Saturday, 30 June 2018

Patient Group Directions for travel vaccines

I for one was very relieved when NHS England started writing templates for PGDs for a selection of the NHS vaccines we use for travel because prior to this locally we had none and were having to use PSDs even to give hepatitis A and typhoid vaccines.  It was quite a nightmare to manage and had been ongoing for some time.

HOWEVER, it is important to note that these template documents require further authorisation, in Section 2 of the PGD document before they can be used. This is a legal requirments and the full details are provided in the second paragraph on the GOV.UK website here but also within the PGDs themselves and the additional signatory boxes are found usually on page 4 of the documents.  Therefore, you cannot download and use the PGDs on the site given above.  Instead you must use the site for your area and sometimes someone within your CCG may send the PGDs to you.  Always check you have the additional authorisation as well, then read the PGD in full before you sign it.  Once done you can administer the vaccines legally after you've done a thorough travel risk assessment.

NHS England have five regional teams as follows

Searching for PGDs on each site above will lead to some - this is what I've found so far!

The London Regional team have a set of the currently available travel vaccines PGDs in one place, as have the South West regional team.

However the other teams seem to have a variety for certain areas only and I've found it confusing.  I need to do some more work on this so keep coming back to review this blog!

If you have been notified of your PGDs by your CCG, just double check that they have the local signature (or signatures) on page 4 as well.  I understand only one signature can be sufficient whereas some areas supply more than one signature.  Some areas also seem to have less travel PGDs available than others but I'll get back with more detail in due course.

I wonder what is happening regarding travel vaccine PGDs in Northern Ireland, Scotland and Wales.  If you can enlighten me, then please make contact and I can add it to the blog.  See here.

Friday, 11 May 2018

Malaria Chemoprophylaxis leaflets

Advising on malaria prevention should be part of our consultations in primary care if a patient is travelling to a malarious area as it would form part of the additional 'service' we are paid for within the 'global sum'.  (For more details of this service see here).

However I'm aware that many now just tell their travellers to go to the pharmacy.  Whilst I appreciate this is part of the challenge we have in the time allotted for a travel consultation, I still feel you should be discussing some of the advice and if malaria chemoprophylaxis is advised for a destination, inform the traveller of the options and come to a joint decision on what they need to take.  At this point it would be sensible to direct them to a pharmacy to obtain them, although always sensible to consider giving a prescription to any pregnant or child traveller when working in primary care as a GP surgery will hold the medical record, not all patients remember their medical and medication history!

To help in the process I've developed some leaflets for the different options for malaria tablets you may be advising.  I designed some in the past, but these new ones not only include information about the tablets and how to take them, but also how to obtain them and then the advice on:

                             Awareness of risk; 
                             Bite prevention; 
                             Chemoprophylaxis and 

This would then provide documentary evidence that you gave the information to your traveller.  I appreciate its a lot of text on the leaflet but information your travellers also need to be given!

They will be found to download at item no. 25 in TOOLS and further information about their use is on this section.  I've also included a leaflet for those who don't need to take malaria tablets but need to be aware of the ABD of advice.

Many now purchase their malaria tablets online for convenience and in some cases to save money.  It's very important we let them know they need to seek a supplier is registered with the MHRA,  I've made this poster below to explain to patients.  This can be found on a 'button' on my Traveller Resources page labelled 'Tips on buying malaria tablets online'. 

Click on the image below to obtain directly - you could print it off and laminate perhaps to show your travellers!

Saturday, 31 March 2018

The provision of travel in an NHS setting

I still get many queries on this topic and many anecdotal stories of different actions a variety of GP practices are taking.  To my knowledge although travel is being reviewed at the moment, little has changed and this is what is supposed to be happening in England (where the queries come from).

Under the GMS contract in England, travel is provided as an 'additional service of vaccinations and immunisations' in a GP practice and payment is made for such in their Global Sum (2%).  Depended on the number of full time GPs, this can be quite a sizable income but many are not actually aware of it.  A GP surgery can 'opt out' of providing the service of travel, but would have to opt out of other services too, such as the pre-school booster, Td/IPV doses to those over 6 who had not completed their five doses for the UK schedule and rabies vaccine for those at risk from rabies from a work related hazard - the full extent of this provision is set out in Annex BA of the Statement of Financial Entitlements (SFE)5 which was published on 30 April 2012 (starting at page 5).

Many surgeries are just stopping the service BUT they cannot do this - they need to inform their CCG, will have the funding taken away and another organisation will need to be found to provide (and be paid) for this NHS service to the NHS patients of the practice deciding to stop.  To decide to stop and keep the money paid into the Global Sum would be fraudulent.

The provision of travel as a service would include:

  • A travel risk assessment
  • Administration of the NHS travel vaccines (hepatitis A and all combined vaccines containing hep A), typhoid, cholera and polio - which would be given as Revaxis to a traveller so the whole vaccine is given as an NHS provision)
  • Appropriate travel advice according the the assessed risk of the trip (including malaria prevention advice)
Full details are on an FAQ page on my website HERE 

In Scotland immunisaiton services have been under review by the Scottish Government and a consultation which concluded that general practice no longer wanted to be responsible for the delivery of the National Immunisation Programme.  Therefore a Vaccine Transformation Programme is being carried out which will include travel.  The programme started this year and is expected to take three years.  

