Guidelines for Immunisation Management in Primary Care

Approximately 50% of children aged 3 years and under with a recorded declined immunisation have received a vaccine before, suggesting whānau may still be open to immunisation. This should be kept in mind when navigating conversations about immunisation.

Definition of a Declined Immunisation

A situation where a parent, guardian, or individual consciously decides not to accept a specific scheduled vaccine or group of vaccines that is offered and available.

Principles for declined immunisations

1. A decline should only be recorded after a conversation (see Appendix A), ideally with a clinician or authorised vaccinator. This must be documented in the child’s clinical record.
2. Declines are a “moment in time” and can be revisited and updated, with vaccinations offered and accepted later. Whānau who decline an immunisation must not be labelled “decliners” or “anti-vaccination”.
3. Ensure whānau have opportunities to discuss any concerns with a health professional or other experienced person best able to respond to these concerns
4. When consumers are able to consent to vaccination, they should be offered the choice to catch up and recalls for vaccination should be applied. See the Code of Health and Disability Services Consumers’ Rights.
5. Failed contact attempts by the service (unless conditions outlined in Section 4 are met) or access barriers (e.g. travel, time) do not justify recording a decline. Primary Care should consider opportunities to improve access points for whānau. 
6. Only record a decline for the vaccines that are due or overdue. Advise whānau they will be contacted for future events and in specific situations (e.g. outbreaks or their health risk status changes). 
7. If an individual or whānau express preference for an alternative service (e.g. OIS) do not record declined immunisation. Complete referral to the appropriate service, document in the clinical record, and continue recalls as appropriate. The practice remains responsible for a child’s immunisation while enrolled.
8. A delay (e.g., wanting to wait until a child is older) should not be recorded as a declined event (refer to Section 2). It should be left as overdue in the PMS. Adjust the next recalls accordingly.

Vaccines may be delayed or missed for various reasons.

Definition of a Delayed Immunisation

A situation where a parent, guardian, or individual consciously decides (or is advised due to clinical contraindication) to defer a specific vaccine or group of vaccines that is offered and available, because either:

• There is a temporary contraindication (e.g., illness / treatment that requires the vaccine to be medically delayed, or caregiver illness) AND / OR
• They want their child to be vaccinated, but they have requested a delay AND / OR
• They are hesitant about vaccinations and require additional support / resources to make an informed decision.

Principles for delayed immunisations

1. Children or whānau choosing to delay vaccination should remain overdue in the PMS and not be referred to OIS, unless they meet referral principles in section 4 (e.g., significant access barriers). The above applies even if children reach the overdue age for outreach referral in Section 3
2. Practices must contact local AIR teams to communicate whānau decisions to delay vaccination, to ensure clear documentation in PMS and AIR. Notifying AIR teams supports robust coordination and OIS referral prioritisation.
3. Ensure hesitant whānau are engaged and have opportunities to discuss their concerns with a health professional or other experienced person best able to respond to these concerns.
4. All whānau must be advised of the risks in delaying vaccination for their tamariki.
5. Secure future appointments at the time; use practice staff for reminders/calls and offer support with attendance if needed.
6. For children with longer term medical contraindications, check specialist recommendations for when vaccines can be re-commenced and ensure recalls are set up and appropriate high-risk schedule applied. If possible, liaise with specialist teams to support hospital vaccinations.

OIS provide vaccination for individuals / whānau. They provide immunisation services for children who: 

• are aged 0-6 years (inclusive) and
• are overdue for vaccination (refer to Section 3) and
• have not been vaccinated or have not engaged despite the practice following best practice guidelines in this document.

OIS are not contracted to provide services to:

• whānau who have categorically declined vaccines in principle
• children who require BCG (tuberculosis) vaccination.

Principles for OIS referrals

If you know the whānau and consider health / access / other family arrangements will make presentation at 6 weeks unlikely, then refer to OIS immediately. Otherwise, the following apply:

1. OIS referrals should be prioritised for children who are unlikely to engage with the practice. As per the PHOSA, practices are expected to manage immunisations for children / whānau who have previously been vaccinated or engaged by the practice.
2. Children should not be referred to OIS until three contact attempts have been unsuccessful, as per the Pre-calls / Recalls section of this document.
3. Children should not be referred to OIS if simple access barriers (see Appendix A) are identified as preventing presentation to primary care. Practices should consider addressing these or link with support providers where necessary.
4. An understanding of local OIS providers is helpful for assessing
   - if a child / whānau is more likely to engage with the OIS due to cultural / language / other factors.
   - if there are significant access barriers that require home visits. 
5. OIS does not permanently enrol patients. Its purpose is to catch up vaccinations and re-engage whānau with primary care. 6 If whānau who have been referred to OIS for immunisation present to practice, offer vaccination (see contraindications).

Prioritise immunisation recalls based on need

• Recall whānau experiencing higher barriers to access first (e.g., those with disabilities, complex health needs, or higher deprivation areas).
• Assign staff to re-call tasks who are appropriately qualified and where possible who are able to build trusted relationships (e.g., can meet cultural and language needs).

Offer opportunistic immunisation

• Practice staff can use patient alerts or recalls identifying attending pēpi who will soon be due, or who have overdue immunisation. If the opportunity arises, casual patients should be offered vaccination.
• Do not postpone or cancel immunisation appointments for pēpi or others that are mildly unwell. Ensure all staff are aware of true contraindications for immunisation.
  Visit the Immunisation Handbook or IMAC for further information.

Ensure your practice feels safe to whānau with pēpi: 

• Ensure the practice feels warm, inviting and safe for whānau and infants.
• Offer dedicated childhood immunisation clinics (e.g., ‘Well-Child Saturdays’) and ensure safe access separate from respiratory clinics, to reassure whānau.
• Welcoming attitudes from reception, practice staff, and clinicians can make a big difference to supporting whānau to feel culturally safe and comfortable to bring several children to the practice without being judged.