​NSW School Vaccination Program
2012 NSW Annual Immunisation Coverage Report
Ebola Virus Disease
Communicable Disease in Child Care

NSW School Vaccination Program

Dennis Meijer, Senior Policy Analyst and Sue Campbell-Lloyd AM, Manager, Immunisation Unit, Health Protection NSW

Introduction

As adolescents have become an increasingly prominent target group for vaccination, school-based service delivery has emerged as an efficient and effective method of providing nationally recommended vaccines to this often hard to reach group.[1] School programs for rubella and then measles-mumps-rubella (MMR) vaccination have been in place in Australia since 1971. Following the introduction in 2003 of meningococcal C vaccine on the National Immunisation Program routinely for infants at 12 months of age with an extensive catch up program, a more systematised approach was introduced to deliver an expanded range of vaccines recommended for adolescents by the National Health & Medical Research Council (see the Australian Immunisation Handbook, 10th edn.). The Australian Government funds the purchase of vaccines and jurisdictions are responsible for program implementation including the funding of school based service provision. In addition NSW provides catch up vaccination to all students in Intensive English Centres. Here we provide a short overview of the routine NSW program.

Program Infrastructure

Planning for the implementation of the program each year commences in the previous year due to the size of the program and the long lead time required for program resources. These include the revision of the operational protocols that guide the safe, effective and consistent implementation of the program and the development and distribution of Parent Infor​mation Kits to ensure that parents are able to provide informed consent for each vaccine administered in the program. Health Protection NSW (HPNSW) liaises annually with the NSW Department of Education and Communities, the Association of Independent Schools of NSW and the Catholic Education Commission NSW to facilitate sector support for the program. HPNSW also provides funding to Public Health Units to purchase equipment to transport and administer vaccines in the program and employ teams of Authorised Nurse Immunisers. These are specially trained nurses who have completed an immunisation education program at the Australian College of Nursing (or equivalent) and who meet the conditions prescribed in the Authority for Registered Nurses and Midwives to be able to administer vaccines without a medical order. HPNSW also arranges the collection and upload of consent form data to an electronic register.

School Clinics

Public health units liaise with high schools at the end of each year to schedule a number of clinics at each school in the following year. At least two Authorised Nurse Immunisers are rostered on for each school clinic to ensure there is sufficient expertise to safely manage any adverse events following immunisation (AEFI). Parent Information Kits that include a consent form, parent information sheet and privacy statement are delivered to schools at the beginning of the year (based on enrolment numbers) and distributed by school staff to eligible students for parents to read and sign. Public health units also provide schools with advice to include in school newsletters to promote the program. The school coordinator collects the returned signed consent forms, prompts for missing forms and liaises with the public health unit regarding the number of students to be vaccinated. Based on this advice, the public health unit ensures there is sufficient vaccine and equipment available to support the operation of the clinics. On the day of the scheduled clinics, the teams arrive early at the school with the vaccines and equipment to set up the room so that there are clear entry and exit points, desks are arranged for administration of the vaccines and a space can be designated for students to be observed for 15 minutes post-vaccination. School staff are responsible for supervising the movement of students to and from the clinic throughout th​e day. The Authorised Nurse Immunisers conduct a pre-vaccination assessment to confirm student identity, check for illness or medical contraindications to vaccination before administering those vaccines for which a parent has given signed consent. Students are provided with a record of vaccination to give to their parent and local doctor.

Adverse events following immunisation

A number of steps are taken to minimise the risk of AEFIs in the program. Clear advice is provided in the Parent Information Kit that students should not be vaccinated if they have any conditions that increase the risk of an AEFI occurring or have a medical contraindication to vaccination. Students are asked about any illness, allergy or contraindication as part of the pre-vaccination assessment and students are monitored for 15 minutes post-vaccination. All Authorised Nurse Immunisers are trained to manage AEFIs, including anaphylaxis. When a new vaccine is introduced to the school program, enhanced monitoring of adverse events is established to quickly identify any potential vaccine safety signals. As AEFIs are notifiable conditions under the Public Health Act 2010, all AEFIs are reported and forwarded on the same day to the Therapeutic Goods Administration (TGA) for review.

