Health protection Scotland Travel and International Health Summary of Yellow Fever Vaccination Centres 2015-2017 Dr Kali Perrow (MBChB, MRCP (Glas), FFTM) Shirley Marshall RGN MFTM RCPSG Introduction Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The virus is endemic in tropical areas of Africa and Central and South America. Large epidemics of yellow fever occur when infected people introduce the virus into heavily populated areas with high mosquito density and where most people have little or no immunity, due to lack of vaccination. In these conditions, infected mosquitoes of the Aedes aegypti specie transmit the virus from person to person. Symptoms of yellow fever include fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue. A small proportion of patients who contract the virus develop severe symptoms and approximately half of those die within 7 to 10 days. Good supportive treatment in hospitals improves survival rates. There is currently no specific anti-viral drug for yellow fever. Yellow fever is prevented by an extremely effective vaccine, which is safe and affordable. All vaccines used to protect against yellow fever must be approved by the World Health Organisation (WHO). In the United Kingdom Stamaril (Sanofi Pasteur) is the only WHO approved, licensed yellow fever vaccine available. With the exception of very rare cases of vaccine-associated neurotropic and viscerotropic disease, yellow fever vaccine is generally considered to be safe. Contraindications include severe hypersensitivity to egg antigens and severe immunodeficiency. Yellow fever is the only disease specified in the International Health Regulations (2005) (IHR (2005)) for which countries may require an International Certificate of Vaccination or Prophylaxis (ICVP) as a condition of entry.(1) Prior to 2014, it was recommended that a single dose of vaccine would confer immunity for 10 years, and consequently an ICVP was only valid for this time period. Subsequent travel to a yellow fever zone would require revaccination. In May 2014, WHO s Strategic Advisory Group of Experts on immunisation advised that a single dose of yellow fever vaccine confers life-long immunity. The vaccine provides effective immunity within 10 days for 80-100% of people vaccinated, and within 30 days for more than 99% of people vaccinated.(2) Accordingly, as of 11 July 2016, for both existing or new ICVP s, revaccination or a booster dose of yellow fever vaccine cannot be required of international travellers as a condition of Country entry regardless of the date their ICVP was initially issued.(3) 1
When a traveller is visiting a country with a yellow fever ICVP requirement and vaccination is contraindicated or where the risk of an adverse event is considered greater than the disease risk, an exemption certificate may be issued after careful risk assessment. The United Kingdom (UK) as a signatory to the IHR is required to designate specific yellow fever vaccination centres (YFVCs). The statutory responsibility for designating YFVCs in Scotland lies with Health Protection Scotland (HPS). Through a programme of registration, training, and audit, HPS maintains and improves standards and consistency of practice within YFVCs in Scotland. This ensures that Scotland meets UK obligations under the IHR as well as contributing to protecting the health of travellers from Scotland. Designated YFVCs in Scotland are required to keep appropriate records of all yellow fever vaccines they administer for a period of 10 years, submitting reports of vaccine utilisation and any adverse events to HPS on an annual basis. Here we report on returns to HPS for the period 1 January 2015 to 31 December 2017. This period covers the time frame before and after the change in regulations regarding the length of time yellow fever vaccines confers immunity and change in ICVP requirements. For the purpose of this analysis, data was extracted and analysed using Microsoft Excel.Health Board area population data for 2015-2017 was obtained from the National Records of Scotland.(4) 2
Results Total Number of registered YFVC In 2017, 236 YFVCs were registered with HPS, compared with 242 in 2016 and 251 in 2015 All YFVCs submitted returns on the number of doses of vaccine administered each calendar year. The data was collated onto a web-based database. In the time frame reviewed over 57% (140-142) of Scottish YFVCs were within Greater Glasgow & Clyde, Grampian and Lothian NHS Health Boards. There was little change between these 3 health boards over the 3 year period. GGC had 24% in all 3 years, (59, 57, 57 centres), Grampian 17% (42, 41, 41 centres) with Lothian at 16-18% (41, 42, 42 centres) from 2015-2017 respectively. (Figure 1) Overall the total number of YFVCs has dropped by ~6% from 251 (2015) to 236 (2017).The largest drop in YFVCs was 4.4% from 2015 to 2016 (251 to 242) and reduced a further 2.5% from 2016 to 2017 (242 to 236) Figure 1: Number of YFVCs by Health Board, 2015-17 3
