Polio Update

I continue to get many questions about polio and although I've written a couple of blogs about it in the past, here is a fresh one with the latest information.  Some detail is taken from the previous blogs....

Here are the topics covered:

1. Explanation of the PHEIC for Polio and the latest news
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 

1. Explanation of the PHEIC for Polio and the latest news

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 will eventually be eradicated, but for now it's about controlling numbers of cases of wild polio virus (WPV) and also circulating vaccine derived polio virus (CVDPV).  There's a map which illustrates the  progress although in 2019, numbers increased rather than declined.  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.

The EC meets every 3 months. The latest meeting was held on the 11th December 2019, then posted on the WHO website on 20th December.  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 of CVDPV occurring in other countries.


2. Detail about the temporary recommendations and what your travellers need to know

This latest meeting named the following countries where implementation of the WHO Temporary Recommendations regulation are currently required.  These are Afghanistan, Angola, Benin, Central African Republic (CAR), Chad, Cote d’Ivoire, Democratic Republic of Congo (DR Congo), Ethiopia, Ghana, Nigeria, Pakistan, Philippines, Togo and Zambia.

Please note the countries involved often change from one meeting to another so this is the situation at the time of writing this blog.

So what do you need to do as a travel health advisor seeing a traveller going to one of these countries?

• If your traveller is going to one of the destinations 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.    

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 - reference on the guidance page here 

4. Details about who to charge for a polio containing vaccine

If you work in Scotland then the advice on TRAVAX allows anyone who needs the vaccine and ICVP for this situation to have it on the NHS if they live in Scotland and the Scottish Government funds it.

If you work in England the guidance is different and you must follow the information on NaTHNaC.  This information will be found in the vaccine advice for polio in the relevant country page information.  Polio vaccine will need to be given within Revaxis or Repevax (depending on age of traveller) but NOT ALL travellers can have this on the NHS.

If working in England, therefore following the NaTHNaC advice, who can you provide the vaccine to as an NHS provision?

• A person who hasn't yet completed their UK schedule and doesn't have 5 doses recorded
• A person who hasn't had a Revaxis booster in the last 10 years for travel purposes
• A pregnant woman
• A person who is immunosuppressed and their household contacts
• A person travelling to a setting with extremely poor hygiene (e.g. refugee camps) or likely to be in close proximity with cases (e.g. healthcare workers)
• A traveller visiting for 6 months or more

All other travellers seen in a GP surgery in England would NOT be entitled to vaccine as an NHS provision but receiving oral polio vaccine on exit from the country should present no problem.

If a traveller is unhappy with this advice, then they could access a polio containing vaccine, but need to obtain this from a private travel clinic and pay for both the vaccine and the ICVP.  A GP surgery cannot provide this privately and charge for the vaccine.

I'm sorry I don't know the charging situation in Wales and Northern Ireland - if you do, perhaps you could e mail me to let me know and I'll update the blog. 

To see the FAQ on charging for travel vaccines on my website - see here.  

Further resources 
NaTHNaC factsheet 
Public Health England Polio: guidance, data and analysis
WHO factsheet on polio

IMPORTANT YELLOW FEVER UPDATE

Recent very important news has been published on yellow fever vaccine.

What is this news all about?
Back in April 2019, the Medicines and Healthcare Regulatory Agency (MHRA) published a Drug Safety Update 'Yellow fever vaccine (Stamaril) and fatal adverse reactions: extreme caution needed in people who may be immunosuppressed and those 60 years and older' found here.
It is strongly advised that you read this page in full, but some of the lead up to this was the fact that in recent months, they had been notified of 2 fatal adverse reactions to yellow fever vaccine. In one case, the vaccine was given to a person with a history of thymectomy following a thymoma (a contraindication in the product information). In another case, the vaccine was given to a 67-year-old with no other known risk factors. Both patients died shortly after vaccination due to suspected yellow fever vaccine-associated viscerotropic disease (YEL-AVD).

The guidance went on to explain they were in the process of reviewing the benefit-risk balance of yellow fever vaccine and measures to minimise risks in the light of these cases and the latest scientific data. The Commission on Human Medicines has convened an Expert Working Group, which will make recommendations. We will update guidance, as necessary.