Quality Assurance

Public health units conduct quality assurance audits on school clinics using a standardised audit tool to ensure that the operation of clinics is consistent with the program’s operational protocols. Any issues identified as part of the audits are raised with the school clinic team to ensure best practice. The audit reports are aggregated and forwarded to HPNSW at the end of each school year to monitor program implementation over time.

Program Data

Vaccination coverage rates for the NSW School Vaccination Program are calculated using the number of vaccine doses administered in the program (provided by public health units) and the number of eligible students based on enrolment data (sourced from schools at the beginning of each school year). Public health units provide aggregate data to HPNSW at the end of each school term and these data are used to calculate vaccination coverage rates for each vaccine and monitor trends over time. Program coverage data are available on Health Statistics NSW. In addition to aggregated coverage data, completed consent forms are collected from public health units at the end of the school year and scanned using Optical Character Recognition (OCR) and uploaded to an electronic register. HPV vaccination data is also forwarded to the National HPV Vaccination Program Register to assist with program evaluation.

Changes over the years​

There have been significant changes to the vaccines offered in the program over time and in the recommended cohorts for some vaccines:

  • In 1988, NSW conducted a Bicentennial measles campaign which offered measles vaccine to all child care and primary school age children.
  • In 1998 the national Measles Control Campaign, which was the first national mass vaccination program since the 1950s polio campaigns, offered measles, mumps, rubella vaccine to all primary school children laying the groundwork that has resulted in the World Health Organization declaration of measles elimination in Australia
  • In 2003 the meningococcal C vaccine was offered to all 1 – 19 year olds over a two year period
  • In 2004 a hepatitis B vaccine catch up program was conducted for Year 7 students who had not received a primary course of vaccine and continued until 2013.
  • In 2007 the three-dose course of human papillomavirus (HPV) vaccine was offered to female students in Years 10-12 . In 2008 it was offered to female students in Years 7 – 10, and routinely to female students in Year 7 from 2009 and was introduced routinely for male students in Year 7 in 2013 with a catch-up program for male students in Year 9 in 2013 and 2014 only
  • a booster dose of diphtheria-tetanus-pertussis (dTpa) vaccine was offered to students in Years 7-12 in 2004, in Year 7 in 2005, in Year 10 from 2009-2012 and has been routinely offered to students in Year 7 from 2010 onwards
  • a catch-up dose of varicella (chicken pox) vaccine has been offered to students in Year 7 since 2006

Which vaccines are currently offered?

In 2014, all Year 7 students are offered HPV, dTpa and varicella vaccination and male students in Year 9 are offered HPV vaccination as part of a national catch-up program. In addition, public health units offered catch-up measles-mumps-rubella (MMR) vaccination in 145 high schools in Terms 3 and 4 as a measles supplementary immunisation activity (SIA). 

HPV vaccination

The primary three-dose course of HPV vaccine is offered to students in Year 7 to prevent the main types of HPV infection that cause cancers and genital warts. Coverage rates for HPV vaccination have increased with the introduction of catch-up vaccination in Year 8 for students who commenced but did not complete the course in Year 7. Given the recent introduction of HPV vaccination for males, the graph below only includes female students to demonstrate changes in coverage rates over time. Coverage data for doses 2 and 3 in 2013 includes catch-up doses provided in Terms 1-3 in Year 8 in 2014 for students who commenced but did not complete the vaccine course in Year 7.

Percentage of Year 7 female student who recieved the human papillomavirus (HPV) vaccine at school, NSW, 2009-2013. The percentage of eligible students who received Dose 1 of the vaccine increased each year from 80% in 2009 to approximately 85% in 2013. The percentage of student recieving subsequent doses also increased from 78% and 68% for Dose 2 and Dose 3 in 2009 to 83% and 80% in 2013. 

dTpa vaccination

A booster dose of dTpa vaccine is offered to students in Year 7 to provide protection against diphtheria, tetanus and pertussis into early adulthood. Coverage rates for dTpa vaccine increased between 2010 (when vaccination for Year 7 students was re-introduced) and 2013 as public health units opportunistically offered the vaccines at several clinics during the school year.

Percentage of Year 7 students who received diptheria-tetanus-pertussis (dTpa) vaccine at school, NSW, 2010-2013. The percentage of eligible students receiving the vaccine increased from 70% in 2010 to 80% in 2013. 

