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doi:10.1111/jpc.12796

REVIEW ARTICLE

Fifty years of immunisation in Australia (19642014):

The increasing opportunity to prevent diseases
Jenny Royle1,2 and Stephen B Lambert3,4
1

NHMRC Centre of Research Excellence in Population Health Research Immunisation in Understudied and Special Risk Populations, The School of Public Health
and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, 2Community Immunisation Paediatrician, NEST
Family Wellness Clinic, Melbourne, Victoria, 3Queensland Childrens Medical Research Institute, Childrens Health Queensland and The University of
Queensland, Brisbane and 4Communicable Diseases Unit, Chief Health Ofcer Branch, Queensland Health, Queensland, Australia

Abstract: Medicine has seen dramatic changes in the last 50 years, and vaccinology is no different. Australia has made a signicant contribution to world knowledge on vaccine-preventable diseases. Certain deadly diseases have disappeared or become rare in Australia following
successful introduction of vaccines. As diseases become rarer, public knowledge about the diseases and their serious consequences has
decreased, and concerns about potential vaccine side effects have increased. To maintain condence in immunisations, sharing of detailed
information about the vaccines and the diseases we are trying to prevent is integral to the continued success of our public health programme.
Modern quality immunisation programmes need to communicate complex information to immunisation providers and also to the general
community. Improving immunisation coverage rates and eliminating the gap in coverage and timeliness between Aboriginal and Torres Strait
Islander peoples and non-Indigenous people has become a high priority.
Key words:

Aboriginal; coverage; immunisation; opportunistic; prevention.

A child born in Australia in 1964 was able to have vaccines

against polio, tetanus, diphtheria and pertussis (Table 1). In
2014 a child is able to have vaccines against 15 diseases.
This paper will outline the success of disease prevention from
the vaccines that have been introduced over the last five
decades and the challenges we now encounter.
Key Points
1 From 1964-2014 the immunisation schedule for children
increased from protection against 4 diseases to 15.
2 The 2014 expanded immunisation schedule includes vaccines
that prevent cancers caused by hepatitis B virus and human
papillomavirus.
3 There remains a gap in the immunisation coverage rates of
Aboriginal and Torres Strait Islander peoples and nonIndigenous people of Australia.
Correspondence: Dr Jenny Royle, NEST Family Wellness Clinic, 289
Kooyong Rd, Elsternwick, Victoria 3185, Australia. Fax: (03) 95285883;
email: jenny.royle@bigpond.com
Conict of interest: Stephen Lamberts institute, the Queensland Childrens
Medical Research Institute, has received reimbursement from Merck for Dr
Lambert to present on the epidemiology of rotavirus in Queensland at three
international meetings. He has previously been a member of vaccine advisory boards for GSK and Sano Pasteur. Dr Lambert is supported by an
NHMRC early career fellowship and a CHF people support fellowship.
Accepted for publication 8 October 2014.

16

Preventing Invasive Bacterial Disease

Infants have high rates of infection with the capsulated
organisms, Haemophilus influenzae type b (Hib), Streptococcus
pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus), because the outer polysaccharide (sugar) capsule
is poorly immunogenic. In 1992, there were 549 cases of Hib
in Australia, the major cause of bacterial meningitis and
epiglottitis.2
In the 1970s, vaccines derived from purified polysaccharides
were developed, such as pneumococcal polysaccharide vaccine
and purified type b capsule of Hib. These were immunogenic
in older children and adults but not in the high-risk infant
population.
The US microbiologist and paediatrician Porter Anderson, in
collaboration with David Smith, is credited with the idea and
the remarkable achievement of rendering capsular polysaccharides immunogenic by conjugating them to immunogenic
proteins such as tetanus toxoid and thus developing the first
conjugate vaccines (against Hib).
The introduction of conjugate Hib vaccines in 1993 transformed hospital emergency departments throughout Australia
over a 6-month period. The rate is now only about one case of
invasive Hib disease per million each year, one of the lowest
rates in the world.3
The first conjugate vaccine against Hib disease introduced in
1993 in Australia was followed by vaccines that shared the
successful conjugate technology: vaccines against invasive

