Survey to understand the provision of Travel Health in General Practice

On 2nd September  I opened a survey and closed it within four days as there were already 1052 responses, the majority (938) were collected within 48 hours.  Here is a snapshot of some of the preliminary results, although I have quite a bit more work to do on it. Thank you to the many of you who completed the survey, including more information and all the additional comments.  The survey was anonymous with the option to include your e mail (and I will be in touch privately in due course if you did this).   

Preliminary results from the survey

Some comments about initial results 

It was both interesting and reassuring that the majority who responded were still delivering travel health in their GP practices, although the results will have somewhat of a bias, since the initial request for responses were posted on my own Facebook page, which would attract readers who have an interest in travel health. Two other pages were used to post this request and these happened the following day, since the request to share the survey had to be accepted by the pages' administrators.  Both these pages are private access.  These were the General Practice Nurse UK page and the RCN General Practice Nurses Forum page.   

However 38 people said they weren't providing a service in general practice, when this is an essential service within the GP contract and should be available to all registered patients.  Sixty respondents said they were only giving the vaccines, but not performing a pre travel risk assessment or advice and 204 were using the system of one person risk assessing by reading the completed pre travel risk assessment forms then passing the task of vaccinating to a colleague.  

The majority of vaccines were administered using the National PGD templates (signed off locally) with 94% of the respondents saying they used this method, however this included many of those described in c. and d in the image above.  These methods could not be used to administer the vaccines using the PGDs though.  This aspect of the survey in point f. is concerning.  

Why did I create the survey?  

Well it was to obtain a picture of what may be happening, as I have many who contact me concerned they are being asked to undertake travel in a way they are not comfortable.  I am not trying to 'cause trouble' or make life even harder.  I appreciate the pressure in primary care is immense.  However, travel health and the NHS vaccines are given as a public health measure and the fact these newer working practices have been created to save time or because they have 'not been funded' puts the nurses at professional risk and violation of their Code.  All I'm trying to do it raise awareness and protect those of you who are unaware that administration of travel vaccines have to abide within the legislation of the tools you're using (in most cases the PGDs).

I have written an initial short article to explain the situation - please do read it  You can download it HERE.   

Article published in Practice Nurse Journal - Sept/Oct issue 2024 

If you subscribe to the journal it can also be accessed online here. 

I have a free course which again explains these scenarios, but also addressed two further situations.  The course would provide you with a certificate for one hour of learning and most importantly, leads to to the many references to back up the information I'm supplying.  Click HERE

Dilemmas in Delivering Travel Health - a one hour online course.  

Further information

The references within the article are also posted below for ease of access.

References:

1.      British Medical Association. gp-contract-agreement-feb-2020.pdf (bma.org.uk) (See 5.4); 2020 [Accessed 08.09.24]

2.      British Medical Association. Travel medication and vaccinations; 2022.  https://www.bma.org.uk/advice-and-support/gp-practices/vaccinations/travel-medication-and-vaccinations   [Accessed 08.09.24]

3.      Leicester, Leicestershire & Rutland Local Medical Committee Ltd; 2024. https://www.llrlmc.co.uk/focusontravelimmunisations  [Accessed 08.09.24]

4.      Royal College of Nursing: career and competence development; 2023 https://www.rcn.org.uk/Professional-Development/publications/rcn-travel-health-nursing-uk-pub-010-573   [Accessed 08.09.24]

5.      Royal College of Physicians and Surgeons of Glasgow.  Good Practice Guidance for Providing a Travel Health Service; 2020.  https://rcpsg.ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service  [Accessed 08.09.24]

6.      Donovan H, Green D, Jenkins J.  Best practice for medicines management and vaccination.  Practice Nursing 2022. https://www.magonlinelibrary.com/doi/full/10.12968/pnur.2022.33.11.465 

7.      NHN Specialist Pharmacy Service.  Introduction to PGDs – SPS – Specialist Pharmacy Service – The first stop for professional medicines Advice.   https://www.sps.nhs.uk/articles/introduction-to-pgds/  [Accessed 08.09.24]

