Travel health update

The world of travel vaccines seems to have gone a little crazy, testing our skills and patience, adding to the pressure in a busy travel consultation. The position changes rapidly so here are some of the most pressing updates

ACWY CERTIFICATE FOR PILGRIMS

The Ministry of Health for the Kingdom of Saudi Arabia published their 2017 guidance in June and amidst the information was the instruction that 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 the validity of the certificate will be for 3 years. The vaccine must also be given not less than 10 days prior to arrival. The instruction for 2016 was to write 8 years on the certificate if giving a conjugate vaccine so this is an important practice point. See http://www.moh.gov.sa/en/hajj/pages/healthregulations.aspx

HEPATITIS A VACCINE SHORTAGES

There are a number of problems regarding the supply of adult monovalent hepatitis A vaccines as outlined in the Vaccine Update (see the latest at https://www.gov.uk/government/publications/vaccine-update-issue-264-june-2017). Guidance has now been issued to manage this situation. This has been decided by Public Health England in consultation with the Joint Committee for Vaccinations and Immunisations (JCVI). While much is now clear and helpful, it could be there may be further directions so it is important to keep reviewing the situation on NaTHNaC (TravelHealthPro) and TRAVAX. Here are a number of situations with an explanation of how to proceed:

1. You have one dose of adult monovalent hepatitis A vaccine left in your fridge.

A traveller who is HIV positive and unvaccinated should take priority for this vaccine as a first dose to maximise protection as the response rate to a vaccine is poorer in this group. For specific guidance on alternative steps to follow if vaccine is not available, see https://travelhealthpro.org.uk/news/225/hepatitis-a-vaccine-shortage-implications-and-advice-for-clinical-practice.

2. An immunocompetent adult needs to commence a course of hepatitis A

During the current shortage, give a paediatric dose of hep A vaccine and advise this traveller to return in one year for an adult dose of hep A vaccine. If you have no paediatric hep A, you can give a combination adult hep A/B instead. If you think hepatitis B protection is also indicated then I would commence a course of Twinrix. I’m aware some CCGs are strongly discouraging use of this vaccine but in this situation it would be a sensible option, and ultimately it is the GP practice’s decision to administer the vaccine if they think it clinically appropriate.

3. A medically well traveller is going to Thailand for 2 weeks to stay in a hotel in Bangkok

The current guidance from NaTHNaC is that only some travellers would need hepatitis A protection, not most travellers, and this scenario would not fit the criteria for vaccination. NaTHNaC has updated the country recommendations at https://travelhealthpro.org.uk/news/223/changes-to-the-country-information-pages-hepatitis-a-vaccine-recommendations. NaTHNaC states: ‘Health professionals are advised to follow recommendations as per the jurisdiction in which they practice’. The advice from TRAVAX remains that vaccination is usually advised for all at risk travellers to Thailand. Wherever you work, travel risk assessment is essential.

4. A traveller returns for a booster of hepatitis A vaccine

The dose-sparing guidance states a booster dose can be delayed beyond the recommended 12 months, up to 5 years, in most circumstances. If the priming dose was given more that 5 years ago then you would administer a paediatric hepatitis A vaccine (or A/B as in scenario 2) but as yet we have no data as to how long this vaccine will provide protection. Just document detail of this consultation at the current time and reassure the traveller this booster will provide protection for the current trip.

Use of these guidance recommendations to vaccinate will require preparation of a patient specific direction unless you are an independent prescriber.

Watch out for further notification on my Facebook page for any news regarding this topic at https://www.facebook.com/TravelHealthTraining/ as well as NaTHNaC and TRAVAX.