Appendix 1: The history of immunisation in New Zealand

During the 1920s the Department of Health, at the instigation of individual school medical officers or medical officers of health, began delivering diphtheria immunisations in a few selected schools and orphanages, but there was no national policy. By 1941 diphtheria immunisation was offered routinely to children aged under 7 years through the School Medical Service and the Plunket Society.

From 1960 the Department of Health programme was delivered by GPs using three doses of non-adsorbed triple vaccine (diphtheria, tetanus and whole-cell pertussis vaccine, DTwP) at ages 3, 4 and 5 months, and a dose of double (diphtheria and tetanus, DT) vaccine before school entry at age 5 years. (For the history of the Schedule’s diphtheria toxoid-containing vaccine history after 1960, see A1.3.14 ‘Tetanus-containing vaccines’).

Haemophilus influenzae type b (Hib) vaccine was added to the Schedule in January 1994, which meant that diphtheria, tetanus, whole-cell pertussis and Hib (DTwPH) vaccine replaced the diphtheria, tetanus and whole-cell pertussis (DTwP) vaccine given at ages 6 weeks, 3 months and 5 months. A monovalent Hib vaccine was given at age 18 months, and a catch-up programme of a single dose of monovalent Hib vaccine was recommended for all children aged under 5 years (ie, those born from January 1989).

From February 1996 the fourth dose was changed to age 15 months and given as DTwPH to reduce the two immunisation events in the second year to one at age 15 months.

DTwPH led to a more than 90 percent reduction in the number of invasive Hib cases in those aged under 5 years but resulted in an increase in the percentage of Hib cases occurring in those aged under 6 months, some of whom had received age-appropriate vaccination. When a supply issue resulted in a change of vaccine in 2000, the opportunity was taken to change to PRP-OMP (polyribosylribitol phosphate outer membrane protein, as Comvax, Hib-HepB combination), which offers substantial protection after a single dose.

This vaccine was used until 2008, when a hexavalent vaccine containing PRP-T Hib component was introduced. This vaccine induces a minimal first-dose response, with some protection after the second dose. It was acknowledged that there was a risk that the change would result in an increase in cases aged under 6 months, but this risk was outweighed by the benefit of reducing the number of injections at each of the first three visits and the reduction in IPD with the introduction of pneumococcal conjugate vaccine (PCV7).

The Hib component of Infanrix-hexa, PRP-T, requires a primary course of three doses with a booster dose at age 15 months, though some protection is induced after the second dose.

In 2006, Hib-PRP-T was funded for older children and adults pre- or post-splenectomy. In 2014 funding was extended to include other high-risk conditions.

HepB was added to the Schedule gradually, starting in September 1985, when it was offered to newborn babies of HBeAg‑positive mothers. Three 10 µg doses of plasma-derived vaccine were given, as recommended by the manufacturer. In March, 1987 the immunisation programme was extended to newborns of all HBsAg‑positive mothers and to children born in certain high-risk districts (Northland, Takapuna, Auckland, South Auckland, Rotorua, Napier and Gisborne).

In 1988 a universal infant vaccination programme was introduced using four low doses (2 µg) of the plasma-derived vaccine H-B-Vax. A catch-up campaign for all preschoolers was undertaken in 1989, and household and sexual contacts of HBsAg‑positive women identified during antenatal screening were also entitled to free immunisation.

In December 1988 H-B-Vax was replaced by a recombinant vaccine, Engerix-B. This was given at the manufacturer’s recommended dose (10 µg) at 6 weeks, 3 months and 15 months of age. Babies of carrier mothers also received a dose of vaccine, plus HBIG at birth. From February 1990 free hepatitis B immunisation was extended to all children aged under 16 years.

In February 1996 the third dose of HepB was brought forward from 15 to 5 months of age to give early protection to infants and to complete the HepB schedule in the first year of life, in the expectation that this would improve vaccine uptake. This schedule continues in 2020, with 10 µg given at ages 6 weeks, 3 months and 5 months as DTaP‑IPV-HepB/Hib (Infanrix-hexa). For infants born to HBsAg-positive mothers, an additional dose of HepB plus HBIG is given at birth.

