Jane Chiodini explains how to draw up a PGD for administration of the pneumococcal vaccine to high-risk adults and children over the age of two

Pneumococcal disease is a serious infection caused by the bacterium Streptococcus pneumoniae (pneumococcus). Invasive pneumococcal disease is a major cause of morbidity and mortality in the elderly, the very young, people without a functioning spleen and those with other causes of impaired immunity.1

It is the most common cause of community-acquired pneumonia, estimated to affect 1 in 1000 adults every year, with a 10-20% mortality rate. It is also one of the most frequently reported causes of bacteraemia and meningitis.1 Common manifestations of the non-invasive form include otitis media, sinusitis and bronchitis.

The bacterium is transmitted via respiratory droplets or oral contact and many people are carriers.2 Worldwide resistance to antimicrobial drugs is increasing, underlining the importance of control through vaccination; it is the only public health measure likely to have any significant impact on the incidence of the disease.1

The Department of Health recommends vaccination for all those aged 2 years or older in whom pneumococcal infection is likely to be more common and/or dangerous, i.e. those with:

  • Asplenia or severe dysfunction of the spleen
  • Homozygous sickle cell disease
  • Chronic renal disease or nephrotic syndrome
  • Coeliac syndrome
  • lmmunodeficiency or immunosuppression caused by disease or treatment, including HIV infection at all stages
  • Chronic heart disease
  • Chronic lung disease
  • Chronic liver disease including cirrhosis
  • Diabetes mellitus.

Despite the recommendations, there is evidence that the majority of high-risk patients are not being protected by pneumococcal vaccination.3 Reports include the cases of two unvaccinated patients who died of pneumococcal disease after undergoing splenectomy 4 and a study of 42 patients whose spleens were removed and who subsequently suffered severe streptococcal infection.5

There is sometimes a reluctance within practices to administer the pneumococcal vaccine at the same time as the influenza vaccine but this is certainly possible1 and research suggests that such management is safe and effective.6

Figure 1:Sample patient group direction for pneumococcal vaccine, Pneumovax® II
Figure 1 (continued):Sample patient group direction for pneumococcal vaccine, Pneumovax® II
Figure 1 (continued):Sample patient group direction for pneumococcal vaccine, Pneumovax® II


Drawing up a patient group direction

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,7 Wales 8 and Scotland.9 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.7-9

To work in accordance with a PGD, the nurse administering the POM must be named within 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 Conduct 10 and NMC Standards for the Administration of Medicines.11

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 vaccine. 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 necessary follow up action and the circumstances
  • A statement of the records to be kept for audit purposes.

In industrialised countries, most pneumococcal disease occurs in the elderly, but S. pneumoniae is the leading cause of severe pneumonia in children under 5 years of age, causing more than one million deaths each year, mostly in developing countries.2

In January 2002 the DoH advised administration of a new conjugate pneumococcal vaccine for children under the age of 2 years in the at-risk group. The guidance is available online at http://www.doh.gov.uk/cmo/cmo0201.htm.

Pneumoccocal vaccination should always be considered for individuals in at-risk groups intending to travel. It is particularly important to ensure that those in the at-risk categories who are going to underdeveloped countries are immunised.12


  1. Salisbury DM, Begg NT (eds). Immunisation Against Infectious Disease. London: Department of Health, 1996.
  2. World Health Organization. International Travel and Health - Vaccination Requirements and Health Advice. Geneva: WHO, 2002.
  3. Legge A. Pneumococcal vaccine remains underused. Care of the Elderly 1995; 7(9): 11.
  4. Anon. Pneumococcal disease. SCIEH Weekly Report 1999; 33(99/08): 67.
  5. Waghorn DJ, Mayon-White RT. A study of 42 episodes of overwhelming post-splenectomy infection: is current guidance for asplenic individuals being followed? Journal of Infection 1997; 35: 289-94.
  6. Fletcher TJ, Tunnicliffe WS, Hammond K et al. Simultaneous immunisation with influenza vaccine and pneumococcal polysaccharide vaccine in patients with chronic respiratory disease. Br Med J 1997; 314: 1663.
  7. NHS Executive. Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE, 2000.
  8. 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). COCNOCDOCSOCPhA-SALEMED3. 22 December 2000.
  9. Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001. www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
  10. Nursing and Midwifery Council. Code of Professional Conduct London: NMC, 2002. http://www.nmc-uk.org
  11. Nursing and Midwifery Council. Standards for the Administration of Medicines. London: NMC, 2002. http://www.nmc-uk.org
  12. UK Departments of Health with the PHLS CDSC. Health Information for Overseas Travel. 2nd edn. London: TSO, 2001.

Guidelines in Practice, September 2002, Volume 5(9)
© 2002 MGP Ltd
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