Friday 2 June 2023

Ongoing PHEIC for poliomyelitis

I have carried over much of the information I wrote in a blog in December 2019 as it remains relevant, but added in some updated news items as well that have been published more recently.  

Here are the topics covered:
  1. Explanation of the PHEIC for Polio 
  2. Detail about the temporary recommendations and what your travellers need to know
  3. Details about the ICVP and how to obtain them
  4. Details about who to charge for a polio containing vaccine 
  5. NEW - Polio virus found in London

    1. Explanation of the PHEIC for Polio 

    A Public Health Emergency of International Concern (PHEIC) is a formal declaration made by the World Health Organization and one was called regarding polio in May 2014.  As a result, the Emergency Committee (EC) meets every three months under the International Health Regulations (2005) (IHR) to review the situation regarding the international spread of polio virus.  The intent is to stop polio being exported from these countries.  Polio remains a PHEIC - the EC meets every 3 months.  At the time of writing, the 35th meeting had been held. Updates are then subsequently put onto the NaTHNaC (TravelHealthPro) and TRAVAX websites to inform you about this and any other polio information such as cases wild polio virus (WPV) and of circulating vaccine derived polio virus (cVDPV) occurring in other countries.

    Polio will eventually be eradicated, but for now it's about controlling numbers of cases WPV and also cVDPV of which there are 3 strains.  There's a map which illustrates the current day situation.  This data is on the Polio Global Eradication Initiative site which has some excellent information explaining the situation, so maybe take the opportunity to look around.

    2. Detail about the temporary recommendations and what your travellers need to know

    The countries involved and the resultant guidance often change from one EC meeting to another and you will need to check the information on the country specific pages of the website you use to assess risk - TravelHealthPro or TRAVAX,  

    So what do you need to do as a travel health advisor seeing a traveller going to one of these countries and what is the guidance?  The risk groups are divided into 3 categories 

    Group 1: States infected with WPV1, cVDPV1 or cVDPV3.
    Group 2: States infected with cVDPV2, with or without evidence of local transmission
    Group 3: States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV.

    The guidance for all three groups is found on a new Polio vaccination recommendations update which was posted on TravelHealthPro on 12th May 2023 

    The Group 1 guidance is the most important, so for convenience I have also explained it here.  
    • If your traveller is going to one of the destinations in Group 1 for LONGER THAN 4 WEEKS they should be asked to provide evidence of having received polio vaccine IN THE LAST 12 MONTHS when they leave the country
    • This evidence has to be produced on an International Certificate of Vaccination or Prophylaxis (ICVP).  
    • If they can't provide this, they may be given oral polio vaccine immediately on exit and provided with a certificate - all free of charge.  
    • For most travellers this is FINE, but because the vaccine given will be oral polio vaccine (OPV) which is a live vaccine, we wouldn't want certain groups to have it e.g. a pregnant woman, someone who is immunosuppressed (see more detail below).  
    • Therefore certain groups are advised to be vaccinated prior to departure.    
    Please ensure you read the guidance on TravelHealthPro as well.  

    Note, in this updated information it states: A booster dose of IPV-containing vaccine should also be considered for immunosuppressed individuals travelling for less than 4 weeks to an area with circulating wild or vaccine-derived virus if they have not received a dose within the previous 10 years. 

    3. Details about the ICVP and how to obtain them - this is guidance if working in England 

    These need to be obtained by telephoning Communisis on 0191 201 50126 because the online provision via NaTHNaC is no longer available.  See the poster below.  Or you could order them from the WHO online shop here.

    • Guidance on how to complete the certificate is on NaTHNaC here 
    • You are able to charge for just the certificate in a GP setting - the certificate booklet costs just over £1 per unit so could add on a modest amount to allow for the work involved 
    • NaTHNaC does not advise writing yellow fever and poliomyelitis on the same certificate - one ICVP per disease should be given - see details on the guidance page 
    4. Details about who to charge for a polio containing vaccine

    For this detail I would refer you to the content in my blog of December 2019 because the specific information no longer appears to be on TravelHealthPro.  I have also heard of issues over claiming back reimbursement for Revaxis and despite trying to establish what is happening, I haven't been able to establish what the correct process is - I continue to try and find out! 

