Health Professionals

The NaTHNaC Yellow Fever Vaccination Centre (YFVC) Initiative

August 2008

The NaTHNaC Yellow Fever Vaccination Centre (YFVC) Initiative: A programme of registration, training, standards and audit.

Professor David R Hill

Director, NaTHNaC

History of Designating YFVCs under International Health Regulations

The administration of yellow fever vaccine has come under International Health Regulations (IHR) since their establishment in 1969 [1]. The IHR were developed as a legally binding code of practice to help protect countries from the introduction of disease. Historically smallpox, plague, cholera and yellow fever were the targeted diseases and there were requirements for both reporting of cases and protection by vaccination when travelling across international borders. However, as smallpox, cholera and plague were controlled (in the case of smallpox, eradicated) or the use of vaccines for protection of international borders was found not to be effective, yellow fever remained as the only disease for which vaccination was required under IHR.

In May 2005 the World Health Assembly adopted a revised set of IHR (IHR (2005)) that came into effect on 15 June 2007. The aim of IHR (2005) is to prepare the world to deal with a broader range of infectious disease threats such as pandemic influenza, SARS, and poliomyelitis, as well as potential threats from non-infectious risks [2]. Yellow fever remains firmly in the IHR (2005) as both a potentially notifiable disease and one for which vaccination is regulated: “State parties shall designate specific yellow fever vaccination centres within their territories in order to assure the quality and safety of the procedures and materials employed.” (IHR, May 2005, Annex 7.2.f) [2].

Until 2003 in England, the Department of Health (DH) was responsible for designating YFVCs under the IHR. Centres that were designated appeared on a searchable database that could be accessed by the public using the internet. 

Upon creation of NaTHNaC in 2002, administration of YFVCs was set as one of its seven core objectives. NaTHNaC began designating YFVCs on behalf of the DH in July 2003. Under its partner organisation, the Health Protection Agency (HPA), NaTHNaC has legislative authority to undertake designation of YFVCs in England (Health Protection Agency Act 2004 and Health Protection Agency Regulations 2005) (see Figure). The programme has now been introduced throughout all practising YFVCs in the UK:

  • In July 2005, the Welsh Assembly formally devolved the administration of YFVCs in Wales to NaTHNaC (Welsh Health Circular, 2005, 064).
  • In April 2007, the Defence Medical Services agreed the NaTHNaC ‘Code of Practice’ for their Medical Branches (Surgeon General’s Policy Letter, #04/07).
  • In August 2007, the Northern Ireland Department of Health, Social Services and Public Safety commissioned NaTHNaC to designate YFVCs in Northern Ireland (Chief Medical Officer of Northern Ireland, HSS(MD) 21/2007).
  • In October 2007, Health Protection Scotland adapted the NaTHNaC programme for the specific needs of YFVCs in Scotland.

Rationale for the NaTHNaC Initiative

Since assuming responsibility for YFVCs in England, NaTHNaC has made the programme one of its key initiatives in achieving its broad goal of “Protecting the Health of British Travellers”. We expect that the initiative will help provide a consistency of practice and improve the care of travellers. The rationale for the initiative is threefold:

  • Promotion of standards around yellow fever vaccination is required under IHR (2005)
  • The British public deserves to know that designated YFVCs are adhering to standards of best practice and that the provider is knowledgeable on the subject
  • Making a decision about yellow fever vaccination is complex:
    • the epidemiology of yellow fever disease is changing
    • the vaccine carries a risk of rare, but serious side effects
    • there are increasing numbers of travellers with special needs going to areas at risk for yellow fever transmission

For the health professional, several challenging questions arise concerning yellow fever vaccination:

  • What is the risk of yellow fever at the traveller’s destination?
  • Is yellow fever vaccination required under IHR (2005)
  • Is it safe to give the vaccine considering the traveller’s age and medical history?
  • How does one balance the risk of yellow fever disease during travel against the safety of the vaccine in an individual traveller?

