Tuesday, 1 August 2017

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

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 
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.


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!  


Thursday, 13 July 2017

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 

Tuesday, 4 July 2017

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.

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.

Thursday, 29 June 2017

Polio and PHEIC

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.  To see the details of the latest meeting see here.  Of late measures were in place just for Pakistan, but from the last meeting, Afghanistan and Nigeria have been added to countries we need to provide special advice to our travellers.  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 and also circulating vaccine derived polio virus (CVDPV).  To see an encouraging map of progress look at this.  This is on the Polio Global Eradication Iniative site which has some excellent information explaining the situation.

Please note, this is a changing picture and guidance may alter after the EC meets every 3 months but updates are then subsequently put onto the NaTHNaC (TravelHealthPro) and TRAVAX websites to inform you.



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

  • If they are going there for LONGER THAN 4 WEEKS they should be asked 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.    
I have been teaching this since 2014 but there are still many who aren't aware of some of the guidance and perhaps you don't know depending on the database you use, but see the following:

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.

ICVP certificates - guidance in England

  • These need to be obtained from the NaTHNaC shop online 
  • 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 

Note: there is anecdotal evidence that ICVPs are not being checked on exit from the country, nor vaccine given, but the advice is a WHO recommendation so we should be following the guidance and inform our travellers about this regardless.

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


Monday, 29 May 2017

Malaria Matters E learning course

Many of you may have already taken this course but some new software means I've now been able to update it and it works smoothly now on a tablet and mobile phone as well as your personal computer! This is a huge relief because although the course has been very well evaluated, worked efficiently for some, has driven others a little bit crazy!  Despite this I know that hundreds of people have also done it and gained great benefit, so I hope it will be plain sailing in the future ..... I'm a 'one man band' and sometimes sorting out IT issues is a real challenge!

Click on the image to see more detail.  


When you enter the e learning platform called 'LearnUpon' to undertake the free of charge course it will tell you you have two weeks to complete it. The platform costs to host the course, but I feel so keen that people learn more about malaria that I make it free to the end user at the current time. I limit the time access to manage this.  If you're mid-way and just haven't had time to finish but really want to do so, please e mail me as instructed on the course and I'll extend your time.  If you looked and decided not to complete then I'll remove your registration to make way for someone else to use it.  

LearnUpon now have an app to manage the course through on a mobile device - for the IoS version on the Apple store click here   I haven't been able to find an Android app for it yet but am still making enquiries.  

Thursday, 25 May 2017

Update on ACWY conjugate vaccine booster

Please note this information was up to date at the time of writing this piece and is updated information to my posting on the subject on 31st August 2016.  It has subsequently been updated again on 22nd June 2017. 

The vaccines we use in the UK and the reason for giving for travel purposes

In the UK we use two quadravalent meningococcal vaccines against the strains A, C, W135 and Y. These two CONJUGATE vaccines are Menveo (supplied by GSK) and Nimenrix (supplied by Pfizer - please note Nimenrix is no longer a black triangle drug). These vaccines are given to travellers going to endemic areas in the meningitis belt of Africa and for travellers undertaking pilgrimage - Hajj and Umrah for which a certificate of proof of vaccination is required, enabling the traveller to obtain a visa for entry to Saudi Arabia.

The Ministry of Health for the Kingdom of Saudi Arabia (KSA) publishes annually its requirements and recommendations for Hajj and Umrah. The new guidance was published in June for 2017 - see here and of significant importance it says 'the conjugate meningococcal vaccine certificate is valid for 5 years.  However, the certificate must state clearly that the Hajji actually received the conjugate meningococcal vaccine. If the vaccine type it not indicated in the certificate, then it will be assumed that it is not the conjugate vaccine and it the validity of the certificate will to be for 3 years.

Whereas in 2016 the KSA announced new information for the length of time to write on the certificate stating 8 years for a conjugate vaccine.  This information should NOW NOT be followed. The should not be administered less than ten days before arrival in the KSA.

For more details about Hajj and Umrah see this NaTHNaC Factsheet

In the UK because we now only use the conjugate vaccines, it is very important to write the name of the vaccine given on the certificate.


UPDATE ON BOOSTING OF THESE VACCINES
On my vaccine chart found at item no. 3 in the TOOLS section of my website, I have put 'when or if a booster should be given is not clear at the current time'  because there is nothing out there giving clear guidance as far as I can see!

  • KSA are saying 8 years for a conjugate vaccine on the certificate (as above). 
  • The Green Book chapter 22 on Meningococcal was updated September  2016 and says:
    • Children and young adults aged 10 years to less than 25 years (including students up to 25 years attending university for the first time) may also be eligible, or will shortly become eligible, for the teenage MenACWY conjugate vaccine. Those in this group who have never received a MenC-containing vaccine should be offered a single dose of the MenACWY conjugate vaccine. No further vaccination is then required.  (page 12)
    • In the section for children and adults with asplenia, splenic dysfunction or complement disorders it says booster doses of MenACWY conjugate vaccine in at-risk individuals are currently not recommended because the need for, and the timing of, boosters has not yet been determined. (page 13)
    • In the section for travellers, the previous information for boosting has just been removed. (page 14)

  • NaTHNaC has no information about boosting. 
  • TRAVAX says 'The need for and timing of a booster dose in those over 1 year of age has not yet been determine'. 
  • The Pharma companies GSK and Pfizer both have data for 5 years. 

Out of interest, looking up information for the CDC Yellow Book online in relation to conjugate vaccines (2016 version still online but also in the 2018 book just published) it says for those over 7 years at continued risk boost at 5 years and every 5 years thereafter for people who are at continued risk.

However here in the UK as nurses we must follow UK guidance.  If and when I learn of any new information then I will post here but at the current time I don't think things are very clear and perhaps you need to phone one of the travel helplines to make a final decision for your traveller after performing a travel risk assessment.  See item no 8 here for these details.









Wednesday, 10 May 2017

Nuggets of Knowledge - Hepatitis A vaccine

Hepatitis A vaccine has caused many a query for a very long time.  I've created a short e learning piece on this in the attempt it will help consolidate the theory about the rules, because once understood, hepatitis A vaccine is actually quite easy.

In the learning I explain these rules and explain the evidence behind them, take you through some of the historical issues of hepatitis A protection and provide some questions to test your knowledge.

The programme has been built in software that should work on desktop computers, tablets and mobile phones.  If the speed of your wifi is slow, some the pages may take a while to load.  On some iPads, it may ask you to watch it through an app called 'articulate' which is free to download.  Click on the image below to access the short learning or here.  At the end you'll be directed to a survey monkey to evaluate your experience.  Please complete this if you can.  Thank you!