    5. New Polio virus found in London 
    On 22nd June 2022 there was a press release from UKHSA about Polio virus detected in sewage from North and East London - see here with a useful video explaining more here.  The Vaccine Update in August 2022 also had some helpful information here.  The Guidance: Polio immunisation response in London 2022 to 2023: information for healthcare practitioners was last updated on 24th May 2023.  

    Further resources 
    NaTHNaC factsheet

    Friday 26 May 2023

    4th Edition of RCN Competency document

    RCN Travel Health Nursing: career and competence development was first published in 2007, with subsequent editions coming out in 2012, 2018 and now 2023.  Over the years this publication has helped to shape the practice of travel health, particularly for nurses not only in primary care but also in the private sector.  

    Prior to the third edition, a survey was undertaken to evaluate its usefulness - this makes interesting reading and can be viewed here.  To say the development has been an unpaid 'labour of love' over the years is certainly true and a very challenging one at that on occasions, but we know it's made a difference, which has always been our priority.  

    For example:

    • It has helps to achieve a reasonable length of time for a consultation - still not enough, but better than the original 5 or 10 minutes nurses were allowed in the early 2000s.
    • It has steered fundamental training in travel health to the point that there is awareness a nurse new to travel health needs an initial minimum two days training, followed by mentorship in the clinical setting before seeing travellers in consultations independently. (As opposed to a possible half day travel event as was the case at that time, then the nurse was left to see travellers unsupervised - which made delivery of care very scary and a steep learning curve at the time). Of course this training recommendation should be the same for anyone undertaking travel health - the standard of care should be the same, regardless of whether the person is a doctor, pharmacist or a nurse. 
    • It contains bold statements to point out standards of care that are necessary for best practice - thus empowering the nurse to use this information when they may experience challenges in their workplace, potentially causing them to act outside these standards of best practice. 
    • It has inspired groups of nurses in countries around the world to develop their own sets of guidance specific to their local circumstances. 
    In May 2023, we presented the fourth edition of this publication as a poster at the International Society of Travel Medicine conference in Basel.  To obtain a copy of this click here or on the image below.  

    But for a more detailed summary of what is new in this 2023 edition, I have written a summary document to help you get to grips with the changes - see here

    However in addition to reading this, you will really benefit from reviewing the whole of RCN Travel Health Nursing: career and competence development document. To access it directly click here or on the image below

    We hope you enjoy using it!  

    Monday 16 January 2023

    Updated Malaria Guidelines

    The UKHSA Guidelines for Malaria Prevention 2022 have been published today and although it's now 2023, this publication reflects the changes that happened for 2022 with the anticipated update for 2023 coming out later this year.  


    I have listed 4 points of particular interest and/or where some of the information has been updated 

    1. A new aesthetic appearance of the document to the UKHSA 'blue' from the previous PHE 'maroon'.  Whilst the index and tables, maps etc. have been hyperlinked again to the relevant pages for each topic from the contents page 2 onwards, another really helpful feature is that all the references in Vancouver style have now also been hyperlinked throughout the body of the text as well, to the reference list on page 160 to 169.  Some of these references have then been hyperlinked to the actual documents, where some are available.  

    2. The chapter on 'Bite prevention' starting on page 20, has been updated and there are a few items which have been enhanced and/or expanded.  One which is helpful is more detail about use of repellents in infants.  The publication states: In some circumstances, ACMP advice may differ from that in repellent manufacturers’ product information. When this occurs, the recommendations in these guidelines (which are based on current expert advice from the ACMP) should be followed.

    So for example, in the section on DEET and infants is says, DEET is not recommended for infants below the age of 2 months. If a particular DEET manufacturer’s product information recommends a higher age cut off for use in children, the ACMP guidance should be followed.