8.      Office for National Statistics: Travel trends 2023 https://www.ons.gov.uk/peoplepopulationandcommunity/leisureandtourism/articles/traveltrends/2023#visits-abroad-by-uk-residents    [Accessed 08.09.24]

9.      UKHSA.  Immunisation training standards for healthcare practitioners; 2018. https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners  [Accessed 08.09.24]

10. Care Quality Commission.  GP mythbuster 107: Pre-travel health services – Care Quality Commission https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-107-pretravel-health-services  [Accessed 08.09.24]

11. Nursing and Midwifery Council.  Delegation and accountability.   Supplementary information to the NMC Code   https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/delegation-and-accountability-supplementary-information-to-the-nmc-code.pdf [Accessed 08.09.24]

12. The Scottish Government.  Vaccination Transformation Programme – Travel Health Services; 2022.  https://www.publications.scot.nhs.uk/files/cmo-2022-13.pdf  [Accessed 08.09.24]

13. NHS England. NHS Vaccination Strategy; 2023. https://www.england.nhs.uk/publication/nhs-vaccination-strategy/ [Accessed 08.09.24]

I do hope this information helps you to understand the current situation.  

Cholera - updated chapter to the Green Book

The much awaited update to chapter 14 of the Green Book on cholera was posted on 1st August 2024.  This chapter is now embedded on the 'Green Book travel chapters' page on the TravelHealthPro website although you can still access it via the conventional route of the UKHSA website as well.  

There are now two oral cholera vaccines available.  Dukoral has been available for some time, and the newer product added to the text is called Vaxchora.  There are significant differences in them as the section from my guide to travel vaccines shows and this updated chart can be obtained from item no. 3 in the TOOLS page on my website.  Vaxchora® is a single dose vaccine, but is also a live vaccine, whereas Dukoral® requires two doses in individuals from 6 years of age and three doses in children from two years up to six years.  

IMPORTANTLY, the Green Book says the two vaccines have different precautions, contraindications and administration instructions, healthcare professionals must check prescribing information carefully.  

Of note, because Vaxchora® is a live vaccine, the Green Book includes the following information

Vaxchora® should not be given to those who: 

• are immunosuppressed (see Chapter 6 Contraindications and special considerations: the green book, for more detail). 
• have rare hereditary problems of galactose intolerance, congenital lactase deficiency, glucose-galactose malabsorption, fructose intolerance, or sucrose isomaltase insufficiency (Vaxchora® contains lactose and sucrose). 
• have received oral or parenteral antibiotics within 14 days prior to vaccination. oral or parenteral antibiotics should be avoided for 10 days following vaccination with Vaxchora®. 
• The immune responses to Vaxchora® may be diminished when this vaccine is administered concomitantly with chloroquine.   Administer Vaxchora® at least 10 days before beginning antimalarial prophylaxis with chloroquine. There are no data regarding concomitant use of Vaxchora® with other anti-malarial drugs.

Some other points of interest in the chapter include:

Indication for use (page 7) - the Green Book says

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

• humanitarian aid workers. 
• persons going to areas of cholera outbreaks who have limited access to safe water and medical care. 
• other travellers to cholera risk areas, for whom vaccination is considered potentially beneficial (e.g. due to their occupation, activities or underlying health problems). 

It has previously been fairly challenging to decide sometimes who the 'other travellers to cholera risk areas' should be but now this sentence in the guidance also provides examples - e.g. due to their occupation, activities or underlying health problems.  The examples in this new chapter (I've highlighted in orange text) possibly makes it easier to determine who should receive vaccine on the NHS as it is now more clearly defined – very often holiday makers just request cholera vaccine when their risk may be exceedingly low and there is not real justification

Information about vaccine storage (page 4) - the Green Book says

Both vaccines should be stored in the original packaging at +2˚C to +8˚C and protected from light.  

However, a new addition to the chapter which is in the SmPC and the PIL for Dukoral® vaccine says the product in the unopened vial and sachet, stored in the outer carton, is stable at temperatures up to 25°C for a period of 14 days. At the end of this period the product should be used or discarded. This information could be helpful for travellers who have fully understood administration instructions and are able to take follow up dose(s) at home. 

Vaxchora® sachets are to be removed from the refrigerator no more than 12 hours prior to reconstitution. Avoid exposure to temperatures above 25°C.

