Travel health update

The pace of travel medicine is picking up, the inclusion of travel health as a core general practice service is still causing confusion, and a number of new travellers’ vaccines have been launched. Jane Chiodini rounds up the latest news to help you keep up to date with this complex field

UPDATE ON GLOBAL PHEICs

A Public Health Emergency of International Concern or PHEIC is the strongest global alert the World Health Organization (WHO) can formally make, and helps to trigger a set of measures and legally binding obligations to facilitate a coordinated international response. This includes temporary recommendations on health measures that states may introduce to prevent or reduce the international spread of disease. Perhaps greater awareness of the term was realised when COVID-19 was declared a PHEIC on 30 January 2020. This ended on 5 May 2023, although as the WHO was keen to point out, the virus is still claiming a life every three minutes, it is still here, it is still killing and it is still changing. Vigilance is still necessary. Similarly, a PHEIC for Mpox was declared on 23 July 2022, and although this ended on 11 May 2023, it is recognised the disease continues to pose a significant threat and ongoing vigilance and management are also needed. From a travel health perspective, it would be of value to point out global risks to your travellers – see my COVID-19 leaflet at no. 26 https://www.janechiodini.co.uk/tools/ for resources to enable their self directed management, and for Mpox, to be aware of types of travellers at greater risk and direct them to appropriate resources such as a posting on TravelHealthPro in early May https://travelhealthpro.org.uk/news/708/celebrating-pride-abroad.

So now, polio remains the only current PHEIC. This has been ongoing since 2014 and the threat from wild polio virus (WPV) and circulating vaccine derived polio virus (cVDPV) remains a significant threat. I have blogged about this several times, but have posted a fresh one as a reminder – see http://janechiodini.blogspot.com/2023/05/ongoing-pheic-for-poliomyelitis.html.

NEW TRAVELLER VACCINES

Sanofi Pasteur launched a new paediatric hepatitis A vaccine on 20 April, Avaxim® Junior. This vaccine contains half the adult antigen content found in the adult vaccine, Avaxim®. Although the Green Book has not yet been updated, the hepatitis A information on TravelHealthPro has, and you can find it at https://travelhealthpro.org.uk/

factsheet/21/hepatitis-a. Of note, the vaccine schedules table of the vaccines, based on Summaries of Product Characteristics (SmPCs) states that Avaxim® Junior provides protection against hepatitis A for up to 25 years following the second dose. The footnote says there is no evidence that further reinforcing doses of hepatitis A vaccine are needed in immunocompetent individuals, but the UKHSA recommends that, until further evidence is available on persistence of protective immunity, a booster dose at 25 years is indicated for those at ongoing risk of hepatitis A. A reminder of all the ‘rules’ regarding hepatitis A vaccine can be found on my short e learning piece at https://www.janechiodini.co.uk/education/online-learning/.

A new cholera vaccine, Vaxchora, is now available. This has not yet been added to the Green Book, TravelHealthPro or TRAVAX. Vaxchora is a live oral vaccine that requires only one dose prior to departure, but has some interactions in use with the typhoid vaccine Ty21A, antibiotics and the antimalarial prophylaxis chloroquine. See section 4.5 of the SmPC found at https://www.medicines.org.uk/emc/product/11330. When national guidance is available, I will add this to my ‘Guide for Travel Vaccines’ chart, item no. 3 at https://www.janechiodini.co.uk/tools/.

A new vaccine, Qdenga, has also been licenced for dengue fever protection in travellers. The live vaccine is licensed from 4 years of age with two doses in the schedule at 0 and 3 months. Although the SmPC is now available at https://www.medicines.org.uk/emc/product/14663/smpc and there is some information on TravelHealthPro at https://travelhealthpro.org.uk/factsheet/13/dengue, NaTHNaC comments that the UK Joint Committee on Vaccination and Immunisation (JCVI) and WHO Strategic Advisory Group of Experts (SAGE) are still reviewing the product information. Recommendations on the use of this vaccine will be published in due course.

A new vaccine for Chikungunya is also expected to be licensed soon, but no specific details are yet available. However, the fact that new travel vaccines are now in the pipeline is exciting and no doubt there will be further news and educational opportunities for these diseases and prevention strategies as time progresses.

GUIDANCE FOR TRAVEL HEALTH

While the provision of service continues to be a challenge, with many GP surgeries still deciding they can no longer provide care to their patients, a number of sources confirm that an NHS travel care model is an essential service in general practice and it must be provided. The service would include the NHS vaccines given where required to provide protection of public health risks from travellers returning with cholera, hepatitis A, polio and typhoid. The NHS website states unequivocally that travel health advice and vaccinations are available from GPs or practice nurses – see https://www.nhs.uk/conditions/travel-vaccinations/.

The Care Quality Commission Mythbuster for pre-travel health services also makes it clear that NHS GP practices are required to offer certain vaccinations for the purposes of travel, free of charge. There has also been confusion with some surgeries sending travellers elsewhere to obtain their pre-travel risk assessment and/or advice. This is not correct. These aspects should be part of the essential service. The details on the CQC Mythbuster, updated in May 2023, clarify that the pre-travel risk assessment must be performed by the healthcare practitioner either: giving the travel vaccine under a Patient Group Direction (PGD), or delegating the administration of the travel vaccine under a Patient Specific Direction (PSD). See https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-107-pretravel-health-services. To ensure the vaccines selected for administration under this legal structure, we must abide by the regulations, having signed the required documentation. Not only is a pre-travel risk assessment required, but the information and advice should be given to the traveller in a shared decision making process to enable informed consent to vaccinate.

Also in May 2023, the fourth edition of RCN Travel Health Nursing: career and competence development was published. This document has been extensively updated and provides information and guidance regarding the incorrect practice described above. The document can be found at https://www.rcn.org.uk/Professional-Development/publications/rcn-travel-health-nursing-uk-pub-010-573 but I have also written a blog to explain far more about the changes which are important for you to be aware of – see http://janechiodini.blogspot.com/2023/05/4th-edition-of-rcn-competency-document.html.

NEW MALARIA PUBLICATIONS

The latest edition of Guidelines for Malaria Prevention in Travellers from the UK was published in January 2023. The section on mosquito bite prevention was enhanced. An important new statement was included: ‘In some circumstances, Advisory Committee on Malaria Prevention for UK travellers (ACMP) advice may differ from that in repellent manufacturers’ product information. When this occurs, the recommendations in these guidelines (which are based on current expert advice from the ACMP) should be followed’. An example would be that the guidelines recommended DEET repellent up to 50% content from 2 months of age, whereas products available stipulate an older age group. Since malaria can be such a severe risk to young children, it is essential that your advice follows the UK guidelines. For further details about changes to this latest publication see my blog at http://janechiodini.blogspot.com/2023/01/updated-malaria-guidelines.html.

Data on 'Malaria imported into the UK: 2021' was published on 30 May 2023 and although case numbers dropped due to reduced travel during COVID-19, there is a clear upward trend again, with Plasmodium falciparum continuing to be the highest risk species, travel to West Africa still the greatest risk region and travellers visiting friends and relatives (VFR) the most common reason for travel in malaria cases in the UK. To read more see https://www.gov.uk/government/publications/malaria-in-the-uk-annual-report/malaria-imported-into-the-uk-2021.