Time flies when you're having fun!

I've had a busy past week, but last Thursday I went up to Glasgow to be awarded an Honorary Fellowship of the Faculty of Travel Medicine (FTM).  This is the highest award the Royal College of Physicians and Surgeons of Glasgow (RCPSG) can make, (see press release) and is bestowed within a ceremony where all the doctors, dentists, podiatrists and travel medicine individuals who have gained qualifications in their chosen subject are given - just as I did when I was admitted to the FTM as a Founding Fellow back in 2006.  

But I sense to have a nurse given this honorary award is very unusual - indeed there hasn't been a nurse in the FTM to receive this to date.  The event comprised processing into the College Hall behind the President.  After an introduction, the Past President (Prof. Jackie Taylor who shortened a trip abroad to be there, and a real trail blazer being the first female President of the College since 1599) read out a citation she had written, while I was required to stand at the front of the room facing the audience.  Now whilst I have great pride in receiving such an honour, I found this bit embarrassing.  My parents instilled in us as a family it was distasteful to 'brag' and if we did do well at school for example, it was always said 'and what did the others get' which immediately deflated any sense of pride one may have had - does anyone of my generation recognise that?!  That said, I'm sure if they were alive today they would be proud!  

The above video was recorded by my husband Peter.  It may need a couple of clicks to work!  

After the citation I had to sign the register of the Honorary Fellows.  This is such an historic book and has signatures dating back to 1894 including Joseph Lister and Princess Diana.  If you'd like to view a short video clip about the book see here (it was posted on FB, so only accessible if you're on the FB platform I think).  

If you wanted to watch the full award ceremony, and it illustrates how well College undertake this activity, welcoming medical people from all over the world you can view it on YouTube HERE.  The event starts at about 17 minutes into the video, a procession into the hall, then the President, Dr Mike McKirdy welcoming everyone, my citation at about 20 minutes in, followed by an award for the President's medal, the diplomats' celebration and finally a speech by the President.  

I'm not sure where the past nearly 30 years in travel medicine have gone, nor indeed the 51 years I've been a nurse, but perhaps it's increasing age that's making me nostalgic.  Travel Medicine was the first thing that really gave me a buzz comparable to my time as a Ward Sister back in my training hospital St. George's in London.   I've regained contact with one of the lovely consultants on my ward back then - Dr Douglas Maxwell. himself a Fellow RCPSG, and I wrote to let him know I was going up to Glasgow, but we've recently had some warm exchange about the past and it turned out he had been following my career in my position in College through the newsletters!   After I knew him, he became the Clinical Dean at St George’s and was instrumental as Chair of a Working Group in setting up the graduate entry programme for medical students.  And while up in Glasgow I also met up with Fiona who was a student and then staff nurse on my ward.  She stood out a mile as such an empathic nurse with the highest standards, who after marrying moved to Edinburgh and had a long career in health visiting - we had a wonderful time meeting up and reminiscing along with catching up about things in life.  

SO WHY HAVE I WRITTEN THIS BLOG?

Well I sent the clip of the ceremony to a non medical friend, Alison, who is beautiful both inside and out 😍.  I found this news item about her here and those of you who know my passion for Liberty fabric will understand how I came to meet her!  This morning she wrote 'Wow you are a great inspiration and truly a testimony to your profession.  Be proud of your achievements'.  I then explained the 'bragging discomfort' as I described above and she said, 'your resilience and determination will inspire others to do the same', which was a completely different take on the news and I hadn't considered in this light at all - so then I wrote this blog 😂.  

As I start to revalidate again, I know I am very proud to be a nurse but somehow it does feel right now we are sometimes a 'downtrodden' profession.  I rarely comment on anything political, but the news this week of the recommended payrise was disappointing and I know many GPNs who have not even received the 6% payrise from their practices in England which the RCN and BMA have jointly spoken about.  GPNs are so hard working and the salt of the earth in General Practice.  A group that I've always wanted to help and support and this has given me so much pleasure over the years.  I feel privileged to have been able to use my skills, knowledge and a platform to help.  

