Immunizations: Bringing Newcomer Children Up-to-date
- Confirming or updating immunizations is not part of the routine immigration medical examination. Do not assume that newcomer children are completely immunized as per the Canadian schedule.
- Country-specific immunization schedules vary based on local epidemiology and policies. Vaccination schedules from other countries can be found on the WHO website.
- 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.
- Provincial and territorial catch-up immunization schedules for infants and children are available from the National Advisory Committee on Immunization, and should be used for children who are not fully immunized according to current guidelines.
- Newcomer families and their health care providers need clear and easy-to-follow instructions for future vaccination visits.
Ensuring that a child new to Canada is up-to-date with all immunizations is an important task that poses some unique challenges. Confirming or updating childhood immunizations is not a part of the routine immigration medical examination, and clinicians cannot assume that newly arrived children have received all of the vaccinations recommended for children in Canada. Careful examination of any vaccine records a child does have is important, but remember: such documents may require translation and may be inaccurate or even falsified.
When a little vaccine history is as good as none
A family from the Democratic Republic of Congo recently arrived in Canada as refugees. They have 4 children. They have spent the last several years in various refugee camps in Tanzania and Kenya, and speak little English or French. The father only speaks and understands Lingala and some Swahili. With the assistance of an interpreter, the family tells 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 of the children are healthy now, although they had several episodes of diarrheal illness and respiratory infections while living in the refugee camps.
- 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 barrier can greatly enhance communication between the family and health care professionals. Whenever possible, a trained interpreter or interpreter service (e.g. language line) should be used. Friends or family members—particularly children—should not be used as interpreters.
- 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 may be misdiagnosed as ‘measles’. All of the children > 12 months of age 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) recommendations for routine immunizations. The WHO recommendations for routine immunizations are 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 is on the WHO website.
When immunization records are available
Health care providers cannot rely on a 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
- 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 and WHO standards
Keep in mind that children immunized according to the WHO recommendations for routine immunizations 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 as soon as possible after birth in the WHO schedule. This vaccine is not routinely given in Canada, except in Nunavut.
- 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 later, most often between ages 4-6 years. Doses given before a child is 12 months of age are not considered ‘countable’ and should be followed up with 2 doses at least 4 weeks apart after 12 months of age.
- Oral polio vaccine and inactivated polio vaccine is used in many African and Asian countries, while only inactivated polio vaccine is used in Canada.4 Doses of oral polio vaccine are considered countable as long as all the criteria listed above are met.
- Rotavirus, mumps, meningococcal, Haemophilus influenzae type b, pneumococcal, hepatitis A, and varicella vaccines are not routinely given by public health systems in most resource-limited settings,1,4 but may be available for those able to pay for them. While vaccination schedules vary in Canada depending on province or territory, all of these vaccines, with the exception of hepatitis A, are part of the routine provincial and territorial schedules. Hepatitis A vaccine is part of the routine vaccination schedule in Quebec only.
When immunization records are unreliable or unavailable
As a general rule, when a child’s vaccine record is unreliable or unavailable, vaccines should be provided as if the child were un-immunized.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. Therefore these tests are not routinely recommended.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 immunity is vaccine-derived.
The clinical diagnosis of a vaccine-preventable disease without serological testing should not be accepted as evidence of immunity. However, 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 young immigrants are sufficiently low that varicella vaccination may be considered routinely.5
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.
- For children younger than 7 years of age: see Routine immunization schedule for children < 7 years of age not immunized in early infancy.
- For children 7 through 17 years of age: see Routine Immunization Schedule for Children ≥ 7 Years of Age up to 17 Years of Age Not Immunized in Early Infancy.
- If a child has a congenital or acquired immunodeficiency (e.g., HIV infection), live viral vaccines such as measles, mumps, rubella and varicella may be contraindicated. See the Canadian Immunization Guide: Vaccination of Specific Populations for specific advice.
- For complex cases, consider contacting local public health authorities. An immunization expert can you help design an appropriate catch-up schedule.
If HIV infection is suspected, the child should have HIV serology performed 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. Rather, they are screened if they have any risk factors. 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 a chronic medical condition or risk factor that puts them at higher risk of certain infections may require additional immunizations. 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.
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 and Hajj pilgrims)
- Laboratory personnel with exposure to meningococcus
- Military personnel
- Close contacts of a case with invasive meningococcal disease (IMD)
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
- 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. In some provinces/ territories, the vaccine is not routinely given until children are in grade 6 or 7. Several provinces are now administering hepatitis B vaccine in infancy. 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
- 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
- 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
Quebec’s routine immunization schedule includes one dose of Hepatitis A vaccination.
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.
- Refer them to the correct provider (e.g,. public health or other as appropriate)
- Remind families 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.
- Consider the phone app CANImmunize to help families keep track of vaccinations received for their children as well as reminders for follow up appointment.
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 a single visit.
- The Public Health Agency of Canada (PHAC). Canadian immunization guide: Evergreen edition. For province/territory-specific schedules, see: www.phac-aspc.gc.ca/im/is-pi-eng.php For current NACI guidelines, see: www.phac-aspc.gc.ca/naci-ccni. The PHAC also has parent handouts in multiple languages.
- The Public Health Agency of Canada (PHAC). A Parent's Guide to Vaccination. The guide is available in multiple languages.
- CANImmunize: Digital vaccination record app. www.canimmunize.ca/en/home
- Centers for Disease Control and Prevention (CDC). Immigrant and refugee health. The CDC also has multilingual, downloadable handouts on immunizations.
- World Health Organization. Immunization, vaccines and biologicals.
- American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In:Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL. American Academy of Pediatrics; 2018: 100-103.
- Cilleruela MJ, de Ory F, Ruiz-Contreras J, et al. Internationally adopted children: What vaccines should they receive? Vaccine 2008;26(46):5784-90.
- 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.
- 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.
- Greenaway C, Boivin JF, Cnossen S, Rossi C, Tapiero B, Schwartzman K, Olson S, Miller M. Risk factors for susceptibility to varicella in newly arrived adult migrants in Canada. Epidemiol Infect 2014;142:1695-1707.
- Devika Dixit, MD
- Nipunie Rajapakse, MD
- Susan Kuhn, MD
Last updated: July, 2023