Typhoid fever is a systemic infection caused by the Gram-negative bacillus Salmonella typhi. The bacterium is transmitted by the faecal-oral route, usually through food or drink contaminated by the excreta of a human case or carrier.
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-eastern Europe. An estimated 16 million cases of typhoid fever and 600000 related deaths occur worldwide every year.1
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 infection is untreated, complications can develop, the most common being intestinal bleeding or perforation which can cause severe illness and death.
Typhoid is a notifiable disease in the UK. Since the mid-1990s, the number of typhoid cases reported in England and Wales has fallen, with 165 in 2000 (105 of which were travel related) and 170 (96 travel related) in 2001.2
Around 10% of patients with typhoid fever will excrete organisms in their faeces for 3 months following the acute illness, and 2-5% become permanent carriers. The likelihood of this increases with age, especially in women.3
Precautions for travellers
Typhoid vaccine is available, in injectable and oral forms, but it must be remembered that the vaccines are not 100% effective. Travellers abroad should be scrupulous about personal hygiene and be cautious about what they eat and drink:
- Unless the water supply is known to be safe, use only boiled water, bottled water or water treated by a sterilising agent. This also applies to ice cubes in drinks and water for cleaning teeth.
- Contaminated food is the most common source of many diseases abroad including typhoid, and prevention can be helped by eating only fresh, well cooked food; avoiding leftovers and reheated foods and ensuring that meat is thoroughly cooked. Vegetables should also be cooked and salads avoided. Eat fruit that can be peeled; never drink unpasteurised milk; avoid ice cream and do not buy food from street vendors? stalls. Washing the hands after using the toilet and before eating or handling food is strongly advised.
Figure 1: Sample patient group direction for typhoid vaccine. Typherix Figure 1 (continued): Sample patient group direction for typhoid vaccine. Typherix Figure 1 (continued): Sample patient group direction for typhoid vaccine. Typherix
Setting up a PGD
Patient group directions (PGDs) have been a legal requirement in the NHS throughout the UK since 9 August 2000. National guidance is now available in England,4 Wales,5 and Scotland.6 PGDs should be in place for the administration of these prescription-only medicines (POM) 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.4-6
To work in accordance with a PGD, the nurse administering the POM must be named in the document and must sign it, as must the senior doctor giving his or her authorisation for the nurse to work within the PGD. To do this, the doctor must be satisfied that the nurse has adequate knowledge and is competent to administer the immunisation in line with the Nursing and Midwifery Council (NMC) Code of Professional Conduct7 and NMC Standards for the Administration of Medicines.8
It is useful to gather together all the information you need before starting work on a PGD, and it is essential to have the Summary of Product Characteristics (SPCs) for the vaccines to hand. SPCs are available directly from the drug manufacturers and on the internet at http://emc.vhn.net/.
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 necessary and the circumstances
- A statement of the records to be kept for audit purposes.
Healthcare professionals giving travel health advice will find recommendations for typhoid vaccination in the DoH publication Health Information for Overseas Travel commonly referred to as the ??Yellow Book? which was distributed to all GPs and practice nurses at the end of 2001.9 This is also available on the internet at: https://www.the-stationery-office.co.uk/doh/hinfo/index.htm
Guidelines on the management of typhoid in schools and nurseries can be found at: http://www.phls.co.uk/advice/schools/typhoid.htm
- Centers for Disease Control and Prevention. Health Information for the International Traveller 2001-2002. Atlanta: US Department of Health and Human Services, Public Health Service, 2001.
- Public Health Laboratory Service Facts and Figures http://www.phls.co.uk/facts/Gastro/Salmonella/salmtyphAnn.htm
- Department of Health. Immunisation against Infectious Disease. London: HMSO, 1996.
- NHS Executive. Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE, 2000.
- 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 DOCSOCPhA-SALEMED3. 22 December 2000.
- Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001. www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
- Nursing and Midwifery Council. Code of Professional Conduct. London: NMC, 2002. www.nmc-uk.org
- Nursing and Midwifery Council. Standards for the Administration of Medicines. London: NMC, 2002. www.nmc-uk.org
- UK Departments of Health with the PHLS CDSC. Health Information for Overseas Travel, 2nd edn. London: TSO, 2001.