"We don't offer cholera here – you'll need to go private."

If you work in travel health, you may have used or heard this phrase before. Cholera vaccination is one of the most misunderstood travel vaccines in UK primary care. Because it is used relatively infrequently and administered orally, many clinicians assume it falls outside NHS travel services or requires private referral. In reality, the picture is far more nuanced.

Questions commonly arise in practice such as:

• Is cholera NHS funded or private?

• Does a GP have to prescribe it?

• Can practice nurses administer it?

• Does it require specialist training?

• How is an oral vaccine actually given?

The good news is that cholera vaccine is far less complicated than many people fear.

The million dollar question: Is cholera vaccination NHS funded?

Yes. when indicated for travel, cholera vaccine is included within NHS additional travel services in England. The British Medical Association (BMA) guidance lists cholera alongside hepatitis A, polio and typhoid as NHS travel vaccines. This means that patients who meet the criteria for vaccination should not automatically be directed to private clinics solely because they require cholera vaccine. Of course, practices may choose not to provide travel services at all, or may have limited appointment capacity. In those situations, signposting elsewhere may be appropriate. However, it is not appropriate to routinely send patients privately simply because the vaccine required is cholera.

If a practice is unable to offer any NHS travel vaccinations due to local arrangements or capacity constraints, then referral elsewhere may be reasonable. What should be avoided is treating cholera differently from other NHS-funded travel vaccines simply because it is used less frequently.

Who actually gets cholera vaccine?

There are an estimated 1.3–4.0 million cases of cholera and between 21,000 and 143,000 deaths due to cholera worldwide every year. If you are working for a humanitarian response organisation you will potentially be giving the vaccine to every client! But in general practice, very few travellers require cholera vaccination. And of course, modern travel health practice is based on individual risk assessment rather than destination alone. Current UK recommendations can be found on TravelHealthPro, where indications include travellers at increased risk such as:

• Humanitarian aid workers

• Healthcare workers responding to outbreaks

• Travellers visiting areas experiencing active cholera outbreaks

• Individuals with limited access to safe food and water

• Certain higher-risk long-stay travellers

Most tourists staying in standard accommodation will not require cholera vaccination (however still need the standard food and drink precaution advice!). As with all travel vaccines, the decision should be based on an individual risk assessment considering destination, itinerary, accommodation, activities, duration of travel and underlying health conditions.

What training is required?

Another common question from practices is whether cholera vaccination requires additional specialist training because it is an oral vaccine or because some doses may be taken at home. In reality, there is no nationally mandated, cholera-specific training requirement. Clinicians providing travel health services should instead work within the same competency frameworks that apply to travel medicine and immunisation more broadly.

The National Minimum Standards and Core Curriculum for Immunisation Training recommend that clinicians administering vaccines have appropriate foundation training and maintain competence through regular updates. In practice, many nurses working in travel health will have completed a minimum two-day immunisation course alongside specific travel health training, often a minimum of a two-day foundation course in travel medicine. And of course, a lot of vaccine-based information can be found in the Green Book.

As with all areas of practice, clinicians should work within the limits of their competence and seek additional support or training where required.

The fact that cholera vaccines are oral preparations does not fundamentally alter professional accountability. The same principles of medicines management and vaccine administration apply: ensuring an appropriate risk assessment has been undertaken, confirming the patient meets inclusion criteria, providing counselling on administration, documenting advice given and maintaining appropriate records.

Where nurses are working under a valid Patient Group Direction (PGD), they may undertake the assessment and supply or administer the vaccine in accordance with the PGD, without requiring an individual prescription from a GP. If a prescriber is issuing a prescription outside a PGD, usual prescribing principles apply. The prescriber should be satisfied that they have undertaken or reviewed an appropriate assessment before prescribing.

In short, cholera vaccine should not be viewed as a "special case" requiring unique governance or special training arrangements. It is simply another travel vaccine - albeit one that is oral and used relatively infrequently.

Which cholera vaccines are available?

There are currently two licensed oral cholera vaccines used in UK travel medicine:

Although both are oral vaccines, they differ in schedule, age indications and administration requirements. Because these vaccines are used relatively rarely, practices often do not keep stock routinely. This can lead to uncertainty and the assumption that the vaccine is "private only." In reality, many GP practices simply order the vaccine on a case-by-case basis when required.