    On page 23 there is expanded information about plant-based repellents acknowledging they have become more popular in recent years.  The guidelines comment that for those travellers preferring plant-based repellents, Eucalyptus citriodora oil, hydrated, cyclized is the only active ingredient recommended by ACMP.  So, Eucalyptus citriodora oil, hydrated, cyclized is also an effective repellent.  The guidance goes on to state that 15% DEET slightly outperformed 15% Eucalyptus citriodora oil, hydrated, cyclized as a repellent against Anopheles stephensi under laboratory conditions, but Eucalyptus citriodora oil, hydrated, cyclized remains a very useful repellent. If Eucalyptus citriodora oil, hydrated, cyclized is chosen by the traveller, more frequent application would be required than if DEET were used.  See page 23 for further details.  

    3. The General Issues notes on page 12 should be read as they are helpful and this year they also acknowledge that for doctors and nurses providing travel services in England who are regulated by the Care Quality Commission (CQC), the CQC website confirms that the provision of travel health services includes pre-travel risk assessments and travel health advice including malaria prevention. 

    4. Useful statements (that were previously FAQs) are found on page 77 - 86, but are not detailed in the contents list.  These cover the following topics

    • Malaria prevention advice for travellers going on cruises
    • Once you get malaria, it keeps coming back – true or false
    • Alternative antimalarial drugs which can be used for areas where chloroquine and proguanil are advised if they are unsuitable for a particular traveller
    • Which antimalarial to give to a traveller with a history of psoriasis
    • Which antimalarial to give a traveller who is taking anticoagulants
    • How long a traveller can take different antimalarial drugs
    • Antimalarial drugs which are suitable for women during pregnancy
    • Antimalarial drugs which can be taken by women breastfeeding
    • The easiest way to calculate the correct dose of chloroquine for babies and young children
    • Advice for travellers travelling through areas where different antimalarials are recommended
    • Antimalarial drugs for a traveller who has epilepsy
    • Advice for a traveller with glucose 6- phosphate dehydrogenase deficiency
    • Advice for people working on oil rigs
    • Advice for the traveller on a stopover
    • Doxycycline’s effect on oral contraception
    • Advice for travellers who discontinue chemoprophylaxis on or after return to the UK due to drug side-effects

    Wednesday 10 August 2022

    Polio Virus found in sewers in London

    I posted on my Facebook page on 22nd June about the breaking news that polio virus had been found in sewage samples in London.  An update posted on the UKHSA website today informs that following the discovery of type 2 vaccine-derived poliovirus in sewage in north and east London, the Joint Committee on Vaccination and Immunisation (JCVI) has advised that a targeted inactivated polio vaccine (IPV) booster dose should be offered to all children between the ages of 1 and 9 in all London boroughs.  No clinical cases of polio have been reported to date, but the virus can cause a paralysis and by initiating this vaccination campaign in London, it will ensure a high level of protection from paralysis and help reduce further spread of the virus.  Nationally the overall risk of paralytic polio is considered low because most people are protected from this by vaccination.  The news story for this is found on the UKHSA website here.  

    A great new leaflet for parents explaining the importance of this action has been published here and it's also available to download in other languages from the Health Publications website.  Copies available to order are in Albanian, Arabic, Bengali, Bulgarian, Chinese, Chinese (simplified), Estonian, Hindi, Gujarati, Italian, Latvian, Lithuanian, Polish, Panjabi, Pashto, Russian, Spanish, Somali, Turkish, Tigrinya, Ukrainian, Urdu, Yoruba and Yiddish. It is also available as a braille, British Sign Language (BSL) and large print copy.  The collection is a fantastic resource.    

    Added to this there are inactivated polio vaccine (IPV) booster campaign information materials for healthcare practitioners, including a polio campaign vaccination letter and important guidance to read.  A helpful IPV Booster campaign algorithim poster is also available here or click on the image below.   

    Vaccines used will be Infanrix hexa, Vaxelis, Boostrix-IPV and Revaxis.   Revaxis can be given to children 6 years and older and the PGD updated yesterday for revaxis, included information within the inclusion criteria section for case management in an outbreak situation - see here.  You will find the details of legal mechanisms available to administer the vaccines in the important guidance link above or here.  

    Details of delivery of the immunisation programme have not yet been announced in detail, The guidance so far says the following:

    Communication for general practice and other immunisation providers about the IPV booster campaign roll-out:  NHS London will communicate through existing routes to ensure that vaccine providers are kept up to date with operational delivery matters relating to the IPV booster campaign.

