Polio Virus found in sewers in London

I posted on my Facebook page on 22nd June about the breaking news that polio virus had been found in sewage samples in London.  An update posted on the UKHSA website today informs that following the discovery of type 2 vaccine-derived poliovirus in sewage in north and east London, the Joint Committee on Vaccination and Immunisation (JCVI) has advised that a targeted inactivated polio vaccine (IPV) booster dose should be offered to all children between the ages of 1 and 9 in all London boroughs.  No clinical cases of polio have been reported to date, but the virus can cause a paralysis and by initiating this vaccination campaign in London, it will ensure a high level of protection from paralysis and help reduce further spread of the virus.  Nationally the overall risk of paralytic polio is considered low because most people are protected from this by vaccination.  The news story for this is found on the UKHSA website here.  

A great new leaflet for parents explaining the importance of this action has been published here and it's also available to download in other languages from the Health Publications website.  Copies available to order are in Albanian, Arabic, Bengali, Bulgarian, Chinese, Chinese (simplified), Estonian, Hindi, Gujarati, Italian, Latvian, Lithuanian, Polish, Panjabi, Pashto, Russian, Spanish, Somali, Turkish, Tigrinya, Ukrainian, Urdu, Yoruba and Yiddish. It is also available as a braille, British Sign Language (BSL) and large print copy.  The collection is a fantastic resource.    

Added to this there are inactivated polio vaccine (IPV) booster campaign information materials for healthcare practitioners, including a polio campaign vaccination letter and important guidance to read.  A helpful IPV Booster campaign algorithim poster is also available here or click on the image below.   

Vaccines used will be Infanrix hexa, Vaxelis, Boostrix-IPV and Revaxis.   Revaxis can be given to children 6 years and older and the PGD updated yesterday for revaxis, included information within the inclusion criteria section for case management in an outbreak situation - see here.  You will find the details of legal mechanisms available to administer the vaccines in the important guidance link above or here.  

Details of delivery of the immunisation programme have not yet been announced in detail, The guidance so far says the following:

Communication for general practice and other immunisation providers about the IPV booster campaign roll-out:  NHS London will communicate through existing routes to ensure that vaccine providers are kept up to date with operational delivery matters relating to the IPV booster campaign.

There's a really helpful video about this polio situation (filmed before the announcement of the vaccination plans) which explains it really well.  See here.  

Use of Revaxis vaccine - which stock?

I've recently been asked again about the use of revaxis and the supply of vaccine you must use within General Practice in England.  Here is a brief summary.  

Revaxis is given as part of the National Immunisation Schedule (the fifth and final dose being given to those 14 years of age - see the complete routine immunisation programme details).   For this purpose, and to catch anyone up if they have not got records of five doses of vaccine to protect against tetanus, polio and diphtheria, then you can use the centrally supplied stock ordered via ImmFrom, delivered by Movianto.   

If after five doses are recorded, a traveller needs revaxis for travel purposes, for disease protection identified within your pre travel risk assessment, they are still entitled to receive this vaccine as an NHS provision every 10 years.  However, you must not use the centrally supplied stock any longer.  

The evidence for this is found in chapter 3 of the Green Book on page 21 where is states 'Healthcare professionals should ensure they are using appropriately sourced vaccines for the particular clinical circumstances. Using centrally purchased vaccines for incorrect purposes could prevent NHS patients who require immunisation from being able to access it. If centrally purchased vaccines are knowingly used for non-approved circumstances, particularly private health services, this may also be considered fraudulent'.

So although in an NHS surgery use of revaxis is NOT private, you must purchase in the vaccine to use for travel and then claim the cost of it back.  The claiming for these vaccines is done on an FP34D form through the NHS Business Services Authority.   

How do you manage this?

• Essentially you need to keep two separate stocks of revaxis in your vaccine fridge, clearly labelling which is for which purpose.  
• Challenges come when healthcare professionals who aren't aware of the rules and infrequently give vaccines, retrieve stock from the vaccine fridge and use the wrong supply then don't inform those who manage the stock take either!  
• A clear notice and education to all can help but isn't foolproof! Some surgeries actually use the ImmForm stock for all use of revaxis but then if one is given for travel purposes, record this and make sure they order in a dose from their travel vaccine supplier to replace the ImmForm stock. This isn't a foolproof process either and requires good organisation.

Whoever said travel was simple - so many aspects of the detail behind travel health practice is complex and it is also hard to find the information for anything non clinical.  So I hope this blog helps :-) 

Provision of cholera vaccine in a GP surgery

The question about giving cholera vaccine was recently discussed in a forum posting but it's a topic that is frequently asked so I thought I would do a blog about it 😊 This information applies to England - see the note* at the bottom of this piece for further detail. 

Cholera vaccine is administered as an ESSENTIAL SERVICE IN GENERAL PRACTICE and therefore a surgery must not charge a patient for the vaccine.  For more details about this - see here.  

This blog will address the identification of who needs cholera vaccine, how you prescribe it and how it is administered.  

STEP 1 - DOES YOUR TRAVELLER NEED CHOLERA VACCINE? 

