MMR clarification on use of vaccine for travel

Just managed to get a blog done before the end of 2017 and apologies I haven't done many over the past few months, the Autumn has been particularly busy.

Measles remains endemic in many countries around the world and in Europe there have been big outbreaks particularly in Romania, Italy and Germany and imported cases from Romania have led to outbreaks in Leeds, Liverpool, Birmingham and Manchester.  More detail is available on TravelHealthPro  where it reminds us 'elimination can only be sustained by maintaining and improving coverage of the MMR vaccine in children and by using all opportunities to catch up older children and adults who missed out on the vaccine'.

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).

In the December issue of Vaccine Update it clarifies 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.  I've been asking this question for many years so its good to have a confirmed answer in writing! 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. 

MASTA conference

The MASTA conference is being held at the Royal College of Physicians on the 10th November 2017 and I'm doing a one hour update - so much to cover in that time!  I've prepared yet another page of resources to help lead delegates to all the resources mentioned for quick access.  Click on the image below to go to the dedicated section on my website.

Best Practice in Nursing

I'll be speaking at this conference on Thursday 19th October.
The session is entitled 

FAQs on Travel Health - are you up to date?

The link to the conference website information which includes the objectives and more details is here

As usual I've prepared a page with links to resources and these can be found by clicking on the image below.  

Men ACWY booster for travel

Just updating some slides and checking references I found that the Meningococcal disease factsheet on TravelHealthPro was updated on 8th September and the following has been put:

Reinforcing immunisation
The Joint Committee on Vaccination and Immunisation (JCVI) Committee reviewed information on length of protection following ACWY conjugate vaccination. Antibody against serogroup A disease was the first to wane, and this meant boosting was important for travel, but less important for the routine MenACWY programme in the UK. For travellers at continued risk, the Committee agreed that boosting every five years would be a sensible approach until data became available.  

The reference to this is in the JCVI draft minutes of their meeting on 7th June 2017.

This is so good to establish amidst all the current confusion in travel right now!  Don't forget the length of time to be written on a certificate for visa entry for Pilgrims to Hajj or Umrah is now 5 years and the paperwork must clearly state that the vaccine given was a meningococcal conjugate vaccine.  See the information from NaTHNaC here 

Please note, this information supersedes my blog of 25th May regarding the boosting of ACWY vaccine see here

And just out of interest - this vaccine has always been under the category of you may charge for it (like hepatitis B) but that doesn't mean you have to charge.  This clarification remains in the BMA GPC document Focus on Travel Immunisation, guidance for GPs,  published in November 2012.  To obtain a copy go to DOWNLOADS on the page here.  However on the main webpage it says it is a private vaccine for travel only. I have made enquiries regarding the discrepancy.  Of interest this is one of the vaccines in the NHS Consultation - see a short piece explaining this here.  

I think this is one of the travel vaccines most GP surgeries choose to charge their patients for but the confusion needs to be resolved one way or another.

Review of the last two weeks!

I've been on holiday for a fortnight and what a lot has happened in the world of travel medicine during that time.  Here is a quick summary of some changes and links to a few of the key resources:

VACCINE SHORTAGES continue and Public Health England have now published guidance documents for Hepatitis A infection: prevention and control guidance with all documents on this page here. There are two documents specifically about hepatitis A vaccine

• Hepatitis A vaccination in adults - temporary recommendations  
• Hepatitis A vaccination in children – temporary recommendations

I would suggest there is no quick fix to understanding the guidance, you need to print it off and have within your consultation.  And remember that NaTHNaC has reviewed and updated the hepatitis A country specific information and vaccine recommendations to provide up-to-date recommendations for travellers and travel health professionals - see here 

Hepatitis B vaccine is also in short supply and one document covers this topic for temporary measures 

• Hepatitis B vaccination in adults and children: temporary recommendations

We are reminded that for all this guidance from PHE, this temporary advice is not absolute and requires some clinical judgement and a detailed individual risk assessment.

