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.   

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

NaTHNaC Polio vaccination recommendations update
UKHSA Polio: guidance, data and analysis
WHO factsheet on polio

The Polio Global Eradication Initiative and their page for the UK situation 

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!  

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.  

CLICK ON THE IMAGE BELOW TO ACCESS

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

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.