Cholera is perhaps a vaccine less used when seeing travellers in primary care but it is an NHS vaccine which if required following a careful pre travel risk assessment, should be provided in a GP surgery.  For details of this and how you can provide it, take a look at a previous blog I wrote on the topic in April 2022 and please pay particular attention to STEPS 2 and 3.  

Hepatitis B: the green book, chapter 18

 An update to Hepatitis B: the green book, chapter 18 was posted on the website on 9th April 2024 and the update information posted and copied below says that in this new chapter they have 

Updated to remove the single booster dose in healthy immunocompetent adults who have completed a primary course, advice for pre-exposure vaccination of recipients of solid organ transplants, more detail on assessing occupational risk and inclusion of 2 new adult vaccines. Signposting to clinical guidance on management of the pregnant woman, including use of antiviral treatment in third trimester.

That's quite a lot of detail and in this blog I only intend to refer to the updated news I've read in the current chapter in relation to travel health.  Therefore please look at the chapter if you use hepatitis B vaccine for indications other than travel.  This is my interpretation in brief - 

Three new vaccines added

1. Vaxelis® which is used as a 6 in 1 vaccine in the childhood programme given at 8, 12 and 16 weeks.  This is just of interest to be aware of in the programme, because you need to know about this to provide any general vaccines within your pre travel health consultation. 
2. Heplisav B® Use from the age of 18, dose of 20 micrograms - 0.5ml  of two doses on a 0 and 1 month. 
3. PreHevbri® Use from the age of 18, dose of 10 micrograms – 1.0ml of three doses on a 0, 1 and 6 month schedule

Note: Heplisav B® and PreHevbri® both have a black triangle status.  The Green Book says on page 16/17 that both these vaccines may be preferred in those who are likely to have a poorer response to vaccine, or have not responded to other monovalent vaccines.  I would advise you to read the full details in the Green Book about these new vaccines.  They are included in the National PGD template for hepatitis B, but this document specifically states it cannot be used if a hepatitis B vaccine is being given solely for the purpose of overseas travel.  If you were using them for travel purposes you would need to be a prescriber, give under a PSD or develop your own private PGD as hepatitis B vaccines are now a private provision for travel.   

The main update for travel is the preferred schedule of 0, 1 and 2 months which in the previous February 2022 edition of the Green Book chapter said  'for pre-exposure prophylaxis in most adult and childhood risk groups, an accelerated schedule should be used, with vaccine given at zero, one and two months’.  

The rational was that completion rates were achieved with the accelerated schedule in groups where compliance is difficult.  It was thought this was likely to offset the slightly reduced immunogenicity when compared with the zero, one and six month schedule.  

It stated ‘An alternative schedule at zero, one and six months should only be used where rapid protection is not required and there is high likelihood of compliance.  

However in the April 2024 edition of the Green Book chapter, Page 16 stated ‘For pre-exposure prophylaxis in most adult and childhood risk groups, an accelerated schedule should be used (some exceptions discussed below), with vaccine given at 0, 1, 2 and 12 months.

And then on page 17 when going on to discuss boosters, it says ‘the current UK recommendation is that immunocompetent children and adults who have received a complete primary course of immunisation (either 8, 12 and 16 weeks old in babies or the standard 0,1,6 months or accelerated 0,1,2,12 months schedules for children and adults) do not require a reinforcing dose of hepatitis B-containing vaccine’. 

SO MY CONCLUSION WOULD BE

• If giving hepatitis B vaccine for travel, give a schedule of 0, 1, 2 and 12 months now in preference to a 0,1 and 6 month schedule
• Advise the traveller they would not need a further booster
• Take note that from the statement at the current time, once children have had the three doses of hep B in the combined 6 in 1 vaccine at 8, 12 and 16 weeks, there is no recommendation for a follow up booster). 

Hepatitis B resources related to this posting 

Hepatitis B: the green book, chapter 18 - GOV.UK (www.gov.uk) updated April 2024

Hepatitis B vaccinations (bma.org.uk)

See my travel vaccine guide chart in Tools - item no. 3 here.  Below is an extract on the hep B vaccines we could use in a travel context.