Unsurprisingly Shetland, Orkney and The Western Isles have amongst the smallest number of registered centres, however when considering population numbers these Health Boards are actually very well served having 9,9 and 7 YFVCs respectively per 100,000 population in 2017 compared with GG&C having only 5 YFVC per 100,000 in 2017. (Figure 2). Borders Health Board has seen the number of YFVC reduce consistently between 2015 and 2017 from 5 to 1 centres. As of 2017 Borders Health Board now has the least number of YFVC per 100,000 population (1) 0.4% of the total YFVC clinics in Scotland. (Figure 2). The reason for this reduction is unclear as currently reasons for centres de designating is not captured in the HPS data base. Figure 2: Number of YFVCs by Health Board per 100,000 population, 2015-2017 4
Number of doses of yellow fever vaccine administered per health board Figure 3 below, shows the number of yellow fever vaccine doses administered per health board over the 3 year period. A decrease in the total number of doses administered annually by all Health Boards relates to the decrease in YFVCs with 8914, 7921, and 7337 doses administered respectively from 2015 to 2017. Borders Health Board administered 91, 26 and 6 doses between 2015-2017, which corresponds with the previous information regarding the decrease in centres from 5 in 2015 to 1 in 2017 (shown in Figure 1). Forth Valley is the only Health Board showing a significant increase in annual doses and increased from 267 in 2016 to 328 in 2017 (up 23%). Western Isles Health board has shown the most significant decrease from 47 doses to 8 in 2016, 2017 respectively (down 83%). Figure 3: Number of doses administered by YFVCs by Health Board, 2015-2017 5
Number of doses of yellow fever vaccine administered per YFVC The main range of doses administered annually by individual centres continues to be between 1 and 50 doses for over 70% of the YFVCs with 70%, 77% and 72% respectively from 2015 to 2017. There has been a steady increase each year in YFVCs administering1-10 doses annually. However the most noticeable change is in those administering11-50 doses annually, which has seen a decrease of 18% with 83 YFVCs in this range in 2017 compared to 102 in 2016. (Figure 4) Figure 4: Range of doses administered by YFVCs by Health Board, 2015-2017 6
Type of YFVC YFVC are required to register which type of YFVC they are, i.e. part of a health centre, an occupational health clinic, private travel clinic, pharmacy travel clinic etc. Figure 5a shows that the largest number of registered yellow fever vaccination centres in Scotland are part of a Health Centre or Surgery of a registered general practitioner (59%). 14% of the results returned selected Other category when asked to register the type of centre they are, but did not specify what this was. Only 3% of YFVCs in Scotland are managed by an NHS Trust or Health Board. Figure 5a: Type of YFVCs in Scotland 2017 A further breakdown of type of YFVC by Health Board can be seen in Figure 5b. 7
Figure 5b: Type of YFVCs by Health Board 2017 Figure 6a shows that over half (58%) of all Health Board areas in Scotland will see both Practice patients and members of the public. Only 10% are restricted to practice patients only. Figure 6a: Type of travellers seen at YFVCs in Scotland 2017 A further breakdown of traveller type by Health Board area can be seen in Figure 6b. 8
Figure 6b: Type of travellers seen at YFVCs by Health Board 2017 Number of adverse events There were no adverse events reported by any of the YFVC in the 3 year period. 9
Conclusion A standard suggesting the minimum number of YFVC per 100,000 population or per health board does not exist. The results of this audit show that Scottish health boards have between 1 and 57 centres per board, corresponding to between 1 and 9 centres per 100,000 population. Clearly for Borders health board, if the remaining centre were to close, its residents would have to travel outwith their board area to seek vaccination. It may be appropriate for Health Protection Scotland to make a recommendation for the minimum number of YFVC per health board and 100,000 population, particularly in light of the Vaccine Transformation Programme (see below) This report has highlighted that the number of yellow fever vaccination centres and doses administered in Scotland has gradually decreased over the 3 year period reviewed. This gradual decrease could be related to the 2014 WHO advice that yellow fever vaccine gives lifelong immunity in most people and the 2016 updates