Administering a combined vaccine against hepatitis A and typhoid improves compliance and benefits both patient and doctor, explains Jane Chiodini

Although combined vaccines have been part of the national childhood immunisation programme for some time, combined travel vaccines, including combined hepatitis A and typhoid vaccine, are a more recent development. The benefits of combined travel vaccines are summarised in Box 1 (below).1

Box 1: Benefits of combined travel vaccines
  • Fewer injections thus less discomfort
  • Fewer visits to the doctor
  • Increased compliance
  • Greater convenience for patient and doctor/nurse
  • Simpler logistics (transport, storage, records)
  • Less time needed to prepare and administer the vaccines
  • Frees up an additional site for vaccination
  • Simpler to protect against more than one infectious disease
  • Simpler immunisation schedule
  • Valuable appointment time saved

Hepatitis A and typhoid are both common travel-related diseases. The hepatitis A element of the combined vaccine can be treated as the first dose of a full course or as the booster dose, while the typhoid element provides protection for 3 years.

Hepatitis A

Hepatitis A is a highly infectious disease, caused by a virus transmitted by the faecal-oral route. The most common method of transmission is from person to person, although travellers are at risk from contaminated food and drink.

Hepatitis A is endemic throughout the world and hyperendemic in areas where sanitation is poor. Individuals travelling outside northern and western Europe, Scandinavia, North America, Japan, Australia and New Zealand, should consider immunisation against hepatitis A.

There is some evidence of protection even when the vaccine is given after exposure, and it is still considered likely to prevent or at least modify the infection.1 Vaccination should therefore be considered for travellers who present shortly before departure.


Typhoid fever is a systemic infection caused by the Gram-negative bacillus Salmonella typhi. It is transmitted by the faecal-oral route, usually through food or drink that has become contaminated with the faeces of a human case or carrier.

Symptoms of this septicaemic illness include fever, headache, abdominal discomfort, constipation, often a dry cough and sometimes confusion. After 7-10 days, the fever reaches a peak, rose spots may appear and diarrhoea begins. Treatment is with antibiotics.

If the disease is untreated, complications can develop, the most common being intestinal bleeding or perforation which can cause severe illness and death.

Typhoid is predominantly a disease of countries with poor sanitation and poor standards of personal and food hygiene, especially in Africa, Asia, Central and South America and south-east Europe.

The vaccines are not 100% effective and travellers should still take sensible precautions regarding food and drink and personal hygiene.

Unless the water supply is known to be safe, use only boiled water, bottled water or canned drinks and water treated by a sterilising agent, including ice cubes in drinks and water for cleaning teeth. Contaminated food is the most common source of many diseases abroad including typhoid. Prevention can be helped by eating only food that is fresh and well cooked, and avoiding leftovers and reheated foods.

Meat should be thoroughly cooked, and vegetables should also be cooked and salads avoided. Fruit should be peeled before eating, while unpasteurised milk should never be drunk. Ice cream and food bought from street vendors’ stalls should be avoided. Handwashing after going to the toilet, and before eating or handling food is strongly advised.

Setting up a PGD

The sample patient group direction (PGD; Figure 1) is a generic PGD and must be adapted for local use to relate to the particular product used.

Figure 1: Sample patient group direction for combined hepatitis A and Typhoid vaccine
Figure 1 continued : Sample patient group direction for combined hepatitis A and Typhoid vaccine
Figure 1 continued : Sample patient group direction for combined hepatitis A and Typhoid vaccine

PGDs have been a legal requirement throughout the UK since 9 August 2000 in the NHS. National guidance is now available in England,2 Wales3 and Scotland.4 PGDs should be in place for the administration of these prescription only medicines to groups of patients who may not be individually identified before presentation at the surgery.

Therefore nurses administering these vaccines must only do so if there is an appropriate PGD in place. To do otherwise, would be to act illegally and could result in a criminal prosecution under the Medicines Act.2-4 It is now more than 2 years since the change in the law and imperative that such documents are in place.

To work in accordance with a PGD, the nurse administering the prescription only medicine must be named in the document and must sign it, as must the senior doctor giving his/her authorisation for the nurse to work within the PGD. Before signing, the senior doctor in the practice must be satisfied that this nurse has adequate knowledge and is competent to administer the immunisation in line with the Nursing and Midwifery Council (NMC) Professional Code of Conduct5 and NMC Standards for the Administration of Medicines.6

It is useful to gather together all the information you need before starting work on a PGD, and it is essential to have access to the summary of product characteristics (SPC) for the vaccines. SPCs are available directly from the drug manufacturers and on the internet at

The PGD should include:

  • The name of the business to which the direction applies
  • The date the direction comes into force and the date it expires
  • A description of the medicine(s) to which the direction applies
  • Class of health professional who may supply or administer the vaccine
  • Signature of a senior doctor or dentist and a pharmacist
  • Signature of an appropriate health organisation
  • The clinical condition or situation to which the direction applies
  • A description of those patients excluded from treatment under the direction
  • A description of the circumstances in which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral
  • Details of the appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration and minimum or maximum period over which the medicine should be administered.
  • Relevant warnings including potential side-effects
  • Details of any follow up action and the circumstances
  • A statement of the records to be kept for audit purposes.


  1. Zuckerman J. Vaccine-preventable disease, in: Zuckerman J (ed): Principles and Practice of Travel Medicine. Chichester: John Wiley & Sons, 2001.
  2. NHS Executive (2000) Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE, 2000.
  3. The National Welsh Assembly. Review of Prescribing, Supply and Administration of Medicines - Sale, Supply and Administration of Medicines by Health Professionals Under Patient Group Directions (PGD). COCNOC DOCSOC PhA-SALEMED3. 22 December 2000.
  4. Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001.
  5. Nursing and Midwifery Council. Code of Professional Conduct. London: NMC, 2002.
  6. Nursing and Midwifery Council. Standards for the Administration of Medicines. London: NMC, 2002.

Guidelines in Practice, May 2003, Volume 6(5)
© 2003 MGP Ltd
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