In 2014, HepB was made available to individuals at high risk of hepatitis B disease or its complications. In 2015, funding was extended to include other high-risk conditions.

Human papillomavirus (HPV) vaccination, using Gardasil, a quadrivalent vaccine containing virus-like particles (VLPs) derived from HPV types 16, 18, 6 and 11 (HPV4), began in New Zealand on 1 September 2008 and was initially offered only to females born in 1990 and 1991. In 2009 the programme was extended to females born from 1992 onwards. In 2009 and 2010, HPV immunisation was offered through most participating schools to females in school years 8–13.

From 2011 the HPV immunisation was only offered in participating schools to females in school year 8. HPV immunisation was also available through family doctors, local health centres and most Family Planning clinics for females who did not attend a participating school or who did not want to have it at school. In 2013 HPV vaccine was funded (for delivery in hospitals only) for other groups at risk of HPV-related disease; from 2014, high-risk groups have also been able to access HPV vaccine in primary care. In 2015, funding was extended to include other high-risk conditions.

Males became eligible for HPV vaccine in 2017, with funding extended to include all males and females aged 26 years and under. The nine-valent HPV vaccine (HPV9, Gardasil 9) replaced HPV4, and a two-dose schedule was recommended for immunocompetent children aged 9–14 years.

Funded influenza immunisation was introduced in 1997 for people aged 65 years and older. From 1999 the vaccine became funded for younger people (aged from 6 months to 64 years) who were at increased risk of influenza complications. In 2010 funded vaccine was extended to pregnant women, and in 2013 to children aged under 5 years who have been hospitalised for respiratory illness or have a history of significant respiratory illness. In 2015, funding was extended to include other high-risk conditions. In 2018, quadrivalent influenza vaccine replaced the previously used trivalent vaccine.

The measles vaccine was introduced in 1969 for children aged 10 months to 5 years who had not had measles, and for those aged under 10 years at special risk. In 1974 the recommended age for measles vaccine was changed from 10 months to 12 months, and in 1981 it was changed to age 12–15 months. These changes attempted to achieve a balance between too early immunisation, where the vaccine is neutralised by maternally acquired antibody, and the requirement to protect the very young during an epidemic.

MMR (measles, mumps and rubella) vaccine was introduced in 1990 to be given at age 12–15 months in place of the measles vaccine. The dose at age 11 years was introduced in 1992. In 1996 the timing of the first dose of MMR was changed to age 15 months, to be given at the same time as the booster dose of diphtheria, tetanus, whole-cell pertussis and Haemophilus influenzae type b (DTwPH) vaccine.

At the start of the 1997 epidemic, the measles immunisation campaign, using MMR, targeted all children aged under 10 years. During the campaign, the recommended time for the first dose was brought forward to age 12 months, and in Auckland a dose was recommended for children aged 6–11 months, to be repeated at age 15 months.

The national coverage achieved in the campaign is not known, but estimates for the school-aged population range from 55 percent for Auckland to 85 percent for the Wellington region.

In 2001 the Schedule was changed to give the first dose of MMR at age 15 months and the second dose at 4 years. There was a school catch-up programme for the second MMR dose for children aged 5–10 years. This schedule of two doses of MMR at 15 months and 4 years continued.

Vaccine-derived maternal antibody levels, which protect young infants, are lower and wane earlier than the antibody levels derived from natural infection. It is likely that in due course the age of the first dose of measles-containing vaccine will be changed to age 12 months.

In 2014, MMR became available for (re)vaccination following immunosuppression (upon specialist advice).

In 2020, the Schedule changed to recommend the first dose of MMR be given at 12 months and the second dose at 15 months.

In March 2023, the four-component recombinant meningococcal B vaccine was introduced to the routine Schedule at ages 3, 5 and 12 months. An alternative schedule was offered at ages 2, 4 and 12 months. A catch-up programme was available for those aged 12 months – 59 months until 31 August 2025. Targeted meningococcal ACWY and B programmes continued.

Mumps vaccine (as MMR) was introduced to the Schedule in 1990 for children aged 12–15 months. (See section A1.3.6.)