Varicella vaccination

A catch-up dose of varicella vaccine is offered to students in Year 7 who have not previously been vaccinated (usually at 18 months of age) or had chickenpox disease. There has been an overall increase in coverage rates for the catch-up dose of varicella vaccine between 2006 and 2013 possibly due to more children being eligible for vaccination due to a reduction in the incidence of chickenpox in children following the introduction of routine infant vaccination in 2005.

Percentage of Year 7 students who received varicella (chicken pox) vaccine at school, NSW, 2006-2013. The percentage of eligible students receiving the vaccine increased from 33% in 2006 to 53% in 2013. 

Conclusion

The NSW School Vaccination Program continues to be an effective service delivery model to achieve high coverage and protect adolescents from a range of vaccine preventable diseases. Ongoing challenges include the need to maximise consent form return and to ensure there are sufficient Authorised Nurse Immunisers available to support implementation of the program. The Parent Information Kits are reviewed annually to assist with parental compliance with consent for vaccination. HPNSW also supports expansion of the Authorised Nurse Immuniser workforce by funding scholarships for registered nurses and midwives to undertake the required immunisation education to administer vaccines without a medical order.

More information about the NSW School Vaccination Program is available.

References

  1. Ward, KF, Quinn, HE, Menzies, R and McIntyre, P. A history of adolescent school-based vaccination in Australia. Communicable Diseases Intelligence, 37 (2): 168-174. https://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3702-pdf-cnt.htm/$FILE/cdi3702j.pdf

2012 NSW Annual Immunisation Coverage Report

The National Centre for Immunisation Research and Surveillance develops an annual immunisation coverage report for NSW as part of its Memorandum of Understanding with NSW Health. The report is an opportunity to review how NSW is performing in relation to maximising immunisation coverage rates, particularly with children.

The report for 2012 found that the National Immunisation Program was successfully implemented in NSW with vaccination coverage rates above 90% for children at 1, 2 and 5 years of age and above 80% for adolescents for the first and second dose of human papillomavirus (HPV) and the single dose of diphtheria-tetanus-pertussis (dTpa) vaccine. The report identifies a number of ongoing challenges, including vaccination delay in Aboriginal children.

The complete 2012 NSW Annual Immunisation Coverage Report is available.

Ebola Virus Disease

Greer Dawson, Public Health Officer Trainee, NSW Ministry of Health

Ebola virus is a virulent pathogen that can cause severe haemorrhagic fever in both human and non-human primates. In past outbreaks, case fatality rates in humans have been as high as 90%.[1] In the absence of both prophylaxis and treatment, Ebola virus is an important public health pathogen and biological threat,[2] and is of particular concern given the current outbreak in West Africa remains out of control.

Ebola virus is a filovirus belonging to the virus family called Filoviridae. There are five distinct species of Ebola virus: Tai Forest, Sudan, Zaire, Reston and Bundibugyo. Reston is the only filovirus that is not known to cause severe disease in humans, although it can be fatal in monkeys.[2] It is a classic zoonosis with persistence of the virus in a reservoir species generally found in endemic areas. Apes and humans are susceptible to Ebola and are regarded as end hosts rather the reservoir species.[2] Until recently the reservoir was unknown, however evidence of asymptomatic infection by Ebola virus in fruit bats suggests that they could be the natural reservoir [3] It is thought that outbreaks occur following introduction of the virus is into human populations via handling of an infected animal carcass. Human to human transmission then occurs through direct contact (via broken skin or mucous membranes) with blood or body fluids of an infected patient during the acute phase of illness.[4] Contact with cadavers during preparation and funeral procedures pose a significant risk for transmission.[4]

Onset of symptoms occurs abruptly following an incubation period of between two and 21 days. Early symptoms are non-specific and are characterised by fever, chills and myalgia followed by diarrhoea, vomiting, and impaired kidney and liver function. Cases progress to septic shock and multi organ failure, and may be accompanied by profuse internal and external bleeding,[2] although in the current west Africa outbreak bleeding has not been as prominent as in previous outbreaks.[6] While experimental treatments are available, there is no specific vaccine or treatment that has been proven to be effective against Ebola virus disease. In the absence of treatment, symptoms are managed as they appear, and care is largely supportive.[7] Prevention measures aimed at reducing risk of transmission are also critical.

