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.