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Journal of Paediatrics and Child Health 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

J Royle and SB Lambert

Table 1

Fifty years of immunisation in Australia

Fifty years of new vaccines, new combinations and key events in Australia

Decade

New vaccines

To 1964

Tetanus toxoid (1945)

DTPw (1953)
IPV (1956)
OPV (1966)
Measles (1970)
Rubella (1971)
CDT (1975)
Mumps (1982)
ADT (1982)
HepB (serum-derived) (1982)
HepB (recombinant) (1987)
Hib (1993)
HepA (1994)
Pertussis acellular (1997)
Inuenza (1999)
Pneumococcal polysaccharide (23vPPV) (1999)
Pneumococcal conjugate (7vPCV) (2001)
Varicella (2003)
Meningococcal C conjugate (2003)
dTpa (2004)

19651974

19751984

19851994

19952004

20052014

HPV (2007)
Rotavirus (2007)
Pandemic inuenza vaccine (2009)
Pneumococcal conjugate (10vPCV) (2009)
Pneumococcal conjugate (13vPCV) (2011)

New combinations

Key events

IPV changes to OPV (1966)

MM (measlesmumps) (1982)

Targeted hepB for high-risk (1982)

MMR (1989)

DTPw 45 year booster (1994)

DTPa (1997)
Hib-hepB (2000)

ACIR established (1996)

NCIRS established (1997)
ATAGI established to advise the Federal Health
Minister (1997)
Rotashield rotavirus vaccine associated with
increased risk of intussusception (1998/1999)
Lancet published case series by Wakeeld
(1998)19
Universal hepB infant programme (2000)
OPV changes to IPV (2005)
Funding advisory function of ATAGI transferred
to PBAC (2005/2006)
HPV register established (2008)
Adult pertussis booster vaccine for adults in
contact with infants < 6 months (2009/2010)
WHO declares Australia polio free (2010)
Lancet retracts Wakeeld publication (2010)
Inuenza vaccine and febrile seizures (2010)
HPV vaccine for teenage boys (2013)
95% coverage rate target announced for infants
(2014)
WHO declares Australia to be in a measles
elimination phase since at least 2009 (2014)

Hexavalent and pentavalent

DTPa vaccines (e.g. DTPa-hepBIPV-Hib (2005)
Hib-MenC (2013)
MMRV (2013)

Adapted from reference.1

Variable funded programmes in different states and territories. 23vPPV, 23-valent pneumococcal polysaccharide vaccine; 7vPCV, 7-valent pneumococcal
conjugate vaccine; ACIR, Australian Childhood Immunisation Register; ADT, adult diphtheria-tetanus; ATAGI, Australian Technical Advisory Group on
Immunisation; CDT, child diphtheria-tetanus; DTPa, diphtheria-tetanus-pertussis, acellular; dTpa, diphtheria-tetanus-pertussis, acellular (reduced antigen
content); DTPw, diphtheria-tetanus-pertussis, whole-cell; HepA, hepatitis A; HepB, hepatitis B; Hib, Haemophilus Inuenzae type B; HPV, human
papillomavirus; IPV, inactivated polio vaccine; MenC, Meningococcal conjugate; MMR, measles-mumps-rubella; MMRV, measles-mumps-rubella-varicella;
NCIRS, National Centre for Immunisation Research and Surveillance; OPV, oral polio vaccine; PBAC, Pharmaceutical Benets Advisory Committee; WHO,
World Health Organization.

pneumococcal disease (2001), meningococcal C disease (2003)

and more recently pneumococcal vaccines with broader serotype protection (2011).
Most medical students and paediatricians now complete their
training without having seen a single case of Hib epiglottitis.
However, the capsule of serogroup B meningococcus mimics
brain glycoproteins and is poorly immunogenic at all ages, so
meningococcal disease persists. A prolonged outbreak of

serogroup B meningococcus in New Zealand, particularly in

Maori and Pacific peoples, led to the development of outer
membrane vesicle vaccines that were moderately immunogenic
but have limited use for other strains of serogroup B meningococcus.4 New outer membrane protein-based serogroup B
meningococcus vaccines have been developed, including
Bexsero, Novartis, Basel, Switzerland, which has been licensed
in Australia but is not currently funded.

