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.  

Polio and the PHEIC

I've been asked about this subject a number of times recently so just wanted to remind you that I wrote a comprehensive blog about the situation, who can have vaccine, who has to pay for it and how you obtain the ceritificates etc. back in June 2017.  To see this information click HERE

The 18th meeting of the Emergency Committee (EC) under International Health Regulations (IHR) 2005 has recently been held and guidance now applies to Afghanistan, Nigeria, Pakistan, Papua New Guinea and Somalia. 

Just a reminder that the Global Eradication Programme has some excellent information on it's website HERE and this map resource will give you the latest information about the polio cases and more! 

Rabies vaccine for travellers

This blog is only addressing the recent changes to rabies vaccine courses and information about boosters FOR TRAVELLERS.  There has also been new information for pre-exposure advice for other groups and for post-exposure treatment for all, but look here for more details on this and on the publications mentioned below.

On 10 July 2018, an updated chapter for rabies (chapter no. 27 in the Green Book) was published.  Then Vaccine update: issue 282, August 2018, rabies special edition was published on 13 August 2018.  Both publications have useful and interesting information about rabies vaccine which should be read.  NaTHNaC also updated their rabies fact sheet on 10 July 2018.

What was the advice regarding rabies pre-exposure prophylaxis and what were the changes for a traveller? 

• It was stressed that the use of pre-exposure prophylaxis (we refer to as PrEP) reduces the need for rabies immunoglobulin and the number of rabies vaccines given if the traveller is bitten by a potential rabid animal.  Those who receive a primary pre-exposure course (including at least 3 documented doses) and then have a rabies risk exposure would be managed as fully immune for the purposes of post-exposure treatment (we refer to as PEP)
• In the UK we have always chosen to give 3 doses of rabies vaccine (2.5 IU; one vial) and this continues as the preferred schedule for travellers - given IM on days 0, 7 and 21-28
• However there is now an accelerated schedule for UK practice given on days 0, 3 and 7 (and a final dose on day 365) which could be used if the traveller does not have time to complete the course on days 0, 7 and 21-28

Additional important information 

• The Green Book states the JCVI recommends the intramuscular route rather than the intradermal route (except for those with bleeding disorders).  However it also says while IM is preferred, suitably qualified and experienced healthcare professionals may give the vaccine via the intradermal route for pre-exposure prophylaxis.  This will be 'off label' use and is on the prescriber's own responsibility as this route is not covered by the manufacturer's Product Licence.  See page 4 of the Green Book rabies chapter for more information

• The vaccines we use in the UK are Rabies Vaccine BP and Rabipur® - which contain 2.5IU rabies antigen in a 1ml dose which may be used interchangeably.  Vaccines in other countries may contain different concentrations of rabies antigen

• Please note the information for pregnant women, breast feeding, those with immunosuppression and HIV infection on page 11 of the Green Book, page 9 of the Vaccine Update 

Booster doses of rabies vaccine

• Both the Green Book and Vaccine Update say many travellers may not require a booster dose 
• The emphasis for the need of a booster depends on doing a risk assessment which will include the activities being undertaken, the rabies risk in the country being visited and the ability to access post-exposure medical care
• The Vaccine Update explains further that the purpose of a booster is to ensure the individual is fully primed for a longer period of time to allow sufficient time to access post-exposure medical care in remote areas
• If a traveller is given the accelerated schedule on days 0, 3 and 7 then a fourth dose should be given on day 365 - this is NOT a booster dose, but part of the primary course (see page 5 of the Vaccine Update for more detail)
• A booster dose can then be given at any time from one year after the primary course has been completed although the Vaccine Update says the booster may be most effective if offered 5  years or more after the primary pre-exposure course
• ONLY ONE BOOSTER is needed in the patient's lifetime when given to a traveller

Personal comment

• The SmPC for Rabies Vaccine BP does not include the accelerated 0, 3, 7 and 365 day schedule, and the SmPC for this accelerated schedule for Rabipur states to be used in the 18-65 year old age group.  HOWEVER, the NaTHNaC fact sheet (table 1) indicates this new accelerated schedule can be used with either vaccine and in any age group

• The previous Green Book chapter stated that travellers can be considered for a booster who had a primary course over 10 years ago.  However this has now changed and is based on the thorough risk assessment as mentioned above and can be given from one year.  The impact is the contradiction to the advice we may have given previously, so this new advice will need to be managed carefully when discussing with a traveller.  