    There's a really helpful video about this polio situation (filmed before the announcement of the vaccination plans) which explains it really well.  See here.  

    Monday 2 May 2022

    Use of Revaxis vaccine - which stock?

    I've recently been asked again about the use of revaxis and the supply of vaccine you must use within General Practice in England.  Here is a brief summary.  

    Revaxis is given as part of the National Immunisation Schedule (the fifth and final dose being given to those 14 years of age - see the complete routine immunisation programme details).   For this purpose, and to catch anyone up if they have not got records of five doses of vaccine to protect against tetanus, polio and diphtheria, then you can use the centrally supplied stock ordered via ImmFrom, delivered by Movianto.   

    If after five doses are recorded, a traveller needs revaxis for travel purposes, for disease protection identified within your pre travel risk assessment, they are still entitled to receive this vaccine as an NHS provision every 10 years.  However, you must not use the centrally supplied stock any longer.  

    The evidence for this is found in chapter 3 of the Green Book on page 21 where is states 'Healthcare professionals should ensure they are using appropriately sourced vaccines for the particular clinical circumstances. Using centrally purchased vaccines for incorrect purposes could prevent NHS patients who require immunisation from being able to access it. If centrally purchased vaccines are knowingly used for non-approved circumstances, particularly private health services, this may also be considered fraudulent'.

    So although in an NHS surgery use of revaxis is NOT private, you must purchase in the vaccine to use for travel and then claim the cost of it back.  The claiming for these vaccines is done on an FP34D form through the NHS Business Services Authority.   

    How do you manage this?

    • Essentially you need to keep two separate stocks of revaxis in your vaccine fridge, clearly labelling which is for which purpose.  
    • Challenges come when healthcare professionals who aren't aware of the rules and infrequently give vaccines, retrieve stock from the vaccine fridge and use the wrong supply then don't inform those who manage the stock take either!  
    • A clear notice and education to all can help but isn't foolproof! Some surgeries actually use the ImmForm stock for all use of revaxis but then if one is given for travel purposes, record this and make sure they order in a dose from their travel vaccine supplier to replace the ImmForm stock. This isn't a foolproof process either and requires good organisation.

    Whoever said travel was simple - so many aspects of the detail behind travel health practice is complex and it is also hard to find the information for anything non clinical.  So I hope this blog helps :-) 

    Thursday 14 April 2022

    Provision of cholera vaccine in a GP surgery

    The question about giving cholera vaccine was recently discussed in a forum posting but it's a topic that is frequently asked so I thought I would do a blog about it 😊 This information applies to England - see the note* at the bottom of this piece for further detail. 

    Cholera vaccine is administered as an ESSENTIAL SERVICE IN GENERAL PRACTICE and therefore a surgery must not charge a patient for the vaccine.  For more details about this - see here.  

    This blog will address the identification of who needs cholera vaccine, how you prescribe it and how it is administered.  


    The decision as to whether or not your patient needs to receive cholera vaccine is based on a careful pre travel risk assessment, including where they are travelling to; the length of time away and the activities they are undertaking.  Having established this information you should then check the county destination on TravelHealthPro.   Also ensure you check the outbreaks present and any news in the country your traveller is going to. The recommendations for use of the vaccine can be seen on page 104 in Chapter 14: Cholera in the Green Book but for convenience, I have also copied the text below.

    Immunisation against cholera can be considered, following a full risk assessment, for the following categories of traveller :

    • relief or disaster aid workers
    • persons with remote itineraries in areas where cholera epidemics are occurring and there is limited access to medical care
    • travellers to potential cholera risk areas, for whom vaccination is considered potentially beneficial.


    If after your risk assessment and discussion with the traveller, you conclude they do need vaccine then how is it prescribed? There are two ways but read the detail under a PGD as well.