How are cholera vaccines given?

One of the reasons cholera vaccination causes uncertainty is that, unlike most travel vaccines, both currently available products are administered orally rather than by injection. However, this does not make them inherently more complicated, just different. Both vaccines should be administered according to their Summary of Product Characteristics (SPC) - linked in their names above - and clinicians should familiarise themselves with the relevant product guidance before use (as you would normally for any medicine).

Dukoral

Dukoral is an inactivated oral cholera vaccine and is the product most commonly encountered in UK travel medicine because it has been knocking around for a while now. The primary course for adults and children aged 6 years and over consists of two doses given at least one week apart, with the course completed within six weeks. If more than six weeks elapse between doses, the primary course should generally be restarted. Children aged 2–5 years require three doses. Protection develops approximately one week after completion of the course. A booster dose may be recommended if ongoing risk remains and this would be within 2 years for adults and children aged 6 years and above, and within 6 months for children aged 2–5 years

Dukoral requires reconstitution before administration. The vaccine is supplied with effervescent granules that are dissolved in water to create a buffer solution before the vaccine suspension is added and mixed. Patients should avoid eating or drinking for one hour before and one hour after administration. Oral medicines should also be considered, as food and medicines may affect vaccine effectiveness.

Vaxchora

Vaxchora is a LIVE attenuated oral cholera vaccine given as a single dose (careful with usual live vaccine interactions). Unlike Dukoral, no second dose is required. Protection develops rapidly, making it particularly useful where departure is imminent. The vaccine should be administered at least 10 days before potential exposure to cholera. As with Dukoral, patients should avoid eating or drinking for one hour before and after vaccination. Vaxchora also requires preparation immediately before administration according to the manufacturer's instructions.

Because of the preparation required, many practices and private clinics administer the vaccines in clinic, although some local arrangements allow self-administration following appropriate counselling.

So, administering in clinic or at home?

Although cholera vaccines are oral, there is no requirement that they must always be self-administered at home. Indeed, many travel clinics routinely prepare and administer oral cholera vaccines within the clinic setting to ensure correct preparation, timing and counselling. Practices may choose local arrangements that suit their workflow. Staff should ensure patients receive clear written and verbal advice regarding:

• Timing of doses

• Food and drink restrictions

• Management of missed doses

• The importance of completing the schedule before travel

As with all travel vaccines, administration should be documented in the patient's records, including batch number, expiry date and advice given.

How is cholera vaccine supplied?

Practices adopt several different approaches:

1. Ordering stock when needed

Many practices do not routinely hold cholera vaccine stock due to the infrequency of use. Instead, the vaccine is ordered on a case-by-case basis when a traveller meets the criteria.

2. FP10 prescription

Some practices issue an FP10 prescription for the patient to collect from a community pharmacy. In this situation, the patient pays only the standard NHS prescription charge (if applicable), rather than paying privately for the vaccine itself.

3. In-clinic administration

Private travel clinics commonly keep cholera vaccine in stock and administer it in clinic. However, this is not exclusive to the private sector, and NHS practices may adopt similar approaches where appropriate.

Does a GP have to assess every patient?

This is another common source of confusion.

Because cholera vaccines are oral preparations and some doses may be taken at home, clinicians sometimes assume that GP assessment or prescribing is mandatory. In many cases, this is not so. Where nurses are working under an appropriate PGD, they may undertake the travel risk assessment and supply or administer the vaccine within the terms of that PGD. An individual Patient Specific Direction (PSD) is therefore not necessarily required. However, where vaccination is provided outside a PGD, or where prescribing is required, prescribers should ensure they undertake or review the clinical assessment in line with local governance arrangements and professional accountability.

Final thoughts

Cholera vaccine is uncommon, and can appear to be a little mysterious.

Perhaps it causes anxiety because it is oral, infrequently used and not always kept in stock. Yet in governance terms, it should be approached like any other travel vaccine: undertake a robust risk assessment, follow medicines management procedures and work within your competence.

The question in general practice should not be "Do we offer cholera vaccine?" but rather "Does this traveller meet the criteria for cholera vaccination?"

And if they do, NHS-funded provision should be considered before automatically directing them to private services.

But keep calm, you got this!