The decision as to whether or not your patient needs to receive cholera vaccine is based on a careful pre travel risk assessment, including where they are travelling to; the length of time away and the activities they are undertaking.  Having established this information you should then check the county destination on TravelHealthPro.   Also ensure you check the outbreaks present and any news in the country your traveller is going to. The recommendations for use of the vaccine can be seen on page 104 in Chapter 14: Cholera in the Green Book but for convenience, I have also copied the text below.

Immunisation against cholera can be considered, following a full risk assessment, for the following categories of traveller :

• relief or disaster aid workers
• persons with remote itineraries in areas where cholera epidemics are occurring and there is limited access to medical care
• travellers to potential cholera risk areas, for whom vaccination is considered potentially beneficial.

STEP 2 - HOW IS THE CHOLERA VACCINE PRESCRIBED?

If after your risk assessment and discussion with the traveller, you conclude they do need vaccine then how is it prescribed? There are two ways but read the detail under a PGD as well.

1. On an NHS prescription (FP10) which they would take to the pharmacy, but then in normal circumstances, need to pay the prescription fee, but they are not paying for the vaccine itself.  (see below for comments on administration using this method).  
2. Under a patient specific direction (PSD) signed by a qualified, registered prescriber before the vaccine is administered.  See here for more details about this process
3. Under a patient group direction (PGD), There was a national PGD template created in the past, but it is no longer available on the National PGD Template collection page now - see here.   Apparently this is because supplies made under PGDs are required to be appropriately packaged and labelled. Since the availability of such supplies of oral cholera vaccine cannot be assured when writing a national PGD, these oral vaccines are better suited to provision by normal prescription and dispensing services.

Of note, there is a PGD available in Scotland, published on 01.02.22 but could not be used in England.  See here

STEP 3 - HOW IS THE CHOLERA VACCINE ADMINISTERED?

The method of administration is dependant on how this vaccine is prescribed.  Cholera vaccine needs to be stored in the cold chain of +2ºC to +8ºC 

• If prescribed on an FP10 to take home and self administer, you need to give the traveller instructions for storage of the vaccine, but many would argue 'how can you ensure this will happen in a domestic fridge'.  
• You could give them an FP10 and instruct them to return the vaccine on collection immediately to the surgery for you to store it in your vaccine fridge (or in some cases the pharmacy will deliver this prescription directly to your surgery) to maintain the cold chain.  
• If giving under a PSD or PGD, then you would have already ordered the vaccine in to your surgery from the manufacturer (or another supplier) and store it in your vaccine fridge, ready to use when required.  Using this method, you then claim back the cost of this NHS vaccine that your surgery purchased.  Because there are two doses of cholera vaccine (three in the case of children 2-6 years of age) this will require follow up appointments.  
• Many Medicine Management Committees in CCGs gave instructions that patients were not to be given this oral vaccine to take home to self administer because the cold chain could not be guaranteed.  

For more details see the Cholera Factsheet from NaTHNaC and for the vaccine Dukoral see here.  

CHOLERA VACCINE FUNDING?

Whilst Cholera vaccine is an NHS provision, if you are administering it within your surgery you need to purchase it in from the manufacturer (Valneva) or through your preferred vaccine supplier - just as you would the other NHS travel vaccines.  The cost of claiming these vaccines back in done on an FP34 form.  The claims are done through the NHS Business Services Authority - see here.  

REGIONAL PROVISION OF CHOERA VACCINE?

* From 1st April 2022, travel health service delivery in Scotland is no longer provided in GP surgeries, but from their 14 Health Boards, depending on where the individual traveller lives and the systems used in each may well be different.  However, one constant is FitForTravel. When you go onto the website you'll notice a red banner at the top of the page which the travellers are advised to first visit, read the information and then follow up their care if needed.  

I am unclear how cholera vaccine is provided in Northern Ireland and Wales, but if anyone in those areas can help to provide more information, I am very happy to include it in this blog.  Please e mail me: jane@janechiodini.co.uk 

Hepatitis B vaccine and healthcare workers

Back in November last year, new updated PGDs were released including one for hepatitis B.  To see the collection see here and for the template specifically for hepatitis B here.  

Remember these template documents require further authorisation in section 2 of the PGD document before they can be used.  I wrote a blog about the process back in 2018.  For those wanting more information about prescribing travel vaccines, see this FAQ.  

The changes from previous versions are noted in the documents.  One thing that stood out for me on the hepatitis B PGD was that a new change found on page 2 said 'removal of reference to booster doses for healthcare workers'.  

Back in 2018, a document was published by Public Health England of the time called 'Plan for phased re-introduciton of hepatitis B vaccine for lower priority groups in 2018'.  In it, under 'Booster doses for healthcare workers' it said 'On the advice of the Joint Committee on Vaccination and Immunisation (JCVI), boosters (priority group 5) will no longer be routinely required in healthy, immunocompetent adults who have completed a primary course of vaccine, including healthcare workers who are known responders'.  To access this document click here and see page 8 and directly here.  The group 5 was referred to in this document from the previous year, on page 8.  

Hepatitis B: the green book, chapter 18 was updated on 4th February 2022.  On page 13 regarding boosters of hepatitis B, it states that healthcare workers (including students and trainees). should be offered a single booster dose of vaccine, once only, around five years after primary immunisation.  

I'm personally not involved in the immunisaitons of healthcare workers, but for those of you who work in occupational health and are, I thought it may be useful to highlight this information.