• A new leaflet What to do if you have to wait for a dose of hepatitis B vaccine: advice for patients was published on 7th August

NATIONAL DATABASE DEVELOPMENTS

NaTHNaC are changing their telephone advice line opening hours from 7th August 2017, in response to customer feedback. For details of the news item see here .  NaTHNaC have also launched an new e learning course on risk assessment - see here 

TRAVAX has upgraded their website and it's being trialed alongside the original website just now on a 'Beta site' which allows any potential issues to be resolved before it goes 'live'.  The site has a more modern feel, works intuitively now on devices such as tablets, mobile phones and laptops, and the popular suitcase feature has been enhanced further.  For example, one can also include a message for your traveller if sending them advice by e mail.  For more details see here 

TRAVEL IMMS IN THE FUTURE

Following the news in the press in March, a consultation document has now been launched 'Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs' - see here.  The section for travel is on page 23 here and the FAQ document is also interesting.  I will be writing about this in the August Practice Nurse Update, so more detail shortly.   

And here are some of my holiday pictures!  

Hepatitis B - New Green Book chapter

A new Green Book chapter (18) was posted online on 6th July 2017.  This new version includes information about the introduction of hepatitis B into the childhood immunisation programme in the hexavalent combination vaccine which will be given to babies born on or after 1st August 2017.  For this reason there are currently two versions of chapter 18 as the information for babies born up to and including 31st July remains current.   However on this holding page the information 'For indications other than babies, we recommend that you consult the new chapter that contains the most recent advice', is relevant so here is a short summary of some of the changes I've noticed with an emphasis on travel health.

The new chapter has been reordered is some places, but the new type font makes it easier to read and I liked the layout.  The pages have been re numbered and at the bottom of each page it has the chapter number then the page number e.g. Chapter 18 -1 and it ends at Chapter 18 - 24.  Terminology for intravenous drug users (IDU) has been changed to people who inject drugs (PWID).

What is different for travel?
The change is found on page 13 under the heading Reinforcing doses for those who have received pre-exposure immunisation.  An increased number of references have been given and the text includes information from the World Health Organization.   The conclusion in this section is that the current UK recommendation is that those who have received a primary course of immunisation, including children vaccinated according to the routine childhood schedule and individuals at high risk of exposure, do not require a reinforcing dose of HepB-containing vaccine, except in the following categories:

• healthcare workers (including students and trainees), who should be offered a single booster dose of vaccine, once only, around five years after primary immunisation
• patients with renal failure 
• at the time of a significant exposure (see the chapter, but this group would include babies born to hepatitis B positive mothers )

Basically we would no longer give a booster to a traveller at 5 years under normal circumstances and whereas the previous chapter was more difficult to clarify, this is now a lot clearer.  

OTHER ITEMS OF INTEREST but NOT TRAVEL RELATED (but please ensure you read further)

Babies born to hepatitis B infected mothers management which is named the selective neonatal immunisation programme as follows:

• A monovalent hepatitis B vaccine given at birth (within 24 hours of delivery as already actioned currently) 
• A monovalent hepatitis B vaccine given at 4 weeks
• A hexavalent hepatitis B-containing vaccine at 8 weeks, then at 12 weeks and at 16 weeks
• A monovalent hepatitis B vaccine at one year, alongside a test for HBsAg.

A further dose at 3 years 4 months is NO LONGER recommended but this pre-school booster check should be used to check the child has been fully immunised against hepatitis B and tested for infection.  

A newborn infant born to a hepatitis B negative woman but known to be going home to a household with another hepatitis B infected person should be offered a monovalent dose of hepatitis B vaccine before discharge from hospital and then continue to routine schedule at 8 weeks.  

If you are involved in this type of management please make sure you read the chapter (page 13 - 15)

OTHER INCLUSIONS IN THE NEW CHAPTER OF INTEREST

• Blood testing - information remains the same that we would not blood test a traveller but for those at occupational exposure the chapter now says anti-HBs titres should be checked ONE TO TWO MONTHS after the completion of a primary course (rather than 1 - 4 months as in the previous chapter.  See page 18
• A new heading: neurological conditions has been added on page 20
• A new short paragraph added under adverse reactions says: Confirmed anaphylaxis occurs extremely rarely. Data from the UK, Canada and the US point to rates of 0.65 to 3 anaphylaxis events per million doses (Bohlke et al., 2003; Canadian Medical Association, 2002).  See page 21
• Under 'supplies' details are included for Scotland and Northern Ireland.