The largest outbreak to date began in December 2013 in Guinea in west Africa, quickly spreading to neighbouring countries Sierra Leone, Liberia, Senegal and Nigeria. As at 21 November a total of 15,351 probable, confirmed and suspected cases have been reported in six affected countries (Guinea, Liberia, Mali, Sierra Leone, Spain and the United States) and two previously affected countries (Nigeria and Senegal). There have been 5,459 deaths.[8] Figure 1 shows the total number of cases and deaths from Ebola virus disease by country.

Figure 1: Total number of cases deaths from Ebola virus disease by country, 2014.
The total number of case deaths from Ebola virus disease by country in 2014. Of a total 15351 cases, 5459 resulted in death. In decreasing order: 7082 cases in Liberia resulted in 2963 deaths; 6190 cases in Sierra Leone resulted in 1267 deaths; 2047 cases in Guinea resulted in 1214 deaths; 20 cases in Nigeria resulted in 8 deaths; 6 cases in Mali resulted in 6 deaths; 4 cases in USA resulted in 1 death and 1 case each in Senegal and Spain resulted in 0 deaths.
Source: WHO[8]

Containment of the current outbreak has been challenged by poor health infrastructure and inadequate resourcing. The number of cases has far exceeded health system capacity, which has led to more cases and a collapse of the health system.[9] Stigma and fear, as well as a number of cultural issues have also presented as significant challenges for prevention. Additionally, the socio-political and economic conditions in west Africa (including the relative poverty that leads to the consumption of bush meat in the first place) should be considered for the role they have played in both instigating and perpetuating the current outbreak. These provide important lessons for the prevention and management of Ebola virus disease in the future.

References

  1. Leroy EM, Gonzalez JP, Baize S. Ebola and Marburg haemorrhagic fever viruses: major scientific advances, but a relatively minor public health threat for Africa. Clinical Microbiology and Infection. 2011;17(7):964-76.
  2. Feldmann H, Geisbert TW, Feldmann H, Geisbert TW. Ebola haemorrhagic fever.(Disease/Disorder overview). The Lancet. 2011;377(9768):849.
  3. Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassanin A, Yaba P, et al. Fruit bats as reservoirs of Ebola virus. Nature. 2005;438(7068):575-6.
  4. Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al. Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites. Journal of Infectious Diseases. 2007;196(Supplement 2):S142-S7.
  5. MacNeil A, Rollin PE. Ebola and Marburg hemorrhagic fevers: neglected tropical diseases? PLoS neglected tropical diseases. 2012;6(6):e1546.
  6. Centres for Disease Control and Prevention. Ebola Virus Disease [cited 2014 November 27]. Available from: http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html
  7. Feldmann H. Ebola — A Growing Threat? New England Journal of Medicine. 2014;0(0):null.
  8. World Health Organisation. Ebola Response Roadmap Situation Report Update - 21 November 2014 [cited 2014 27 November]. Available from: http://apps.who.int/iris/bitstream/10665/144117/1/roadmapsitrep_21Nov2014_eng.pdf?ua=1
  9. Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014 — New Challenges, New Global Response and Responsibility. New England Journal of Medicine.0(0):null.

Communicable Disease in Child Care

Sophie Norton, Public Health Officer Trainee, NSW Ministry of Health;
Shopna Kumari Bag, Career Medical Officer, Communicable Diseases/ Manager, Infectious Diseases Team, Public Health Unit, Western Sydney Local Health District;
Dennis Meijer, Senior Policy Analyst, Immunisation Unit, Health Protection NSW

Introduction

The number of children attending formal day care in Australia is increasing. A survey carried out by the Australian Bureau of Statistics in 2011 [1] found that 22% of children aged below two years and 54% of two and three year olds usually attended formal day care. As this represents a significant proportion of the population circulation of communicable diseases in child care can have a significant impact on disease burden in the community.

Communicable Disease Risk in Child Care

The immune system of a young child is relatively naïve to the many pathogens circulating in the community. While passive immunity is received transplacentally as maternal Immunoglobulins this is less effective than actively acquired immunity and declines over the first few months of life. Infants also have deficient B-cell responses which increases their susceptibility to a number of pathogens such as polysaccharide coated bacteria [2,3]. Young children also have a decreased knowledge of and ability to manage their own hygiene. The risk of communicable disease transmission is therefore increased in child care compared to the general community as pathogens are more likely to cause disease in this young population, this population is concentrated in one area and there is increased means of transmission.