A summary box was included: 

The Green Book at the time (updated in January 2019) provided clarity over individuals who had had an incidental removal of their thymus gland including the following details:

* To date there is no evidence of increased risk of yellow fever vaccine–associated serious adverse events in people who have undergone incidental surgical removal of their thymus (e.g. during cardiac surgery) or have had indirect radiation therapy in the distant past. People who had incidental removal of their thymus after the age of one year may therefore receive a yellow fever vaccine following a detailed risk assessment. A cautious approach is recommended for those who had incidental removal of their thymus before the age of one year. In these cases further advice should be sought.

In addition the NaTHNaC YF Factsheet on TravelHealthPro also provided the same message.  

So this is what I have been teaching this year.... 

BUT PLEASE NOTE THIS GUIDANCE HAS CHANGED, 

even though the Green Book from January 2019 remains 

online at the current moment.  

So what has happened recently?

On 21st November NaTHNaC posted an update on TravelHealthPro entitled REVIEW OF SERIOUS ADVERSE EVENTS FOLLOWING YELLOW FEVER VACCINATION and on 22nd November TRAVAX posted a similar update entitled Strengthened Recommendations to Minimise Risk of Serious and Fatal Reactions to Yellow Fever Vaccination (password required for the latter link).  

'The Commission on Human Medicines (CHM) has recommended strengthened measures to minimise the potential risk of rare but serious and fatal adverse events associated with yellow fever vaccination in those with weakened immune systems, and in particular those aged 60 years or older and anyone who has had their thymus removed.

A joint letter from the MHRA, PHE, HPS and NaTHNaC gives further detail viewed HERE.

So although the Green Book chapter (35) on Yellow Fever is currently still up online as the January 2019 chapter, the GUIDANCE HAS CHANGED.  An update notice has been put on the landing page for this chapter which says 'The Commission on Human Measures (CHM) has recommended strengthened measures to minimise the potential risk of rare but serious and fatal adverse events associated with yellow fever vaccination in those with weakened immune systems, and in particular those aged 60 years or older and anyone who has had their thymus removed.

The Green Book chapter will be updated accordingly but for now, please see a joint letter issued by the MHRA, PHE, HPS and NaTHNaC which gives further detail'. See the image below as the page appears today.  

WHAT ARE THE KEY POINTS?

I have copied and pasted the information from the letter in the text below, but please make sure you click on the link and read it in full. 

Here is some of the important information

• In people aged 60 years or older, due to a higher risk of life-threatening side effects, the vaccine should be given only when there is a significant and unavoidable risk of acquiring yellow fever infection, such as travel to an area where there is a current or periodic risk of yellow fever transmission - this would exclude travel to areas in which vaccination is ‘generally not recommended’ by WHO
• Only healthcare professionals specifically trained in benefit-risk evaluation of yellow fever vaccine should administer the vaccine, following their individualised assessment of a person’s travel itinerary and suitability to receive the vaccine
• Do not administer the vaccine to people:
• who have had their thymus gland removed for any reason
• who are taking biological drugs that are immunosuppressive or immunomodulating
• who have a first-degree family history of YEL-AVD or YEL-AND following vaccination that was not related to a known medical risk factor (i.e. in case of an unidentified geneticpredisposition).

Thoroughly inform vaccinees about the early signs and symptoms of these side effects and to urgently seek medical attention if these side effects are suspected – this will support rapid identification and referral for treatment of YEL-AND and YEL-AVD. The manufacturer’s patient information leaflet should be given to everyone receiving a yellow fever vaccine as part of the travel consultation.

The letter goes on to let readers know that 

The above recommendations are in addition to the full list of contraindications and precautions described in the current Summary of Product Characteristics and patient information leaflet, which will be updated in due course. Standardised pre-vaccination screening checklists are also being produced, along with a patient group direction (PGD) template. A further communication will be issued when these are ready to ensure they are implemented in clinical practice. An article will be published in the MHRA’s Drug Safety Update (https://www.gov.uk/drug-safety-update) with a detailed assessment report and more information about the risks and manifestation of YEL-AVD and YEL-AND.

The Report of the Commission on Human Medicine’s Expert Working Group on benefit-risk and risk minimisation measures of the yellow fever vaccine can be found HERE

This post and links to more resources will be updated as they become available.  