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Journal of Paediatrics and Child Health 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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Fifty years of immunisation in Australia

J Royle and SB Lambert

Preventing Hospitalisations from

Gastroenteritis: Rotavirus Vaccine
In the pre-vaccine era, rotavirus, which was discovered by Ruth
Bishop and colleagues in Melbourne in 1973, was estimated to
cause 10,000 hospitalisations each year in children less than 5
years of age and accounted for 50% of hospital admissions for
gastroenteritis.5
Oral live attenuated rotavirus vaccines were introduced
nationally in Australia in 2007, since inclusion in the National
Immunisation Program rotavirus-coded hospitalisations in Australia have fallen by 71%.6
Post-licensure surveillance identified a small increased rate of
intussusception associated with Rotarix (GlaxoSmithKline,
Brentford, UK) and RotaTeq (CSL Limited/Merck and Co., King
of Prussia, PA, USA) (six additional cases of intussusception
among every 100,000 infants vaccinated or 14 additional cases
per year in Australia).7,8 This information needs to be communicated to health-care providers and the public.

The Use of Immunisations During and

Around Pregnancy
Up to 90% of infants born to mothers infected with rubella in
the first trimester are born with abnormalities that form part of
congenital rubella syndrome (CRS). In 1941, a Sydney ophthalmologist Norman Gregg overheard conversations between
mothers of babies born with cataracts in his waiting room saying
they had German measles (rubella) in the first trimester.9 Gregg
studied the mothers and babies and showed most had positive
rubella serology. His description of rubella virus embryopathy
led to the development of a vaccine, which was introduced into
Australia in 1971 in the form of schoolgirl vaccination. Greggs
paper pre-dated the thalidomide disaster and was truly remarkable as the first occasion anyone recognised that an external
agent affecting the pregnant mother could harm the fetus.
The ability to vaccinate females against rubella reduced the
incidence of rubella embryopathy in Australia but cases continued. In 19931994, rubella immunisation, delivered as
measlesmumpsrubella (MMR) vaccine, was introduced for all
Australian adolescents, male and female, and in 1998 it was
moved to a universal two-dose infant programme with a preschool booster. This is an interesting example of altruistic
immunisation: boys are immunised more to protect girls (and
the boys future children) than to protect the boys themselves.
Between 2004 and 2008, only two cases of CRS were reported
in Australia, both to mothers born outside Australia.1
Women born overseas in countries without high coverage of
rubella immunisation are an important target group for
catch-up MMR immunisation prior to pregnancy in Australia.10
There is appropriate concern about giving unnecessary medications or vaccines to pregnant women. However, certain vaccinations during pregnancy can be used to the advantage of both
the pregnant woman and the fetus.
Seasonal influenza infection is a threat to all pregnant women
as it causes a high maternal morbidity and carries risks to the
fetus. Maternal influenza immunisation protects the mother
and her infant against influenza.11,12 The World Health
Organization and the Australian Technical Advisory Group on
18

Immunisation recommend that inactivated influenza vaccine

should be given to women at any stage of pregnancy to protect
them and their newborn child from influenza.1
Pertussis booster vaccine given in the third trimester is
safe13 and provides transplacental antibodies that protects the
fetus as well as the mother.14 Third trimester acellular pertussis
vaccine was recommended in the USA in 2011, the UK in
201213 and is included as an option in the Australian Immunisation Handbook 2013.1