This is where the NaTHNaC programme may be most valuable, as it aims to clarify these issues and provide guidance to YFVCs. Indeed, based on the calls to the NaTHNaC national telephone advice line, these are the type of queries with which YFVCs are most challenged; 15% of the thousands of calls to our advice line relate to yellow fever vaccination.

Furthermore, it is expected that our efforts to improve yellow fever vaccine administration will lead to an improvement in the overall practise of travel medicine. This theme has been recently voiced in an editorial: “There is no linkage of licensure with providing a higher quality of travel medicine care, but there ought to be… Having a YF vaccination license must carry with it the weight of a higher standard of care, a higher level of training, and the responsibility to protect the traveler from other health threats” [3].

The NaTHNaC Programme

NaTHNaC has undertaken a programme of registration, training, standards and audit. 

Registration: The details of the registration process can be found on the website in the Resources for Yellow Fever Vaccination Centres. Those practices that wish to become YFVCs should download the Yellow Fever Vaccination Centre Information Pack. Each YFVC is required to renew its registration by paying a registration fee on an annual or biennial basis.

Training: Each YFVC is required to have a member of its staff trained on a biennial basis. In order to accomplish this, NaTHNaC has developed a comprehensive training programme, and we are fortunate to have an excellent group of Associate Trainers who help the core NaTHNaC staff deliver the training. Upon completion of the programme, the staff member will have an understanding of both the clinical aspects of yellow fever vaccination and best practice in being a YFVC.

It is expected that the staff member who attended training will share the knowledge and materials with other personnel at their YFVC who are involved with yellow fever vaccination. It is clear from the calls to our advice line and from a survey we performed of YFVCs in England [4], that there is a wide range of experience, training and capability within travel medicine and with yellow fever vaccination in particular. The NaTHNaC yellow fever training programme will provide a consistent standard of knowledge in all centres.

The two-year interval for training was chosen to ensure that YFVCs are informed of the new information concerning yellow fever risk areas and vaccination, and so that additional staff at YFVCs will have an opportunity to attend training.

Standards: Twelve standards have been set by NaTHNaC to which YFVCs must adhere (see Appendix). The responsible medical practitioner for each centre signs the Code of Practice on behalf of their centres thereby agreeing to adhere to these standards. The standards represent best practice in this field.

Audit: Each centre is required to return to NaTHNaC an annual audit of vaccine use (available from the YFVC log-in section of the website). This allows NaTHNaC to review vaccine use on a country-wide basis.

In addition to the audit of vaccine use, NaTHNaC will be instituting an Assessment and Audit instrument to ensure that best practice around yellow fever vaccination is being carried out. YFVCs will usually complete this on-line, but a site visit of YFVCs is possible. There will be more information about this forthcoming.

In support of our programme, NaTHNaC is working with the Health Care Commission (England) and the Healthcare Inspectorate Wales, as well as developing a collaborative relationship with local health authorities to assure best practice.

Once YFVCs have completed their registration process, they are listed on the YFVC Locator on the NaTHNaC website. Information about the centre and its location can be accessed at this site by the British public and other interested parties.

International Certificates of Vaccination or Prophylaxis

When IHR (2005) came into force in June 2007, it was necessary to introduce a new International Certificate of Vaccination or Prophylaxis (ICVP).  This replaces the old International Certificate of Vaccination or Revaccination Against Yellow Fever, and enables the ICVP to be used to document prevention against international public health threats in addition to yellow fever, should this be mandated by the World Health Organization [5].

The ICVP was sent to all YFVCs in October 2007 and will be distributed by Sanofi Pasteur MSD when centres place their vaccine orders. Further information about obtaining the ICVP in the UK can be found at http://www.nathnac.org/pro/FAQsYFCerts.htm. 

