Centers for Disease Control and Prevention (CDC) has a useful resource for interpreting vaccine components and identifying products by their trade name. 

STEP 2: Which immunizations does this child need?

Differences between Canadian standards and EPI Plus

Keep in mind that children immunized under the EPI Plus schedule are not fully immunized in accordance with the routine childhood schedule recommended by Canada’s National Advisory Committee on Immunizations (NACI).

Notable differences between the NACI schedule and the WHO schedule:

  • Bacillus Calmette-Guérin (BCG) vaccine for protection against tuberculosis (TB) is recommended at birth in the WHO schedule. This vaccine is not routinely given in Canada, except to children living in very specific geographic areas (e.g., some Aboriginal communities).
  • The measles vaccine is often given as a single, monovalent vaccine (i.e., no mumps and rubella components) in the WHO schedule and is administered at 9 to 12 months of age.1,4 In Canada, the first dose of a combination measles, mumps, rubella +/- varicella (MMR or MMRV) vaccine is given at 12 to 15 months of age, with a booster at 18 months or anytime later, though typically before school entry. Doses given before a child is 12 months of age are generally not considered ‘countable’ and should be followed up with 2 doses after 12 months of age.
  • Oral polio vaccine is used in many African and Asian countries, while inactivated polio vaccine is used in Canada.4 These doses of oral polio vaccine are considered countable as long as all the criteria listed above are met.
  • Rotavirus, meningococcal, Haemophilus influenzae type b, pneumococcal, hepatitis A, and varicella vaccines are not routinely given by public health systems in most developing countries,1,4 but may be available for those able to pay for them.  While schedules vary in Canada depending on location, all these vaccines except for hepatitis A are routinely given in most provinces or territories.

When immunization records are unreliable or unavailable

When a child’s vaccine record is unreliable or unavailable, vaccines should be provided as if the child were non-immunized, as a general rule.1 If a child receives an immunization that was received previously (“re-immunization”), it is usually safe, though there is increased risk of a local reaction with some vaccines. While serological tests may be available for diphtheria, tetanus, hepatitis A, measles, mumps, rubella, varicella and hepatitis B, they are not sufficiently comprehensive (e.g., polio is not available), cost-effective or time-sensitive to be practical in most cases.1 Furthermore, false positive results can occur for mumps (i.e., the child is seropositive but not protected), and false negative results can occur if varicella or hepatitis A vaccine immunity is vaccine-derived.

When there is history of disease

The clinical diagnosis of a vaccine-preventable disease without serological testing should not be accepted as evidence of immunity. For children born in 2004 and later, a health care provider’s diagnosis of varicella or herpes zoster can be considered a reliable history of varicella disease. Because varicella vaccine is not routinely administered in most countries and varicella infection is less common in tropical countries, many children immigrating from those regions will be susceptible. Limited studies have shown that seroprotection rates in immigrant children younger than 7 years of age are sufficiently low that varicella vaccination should be given routinely.5,6

Canadian standards for immunization

Current Canadian immunization recommendations are on the NACI website.

Here are some other useful tools:

  • An interactive immunization schedule: The Public Health Agency of Canada (PHAC) has an online tool for families and health care providers navigating the routine immunization schedule, based on a child’s immunization records and/or serology, along with a province/territory of residence, and age: for children 6 years of age and younger, and for school-aged children.
  • The routine childhood immunization schedules from NACI: From birth to 17 years of age.
  • Provincial and territorial immunization schedules: Immunization protocols vary by province and territory. While all jurisdictions follow NACI guidelines, the timing of certain immunizations is different. The PHAC website links to all individual provincial and territorial immunization schedules.

STEP 3: Creating an appropriate catch-up schedule

Catch-up schedules are used for children who are un- or under-immunized (whose immunizations are not up-to-date). NACI-recommended catch-up schedules follow here, based on age of the child.

HIV infection

If HIV infection is suspected (e.g., if a child’s mother is HIV-positive or has died, or you observe failure-to-thrive or chronic medical problems that are unexplained), the child should have HIV serology done before giving any live vaccines.

Currently, children younger than 15 years of age are not routinely tested for HIV infection as part of their immigration medical examination.  Read more about HIV/AIds in newcomer children and youth in this resource.

STEP 4: What underlying conditions or risk factors require additional immunizations?

Children living with an underlying medical condition or risk factor that puts them at higher risk of certain infections may require immunizations above and beyond those given to healthier children. Once a child is ‘caught up’ on steps 1 to 3, it’s time to assess their need for additional protection, especially if they fall into any of the following high-risk categories noted below. See NACI guidelines for specific advice.