And to many of the nurses who I've worked with in travel medicine and particularly those who have been part of the FTM, I repost this image I put up during COVID in 2020 when I was working as the Dean.  I thank many of you who gave me such support at that time. It has been a true pleasure to work closely with you, some I initially trained and had the joy of supporting and mentoring since, who then just became very good friends and valued peers.  We have contributed so much to this field and should continue to do so and value our true worth.  

And so this honour from the Royal College is perhaps something I should be proud to share - and I did post on LinkedIn this week (which I rarely use), when I mentioned I feel a digital platform coming on as I have some wonderful memories through my career as many of you reading this will, but it would be great fun to document some of it!  So that's the next project for 2025!  

Time for a little reflection with much gratitude

💗I don't often post personal blogs, but I'm feeling a great need right now, so hope you'll forgive my indulgence.  

The news out there seems all doom and gloom and somehow heightens my sense of a great need for more kindness in the world. As I reach a big '0' birthday this week, I have to feel very grateful, because as many of you know, I was diagnosed with a stage 3 breast cancer, 15 years ago.  Recent health problems have led to me having a full body scan, which has reassured me no cancer has been detected from the top of my head to my knees!  So I have great reason to be very thankful, but at the same time, it's made me reflect even more than usual.  

The recent extremely sad and upsetting news about Sir Chris and Lady Sarah Hoy demonstrates just how fragile life can be - I've been listening to 'All That Matters' amidst tears at times and full respect in equal measure.  It's wonderful that people are more open and discuss their journeys, but the power of strength many have, continues to fill me full of admiration for their openness and apparent ability to cope in such times. I remember back in 2009, I gained a strength I didn't know I had, but this was also helped along by much kindness shown to me at the time from many friends, colleagues and of course a loving family, but also many I didn't know.  

One of those people was Trevor Sorbie MBE.  So I was greatly saddened to learn in the news of him passing away and hadn't been aware of his bowel cancer diagnosis. I wish I had, because I would have written to him.  But this video of him and his wife Carole appearing on 'This Morning' just a month ago was incredible.  So the back story is that Trevor helped me in 2009 and showed a kindness that blew me away, making such a difference at that fragile time of my life.  I wrote a quarterly editorial for a craft magazine for 20 years (1996 to 2016) called Craft Creations, that was all about making hand made greetings cards. In the early days I also designed a few cards, the patterns were published, but it coincided with starting my travel medicine training.  So in the end I wrote the editorial only, which on reflection has turned into a bit of a catalogue of my life at the time.  

I found the edition from Summer 2009 when I wrote about Trevor.  He set up a charity called 'My New Hair' which provides support and advice for medical hair loss and he used to teach hairdressers to cut wigs so they looked natural.  I explain it in the Summer 2009 editorial, so please read it here.  I also wrote a follow up piece in the Autumn of 2009, at a time I was just about starting to need to wear the wig, but explain a memorable day out!  The Autumn editions were always full of beautiful Christmas card patterns and instructions, so please contact me if you'd like to see it!  

                           You can also read the editorial here 

I didn't know that Trevor was the originator of the 'Wedge' hairstyle.  In my nurse training and time working as a staff nurse at St. George's Hospital I shared a flat with three great friends and we all went to a hair salon on the King's Road called 'Sissors' and had these hair styles.  There's a larger picture of my sporting the cut in my staff nurse uniform, at the bottom of a blog I wrote in lockdown!  

Today I'm about to finish some travel medicine work, make another posting on my FB page in relation to travel health and then finish some cards to take along to the salon to hopefully get delivered to Trevor's wife, along with a message.  But also in conclusion, I have a number of close family members, some good friends and colleagues going through tough times just now - you know who you are - and I send my love, a big hug of kindness and many positive thoughts to you 😘💗xxx 

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.