Tetanus vaccine: 5 doses?

This isn't travel but because we have to also ensure patients are fully protected with the national immunisation schedule for tetanus I still think it's important.

A little history
For many years I've said once you have had 5 doses of tetanus containing vaccine then you are protected for life within the UK.  Information written in the Green Book chapter on tetanus published in 2005 and 2007 indicated that if you then sustained a tetanus prone you would require treatment which would be tetanus-specific immunoglobulin but such documents are not available online any more.

The Patient Info website on their page here states:
The primary course of three injections gives good protection for a number of years. The fourth and fifth doses (boosters) maintain protection. After the fifth dose, immunity remains for life and you do not need any further boosters (apart from some travel situations). 

We would however, administer more tetanus containing vaccine (in excess of the 5 doses) if someone was travelling to an area where there is risk and it may not be possible to secure treatment for a tetanus prone wound.  In this situation, we would continue to give a tetanus containing vaccine (Revaxis) every 10 years if needed.

New guidance
However new guidelines published by PHE on 9 November 2018 entitled Tetanus: advice for health professional  Guidance on the treatment of tetanus cases and management of tetanus prone wounds leads me to think the limit of 5 doses is not necessarily the case any longer.   The Green Book chapter 30 for tetanus was also updated on 26 November 2018 and provides a more comprehensive perspective of what is a 'tetanus prone wound'.

The table for treatment (page 11) then outlines who should receive treatment and this indicates that even those born after 1961 (when tetanus came into the national immunisation programme) with a history of accepting vaccines (which to my mind means they should have had all five doses) would still have a further dose of tetanus if they sustained a tetanus prone injury and possibly if it was more than 10 years since their last tetanus containing vaccine - but this doesn't actually seem to be stated.

I'm trying to get this verified and will post further information here when I do.  Meanwhile I've highlighted the sections of the table by adding extra comments, which lead me to think this - see below, but if you have a patient in this situation, please always check these resources thoroughly yourself.

Indemnity in General Practice

This posting has been updated because further clarification was posted in May 2019 on the NHS Resolution website.  To see the latest blog click here

Emporiatrics

A little history!

Emporiatrics has been the 'magazine' of the Faculty of Travel Medicine since the Autumn of 2010 when Sandra Grieve and I set it up as a general newsletter.  The publication continued to be produced every 6 months with Sandra undertaking this task as sole editor from Autumn 2013 - until she decided to step down last year.  Sufficient thanks could never be fully expressed for her dedication.  The time and toil of such work cannot be underestimated, taken on by individuals who receive no pay for such, just created with a passion for the subject and a desire to spread news and information to the travel medicine community.  To see these previous publications see here.

In financially restricted times the publication needed to change in focus and direction, so it was decided to put it into an online platform which was mobile friendly - that is the way the world is moving.

The Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow comprises healthcare professionals from a medical, nursing and pharmacy background of differing grades - from those very senior (with formal qualifications, some up to Masters level or have taken Membership exams to be admitted to Fellow, Member and Associate level giving them post nominals) to those extremely new to practice.  The FTM mission is to lead the way in helping to raise standards of practice and achieve greater uniformity in provision of services in order to protect the health of the traveller.  Bringing members in at the Affiliate level is intended to support the largest group of travel health practitioners in UK practice - support and enthuse them to hopefully take further studies and become experts themselves.

Providing support to such a diverse group is challenging, but it is hoped that those more senior would benefit from a subscription in the membership fee to Travel Medicine and Infectious Disease (TMAID) which is the official journal of the Faculty of Travel Medicine and that these individuals get involved to support the work of the FTM - and many do!

Those with an interest in travel medicine, but not trained in the subject can join the FTM as Affiliates for £30 per annum.  This entitles them to reduced subscriptions to educational events, access to the journal TMAID and Emporiatrics which is now being produced three times a year.  However it is intended that the provision of Emporiatrics is primarily orientated to this group of Affiliates - which comprise mostly nurses and pharmacists who are the main providers of travel consultations.

The electronic magazine includes the latest news of FTM activity, a travel health update, FAQs, articles on individual practitioners' passions, hints or tips.  For those who want greater academia, there is a section about TMAID.  The benefit of an online resource is that it can take a user to all sorts of resources in just a click, the variety is great with direct weblinks, videos, downloadable files and a podcast.

Emporiatrics was put together entirely by travel health professional individuals who gave of their time freely, because they felt keen to contribute to the educational arena at this more introductory level and hopefully make a difference ....... to saying nothing of giving colleagues additional support in this challenging field of practice.

If you would like to have a look at this resource click HERE and work your way though it.

Safeguarding Children and Young People

Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff is a new Intercollegiate document published by the Royal College of Nursing on 30th January 2019.  This is the 4th edition replacing the 2014 publication which was previously hosted on the Royal College of Paediatrics and Child Health website.  Today, if working in Primary Care as a nurse, we have to be trained in Safeguarding to Level 3.  I found the most meaningful way of understanding and appreciating the training was in an all day face to face session although I know many undertake this online.

Click on the image below  to access.

PLEASE NOTE: Page 28 also states that the minimum level that should apply to pharmacists is level 2.  Those pharmacists undertaking professional care activities and services in care homes, urgent and emergency care settings, travel clinics, GP practice and out of hours service require level 3 competency.  