To download the current Yellow Fever Vaccine: Traveller Checklist from NaTHNaC - see here (published 10.07.19)
Latest News from NaTHNaC  - Yellow fever vaccination recommendations: persons aged 60 years or older posted 25.11.19 here  
NaTHNaC Yellow fever:  Information for Travellers Leaflet here

To view the CQC Mythbuster no. 91 on Patient Safety Alerts see here
To sign up for MHRA Patient Safety Alerts see here

PGD templates from PHE updated

Yesterday Public Health England published updated templates for the PGDs for Hepatitis A, combined hepatitis A+B and Revaxis for use in England.  See the full list of PGDs here.  These new documents (found under the section 'individuals at increased risk') will be valid until 31st October 2021 for these specific travel vaccines we provide in an NHS travel service in primary care.  Remember though, they cannot be used until signed off (in Section 2, usually found on page 4) by your organisation that has the legal authority to authorise the PGD. To remind you, NHS England has five regional teams as follows and I've hopefully identified the page on the websites where access to the PGDs are found:

North regional team

Midlands and East regional team

London regional team

South East regional team

South West regional team 

Some points of interest within the new PGD for combination hep A + B vaccine

The PGD for Twinrix, Twinrix Paediatric and Ambirix says

Inclusion for use within a travel context: are individuals over 1 year of age requiring Hepatitis A and Hepatitis B pre-exposure prophylaxis where hepatitis A and hepatitis B vaccination is currently recommended for travel by NaTHNaC (see the Travel Health Pro website for country-specific advice on hepatitis A and hepatitis B vaccine recommendations).

Criteria for exclusion

require solely hepatitis B vaccination for overseas travel purposes

Action to be taken if the patient is excluded
Individuals requiring solely hepatitis B vaccination for overseas travel purposes should be administered hepatitis B in accordance with local policy. However, hepatitis B vaccination for travel is not remunerated by the NHS as part of additional services and is therefore not covered by this PGD unless hepatitis A vaccination is also indicated, and a combined HepA/B vaccine is used.

Off-label use
The Twinrix® Adult schedule given at 0, 7 and 21 days is licensed for adults (that is those from 18 years of age) but may be used off-label in those from 16 to 18 years of age where it is important to provide rapid protection and to maximise compliance (this includes PWID) in accordance with Chapter 18 of ‘The Green Book’.

COMMENT 

• Were you aware the PGD specifies you need to use TravelHealthPro within your travel risk assessment when identifying the vaccine recommendation? 
• It's very useful that the off-label use of of Twinrix Adult for the 0, 7 and 21 day schedule and a 4th dose 12 months after the first dose can be provided under the PGD where insufficient time is available to allow the standard 0, 1, 6 month schedule to be completed.  
• The PGD says (under the section 'Dose and frequency of administration'): For travellers, vaccine should preferably be given at least two weeks before departure but can be given up to the day of departure. 
• Reference to the new Vaccine Incidence Guidance document republished on 19 September was also included 

Falsified Medicines Directive

Substandard and Falsified (SF) Medical Products represent a dangerous global problem.  There is quite a good video explaining the problem and the World Health Organization have a factsheet and links to further resources here.

A Falsified Medicines Directive (FMD) was adopted in 2011, aiming at guaranteeing the safety and quality of medicines sold in the European Union (EU).  The final stage of this initiative was adopted on 9 February 2019 when new rules on safety features for prescription medicines sold in the EU were applied.  This link will also provides information about global falsified medicines directives in progress around the world, this is certainly not just a UK or EU issue.  

The UK is governed by the EU directive just now and these rules mean that the industry has to affix a 2-D barcode and an anti-tampering device on the box of prescription medicines.  The EU published a video to explain the safety features.  An explanation has been published on the GOV.UK website regarding 'How the Falsified Directive Works'.  NHS Digital has a great deal of information - Falsified Medicine Directive implementation toolkits here  PHE have also published a document 'FMD guidance for recipients of PHE supplied vaccines here.  

This blog is aiming to provide basic information about the FMD - I have found it a complex subject and am no expert.  I hope the links provided will give you additional resources to research and understand the subject.

Information about this development was published in the April edition of Vaccine Update (page 11).  It said that vaccines used in the National immunisation programme would come under this new regulation and in practice this means that at the end of the supply chain before a vaccine is administered to a patient, the integrity of the product seal should be checked and the barcode on the packaging should be scanned to verify authenticity and register the removal of the product from the supply chain on a central database - this is the process of decommissioning.