A number of studies support this assumption that attendance at child care centres leads to increased exposure to some common communicable diseases [4,5]. Further to this these studies indicate that entry into child care and therefore exposure at a particularly young age afforded little to marginal protection in the later years of child care. The risk of exposure to harmful communicable diseases also extends to staff working in child care. A study looking at females of child baring age in Amsterdam found that child care workers have higher seroprevalence rates for Parvovirus B19 1.2 (95% CI 1.1-1.3) and Cytomegalovirus 1.7 (95% CI 1.3 – 2.3) than non-child care workers [6].

Common Childhood Infectious Diseases

Gastroenteritis is a commonly experienced illness in child care (Figure 1). Often the cause of outbreaks, most gastroenteritis in children is of viral origin which can be transmitted directly or indirectly by the faecal oral route and can be air borne [7]. Norovirus is one of the most common causative pathogens [8] as was rotavirus until the introduction of the rotavirus vaccine to the Australian NIP in 2007. This greatly decreased the prevalence and therefore reduced the great morbidity that was associated with rotavirus [9].

Respiratory illness is prevalent in children aged less than five years. While common causative pathogens include rhinovirus, enterovirus, respiratory syncytial virus and influenza, illness caused by the bacterium Bordatella pertussis is of particular concern due to apnoeic episodes that can be experienced by infants and the prolonged period of severe paroxysmal coughing that can follow untreated infection [7,10]. Transmission of the bacteria is by large droplets and direct contact with respiratory discharges. Public health actions in child care focus on protecting infants who have not completed their primary course of pertussis containing vaccine [10,11].

Fifth disease caused by parvovirus B19 and hand foot and mouth disease caused by enteroviruses such as Coxsackie virus A-16 and Enterovirus 71 are common illnesses experienced as outbreaks in child care centres. Both usually cause fairly mild illness and have rashes which are distinctive to them but they have been associated with more severe illness as well. Parvovirus B19 can cause severe chronic anaemia to immune compromised individuals including foetuses of pregnant women [12]. Hand foot and mouth disease can be associated with increased rates of neurological disease such as meningitis [13].

Prevention and Control

Good policy development regarding infectious disease prevention by child care centres is necessary. This is guided by the Education and Care Services National Regulations [14] with referral to comprehensive resources such as the Staying Healthy manual [15]. Key to preventing spread of communicable diseases is adherence to exclusion periods for suspected cases and notification of diseases as outlined by NSW Health [16] for comprehensive contact follow up. Providing information to parents when cases occur and encouraging them to keep their child at home if they display symptoms is both important and a challenge.

Childhood Immunisation

The National Immunisation Program (NIP) provides free vaccines at the recommended milestones to provide protection against a range of vaccine preventable diseases that were once common in childhood. A study carried out in an area of Sydney with low immunisation rates and a high proportion of overseas-born residents identified factors responsible for differences in knowledge and uptake of childhood immunisation. Key individual factors included poor knowledge and a family’s socio-economic wellbeing. Health system factors included access issues, difficulties in developing catch-up vaccinations for overseas-born children, lack of reporting of overseas vaccinations to the Australian Childhood Immunisation Register, and lack of uniformity of vaccination records provided for childcare and primary school enrolments. [17]

Legislative changes

Vaccination requirements for children enrolling in child care were strengthened with recent amendments to the NSW Public Health Act 2010 and the NSW Public Health Regulation 2012. From 1 January 2014, child care centres cannot enrol a child unless the parent/guardian has provided documentation that shows that the child:

  • is fully vaccinated for their age; or
  • has a medical reason not be vaccinated; or
  • has a parent/guardian who has a conscientious objection to vaccination; or
  • is on a recognised catch-up schedule if their child has fallen behind with their vaccinations

NSW Health works in partnership with the NSW Department of Education and Communities (DEC) to monitor compliance with the new requirements by ensuring that DEC inspectors routinely check that the required documentation is kept on file as part of routine regulatory activities. More information about the changes to vaccination requirements for children enrolling in child care is available.

