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.  

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 :-) 

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 

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.  

Providing a travel service in primary care.

This certainly isn't the first time I've written on this subject, but I get a lot of queries from Practice Nurses, understandably concerned because they are being told: 

1. their surgery has decided not to deliver a travel service or 
2. they are 'not allowed' to perform a pre travel risk assessment and/or to give advice to their patients, but instead, just to give the vaccines needed for the travellers' trip abroad.  

Some practices are telling patients they need to go to a private travel clinic for all their travel needs.  Others are told they need to go to a private provider to find out what is needed, or to look for themselves online.  The traveller is then requested to make an appointment for the nurse to just 'adminster the vaccines' that have been identified - and that is all.  

I totally understand that everyone in General Practice is so busy, overloaded by all the demands your roles entail, made so much worse by the COVID-19 pressure and workload.  So managing the travel consultation in this way may be seen as sensible to cut down on time, whilst still delivering a travel vaccine service. 

1.  A General Practice in England must now deliver a travel health service.  The new GP contract seen here says (at 5.4) ‘Vaccinations and immunisation becomes an essential service which should be available to the whole practice population, rather than an additional service. All practices will be expected to offer all routine, pre- and post-exposure vaccinations and NHS travel vaccinations to their registered eligible population.  Therefore travel is now part of the Global Sum and you must provide the service.  

2. And here is my rationale for saying this shortcut for travel should certainly NOT BE DONE.

A pre travel risk assessment must be undertaken prior to administering any vacines to ensure the correct protection is advised depending on many factors, including the previous medical and vaccine history, history of any allergies, any medication the traveller is taking, their current health status, where they are travelling to, how long for, what they are doing, and so the list goes on.  If the traveller is sent to an online information resources or to a private travel clinic to determine the outcome of the assessment, as the person administering the vaccine(s) how would you know if the assessment was undertaken correctly?  If you  'just gave the vaccine' and it was wrong - you would still be professionally accountable for your actions. In addition, travel health is so much more than just the vaccines and the advice is essential, including malaria prevention.  Within an appointment it's certainly not possible to cover everything, but important to highlight the key topics and direct the traveller to sound resources of advice so that they study the information further.  Suggestions for good advice include using the e mail service on TRAVAX, direct your traveller to TravelHealthPro and fitfortravel, suggest they download and study the KnowAsYouGo App, and I also have a general advice leaflet on my website.  

The RCN Competency document, found here clearly states (on page 19) that this practice is considered unsafe. Those healthcare practioners who ‘just give vaccines’ according to information the traveller has obtained or identified, put themselves at significant risk. Nurses practising in the UK are reminded of their personal accountability and compliance with The Code when advising travellers.  

See a short update I wrote in Practice Nurse in June 2021 on this subject - here.  

Please note this is about the NHS travel vaccines.  A GP surgery can also opt to provide other private travel vaccines but it is just that, optional.  

Air bubbles in syringes

Back in December 2014, I wrote a blog about this subject as guidance had been put in the Vaccine Update for November/December 2014, which was the first official guidance I'd seen on the subject.  At that time it said "You shouldn’t get rid of the air bubble. To try to expel it risks accidently expelling some of the vaccine and therefore not giving the patient the full dose. The air bubble is also there for a reason – the air injected into the muscle forms an airlock preventing the medication seeping out along the needle tract into subcutaneous tissue and onto the skin. The small bolus of air injected following administration of medication clears the needle and prevents a localised reaction from the vaccination". However things have moved on since then so please read on!  

This subject has come up recently within training ongoing for the COVID-19 vaccine. The COVID-19 vaccination programme document from Public Health England, Information for healthcare practitioners, was last updated on 26 February 2021.  Within this document it says 'any air bubbles should be removed before removing the needle from the vial in order to avoid losing any of the vaccine dose'.  This is stated on pages 41, 44 and 48 referring to all three brands of COVID-19 vaccine we're currently using in the UK.  

Guidance is also provided on a very useful webinar training by Sarah Lang who is well known in the world of travel medicine but also within immunisation for the national programme especially for children.  Sarah delivered a series of webinars on behalf of PHE London.  The session on Vaccine administration - best practice is excellent in its content and delivery and is provided on a video (which you can download as an MP4) but the slides are also given in a PDF (in which the sound of the presentation is provided within the document).  On slide 16 (just after 14 minutes) Sarah discussed air bubbles and then also goes on to explain injection sites as well.  The whole presentation is very worth watching, including issues such as timing you may have for an appointment, pain reduction etc.   Click HERE to access the whole series.  For the session on Vaccine administration - best practice click HERE or on the image below.  (Tip, the links provided can be accessed via the PDF document which also gives the best resolution to the presentation although the slides don't move along in time to the spoken content).  

IN SUMMARY in relation to AIR BUBBLES

• Leave air bubbles in pre filled syringes (PFS)
• For a non pre filled syringe, prime the syringe up to the hub of the needle and any air bubbles should be removed before removing the needle from the vial in order to avoid losing any of the vaccine dose.

COVID-19 Vaccination e-learning programme

Health Education England e-Learning for Healthcare has worked in partnership with Public Health England and NHS England and NHS Improvement to develop the COVID-19 Vaccination e-learning programme.  The e-learning programme is designed to provide the health and care workforce involved in the national COVID-19 vaccination programme with the knowledge they need to confidently promote high uptake of the vaccine and deliver the vaccine programme effectively.

The programme currently consists of one core knowledge session, which covers subjects including vaccine eligibility and legal aspects, and an accompanying multiple-choice assessment session.  All those undertaking this e-learning should complete the core knowledge session as this is designed to provide essential knowledge about COVID-19 and the key principles of vaccination needed to deliver the vaccine.

                           

The e-learning sessions describe the national COVID-19 vaccination programme for England. Most of the information in the sessions will be relevant for those involved in the programme throughout the UK and Crown Dependencies. However, those undertaking the programme in Northern Ireland, Scotland, Wales and the Crown Dependencies should be aware that some details as to how the programme will be delivered may be different. Vaccinators should therefore ensure that they refer to any country-specific information available, so they are familiar with the details of the programme for the country they are practising in.

This e-learning programme provides theoretical training.  Practical training in vaccine administration, and assessment and sign-off competency is also required before administering the COVID-19 vaccine.

Learners should also complete the vaccine specific session(s), when available, which will provide more detailed information about the vaccine(s). The assessment sessions should be completed after each knowledge session.  More vaccine-specific sessions will be added as and when more COVID-19 vaccines become available.

Additional, complementary, e-learning sessions including Basic Life Support, anaphylaxis and statutory and mandatory training are available to support vaccinators’ training and education.

For more information about the COVID-19 Vaccination programme, including details on how to access, visit the e-LfH website. (or click on the image above). 

Please note, this information was copied directly from the e mail sent by the Directorate of Innovation and Transformation, Technology Enhanced Learning, e-Learning for Healthcare.