A monovalent pertussis vaccine was introduced by the Department of Health in 1945, and from 1953 it was also available combined with the diphtheria and tetanus vaccine. Routine childhood immunisation began in 1960 using the plain (ie, no adjuvant, not adsorbed) diphtheria, tetanus and whole-cell pertussis (DTwP) triple vaccine. Three doses were given, at ages 3, 4 and 5 months.

In 1971 the policy was altered to two doses of adsorbed triple vaccine given at ages 3 and 5 months. It was believed efficacy would be unaltered and the risk of serious reactions would be reduced. Following this schedule change, there was a progressive increase in hospitalisation rates in 1974, 1978 and 1982. Review of the increase in hospitalisations led to the addition, in 1984, of a third dose of DTwP, given at age 6 weeks, to provide earlier protection. From 1994 whole-cell pertussis vaccine was administered as a quadrivalent vaccine with diphtheria and tetanus toxoids and conjugate Haemophilus influenzae type b (diphtheria, tetanus, whole cell pertussis and Haemophilus influenzae type b – DTwPH).

A fourth dose of pertussis vaccine was added in 1996 (as DTwPH vaccine), given at age 15 months, with the goals of increasing protection in young children and reducing risk of transmission to younger siblings.

Acellular pertussis vaccine was introduced in August 2000, and diphtheria, tetanus and acellular pertussis (DTaP) and DTaP/Hib replaced the whole-cell pertussis vaccines. In February 2002 the vaccine given at ages 6 weeks, 3 months and 5 months was changed to DTaP with inactivated polio vaccine (DTaP-IPV), and a booster dose of DTaP‑IPV was introduced and given at age 4 years to protect children during the early school years and to decrease transmission of the infection to younger children.

In 2006 the timing of the booster components of the pertussis schedule was changed to extend vaccine-induced protection into adolescence. Following the three doses of a pertussis-containing vaccine in the first year of life, booster doses are given at ages 4 and 11 years. Since March 2008 the acellular pertussis vaccine has been delivered as DTaP‑IPV-HepB/Hib for the primary immunisation series, scheduled at ages 6 weeks, 3 months and 5 months; as DTaP-IPV at age 4 years; and as Tdap at age 11 years. In comparison with DTaP, Tdap contains smaller doses of tetanus and diphtheria toxoids and the pertussis antigens.

Since January 2013 pregnant women have been eligible for a booster dose of Tdap vaccine. Initially, this was under the outbreak policy and became part of high-risk funded vaccine criteria in July 2015. In 2014, pertussis-containing vaccines (as DTaP‑IPV-HepB/Hib, DTaP-IPV and Tdap) became available for (re)vaccination of children with certain high-risk conditions. This was extended to high-risk adults (as Tdap) in 2015. In 2019 eligibility for pregnant women was extended to include when given any time in their second or third trimester, with a recommendation it be given from 16 weeks’ gestation every pregnancy, preferably in the second trimester.

In 2020, Tdap replaced Td for adult vaccinations at age 45 years and 65 years. Tdap is only offered at age 45 years for those who had not previously had four tetanus containing vaccinations.

The 7-valent pneumococcal conjugate vaccine (PCV7, Prevenar 7) and the 23-valent pneumococcal polysaccharide vaccine (23PPV, Pneumovax 23) were introduced in 2006 for high-risk individuals. PCV7 became part of the Schedule in June 2008, with four doses recommended at ages 6 weeks, 3 months, 5 months and 15 months.

In July 2011, the 10‑valent pneumococcal conjugate vaccine (PCV10, Synflorix) replaced PCV7 and the 13-valent pneumococcal conjugate vaccine (PCV13, Prevenar 13) was introduced for some high-risk children. PCV13 replaced PCV10 on the Schedule in July 2014. In 2015, PCV13 became available for adults with certain high-risk conditions.

PCV10 replaced PCV13 on the usual childhood schedule in July 2017, with PCV13 and 23PPV continuing for high-risk individuals.

In July 2020, the PCV10 schedule changed to a two-dose primary plus booster given at 6 weeks, 5 months and 12 months. The PCV13 remained at a three-dose primary series plus booster for high-risk individuals, providing an additional dose at age 3 months to the usual Schedule. In December 2022, PCV10 was replaced with PCV13 for all infants as a two-plus-one schedule.