Sunday, 4 February 2018

Mosquito bite prevention advice

I feel mosquito bite prevention advice is crucial to the care we give to travellers.  Bite prevention is essential in the prevention of diseases such malaria, dengue, chikungunya, Zika and although there are vaccines for travellers against yellow fever, Japanese encephalitis etc. prevention of transmission is still important.  However I also recognise that in many of your time constrained consultations, there isn't always time to talk about everything.

So I have created a booklet which you could possibly print off or have displayed on your computer to show to your traveller and maybe select certain pages when you discuss some of the advice.  It has been created in a very visual format.  The image below shows just some of the pages and there is also quite a bit of text so the pages are self explanatory.  Click on the image below to access this educational aid directly or it can also be found in TOOLS, item no. 23 here.

I have also put it on the Traveller Resources page which you could show them so that they could review for further information after the appointment.  A quick way of finding it is to also look for the image 'platform 9¾' at the bottom of the home page. 

Wednesday, 31 January 2018

Malaria Matters - a little history

This is not the first time I've blogged about Malaria Matters!  This is an e learning course which will take you through the Guidelines for malaria prevention in travellers from the UK, published by Public Health England on an annual basis.

In 2008 I was invited by GSK to write the material for this course and work alongside a medical education company to produce an interactive modular course based on the guidelines.  The opportunity was both exciting and daunting at times, but resulted in a CD Rom which was initially launched in 2009 and given out to customers purely as an educational tool and was used for a good two years.  However sadly updating it with new guidelines was a large task and it was decided no longer possible to produce by the company.  However, they very generously allowed me to take over its ownership from that point.

In 2014 I started to develop the course material working with an e learning designer to put the course onto an e learning platform.  It was at this time I won the Triennial Scholarship (of £2000) from the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow and the award helped towards production costs.  For more details of my report see here

Since that time I have developed my own e learning skills such that I've been able to update the work each year in line with the latest guidelines document.  I undertake this work gladly in my own time and receive no income for such.  However to host it on a platform which produces a certificate comes at quite a significant cost and I was keen to continue providing the learning free of charge.

Therefore in 2018 I've moved the course onto a new platform which is in fact a lot easier to use, has no time limit in which to undertake the work and means people can undertake the learning on mobile phones and tablets as well as a computer - the choice is yours!  A certificate of completion also doesn't really prove you learnt anything, so today a written reflection of the learning and how it will change or improve your practice is of far greater worth for your CPD.

I therefore hope people will continue to undertake and learn from Malaria Matters and enjoy the experience.

Click on the image below to access the course directly.  

To see the page on my website for more information see here

Sunday, 31 December 2017

MMR clarification on use of vaccine for travel

Just managed to get a blog done before the end of 2017 and apologies I haven't done many over the past few months, the Autumn has been particularly busy.

Measles remains endemic in many countries around the world and in Europe there have been big outbreaks particularly in Romania, Italy and Germany and imported cases from Romania have led to outbreaks in Leeds, Liverpool, Birmingham and Manchester.  More detail is available on TravelHealthPro  where it reminds us 'elimination can only be sustained by maintaining and improving coverage of the MMR vaccine in children and by using all opportunities to catch up older children and adults who missed out on the vaccine'.

The Vaccination of individuals with uncertain or incomplete immunisation status flowchart published by Public Health England (most recent edition November 2017) has excellent guidance regarding your course of action if doses are missed, and one of the statements is ' Two doses of MMR should be given irrespective of history of measles, mumps or rubella infection and/or age'.

Dealing with people born before 1970 has historically caused a greater quandary, but while the Green Book acknowledges this cohort are more likely to have had all three natural infections and are less likely to be susceptible, it states MMR vaccine should be offered to those who request it or if they are considered to be at risk of high exposure (see page 219).

In the December issue of Vaccine Update it clarifies that ImmForm stock can be used - the exact wording says Central MMR vaccine stock (ordered from Immform) can be used to catch-up anyone of any age – this also covers opportunistic catch-up prompted by travel.  I've been asking this question for many years so its good to have a confirmed answer in writing! Moreover, it says an item of service fee can be claimed manually via the CQRS MMR programme for each dose of MMR administered to patients aged 16 years or over. This includes patients born before 1970 who have no history of measles or MMR vaccination.  See page 5 of the Vaccine Update issue 273.

Thursday, 9 November 2017

MASTA conference

The MASTA conference is being held at the Royal College of Physicians on the 10th November 2017 and I'm doing a one hour update - so much to cover in that time!  I've prepared yet another page of resources to help lead delegates to all the resources mentioned for quick access.  Click on the image below to go to the dedicated section on my website.