REMINDER ACCESS TO KEY RESOURCES

GREEN BOOK CHAPTER 27 RABIES

SPECIAL ISSUE VACCINE UPDATE NO. 282  #BeRabiesAware

NaTHNaC FACT SHEET ON RABIES 

Patient Group Directions for travel vaccines

I for one was very relieved when NHS England started writing templates for PGDs for a selection of the NHS vaccines we use for travel because prior to this locally we had none and were having to use PSDs even to give hepatitis A and typhoid vaccines.  It was quite a nightmare to manage and had been ongoing for some time.

HOWEVER, it is important to note that these template documents require further authorisation, in Section 2 of the PGD document before they can be used. This is a legal requirments and the full details are provided in the second paragraph on the GOV.UK website here but also within the PGDs themselves and the additional signatory boxes are found usually on page 4 of the documents.  Therefore, you cannot download and use the PGDs on the site given above.  Instead you must use the site for your area and sometimes someone within your CCG may send the PGDs to you.  Always check you have the additional authorisation as well, then read the PGD in full before you sign it.  Once done you can administer the vaccines legally after you've done a thorough travel risk assessment.

NHS England have five regional teams as follows

• North regional team
• Midlands and East regional team
• London regional team
• South East regional team
• South West regional team

Searching for PGDs on each site above will lead to some - this is what I've found so far!

The London Regional team have a set of the currently available travel vaccines PGDs in one place, as have the South West regional team.

However the other teams seem to have a variety for certain areas only and I've found it confusing.  I need to do some more work on this so keep coming back to review this blog!

If you have been notified of your PGDs by your CCG, just double check that they have the local signature (or signatures) on page 4 as well.  I understand only one signature can be sufficient whereas some areas supply more than one signature.  Some areas also seem to have less travel PGDs available than others but I'll get back with more detail in due course.

I wonder what is happening regarding travel vaccine PGDs in Northern Ireland, Scotland and Wales.  If you can enlighten me, then please make contact and I can add it to the blog.  See here.

Malaria Chemoprophylaxis leaflets

Advising on malaria prevention should be part of our consultations in primary care if a patient is travelling to a malarious area as it would form part of the additional 'service' we are paid for within the 'global sum'.  (For more details of this service see here).

However I'm aware that many now just tell their travellers to go to the pharmacy.  Whilst I appreciate this is part of the challenge we have in the time allotted for a travel consultation, I still feel you should be discussing some of the advice and if malaria chemoprophylaxis is advised for a destination, inform the traveller of the options and come to a joint decision on what they need to take.  At this point it would be sensible to direct them to a pharmacy to obtain them, although always sensible to consider giving a prescription to any pregnant or child traveller when working in primary care as a GP surgery will hold the medical record, not all patients remember their medical and medication history!

To help in the process I've developed some leaflets for the different options for malaria tablets you may be advising.  I designed some in the past, but these new ones not only include information about the tablets and how to take them, but also how to obtain them and then the advice on:

                             Awareness of risk; 

                             Bite prevention; 

                             Chemoprophylaxis and 

                             Diagnosis.  

This would then provide documentary evidence that you gave the information to your traveller.  I appreciate its a lot of text on the leaflet but information your travellers also need to be given!

They will be found to download at item no. 25 in TOOLS and further information about their use is on this section.  I've also included a leaflet for those who don't need to take malaria tablets but need to be aware of the ABD of advice.

Many now purchase their malaria tablets online for convenience and in some cases to save money.  It's very important we let them know they need to seek a supplier is registered with the MHRA,  I've made this poster below to explain to patients.  This can be found on a 'button' on my Traveller Resources page labelled 'Tips on buying malaria tablets online'. 

Click on the image below to obtain directly - you could print it off and laminate perhaps to show your travellers!

The provision of travel in an NHS setting

I still get many queries on this topic and many anecdotal stories of different actions a variety of GP practices are taking.  To my knowledge although travel is being reviewed at the moment, little has changed and this is what is supposed to be happening in England (where the queries come from).