Meningococcal disease

Patients at increased risk of invasive meningococcal disease should be considered for quadrivalent meningococcal vaccine. These patients may be living with:

  • Anatomical or functional asplenia (e.g., sickle cell anemia)
  • Primary antibody deficiency disorders
  • Complement, properdin or factor D deficiency
  • Acquired complement deficiency due to receiving the terminal complement inhibitor eculizumab (Soliris)

The following groups are also at risk: 

  • Travellers to areas where meningococcal risk is high (e.g., sub-Saharan Africa)
  • Laboratory personnel with exposure to meningococcus
  • Military personnel
  • Individuals with HIV, especially if congenitally acquired

Haemophilus influenzae disease

Patients at increased risk of invasive Haemophilus influenzae disease may be living with:

  • Asplenia or hyposplenism (e.g., sickle cell disease)
  • A cochlear implant
  • Congenital immunodeficiency
  • HIV
  • A hematopoietic stem cell transplant
  • A malignant hematological disorder
  • Solid organ transplant

Hepatitis B:  Recommended recipients of hepatitis B vaccine for pre-exposure prevention

All children in Canada should receive hepatitis B vaccine, but in some provinces/ territories, the vaccine is not routinely given until children are 10 to 12 years of age. Earlier administration is recommended for:

  • All adults and children immigrating to Canada from areas where there is high prevalence of hepatitis B
  • Children born in Canada whose families have immigrated from areas where there is high prevalence of hepatitis B and who may be exposed to carriers in their extended family or when visiting their country of origin
  • Children and workers in child care settings where there is a child or worker who has acute hepatitis B or is a known carrier of the virus
  • Household and sexual contacts of acute hepatitis B cases and carriers
  • Household or close contacts of children adopted from hepatitis B-endemic countries, if the adopted child is HBsAg-positive,
  • Populations or communities in which hepatitis B is endemic
  • Residents and staff of institutions for people with developmental disabilities

Hepatitis B vaccine is also recommended for patients living with:

  • Chronic liver disease, renal disease or undergoing chronic dialysis
  • Hemophilia, and others receiving repeated infusions of blood or blood products
  • Congenital immunodeficiencies
  • A hematopoietic stem cell transplant or awaiting solid organ transplant
  • HIV

And for:

  • Travellers to hepatitis B-endemic areas
  • Health care workers and others with occupational exposure to blood and bodily fluids
  • Any person who wishes to decrease his or her risk of hepatitis B infection

Invasive pneumococcal disease

Patients at increased risk of invasive pneumococcal disease include those living with:

  • A chronic cerebrospinal fluid (CSF) leak
  • A chronic neurological condition that impairs clearance of oral secretions
  • A cochlear implant
  • Chronic cardiac or pulmonary disease
  • Diabetes mellitus
  • Functional or anatomical asplenia (e.g., sickle cell anemia)
  • Sickle cell disease or other hemoglobinopathies
  • Congenital immunodeficiencies involving any part of the immune system
  • A hematopoietic stem cell transplant
  • HIV
  • Immunosuppressive therapy
  • Chronic kidney disease, including nephrotic syndrome
  • Chronic liver disease
  • Malignant neoplasms, including leukemia/lymphoma
  • Solid organ or islet transplant (as a candidate or recipient)

Hepatitis A: Recommended recipients of hepatitis A vaccine for pre-exposure prevention

  • Travellers to or immigrants from hepatitis A-endemic areas
  • Household or close contacts of children adopted from hepatitis A-endemic countries
  • Populations or communities at risk of hepatitis A outbreaks or in which hepatitis A is endemic (e.g., some Aboriginal communities)
  • Patients with chronic liver disease from any cause
  • Patients with hemophilia A or B receiving plasma-derived clotting factors
  • Any person who wishes to decrease his or her risk of hepatitis A

STEP 5: Follow-up

  • Provide families with easy-to-follow instructions for their child’s future vaccinations, including dates and locations where the vaccinations can be administered.
  • Remind them to bring their Canadian vaccination record with them to all appointments.
  • Try to minimize the number of appointments, and ease the process of ‘catching up’ as much as possible for newcomer families with transportation and language difficulties.

According to current recommendations, some newcomer children may require up to 6 vaccinations at their first catch-up visit. There is no maximum number of vaccines that can be given at any one visit.

Selected resources

References

1. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics, 2012.

2. Cilleruela MJ, de Ory F, Ruiz-Contreras J, et al. Internationally adopted children: What vaccines should they receive? Vaccine 2008;26(46):5784-90.

3. Verla-Tebit E, Zhu X, Holsinger E, et al. Predictive value of immunization records and risk factors for immunization failure in internationally adopted children. Arch Pediatr Adolesc Med 2009;163(5):473-9.

4. Piyaphanee W, Steffen R, Shlim DR, et al. Travel medicine for Asian travelers – Do we need new approaches? J Travel Med 2012;19(6):335-7.

5. Christiansen D, Barnett ED. Comparison of varicella history with presence of varicella antibody in refugees. Vaccine 2004;22(31-32):4233-7.

6. Murray TS, Growth ME, Weitzman C, et al. Epidemiology and management of infectious diseases in international adoptees. Clin Microbiol Rev 2005;18(3):510-20.

Editor(s)

  • Devika Dixit, MD
  • Nipunie Rajapakse, MD
  • Susan Kuhn, MD

Last updated: March, 2016

Also available at: http://www.kidsnewtocanada.ca/screening/immunizations
© 2016 Canadian Paediatric Society.
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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