Figure 1: Number of notified cases of gastrointestinal symptoms in children and staff and counts of outbreaks in child care centres, NSW, 2009-2014.
notified cases of gastrointestinal symptoms in children and staff and counts of outbreaks in child care centers fluctuate wildly and irregularly. The lowest reported cases was in June 2014 (6 - 1 staff and 5 children) and the highest reported cases was in September 2012 (41 - 90 staff and 500 children).
Source: NSW Notifiable Conditions Information Management System

References

  1. The Australian Bureau of Statistics. Childhood Education and Care, Australia, June 2011, http://www.abs.gov.au/ausstats/abs@.nsf/Products/4402.0~June+2011~Main+Features~Main+features?OpenDocument, (Accessed 20 July 2014).
  2. PrabhuDas M, Adkins B, Gans H et al. Challenges in infant immunity: implications for responses to infection and vaccine. Nature Immunology, 2011, 12(3):189-194. http://www.nature.com/ni/journal/v12/n3/full/ni0311-189.html
  3. Van den Berg JP, Westerbeek EAM, van der Klis FRM et al. Transplacental transport of IgG antibodies to preterm infants: Review of the literature. Early Human Development, 2011, 87:67-72.
  4. Bradley RH, National Institute of Child Health & Human Development (NICHD Early Child Care Research Network. Child care and common communicable illnesses in children aged 37 to 54 months. Arch Pediatric Adolesc Med, 2003 Feb, 157(2): 196-200.
  5. Zutavern A, Rzehak P, Brockow I et al. Day care in relation to respiratory-tract and gastrointestinal infections in a German birth cohort study. Acta Paediatrica, 2007, 96(10):1494-1499. DOI: 10.1111/j.1651-2227.2007.00412.x
  6. Van Rijckevorsel GGC, Bovee LPMJ, Damen M et al. Increased seroprevalence of IgG-class antibodies against cytomegalovirus, parvovirus B19, and varicella-zoster virus in women working in child day care. BMC Public Health, 2012, 12(475):2-8. doi:10.1186/1471-2458-12-475.
  7. Heyman DL (Ed). 2008. Control of Communicable Diseases Manual (19th Ed). American Public Health Association,
  8. Elliot JE. Acute gastroenteritis in children. BMJ, 2007, January vol 334:35-40.
  9. Buttery JP, Lambert SB, Grimwood K et al. Reduction in Rotavirus-associated acute gastroenteritis following introduction of the Rotavirus vaccine into Australia’s National Childhood Vaccine Schedule. The Pediatric Infectious Diseases Journal, 2011, January, 30(1):S25-S29.
  10. Australian Government Department of Health and Ageing. 2013. The Australian Immunisation Handbook (10th edition). Canberra: DoHA; http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home (Accessed 22 July 2014).
  11. National Guidelines for Public Health Units, Pertussis SoNG, 1 July 2013, Communicable Diseases Network Australia; http://www.health.nsw.gov.au/Infectious/controlguideline/Pages/pertussis.aspx​ (Accessed 20 July 2014).
  12. Beigi RH, Wiesenfeld HC, Landers DV et al. High rate of severe fetal outcomes associated with maternal Parvovirus B19 infection in pregnancy. Infectious Diseases in Obstetrics and Gynecology, 2008, (vol. 2008):1-4. Article ID 524601, doi.org/10.1155/2008/524601.
  13. Enhanced surveillance for enterovirus-associated neurological disease in children Report 8, NSW Health; http://www.health.nsw.gov.au/Infectious/alerts/Documents/EV_Surv_Report_8_to_23June2013.pdf (accessed 17 July 2014).
  14. Ministerial Council for Education, Early Childhood Development and Youth Affairs. Education and Care National Regulations, 9 December 2011, http://www.acecqa.gov.au/national-regulations, (accessed 15 July 2014).
  15. National Health and Medical Research Council, Australian Government. Staying Healthy: preventing infectious diseases in early childhood education and care services (5th Edition), https://www.nhmrc.gov.au/guidelines/publications/ch55 (accessed 20 July 2014).
  16. Disease Notification, NSW Health, NSW Government, http://www.health.nsw.gov.au/Infectious/Pages/notification.aspx (accessed 17 July 2014).
  17. Western Sydney Public Health unit. Barriers to childhood immunisation in Auburn Local Government Area - a qualitative study. Western Sydney Local Health District. March 2014.
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Page Updated: Monday 13 October 2014