The database for the UK is called the National Medicines Verification System (NMVS), supplied by a company called SecurMed UK, which comprises bodies representing manufacturers, importers, wholesalers and pharmacies.  Community pharmacy is represented on SecurMed UK jointly by the National Pharmacy Association and the Company Chemists' Association.  The SecurMed website has helpful information as does the ABPI.

Article 23 of the Directive found on page 28 provides Member States with legal flexibility regarding their respective supply chains about where the decommissioning process should take place.  Additional guidance on 'Article 23 providers', 'Healthcare Institutions' and 'Article 26 exemption' was published by the Medicines & Healthcare products Regulatory Agency (MHRA) in December 2018 - see here.

Within this document is says the UK has classed General Practitioners (GPs) as health centres and therefore healthcare institutions - that includes both dispensing and non-dispensing GPs.  Therefore GP surgeries must decommission medicines.   Here is a toolkit which has been produced for General Practice. 

Travel clinics are not defined in the further guidance about Article 23.  So the first thing is to assess the supply of the vaccines to the clinic whether directly from a manufacturer, wholesaler or pharmacy.  Article 23 then raises the question if they are regarded as a healthcare institution or pharmacy.  What is unclear is if the determination of a healthcare institution covers private travel clinics.  I've been discussing with colleagues and have made some further enquiries.  If and when I find out more I'll update this blog.  The general feeling just now from these discussions is that private travel clinics would probably need to decommission the vaccines and any other drugs administered or supplied to travellers they see in a consultation.

Having searched the online FaceBook forums for 'discussion' on this subject, there was limited information but what seems clear is that GP surgeries have nothing implemented as yet and little to no information has been forthcoming from their CCGs (from those that commented).  Private travel clinics also seem in a state of flux as to what should happen, but some clinics and community pharmacies have scanners already in place.

And then of course the chaotic developments regarding Brexit create another big question since this is an EU Directive.  But whatever happens on that in the future, the UK has and must continue to have a process in place on this important aspect of patient care.  The government updated a page on 'How we propose to regulate medicines if there is a no-deal Brexit' yesterday here but I didn't read anything further on FMD.  

I’m guessing for now the next thing is to continue to increase your knowledge of this important initiative, watch out for news from your CCG or Health Board or private travel clinic owners and eventually we will hear what exactly is to happen!  

Saving time recording your travel consultation!

Back in the summer of 2018 I had an EMIS template built which followed the lines of my travel risk management form found at item no. 2 here.  I put it out there for some of you to trial and it generally received great feedback.  The travel consultation is complex, but sometimes writing up the information to provide evidence of all you covered and advised takes huge effort and significant time.  However in my opinion this is essential not only as best practice, but to also protect the practitioner.

The template is divided into three sections - the tabs are at the top on the left hand side as you look at the screen.  As many answers as possible have been populated into the template so that you need to write very little, but of course the beauty of EMIS is that you can simply add in extra detail if you need to.  The original template had drop down menus.

However we have a wonderful new nurse at the surgery (David Piercy) who is an absolute wizard at EMIS templates.  David has altered the format so that instead of all the information being in a drop down menu template, it's now in a list so you can read it easily and check the box of the answer that suits the best.  It possibly makes the information on the template much longer but on the other hand acts as a great prompt within your consultation.

Added to this wizardry, David has now made it SNOMED ready.  I'm told that all EMIS users will be switched to SNOMED coding so the template has had the adjustments made in readiness.  Now this last sentence is all non-sensical to me but I thought I would add it because if you've used the template in the past and it's working you may still need this new version as the other one may not!

Anyway I hope this helps.  I've put the file into a 'space' you can download it from but it will only work when you import it into your EMIS software.  I have no knowledge about  this aspect (so please don't ask me questions about it), but hopefully someone in your surgery will be able to help.  Or you could Google 'How to import a clinical template into EMIS' because leaflets will certainly come up

SO TO DOWNLOAD THE NEW TRAVEL RISK TEMPLATE 
CLICK HERE! 

and then RIGHT click on the screen and do a 'save as' 

...... all I have left to say is 

And a plea from me - I'd really appreciate you completing a short survey after using the template for evidence that the work, effort and funding put in was all worthwhile (and it would then make a really different reflective account for my revalidation!)  

The survey is HERE.

p.s. I'm not sure such templates can be built in SystmOne but if anyone out there has the skills I'm very happy to work with you from the content perspective.  Please contact me via my website.  

