Travel health update

This month’s Update focuses on just two important changes, to hepatitis A guidance for adults and children, and to rabies prophylaxis in both pre- and post-exposure situations.

HEPATITIS A

Although many of you may be finding it easier to obtain stocks of hepatitis A vaccine, some shortages still exist and therefore the dose sparing guidance remains in place. These documents, separately written for adults and children, were updated in July and can be found at https://www.gov.uk/government/publications/hepatitis-a-infection-prevention-and-control-guidance

The guidance acknowledges that NaTHNaC has updated its hepatitis A recommendations and as a result hepatitis A vaccine will no longer be recommended for most travellers visiting a number of countries. In the adult guidance there is an emphasis on encouraging use of adult antigen content vaccines in adults where possible. This detail is contained in Tables 2 and 4 of the new adult guidance document, but when stock is limited, alternatives are suggested. The recommendation for the use of combined hepatitis A and typhoid vaccine has been removed. No changes have been made on the length of protection for selected choices of vaccines – see table 4. What isn’t clarified yet is that if a half-dose of hepatitis A antigen was given for the priming dose, what length of time the recommended booster dose would last. This scenario may apply for many of your travellers caught up in the shortage that began just over a year ago. For the time being, another vaccine is likely to provide adequate boosting in an immunocompetent person but I suspect we will need to wait until further information becomes available.

For children, the document explains that there have been recent transmission incidents, probably related to imported cases in unvaccinated children who have travelled overseas. Because supplies are improving, children now travelling to countries where hepatitis A is recommended should be offered vaccine prior to travel. The options of vaccines given in Table 2 differ in this new guidance, including use of adult monovalent hepatitis A vaccine as a second option if Havrix Monodose Junior, VAQTA Paediatric or Ambirix are not available. Table 4 for boosting options is largely the same but excludes use of combination hepatitis A vaccine and typhoid vaccine. Please make sure you study the guidance thoroughly. I will be updating my online resource on these hep A shortages found at https://www.janechiodini.co.uk/education/online-learning/

RABIES

A number of changes have been made to pre- and post-exposure rabies vaccine use. The Green Book, Chapter 27, at https://www.gov.uk/government/publications/rabies-the-green-book-chapter-27 indicates that ‘an accelerated course of primary pre-exposure immunisation may be given if there is insufficient time before travel to complete the 21-28 day course. Three doses of rabies vaccine (2.5IU) should be given intramuscularly on days 0, 3 and 7, with an additional dose at one year if they will continue to travel to high risk (enzootic) areas. Where there is sufficient time to complete the 21-28 day course, this is the preferred schedule for those receiving pre-exposure prophylaxis’. The NaTHNaC fact sheet on rabies, which is a very worthwhile and engaging read and can be found at https://travelhealthpro.org.uk/factsheet/20/rabies, indicates that both Rabipur and Rabies BP vaccines can be used for the 0, 3 and 7 day schedule.

Booster dose for travellers

Whereas the previous version of the Green Book discussed considering a booster at 10 years, this timeframe has been removed and the text now states ‘routine booster doses are not recommended for most travellers. A single booster dose of vaccine can be considered, following a risk assessment, in those who have completed a primary course over one year ago and are travelling’. This has made previous advice we’ve given travellers when vaccinating a little challenging at times and if there are further developments I’ll post in a future update.

For non-travel rabies prophylaxis, pre-exposure vaccine will only be provided by PHE for bat handlers, where no formal employer can be identified.

Changes to post exposure management are too great to outline here, but a key point is that the number of doses of vaccine for post-exposure treatment in immunocompetent individuals has been reduced from 5 to 4. For more details see https://www.gov.uk/government/collections/rabies-risk-assessment-post-exposure-treatment-management I’ve updated my online rabies resource which provides links to all the information including a new traveller information video, again at https://www.janechiodini.co.uk/education/online-learning/.

• The August issue of Vaccine update (issues 282) is a special edition on rabies. Find it at https://www.gov.uk/government/publications/vaccine-update-issue-282-august-2018-rabies-special-edition