Limited supplies of the Salk vaccine (inactivated polio vaccine, IPV) became available in 1956, and immunisation initially targeted 8- and 9‑year-old children. As supplies improved, immunisation was extended to include all 5–10-year-olds, then children aged 11–15 years, with approximately 80 percent coverage. By 1960 immunisation was offered to everyone between 6 months and 21 years of age (with three doses of vaccine).

The Sabin vaccine (oral polio vaccine, OPV) was introduced in August 1961, initially for children up to age 12 months; eight months later it was made available to all school children. On completion of this programme in September 1962 the vaccine was offered to adolescents and adults.

In 1967 OPV was given with diphtheria, tetanus and whole-cell pertussis (DTwP) vaccine at ages 3, 4, 5 and 18 months. The deletion of the DTwP dose at age 4 months in 1971 meant the OPV dose at age 4 months was also removed. An extra dose of polio vaccine was added at age 5 years in 1980, based on serological data, which showed decreased immunity to poliovirus types 1 and 3 in school entrants.

In 1996, as part of the Schedule changes, the third dose of the primary series was moved back to the first year of life, with OPV given at ages 6 weeks, 3 months and 5 months. The booster dose was moved to age 11 years, to be given at the same time as the MMR and adult tetanus and diphtheria (Td) vaccines. In 2001 the Schedule was changed to give the fourth dose of OPV at age 4 years, at the same time as the second dose of MMR. Students aged 5–10 years in 2001 who did not receive the fourth dose of polio vaccine at age 4 years were offered a dose at age 11 years.

IPV replaced OPV in 2002 and was included in three doses of DTaP-IPV in the first year of life, with a booster at age 4 years. Those children who had not received four doses of polio vaccine were offered IPV with Tdap, as Tdap-IPV (Boostrix-IPV) at age 11 years in 2006 and 2007. From 2008, Tdap has been offered at age 11 years, as all children should now have received four doses of polio vaccine by age 4 years.

Combined diphtheria, tetanus, acellular pertussis, hepatitis B, inactivated polio vaccine and Haemophilus influenzae type b vaccine (DTaP-IPV-HepB/Hib, Infanrix-hexa) replaced DTaP-IPV (Infanrix-IPV) and Hib-HepB (Comvax) on the Schedule in March 2008.

In 2014, IPV vaccine became available for (re)vaccination following immunosuppression.

The three-dose pentavalent rotavirus vaccine (RV5, RotaTeq) was introduced to the Schedule in 2014, for infants at ages 6 weeks, 3 months and 5 months. In 2017, the two-dose monovalent vaccine (RV1, Rotarix) replaced RV5 on the Schedule, for infants at ages 6 weeks and 3 months.

Immunisation with an attenuated rubella vaccine (Cendehill strain) was first offered to all 4-year-old New Zealand children in 1970, the rationale being to prevent transmission of the wild virus in 5–9-year-old children, who were the main sufferers from clinical disease. At the same time, the Department of Health delivered a school-based programme, which succeeded in immunising 95 percent of children aged 5–9 years. The acceptance rate of the preschool entry dose of rubella was only about 40 percent, and many practitioners did not feel it was appropriate to immunise males.

In 1979 the immunisation policy for rubella was altered to offer the vaccine to girls aged 11 years, in school year 7 (form 1). The aim was to immunise females before they attained childbearing age. In 1990 MMR was introduced at age 12–15 months for all children, and rubella vaccine continued to be offered to girls in school year 7. Since 1992 two doses of rubella vaccine – as measles, mumps and rubella (MMR) vaccine – have been offered to all children, the first dose in the second year of life and the second dose at age 11 years. This was changed in 2001, maintaining the first dose of MMR at age 15 months and changing the second to age 4 years. The aim of this strategy was to prevent rubella epidemics, reduce the background incidence of rubella and continue to protect women before childbearing, therefore eventually eliminating CRS.

In 2001 there was an MMR school catch-up programme throughout the country for all children aged 5–10 years who would no longer receive an MMR dose in school year 7. The rubella schedule continued as two doses of MMR offered at ages 15 months and 4 years.