For the FOURTH time - Indemnity cover for the private travel vaccines - but GOOD NEWS!

Having written three time now about this in March and then May and June  (the latter two blogs I have left up for now so click on the links) this time I'm writing with good news!

This is the detail from the RCN

"In April, a new state-backed indemnity scheme for general practice (GP) staff was introduced in England. The Clinical Negligence Scheme for General Practice (CNSGP) is operated by NHS Resolution. It automatically provides cover to nursing staff working in NHS GP services. It includes self-employed workers and covers all clinical negligence claims that arise from an act (or omission to act) on the part of someone providing a GP service that is NHS-funded in England. In Wales, a similar scheme, General Medical Practice Indemnity (GMPI), was introduced at the same time. Both schemes include travel vaccinations given in GP surgeries except for where vaccinations are paid for by the patient.

The RCN is now extending its indemnity scheme to cover this gap. This means both employed and self-employed RCN members who are providing any paid-for travel vaccinations from GP practices not included in CNSGP in England and GMPI in Wales will be covered by the RCN indemnity scheme".

There was a news item on the RCN website, but this has now disappeared (update on 12.03.22) but this is a useful podcast to help you here and well worth listening to.  Details about the RCN indemnity scheme are here

I've been a member of the RCN since I qualified and am delighted about this news - the provision will be very helpful for General Practice Nurses giving the private travel vaccines going forward. 

Clinical Negligence Scheme for General Practice - a THIRD time

Having written twice now about this in March and then May (the latter blog I have left up for now so click on the link) I am astonished to be writing yet again.

NHS Resolution have now posted a FURTHER update to the document called the Scheme Scope document posted  last month that informed us the CNSGP did cover us for the private travel vaccines given in General Practice.

This new document  dated 12 JUNE 2019 now overturns that advice and it says:

• Travel vaccinations and immunisations funded by the NHS are covered under CNSGP
• Travel vaccinations and immunisations for which patients have to pay a charge are not NHS services and therefore not covered under CNSGP   
• NB. The Department of Health and Social Care (DHSC) had understood that all vaccinations and immunisations, paid for or not, were NHS services. This was based on an understanding that these services were included in the Part 4 GMS contract as an additional service and so were to be regarded as primary medical services. 
• NHS England has clarified that whilst GMS and PMS contracts allow GP practices to administer and charge for certain vaccinations, when the patient pays for the vaccine or immunisation they are considered private health services, not NHS services.  
• DHSC has taken further legal advice and considered this issue carefully. Having done so it has concluded the administration of paid for vaccinations and immunisations are not NHS services so cannot be in-scope of CNSGP. 
• These vaccinations and immunisations are covered under MDO policies.

The document is found here and directly here - see pages 7/8 in the table of information.  So it would seem that if you give private travel vaccines you do need to ensure you have additional indemnity cover from a provider such as the MDU, MPAS etc.

Whilst there is a frustration over the mixed messages we have received to date, I think the important aspect here at the present time is to ensure you are covered if you are working in General Practice and giving any private travel vaccines (and I am guessing involved in malaria chemoprophylaxis as well).  Please make sure you sort this out and share the update with colleagues.

Indemnity in General Practice AGAIN

Back in March there were a number of queries on forums  about the Clinical Negligence Scheme for General Practice (CNSGP) in relation to the private vaccines we may give in General Practice (yellow fever, rabies, meningititis ACWY for travel purposes, tick borne encephalitits and Japanese encephalitis PLUS malaria chemoprophylaxis prescriptions.

The history

From 1st April 2019 NHS Resolution started operating a new state-backed indemnity scheme for general practice in England called the Clinical Negligence Scheme for General Practice (CNSGP).

The website describes what is and isn't covered.

It appeared at the time from enquiries to different medical defence organisations that the private travel vaccines weren't covered.  HOWEVER IT SEEMS THIS TURNS OUT NOT TO BE TRUE!

NHS Resolution have now posted a document dated MAY 2019 called the Scheme Scope document or found directly here.  It's a very useful document so please read.  

It says Travel vaccinations are covered by the CNSGP as long as these vaccinations are delivered under a GMS/PMS/APMS contract or under a sub-contract for the GMS/PMS/APMS services.  In practice, most travel vaccinations will be provided by general practice under a GMS/PMS/APMS contract. The costs of some are reimbursed to the GP practice in the usual manner under the GP contract terms but the costs of some travel vaccinations may not be reimbursable under the contract. For such vaccinations, legislation permits general practice to charge patients directly. This is still an NHS charge and an NHS service so is covered by the CNSGP. 