to yellow fever international certificates of vaccination or prophylaxis(icvp) being valid for life rather than 10 years. This decrease is thus not unexpected. Yellow fever vaccine is a live vaccine and it thus has some significant side effects and relative/absolute contraindications associated with its use. (5) In addition International Health Regulations and the need for an ICVP in part govern the use of the vaccine. These IHRs are reviewed and updated annually by the WHO, and YFVCs must be familiar with these and their interpretation. This makes yellow fever vaccine one of the more complex travel vaccines to prescribe. HPS provides training days for YFVC which must be completed every two years. It is reasonable to assume therefore that YFVC who administer vaccine on a regular basis (i.e. > 1 per week) are likely to be more familiar with the use of the vaccine than those that administer it infrequently, i.e. < 1 dose per year. An increase in the number of YFVC who administer 1-10 doses a year has been noted since 2015 alongside a reduction in the number of centres administering between 11 and 50 doses. No adverse events have been recorded associated with the use of vaccine between 2015 and 2017. The travel and international team of HPS provide a thrice weekly telephone advice line for all health practioners practising travel health. It is not known how many of the YFVC seek advice regarding vaccine use, and whether or not this is more common in the lower vaccine use centres. In addition a retraining online document is available on the HPS website. (6) In 2017 the Scottish Government and Scottish General Practitioners Committee (SGPC) agreed vaccination delivery will move away from the current position of GP practices being the preferred providers. The Vaccinations Transformation Programme (VTP) is reviewing and transforming how vaccinations are delivered in Scotland. The provision of travel vaccinations and travel health advice is currently being assessed. The expectation is that the reformed vaccination programmes will be in place by April 2021.(7) There is anecdotal evidence that some GP practices have already altered their travel health services, and this may account for some of the closures of YFVC. If this audit is repeated in 3 years time it is to be expected that there will be a marked change in the type of YFVC providing this service. In carrying out this audit members of the Travel Team at Health Protection Scotland have become aware of some inadequacies in the data that is collected from YFVC and the supporting material for YFVC on the Health Protection Scotland Website, in particular the data 10
entered on the type of centre. This has led to a review and ongoing update of the yellow fever data base and Website, it is anticipated this will not only improve the service to YFVC s but enable HPS to monitor and assess YFVC provision in Scotland in a robust and effective manner. Further information on Yellow Fever Vaccination Centres in Scotland can be found on the HPS Website: http://www.hps.scot.nhs.uk/yellowfever/index.aspx. Details on how to apply for designation in Scotland as well locating YFVCs can be found here. 11
References 1. World Health Organisation International health Regulations (2005).Second ed. Geneva:World Health Organisation.2005. [cited online 2018 June 28 th ]. Available from URL: http://www.who.int/ihr/publications/9789241596664/en/ 2. World Health Organisation. Yellow fever. Fact Sheets. World health Organisation. Updated 1 May 2018. [cited online 2018 June 27 th ]. Available from URL: http://www.who.int/news-room/fact-sheets/detail/yellow-fever 3. World Health Organisation. Amendment to International Health Regulations 2005.Annex 7.Yellow fever. Geneva World Health Organisation. 2016. [cited online 2018 June 17 th ]. Available from URL: http://www.who.int/ith/annex7-ihr.pdf 4. National Record of Scotland. Mid-Year Population Estimates. 2017. [cited online 2018 June 26 th ]. Available from URL: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-bytheme/population/population-estimates/mid-year-population-estimates 5. TRAVAX. Yellow Fever. TRAVAX. 2018 [cited online 2018 July 13 th ]. 6. Health Protection Scotland. Yellow Fever: Retraining for Registered Centres. Health Protection Scotland. 2017. [cited online 2018 July 13 th ]. Available from URL: http://www.hps.scot.nhs.uk/yellowfever/retrainingregisteredcentres.aspx 7. British Medical Association. Scottish GP Contract 2018. British Medical Association. [cited online 2018 July 2 nd ]. Available from URL: Available from URL: http://www.travax.nhs.uk/diseases/vaccine-preventable/yellowfever/#vaccination6 https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpcscotland/gp-contract-agreement-scotland 12