This is a substantial piece of work.  Details about Level 3: All clinical staff starts on page 27.  Education, training and learning logs are included in Appendix 4 starting on page 91 followed by a reflective log then outcomes for activities.   These tools for use would be very helpful and also enable the practitioner to form a ‘passport’ for those who move on to new jobs or other organisations.

A useful Press Release from the RCN is available here.

The Faculty of Travel Medicine with support of the Royal College of Physicians and Surgeons of Glasgow were involved the development of this document.

Importantly within this document, a reference (78) is made to the RCN Female Genital Mutilation: RCN guidance for Travel services publication which is another key guide you should be aware of.


The CQC Safeguarding children training position statement of February 2018 described 5 levels of competency and for level 3 they said:

Level 3: All clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns.

For their full documentation see here - stating for review in April 2019

So my conclusion is that all clinical staff seeing child travellers must be trained on Safeguarding to level 3 as a minimum.

Using Facebook to keep up to date!

As 2018 comes to a close I thought I'd try to post one more blog on here!  My intention to blog more didn't happen this year - mostly because I seem to be so busy and it's hard to keep all the social media going.  That's not to say I won't still try going into 2019.  My website now has over 70 pages on it and keeping that updated as well is tricky especially as it's only a hobby but one I really enjoy.  If you do notice anything not working, then please let me know via the website, I'd really appreciate it.

The place I 'post' most updates though is on my travel Facebook page.  I know not everyone is keen to get involved in FB and it does mean you need to open up an account, but you don't need to be active on there.  You can use it just to look at what is going on.  It's such a useful platform.  Just today I put a post about two Green Book chapters that have been updated....... here is an image I also posted.

The text to go with it was as follows:
Its very quiet on the travel health front right now but I noticed Chapters 1 and 10 of the Green Book were updated in December. I think these are just formatting changes. Ch.10 on 'Vaccine Damage Payment Scheme' has gone to one page with a link to the information on a gov.uk site. Ch.1 on 'Immunity and how vaccines work' seems to have had a format change only so the pages are updated to include 'December 2018' and the Chapter and page number identified at the bottom of each page. The font looks more modern as well and the green colour a slightly different shade! See https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
While on the subject of how vaccines work, don't forget the new and helpful video posted in May this year from the Oxford Vaccine Group at https://www.ovg.ox.ac.uk/news/how-do-vaccines-work

I'm not sure just how many posts I've put on Facebook in 2018 but sometimes its 2 or 3 in a week and mostly information which will help you in your day to day practice.

So consider joining and find my page at  https://www.facebook.com/TravelHealthTraining then 'like' the page.  You can then follow my postings and will get e mail alerts when I put anything up.

Other useful ones to follow are NaTHNaC, the FCO, the WHO, the CDC etc., all easily found my doing a search.

Have fun!  And a Happy New Year to you all.

FGM support in the travel consultation

News in the Guardian today discussed that the number of girls in England who have experienced or are believed to be at risk of female genital mutilation (FGM) has more than doubled in a year, according to assessments by council social workers.  Analysis of government figures shows that FGM featured in 1,960 social work assessments in 2017-18 – more than twice the 970 cases reported in the previous year.  To see the full details of the article click here

Last week the Faculty of Travel Medicine from the Royal College of Physicians and Surgeons of Glasgow launched a new e learning module on FGM to give those practicing in the field of travel health more confidence when addressing this subject.   Written by two travel health specialist nurses, Sarah Lang and Cathy O'Malley, the work includes a great review of FGM and how to do an assessment in your travel consultation in a video by expert and travel health specialist nurse Ann McDonald and there are videos by Cathy O'Malley, helping you to ask questions that may be perceived as awkward and sensitive - giving you the confidence to tackle the situation.  This is not a scenario you can overlook since we have a mandatory required to report FGM and in our situation this would be a girl under the age of 18 being taken away for the purpose of FGM which we can identify in our travel consultations.

The e learning is free to take and provides a certificate of completion as well.  You'll need to register on the College e learning portal, purchase the course (which costs you nothing) then start to do the learning.  There are many resources and tools within it as well to increase your knowledge - its an essential aspect of our education so please take a look HERE and cease the opportunity.  Or you could click on the image below!

Tetanus Update

N.B. Please note further update since this was written - detailed below on 10th November!)

When discussing tetanus within travel health we've generally said that five doses of tetanus vaccine is sufficient for life in the UK but if travelling to an area where there may be a risk and difficulty in obtaining appropriate treatment, it would be best to give a booster of a tetanus containing vaccine (revaxis) prior to the trip.  Such advice is also guided by the travel risk assessment and country specific information on TravelHealthPro and TRAVAX.  However that advice seems to have changed and I'm not sure how many people saw the following, hence my decision to highlight it!

In July 2018, Public Health England issued interim Recommendations on the treatment and prophylaxis of tetanus prone wounds and within the publication it said the document supersedes both the PHE guidance Tetanus: information for health professionals published in 2015, and the Green Book chapter 30 on tetanus. It now seems if it's more than 10 years since you had a tetanus toxoid vaccine and you sustain a tetanus prone injury you would now be given further vaccine and depending on the risk assessment of the wound, receive a dose to tetanus specific immunoglobulin as well.  This is laid out in table 6 of the document.

I've explained this more fully in the Practice Nurse Travel Health Update for October 2018 - see the image below.

UPDATE ON 10th NOVEMBER 2018

On 9th November the interim guidance discussed above was withdrawn and the updated publication made available HERE or click the image below. 

For more general information on tetanus see my FAQ page here.