The Challenge of Preventing Pertussis

Neither pertussis disease nor pertussis vaccine provides lifelong
protection. The age of highest risk of death from pertussis is the
newborn period and infancy. Maximum protection from the
primary vaccine course is not achieved until after the third dose
at 6 months of age.
Whole-cell pertussis vaccine used in Australia between 1953
and 1997 provided a longer duration of protection than the
acellular vaccines now used but had higher rates of side effects.
Although a child or adult with waning immunity does not
develop life-threatening pertussis, they can infect infants too
young to have completed the primary schedule and at the age of
greatest risk of severe, life-threatening pertussis. Optimising the
protection of infants against pertussis disease requires a combination of reduced chance of exposure, high coverage rates and
timely vaccination. Infants born to mothers given third trimester pertussis vaccine have additional protection until they can
themselves be immunised.1,14

Preventing Liver Cancer and Human

Papillomavirus (HPV)-Associated Cancers
Viruses are an integral part of the causal pathway for certain
cancers. Chronic infection with hepatitis B can lead to liver
cirrhosis and liver cancer. Chronic infection with HPV can lead
to cervical cancer. HPV infection is also associated with a range
of anogenital and oral cancers, in both females and males,
but the causal relationship between virus and cancer is less
clear-cut.
Both HPV and hepatitis B virus can cause infectious asymptomatic disease. Hepatitis B can be transmitted vertically at birth
or horizontally through a range of activities. Opportunistic
catch-up hepatitis B vaccine including unimmunised migrants is
part of an effective national strategy. Hepatitis B is an important
travel vaccine for individuals not already protected.
In 1991, a team led by Professor Ian Frazer developed novel
technology based on virus-like particles leading to the manufacture of vaccines against the two major strains of HPV associated with cervical cancer (16 and 18) and two strains associated
with genital warts (6 and 11).15 In 2007, Australia introduced
the worlds first government-funded HPV vaccination programme for adolescent girls, essentially a population-based
primary prevention strategy against cervical cancer,16 achieving
83% coverage for the first dose and 70% coverage rate for the
full three-dose HPV vaccine schedule in adolescent girls turning
15.16 Rates of high-grade cervical disease, a precursor of cervical
cancer, have declined and to a greater extent in vaccinated than
in unvaccinated women.16 The number of young persons

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Journal of Paediatrics and Child Health 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

J Royle and SB Lambert

attending sexual health clinics with genital warts has plummeted.16 In 2013, Australia also became the first country to
fund HPV vaccination for boys on a cost-effectiveness basis for
improved herd immunity protecting girls from cervical cancer,
as well as reduction of anogenital warts and potential protection
against anogenital cancers in males.

The Australian Childhood

Immunisation Register
A register of vaccines delivered, the Australian Childhood
Immunisation Register (ACIR), was established in 1996. It provides invaluable feedback data on childhood vaccine coverage
rates, enabling programmes targeted at areas of lower coverage.
It is also an important source of data for record linkage studies.
At present, the ACIR only records immunisations in children
<7 years of age. Over many years, there have been calls to
expand the ACIR into a whole-of-life register, to capture more
accurate immunisation coverage rates for adolescents and
adults. This would incur substantial costs. However, with expansion and improvements in general practice software making
electronic notification more common, and the increased use of
the personally controlled electronic health record, it may be
possible to incrementally move towards a whole-of-life register
for minimal additional investment.