In 2014, MMR became available for (re)vaccination following immunosuppression (upon specialist advice).

In 2020, the Schedule changed to recommend the first dose of MMR be given at 12 months and the second dose at 15 months (see section A1.3.6).

The history of tetanus vaccine use prior to the 1960 introduction of diphtheria, tetanus and whole-cell pertussis (DTwP) vaccine is not well recorded, but tetanus vaccine was widely used in World War II and subsequently by the armed forces. In New Zealand, universal infant immunisation with tetanus toxoid began in 1960 with the use of three doses of triple vaccine. Anyone born before 1960 is less likely to have received a primary series, unless they were in the armed forces. Older women appear to be at particular risk.

The first scheduled vaccine used for infants (from 1960) was the DTwP vaccine, with three doses at monthly intervals at ages 3, 4 and 5 months, and a diphtheria and tetanus (DT) booster before school entry (at age 5 years). A DT booster at age 18 months was added in 1964, primarily to enhance protection against tetanus. There was a change to a more immunogenic adsorbed vaccine in 1971, and the dose given at age 4 months was dropped.

In 1980 the dose of DT given at age 5 years was replaced by the monovalent tetanus toxoid given at age 15 years, as part of a move from 10-yearly to 20-yearly boosters for tetanus. It was considered that more frequent boosters were unnecessary and the cause of significant local reactions. There was a return to a three-dose primary series of DTwP (by the addition of a 6-weeks-of-age vaccination) in 1984 because two doses had been inadequate to control pertussis. In 1996 the booster of Td, which had been changed from tetanus toxoid in 1994 (see below), and previously given at age 15 years, was changed to age 11 years.

In 2002 the primary schedule for tetanus, given in combination vaccines at ages 6 weeks, 3 months and 5 months, followed by a dose at 15 months, was changed when a further dose was introduced at age 4 years. The Td given at age 11 years continued.

Since 2006 the childhood schedule for tetanus has been given in combination vaccines at ages 6 weeks, 3 months, 5 months (DTaP-IPV-HepB/Hib), 4 years (DTaP-IPV) and 11 years (Tdap).

Td replaced the tetanus toxoid vaccine in 1994, and 10-yearly boosters were recommended. The change was recommended to maintain the adult population’s immunity to diphtheria, in response to outbreaks overseas affecting adults and the absence of natural boosting because the disease had become rare. Since 2002 adult boosters have been recommended at ages 45 and 65 years (instead of 10-yearly) as a pragmatic attempt to increase coverage in the adult population.

In 2014, Td became available for (re)vaccination following immunosuppression.

In 2020, Td was discontinued and replaced with Tdap for wound prophylaxis and adult booster doses. A Tdap dose is offered at 45 years, for adults who had not previously received four doses of a tetanus-containing vaccine, and at age 65 years.

BCG immunisation was first introduced to New Zealand in 1948 and later extended to all adolescents. BCG immunisation of neonates was introduced in 1976, initially in districts with high rates of active TB.

Universal screening and vaccination of 13-year-olds was discontinued in the South Island in 1963, was phased out in regions of the North Island in the 1980s, and had ceased by 1990. It was stopped because TB had declined to a point at which the advantages of universal vaccination were outweighed by the disadvantages (cost, side-effects and reduced diagnostic value of the Mantoux test). BCG vaccine is now only available to neonates and children aged under 5 years at high risk of TB.

In 2014 two doses of varicella vaccine (VV, Varilrix) were introduced for individuals at high risk of varicella infection. In 2017 one dose of VV was introduced to the Schedule at age 15 months (for children who were born on or after 1 April 2016). One catch-up VV dose was introduced for previously unvaccinated children turning 11 years old on or after 1 July 2017 who had not previously had a varicella infection.

ZV was introduced onto the Schedule on 1 April 2018, as a single dose for adults aged 65 years, with a catch-up programme for adults aged 66–80 years inclusive (the catch up programme ceased on 31 December 2021). In September 2022, live ZV was discontinued and replaced at the age of 65 years with recombinant zoster vaccine (rZV).

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3. Reid S. The further and future evolution of the New Zealand Immunisation Schedule. New Zealand Medical Journal, 2012. 125(1354): 86–99.