Under the GMS contract in England, travel is provided as an 'additional service of vaccinations and immunisations' in a GP practice and payment is made for such in their Global Sum (2%).  Depended on the number of full time GPs, this can be quite a sizable income but many are not actually aware of it.  A GP surgery can 'opt out' of providing the service of travel, but would have to opt out of other services too, such as the pre-school booster, Td/IPV doses to those over 6 who had not completed their five doses for the UK schedule and rabies vaccine for those at risk from rabies from a work related hazard - the full extent of this provision is set out in Annex BA of the Statement of Financial Entitlements (SFE)5 which was published on 30 April 2012 (starting at page 5).

Many surgeries are just stopping the service BUT they cannot do this - they need to inform their CCG, will have the funding taken away and another organisation will need to be found to provide (and be paid) for this NHS service to the NHS patients of the practice deciding to stop.  To decide to stop and keep the money paid into the Global Sum would be fraudulent.

The provision of travel as a service would include:

• A travel risk assessment
• Administration of the NHS travel vaccines (hepatitis A and all combined vaccines containing hep A), typhoid, cholera and polio - which would be given as Revaxis to a traveller so the whole vaccine is given as an NHS provision)
• Appropriate travel advice according the the assessed risk of the trip (including malaria prevention advice)

Full details are on an FAQ page on my website HERE 

In Scotland immunisaiton services have been under review by the Scottish Government and a consultation which concluded that general practice no longer wanted to be responsible for the delivery of the National Immunisation Programme.  Therefore a Vaccine Transformation Programme is being carried out which will include travel.  The programme started this year and is expected to take three years.  

Mosquito bite prevention advice

I feel mosquito bite prevention advice is crucial to the care we give to travellers.  Bite prevention is essential in the prevention of diseases such malaria, dengue, chikungunya, Zika and although there are vaccines for travellers against yellow fever, Japanese encephalitis etc. prevention of transmission is still important.  However I also recognise that in many of your time constrained consultations, there isn't always time to talk about everything.

So I have created a booklet which you could possibly print off or have displayed on your computer to show to your traveller and maybe select certain pages when you discuss some of the advice.  It has been created in a very visual format.  The image below shows just some of the pages and there is also quite a bit of text so the pages are self explanatory.  Click on the image below to access this educational aid directly or it can also be found in TOOLS, item no. 23 here.

I have also put it on the Traveller Resources page which you could show them so that they could review for further information after the appointment.  A quick way of finding it is to also look for the image 'platform 9¾' at the bottom of the home page. 

Malaria Matters - a little history

This is not the first time I've blogged about Malaria Matters!  This is an e learning course which will take you through the Guidelines for malaria prevention in travellers from the UK, published by Public Health England on an annual basis.

In 2008 I was invited by GSK to write the material for this course and work alongside a medical education company to produce an interactive modular course based on the guidelines.  The opportunity was both exciting and daunting at times, but resulted in a CD Rom which was initially launched in 2009 and given out to customers purely as an educational tool and was used for a good two years.  However sadly updating it with new guidelines was a large task and it was decided no longer possible to produce by the company.  However, they very generously allowed me to take over its ownership from that point.

In 2014 I started to develop the course material working with an e learning designer to put the course onto an e learning platform.  It was at this time I won the Triennial Scholarship (of £2000) from the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow and the award helped towards production costs.  For more details of my report see here

Since that time I have developed my own e learning skills such that I've been able to update the work each year in line with the latest guidelines document.  I undertake this work gladly in my own time and receive no income for such.  However to host it on a platform which produces a certificate comes at quite a significant cost and I was keen to continue providing the learning free of charge.

Therefore in 2018 I've moved the course onto a new platform which is in fact a lot easier to use, has no time limit in which to undertake the work and means people can undertake the learning on mobile phones and tablets as well as a computer - the choice is yours!  A certificate of completion also doesn't really prove you learnt anything, so today a written reflection of the learning and how it will change or improve your practice is of far greater worth for your CPD.

I therefore hope people will continue to undertake and learn from Malaria Matters and enjoy the experience.

Click on the image below to access the course directly.  

To see the page on my website for more information see here