Closing the Gap

Closing the unacceptable gap in health between Aboriginal and
Torres Strait Islander peoples and non-Indigenous people is a
national priority. Although the gap in infant immunisation coverage rates has narrowed, timeliness remains a problem.
Certain vaccines are specifically recommended for use only
in Aboriginal and Torres Strait Islander peoples or for a broader
age range than for non-Indigenous persons, because of higher
rates of disease.1 Targeted programmes for Aboriginal and
Torres Strait Islander peoples in relation to influenza and
pneumococcal vaccines are hampered by a lack of data
on coverage rates. Routine inquiry about Aboriginal and
Torres Strait Islander identification at health consultations
will improve the information on Aboriginal status in the
community.
In 2005, hepatitis A vaccine was introduced solely for Aboriginal and Torres Strait Islander children in the Northern Territory, Queensland, Western and South Australia because of the
high incidence and morbidity. Evidence of the programmes
success is that, since 2007, hepatitis A infection is less common
in Aboriginal and Torres Strait Islander peoples than in other
Australians.17
The Aboriginal Community Controlled Health Organisations,
Medical Services and Health Centres in metropolitan, regional
and remote Australia have become a vital provider of primary
health care for many members of the Aboriginal community.
First established in Redfern in 1971, there are now more than
150 throughout Australia. These have greatly influenced raising
the childhood immunisation coverage rates and providing
immunisations for all ages.

Fifty years of immunisation in Australia

Immunisation Safety and Adverse Events

Intussusception is a rare but acknowledged vaccine-associated
risk with oral rotavirus vaccines.7,8
Influenza vaccine is known to cause fever and rarely an
associated febrile seizure in infants and children <5 years of age.
In 2010, however, one influenza vaccine in Australia was associated with febrile seizures, and the use of influenza vaccines in
children was temporarily ceased while the issue was investigated. This brand-specific increased rate of a known vaccine
adverse event reinforces the need for surveillance and timely
safety monitoring systems.18
In 2010, the Lancet retracted the 1998 Wakefield paper that
postulated an association between MMR vaccine, bowel disease
and pervasive development disorder, otherwise known as
autistic spectrum disorder.19 A direct causal link between MMR
vaccine and autism has been disproved, but the controversy
lingers affecting MMR immunisation rates.
Resources developed by the National Centre of Immunisation
Research and Surveillance provide helpful information about
vaccine adverse events.20

Why Do We Continue to Immunise Against

Polio, Diphtheria, Measles and Tetanus?
Imported diseases have the potential to spread locally to people
in Australia unprotected by vaccines.
In 2007, a young adult student from Melbourne returned
from a trip to Pakistan with lower limb weakness. He potentially
exposed many contacts before wild poliovirus was isolated
from his stool.21 In 2011, an unimmunised Brisbane woman
died from diphtheria contracted from a friend who had been
overseas.22
Although endemic measles has been eradicated from Australia,1 measles is no longer rare in Australia in 2014. Travellers
returning from countries with endemic measles regularly bring
measles back with them, resulting in secondary measles cases
and cluster outbreaks and exposing infants too young to have
received measles vaccine.
Unlike polio, diphtheria and measles, herd immunity has no
impact on tetanus. Tetanus spores live in the environment and
individuals expose themselves with tetanus-prone wounds
throughout their lifetime, so each individual needs tetanus
immunisation.

Looking Forward from Today

Improving immunisation coverage for all children and adults is
a key priority of the National Immunisation Strategy for Australia 20132018.23 2014 marks the year where the infant target
rates have been raised to 95%, so Closing the Gap to a raised
bar presents further challenges.
Maintaining confidence in immunisations against diseases
that are becoming rare due to the successful immunisation
programmes in Australia has created challenges. We need to
own and discuss potential vaccine side effects with health-care
providers and the community. It is these conversations that
educate our community to feel comfortable proceeding with
immunisations and thus benefiting from the chance to prevent
diseases.

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Fifty years of immunisation in Australia

J Royle and SB Lambert

Australia has a bright future with new licensed, but as yet

unfunded vaccines for meningococcal B disease (Bexsero) and
herpes zoster (Zostavax, Bio CLS, Parkville, Australia) and many
vaccines against other diseases under development. Vaccines
covering more strains of influenza (quadrivalent) and of HPV
(9-valent) have been developed and will soon be introduced.
Achieving high infant coverage rates coupled with opportunistic catch-up immunisations should prevent disease outbreaks
and further reduce the burden of vaccine preventable diseases
in Australia.

References
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Journal of Paediatrics and Child Health 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)