I think the reference to link to this would be Schedule 5 of the GMS contract from 2004 where it says 'The contractor may demand or accept a fee or other remuneration' then look at section
(g) which says 'for treatment consisting of an immunisation for which no remuneration is payable by the Primary Care Trust and which is requested in connection with travel abroad'.

This new Scheme Scope document doesn't mention malaria chemoprophylaxis but again in the Schedule 5 as above, if you look at section (l) it says  'for prescribing or providing drugs or medicines for malaria chemoprophylaxis'.

What I would say is this has been extremely confusing but I hope this is resolved now!  I've left the rest of the original blog below for information but it's still important you check out you have insurance for your nursing activities outside your NHS care as described on the NHS Resolution website - linked above!

I am currently covered for my work in a GP practice by their group practice policy (because there are a number of GPs using it, the organisation provide additional cover for their practice nurses at no extra cost), BUT making enquiries to this company I was informed that because of the new NHS scheme and that the premiums paid by GPs will be lower, there will be a charge for nurses to be added on to an indemnity policy in the future.  I was told this was approximately £525 if working up to 24 hours a week and £695 if working up to 40 hours per week.  I understand that this will happen when your policy is due up.  

Some years ago now the RCN stopped providing indemnity to practice nurses employed by GPs.  I remained in the RCN though, not only for the professional side, but their indemnity covered me for my self employed work, and other voluntary roles - see the RCN scheme. The information on their website is very helpful about this new development - see here.   Interesting to read on there that “The RCN has heard from members and non-members alike that some GP employers have told them that  they will no longer be purchasing indemnity cover from their medical defence organisations (MDOs). As a result, the MDO will no longer provide them with support for their other legal issues like employment advice, NMC referrals, inquests and many other potential legal issues - please go to the article to read more.  

My understanding is that the principles around vicarious liability for employees remain unchanged. It is not appropriate for a GP employer to try to shift that responsibility onto their employees, so if you're employed in a GP practice you should not be required to purchase your own cover because of these changes. Your employer should take responsibility for professional indemnity cover.  You will need this in addition to the Clinical Negligence Scheme for General Practice 

MMR and travel

I did a blog on MMR and travel back in December 2017.  Measles risk continues not only now in Europe but in other parts of the world as well.  The latest measles data is published on the World Health Organization website here which also provides links to other information including the measles fact sheet.

Look at the latest information on measles from NaTHNaC on TravelHealthPro in relation to your travellers.

The Vaccination of individuals with uncertain or incomplete immunisation status flowchart published by Public Health England (most recent edition November 2017) has excellent guidance regarding your course of action if doses are missed, and one of the statements is ' Two doses of MMR should be given irrespective of history of measles, mumps or rubella infection and/or age'.

Dealing with people born before 1970 has historically caused a greater quandary, but while the Green Book acknowledges this cohort are more likely to have had all three natural infections and are less likely to be susceptible, it states MMR vaccine should be offered to those who request it or if they are considered to be at risk of high exposure (see page 219).

The December 2017 issue of Vaccine Update clarified that ImmForm stock can be used - the exact wording says Central MMR vaccine stock (ordered from Immform) can be used to catch-up anyone of any age – this also covers opportunistic catch-up prompted by travel.   Moreover, it says an item of service fee can be claimed manually via the CQRS MMR programme for each dose of MMR administered to patients aged 16 years or over. This includes patients born before 1970 who have no history of measles or MMR vaccination.  See page 5 of the Vaccine Update issue 273.

There was further excellent information on MMR in the July 2018 Vaccine Update (Issue no. 281) which asked if 'you were up to date with your MMR' on page 5. And the CQC wrote mythbuster no. 37 on Immunisation of healthcare staff which includes MMR.  The relevant information is as follows: Measles, mumps and rubella (MMR) is particularly important to avoid transmission to vulnerable groups. Evidence of satisfactory immunity to MMR is either:

• a positive antibody test to measles and rubella or
• having two doses of the MMR vaccine.

Public Health England have published new leaflets about MMR available in English, Polish, Romanian and Somali.   Order hard copy from here

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.