Registration Fee

In order for NaTHNaC to establish this new programme, it has been necessary to institute a registration fee; £90 per centre annually or £150 per centre biennially. Although the administration of YFVCs was part of the original remit of NaTHNaC, no specific funding was provided to carry out this objective. When centres pay this fee it allows NaTHNaC to carry out the programme to the highest standard. Benefits to YFVCs include:

  • support from NaTHNaC
  • subsidized yellow fever training, helping to reduce the cost of the training sessions
  • access to an up-to-date database of YFVCs on the NaTHNaC website
  • access to value-added resources in the special YFVC log-in site on the NaTHNaC website:
    • listing of yellow fever outbreaks
    • maps of areas at risk for yellow fever transmission
    • information sheet on yellow fever vaccine for travellers
    • sample PGD for yellow fever vaccination
    • sample yellow fever vaccination records
    • sample yellow fever letter of medical exemption
    • sample completed ICVP
    • a template of a temperature log chart
    • yellow fever education resources that include the training slides

Centres that no longer wish to remain a YFVC should contact NaTHNaC and request removal from the database. Centres that are unable to comply with the requirements of remaining a designated centre will be subject to a de-designation process (available from the YFVC log-in section of the website).

Please contact us at: nathnac@uclh.org with any feedback concerning the NaTHNaC YFVC initiative. We are most interested in your comments.

References

1. World Health Organization. International Health Regulations (1969) Geneva: World Health Organization, 1969: 1-79

2. World Health Organization. International Health Regulations (2005). Geneva: World Health Organization, 2005:1-60.

Available at: www.who.int/csr/ihr/en/

3. Spira A. Yellow fever vaccine as a vehicle to better travel medicine. J Travel Med 12:303-5, 2005.

4.  Bryant N, Tucker R, Simons S, et al. Analysis of yellow fever vaccination practice in England. J Travel Med. 15:252-8, 2008.

5.  Wilder-Smith A, Hill DR, Freedman DO. The revised International Health Regulations (2005): impact on yellow fever vaccination in clinical practice. Amer J Trop Med Hyg 78:359-60, 2008.

Links

NaTHNaC Yellow Fever Vaccination Centre information

Yellow Fever Vaccination Centre Locator

Appendix

Code of Practice for Yellow Fever Vaccination Centres

For each centre the registered medical practitioner responsible for the YFVC must sign this declaration:

I confirm that:

a. Only yellow fever vaccines approved by World Health      Organization (WHO) will be administered from this YFVC.

b. Vaccines will be administered only by a qualified medical practitioner working at this YFVC, or by a nurse or other suitable qualified person working at this YFVC, under the direct supervision of a qualified medical practitioner working at this YFVC.

c. Facilities for administering and storing vaccines will conform to acceptable standards.

d. I am responsible for the development of appropriate policies for the safe administration of yellow fever vaccine, and for ensuring that all staff involved in the administration of the vaccine are appropriately trained.

e. A member of each YFVC will attend a NaTHNaC-sponsored yellow fever training session before designation status is granted, and thereafter once every two years

f. Appropriate records of all vaccinations administered will be maintained for 10 years following each vaccination.

g. The ‘International Certificate of Vaccination or Prophylaxis’ documenting  yellow fever vaccination, will be completed and signed by the vaccinator in accordance with WHO International Health Regulations (2005).

h. Vaccine associated adverse events will be reported to the MHRA.

i. Annual returns of vaccine utilisation will be returned to National Travel Health Network and Centre (NaTHNaC) on the form contained in the “Designation of Yellow Fever Vaccination Centres, Information Pack”.

j. NaTHNaC will be notified immediately of any changes that might affect the centre’s designation status, including staff changes, changes of address, and information as to the closure of the centre.

k. Representatives of NaTHNaC will be given access to the centre or receive requested copies of YFVC records to ensure that the centre is complying with the relevant requirements.

l. The centre’s status as a designated YFVC will be renewed at annual or biennial intervals, and appropriate fees will be paid for such renewals. 

The centre needs to conform to the current standards for such centres otherwise there is a risk that its designation status will be withdrawn.

Figure: Responsibility for Designating Yellow Fever Vaccination Centre

Flowchart of responsibility for designating Yellow Fever Vaccination Centres

Click here to see the full size version of this image