    1. On an NHS prescription (FP10) which they would take to the pharmacy, but then in normal circumstances, need to pay the prescription fee, but they are not paying for the vaccine itself.  (see below for comments on administration using this method).  
    2. Under a patient specific direction (PSD) signed by a qualified, registered prescriber before the vaccine is administered.  See here for more details about this process
    3. Under a patient group direction (PGD), There was a national PGD template created in the past, but it is no longer available on the National PGD Template collection page now - see here.   Apparently this is because supplies made under PGDs are required to be appropriately packaged and labelled. Since the availability of such supplies of oral cholera vaccine cannot be assured when writing a national PGD, these oral vaccines are better suited to provision by normal prescription and dispensing services.
    Of note, there is a PGD available in Scotland, published on 01.02.22 but could not be used in England.  See here


    The method of administration is dependant on how this vaccine is prescribed.  Cholera vaccine needs to be stored in the cold chain of +2ºC to +8ºC 
    • If prescribed on an FP10 to take home and self administer, you need to give the traveller instructions for storage of the vaccine, but many would argue 'how can you ensure this will happen in a domestic fridge'.  
    • You could give them an FP10 and instruct them to return the vaccine on collection immediately to the surgery for you to store it in your vaccine fridge (or in some cases the pharmacy will deliver this prescription directly to your surgery) to maintain the cold chain.  
    • If giving under a PSD or PGD, then you would have already ordered the vaccine in to your surgery from the manufacturer (or another supplier) and store it in your vaccine fridge, ready to use when required.  Using this method, you then claim back the cost of this NHS vaccine that your surgery purchased.  Because there are two doses of cholera vaccine (three in the case of children 2-6 years of age) this will require follow up appointments.  
    • Many Medicine Management Committees in CCGs gave instructions that patients were not to be given this oral vaccine to take home to self administer because the cold chain could not be guaranteed.  
    For more details see the Cholera Factsheet from NaTHNaC and for the vaccine Dukoral see here.  


    Whilst Cholera vaccine is an NHS provision, if you are administering it within your surgery you need to purchase it in from the manufacturer (Valneva) or through your preferred vaccine supplier - just as you would the other NHS travel vaccines.  The cost of claiming these vaccines back in done on an FP34 form.  The claims are done through the NHS Business Services Authority - see here.  


    * From 1st April 2022, travel health service delivery in Scotland is no longer provided in GP surgeries, but from their 14 Health Boards, depending on where the individual traveller lives and the systems used in each may well be different.  However, one constant is FitForTravel. When you go onto the website you'll notice a red banner at the top of the page which the travellers are advised to first visit, read the information and then follow up their care if needed.  

    I am unclear how cholera vaccine is provided in Northern Ireland and Wales, but if anyone in those areas can help to provide more information, I am very happy to include it in this blog.  Please e mail me: 

    Friday 18 February 2022

    Hepatitis B vaccine and healthcare workers

    Back in November last year, new updated PGDs were released including one for hepatitis B.  To see the collection see here and for the template specifically for hepatitis B here.  

    Remember these template documents require further authorisation in section 2 of the PGD document before they can be used.  I wrote a blog about the process back in 2018.  For those wanting more information about prescribing travel vaccines, see this FAQ.  

    The changes from previous versions are noted in the documents.  One thing that stood out for me on the hepatitis B PGD was that a new change found on page 2 said 'removal of reference to booster doses for healthcare workers'.  

    Back in 2018, a document was published by Public Health England of the time called 'Plan for phased re-introduciton of hepatitis B vaccine for lower priority groups in 2018'.  In it, under 'Booster doses for healthcare workers' it said 'On the advice of the Joint Committee on Vaccination and Immunisation (JCVI), boosters (priority group 5) will no longer be routinely required in healthy, immunocompetent adults who have completed a primary course of vaccine, including healthcare workers who are known responders'.  To access this document click here and see page 8 and directly here.  The group 5 was referred to in this document from the previous year, on page 8.  

    Hepatitis B: the green book, chapter 18 was updated on 4th February 2022.  On page 13 regarding boosters of hepatitis B, it states that healthcare workers (including students and trainees). should be offered a single booster dose of vaccine, once only, around five years after primary immunisation.  

    I'm personally not involved in the immunisaitons of healthcare workers, but for those of you who work in occupational health and are, I thought it may be useful to highlight this information.