Jane Chiodini, immunisation nurse specialist, explains how to draw up a patient group direction for the combined measles, mumps and rubella vaccine

Measles, mumps and rubella are infectious diseases caused by viruses. While they are mostly mild illnesses, individually they have the potential to cause far more serious consequences as Table 1 shows.1

Table 1: Complications of measles, mumps and rubella
Disease Symptoms Complications
Measles Almost all develop fever, rash, cough, red and painful eyes, swollen glands, loss of appetite, and are generally unwell

Ear infection (1 in 20)
Pneumonia/bronchitis (1 in 25)
Convulsions (1 in 200)
Diarrhoea (1 in 6)
Hospital admission (1 in 100)
Meninigitis/encephalitis (1 in 1000)
Late onset: – Subacute sclerosing panencephalitis (1 in 8000 children <2 years old)
Death (1 in 2500-5000)

Mumps 60-70% develop painful, swollen glands in the cheeks, neck or under the jaw; fever, headache, abdominal pain, loss of appetite, and are generally unwell Swollen, painful testicles in older males (1 in 5)
CNS involvement is common - meningitis/encephalitis (1 in 200-5000)
Pancreatitis (1 in 30)
Deafness - recovery is usually partial or complete (1 in 25)
Mumps during pregnancy can lead to spontaneous abortion
Rubella 50-75% develop low grade fever, headache, conjunctivitis, rash, sore throat, cough, swollen glands, joint pains (mainly women), loss of appetite, and are generally unwell

Joint symptoms
Encephalitis (1 in 6000)
Bleeding disorders (1 in 3000)
Rubella during pregnancy can lead to spontaneous abortion
Congenital rubella syndrome: babies can be born deaf, blind and with heart problems, brain damage and other serious problems

Taken from Department of Health and Health Education Authority Factsheet 1 (1997)

The combined measles, mumps and rubella (MMR) vaccine was introduced in 1988 and since that time the incidence of all three diseases has declined greatly.1,2

To maintain this low incidence, however, high levels of protection must be achieved to prevent a resurgence of any of these diseases. For measles, 95% of the target population should be immunised and for mumps, 80-90%.

The MMR coverage in the UK has now dropped to 88%, and in some areas the level is even lower.3 This decline has been caused by a lack of confidence in the combined vaccine since 1998, when a link between the MMR immunisation and inflammatory bowel disease and autism was reported by a group of researchers at the Royal Free Hospital in London.

Since that time, the evidence has been reviewed by the World Health Organization (WHO), the Department of Health, and independent advisory groups, including the Joint Committee on Vaccination and Immunisation and the Committee on Safety of Medicines. These agencies have concluded that there is no link between the MMR vaccine and inflammatory bowel disease or autism.4

More than 500 million doses of MMR have been given in more than 90 countries since the early 1970s, and the WHO recognises MMR as a highly effective vaccine with an outstanding safety record.4

Advising parents

Continued media attention and controversy over the combined MMR vaccine have created problems for healthcare professionals having to respond to parents' questions about the safety of the vaccine.

An excellent pack, which includes a literature review and information on educational tools, has been prepared, which enables professionals advising parents to:

  • Provide up-to-date information about the safety and effectiveness of the MMR vaccine
  • Have the confidence to discuss the MMR vaccine with parents and be able to dispel any misconceptions
  • Evaluate their own practice
  • Recommend to parents that MMR is the safest way to protect their children
  • Contribute to an improvement in national MMR vaccination rates.

An educational leaflet contained in the pack is also available to download from the website in languages including Punjabi, Gujarati, Urdu, Bengali and Chinese. There is also a video that uses sign language, subtitles and voice-overs also in the languages listed above.

Drawing up a PGD

Patient group directions (PGDs) have been a legal requirement throughout the UK since August 2000. National guidance is now available in England,5 Wales6 and Scotland.7

PGDs should be in place for the administration of prescription-only medicines (POM), including the MMR vaccine, to groups of patients who may not be individually identified before presentation at the surgery.

Nurses administering these vaccines must only do so if there is an appropriate PGD in place. To do otherwise could result in a criminal prosecution under the Medicines Act.5-7

To work in accordance with a PGD, the nurse administering the POM must be named in the document and sign it, as must the practice's senior doctor giving his/her authorisation for the nurse to work within the PGD. This doctor must be satisfied that the named nurse has adequate knowledge and is competent to administer the immunisation in line with the UKCC Professional Code of Conduct8 and UKCC Standards for the Administration of Medicines.9

You should obtain all the information you need on the vaccine before starting to draw up a PGD (see Further information, below).

A PGD should include the following:

  • The name of the business to which the PGD 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.

Further information

It is essential to have access to the Summary of Product Characteristics (SPCs) for the vaccines, available directly from the drug manufacturers or on the internet. SPCs for the MMR vaccine can be obtained from http://emc.vhn.net/

The MMR information pack for health professionals was sent to healthcare professionals who registered on the database to receive immunisation information.

Details of the pack are also available at www.immunisation.org.uk/mmrpack.html, by post from HPE Customer Services, PO Box 269, Abingdon, Oxford OX14 4YN or by fax: 01235 465556.

Figure 1: Sample patient group direction for the combined MMR vaccine, Priorix
MMR PGD page 1
MMR PGD page 2
MMR PGD page 3



  1. Department of Health and Health Education Authority. Measles, Mumps and Rubella Vaccine Factsheet 1. England 1997. http://www.immunisation.org.uk/immresour.html#factsheet
  2. Department of Health. Immunisation against Infectious Disease. London: HMSO, 1996
  3. Public Health Laboratory Service. Communicable Disease Report 2001; 11(4): http://www.phls.org.uk/publications/cdr.htm
  4. Department of Health and Health Education Authority. Top 10 truths about MMR. England 2001.http://www.immunisation.org.uk/mmrpack.html
  5. NHS Executive (2000) Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE.
  6. 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.
  7. Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001.http://www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
  8. UKCC. Code of professional conduct for the nurse, midwife and health visitor. 3rd edn. London: UKCC, 1992.
  9. UKCC. Standards for the Administration of Medicines. London: UKCC, 2000.

Guidelines in Practice, February 2002, Volume 5(2)
© 2002 MGP Ltd
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