PLEASE REMEMBER - this is a short resume of items I thought may be useful to know from this new chapter, but please make sure you go to the publication and read for further information.

Please note my disclaimer

Further resources 
Green Book chapter 18 - Hepatitis B 
Hexavalent combination vaccine: programme guidance from Public Health England
NaTHNaC factsheet Hepatitis B  
A previous blog about Hepatitis B re 0, 1 and 2 month schedule (please note this was written in July 2016 so some of the links may not be working now)

but look out for possible news items updating on this chapter on both NaTHNaC and TRAVAX 

Travel Health Databases

There remains a lot of confusion over the different databases that we use for travel health advice following our travel risk assessments.  I hope this helps to explain what comes from where and some pointers about the services.

NaTHNaC is developed by the team in the National Travel Health Network and Centre and is designed both for healthcare professionals and the public to use.  It is a free of charge service.  The website is called TravelHealthPro and the service is commissioned by Public Health England.  To see more detail see here.  NaTHNaC run a telephone advice service for anyone to use.  For a list of the times of this and the TRAVAX line click here (see item no. 8 in Tools)

TRAVAX is maintained and continually updated by the Travel and International Health Team of  Health Protection Scotland. For more detail see here.  It is free to use in Scotland as an NHS service.  NHS users in Wales can access TRAVAX free of charge through their on-line NHS intranet services centrally funded by their Health Department.  My understand is that users who access it by this route cannot use the 'suitcase' feature.  In England and Northern Ireland a fee is charged for use. Some CCGs pay in England for all surgeries within the CCG to use it, however a surgery can individually subscribe and even an individual person can subscribe as well.  Costs are not that high so see 'About TRAVAX' for further informaiton and scroll to the bottom for prices.  Users of TRAVAX can use their telephone helpline as a support service.

Fitfortravel is the public site of TRAVAX, therefore the guidance is based on the advice given in Scotland.  Healthcare professionals NOT using TRAVAX should not use fitfortravel as a standalone website as this is developed intentionally for the public.  They should be using NaTHNaC as well to receive additional information appropriate to a healthcare professional.

Which database should you use for your day to day assessments and advice?

Yellow fever
NaTHNaC is responsible for a programme of designation, training, registration, standards and audit for Yellow Fever Vaccination Centres (YFVCs) in England, Wales and Northern Ireland (EWNI).  If you work in England, Wales or Northern Ireland you must therefore use TravelHealthPro for issues concerning yellow fever.  If you work in Scotland you must use TRAVAX.   The Scottish Government designated responsibility for the programme of registration and administration of Yellow Fever Vaccination Centres (YFVCs) in Scotland to HPS in December 2006.

Polio 
The guidance on who receives polio containing vaccine as an NHS provision as part of the PHEIC guidance currently for travel to Pakistan, Afghanistan and Nigeria is different between NaTHNaC and TRAVAX and you must follow the guidance in the country in which  you work - see my last blog about this.

Hepatitis A 
NaTHNaC has written on TravelHealthPro  Health professionals are advised to follow recommendations as per the jurisdiction in which they practice.  See the statement at the bottom of this page (just above resources)

Malaria
There are a number of differences in the advice between the two databases and at the current time you could use either, but again, document which one you have referenced.

NOTE UPDATE (WRITTEN 4th JANUARY 2018) 

In October 2017 Public Health England published the 2017 Guidelines for malaria prevention in travellers from the UK - within this document there is a statement on page 8, repeated on page 12 which says  "We recommend health professionals stick to using one resource for country specific malaria recommendations to optimise consistency of advice. Whilst we recognise that other sources of advice are available, healthcare professionals working in England, Wales or Northern Ireland are advised to use the ACMP guidelines as their preferred source of guidance for malaria prevention".

And a bit more information......

Other travel health advice 
At the current time you could use either database but please ensure you document which one you took your advice from.

Can I use a chart instead?
Pulse do publish a chart with vaccine and malaria recommendations but for years now we have advised to use an online database because this will provide you with the most up to date information.  It is far easier to update a website than something that is in print and less easy to monitor.

Why are there variations?
In fairness, different countries do provide varying advice and this is determined by their national bodies that decide on their guidance.  The important aspect is to work within the guidance of the country in which you work.  See CDC for an example of varying advice as an example.