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.  

STEP 1 - DOES YOUR TRAVELLER NEED CHOLERA VACCINE? 

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.


STEP 2 - HOW IS THE CHOLERA VACCINE PRESCRIBED?

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

STEP 3 - HOW IS THE CHOLERA VACCINE ADMINISTERED?

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.  

CHOLERA VACCINE FUNDING?

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.  

REGIONAL PROVISION OF CHOERA VACCINE?

* 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: jane@janechiodini.co.uk