Jane Chiodini discusses the meninigitis vaccines available for travellers, and explains why pilgrims travelling to the Hajj or Umrah must have the quadrivalent vaccine
Globally, 1.2 million cases of meningococcal infection are reported annually, with a death toll of approximately 135 000. The most frequent and largest epidemics occur in the African meningitis belt, which includes all or part of 18 sub-Saharan countries.
Meningococcal meningitis is a systemic infection caused by Neisseria meningitidis and at least 13 serogroups are known. Serogroups B and C are the most common in the UK, but other less common ones include A, Y, W135, 29E and Z.1
The majority of outbreaks in the African meningitis belt are caused by Neisseria meningitidis serogroup A, while serogroup C is responsible for a smaller proportion.2
Currently there are only vaccines available against serogroups A, C, W135 and Y. Table 1 (below) lists the five vaccines available in the UK to provide protection against some of the serotypes.
|Table 1: Meningococcal vaccines|
|Name of vaccine||Manufacturer||Serogroup protection|
|Mengivac (A+C)||Aventis Pasteur MSD||A and C|
|AC Vax||SmithKline Beecham Vaccines||A and C|
|SmithKline Beecham Vaccines||A, C, W135 and Y|
Meningitis A and C vaccine and the newer quadrivalent vaccine ACW135Y are more commonly given to travellers visiting meningitis-endemic areas and to those travelling rough, e.g. backpackers, or those going on extended travel (generally a month or more) or intending to live and/or work with local people.
Parts of the world that present such risk are sub-Saharan Africa and the area around New Delhi, Nepal, Bhutan and Pakistan.
In 1987, there was an outbreak of meningococcal meningitis in Saudi Arabia. As a result, from 1988 all travellers visiting the country for the Hajj annual pilgrimage were required to provide evidence of having received protection against meningitis A by means of a certificate to obtain visa entry to the country.
In 2000 an outbreak of W135 meningococcal meningitis occurred in Saudi Arabia, and guidance was issued in the UK in 2001 to advise all those attending the pilgrimage to obtain protection against this serogroup.3
Unfortunately, this information did not reach all travellers in time to action the recommendation, and up until June 2001, 41 cases had been reported in the UK, of which eight were pilgrims returning from the Hajj and 19 were close contacts. There were 11 deaths in total.4
The global increase in cases resulted in the Ministry of Health and the Government of Saudi Arabia notifying the Ministries of Health of all countries from which pilgrims arrived that vaccination against meningococcal meningitis with the quadrivalent vaccine (serogroups A, C, Y and W135) had been added to the health requirements for arrivals coming to the Umrah and Hajj.4
Even if pilgrims travelling to the Hajj have previously received a meningitis A and C vaccine, they must now also have the quadrivalent A, C, W135, and Y vaccine. This will present a substantial workload for some surgeries. A sample patient group direction (PGD) has therefore been included for this vaccine (see Figure 1, below).
|Figure 1: Sample patient group direction for the quadrivalent meningitis ACW135Y vaccine|
While the PGD for meningococcal vaccine is a legal requirement for administration of the vaccine by nurses, best practice includes giving patients attending the surgery advice about the disease, and information on symptoms to aid early diagnosis, as well as appropriate supporting material to take away and read.
Patient group directions (PGDs) have been a legal requirement for the administration of prescription-only medicines (POMs) by nurses throughout the UK since 9 August 2000. National guidance is now available in England,5 Wales6 and Scotland.7
PGDs should be in place for the administration of POMs to groups of patients who may not be individually identified before presentation at the surgery.
Nurses administering these vaccines should therefore 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.5–7
To work in accordance with a PGD, the nurse administering the POM must be named within the document and sign it, as must the senior doctor giving his/her authorisation for the nurse to work within the PGD.
To do this, however, the senior doctor within the practice must be satisfied that this 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
It is essential to have access to the Summary of Product Characteristics (SPCs) for the vaccines. These are available directly from the drug manufacturers, but can also be found in the Data Sheet Compendium. Such information is also readily available on the internet, and SPCs for the meningococcal vaccines can be obtained from http://emc.vhn.net/. It is of value to obtain sufficient information before commencing work on the relevant PGDs.
Extensive information about meningitis can be obtained from the WHO and the DoH. Contact details are shown in Table 2 (below).
Table 2: Information sources
|World Health Organization||www.who.int/emc/diseases/meningitis/index.html|
|Department of Health - Knowing about Meningitis and Septicaemia||www.doh.gov.uk/pub/docs/doh/menin.pdf|
|Poster for Hajj traveller (also available in Arabic, Bengali and Urdu)||www.doh.gov.uk/traveladvice/hajj.htm|
Once all the resource materials have been collected, the PGD can be drawn up. This should include:
- The name of the business to which the PGD applies
- The date the PGD comes into force and the date it expires
- A description of the medicine(s) to which the PGD 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 PGD applies
- A description of those patients excluded from treatment under the PGD
- 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
?t is of greater value to write PGDs relevant to each vaccine than to write one generically for 'meningitis vaccines', as the inclusion criteria vary, as does some of the vaccine-specific information.
- Department of Health. Immunisation against Infectious Disease. London: HMSO, 1996.
- World Health Organization www.who.int/emc/diseases/meningitis/index.html
- Department of Health. Current Vaccine and Immunisation Issues. PL/CMO.2001/1, PL/CNO/2001/1, PL/CPHO/2001/1 http://www.doh.gov.uk/cmo/cmo0101.htm
- World Health Organization. Disease Outbreaks Reported 22 June 2001. Meningococcal disease, serogroup W135 - Update 2. http://www.who.int/disease-outbreaknews/n2001/ june/22june2001.html
- 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). COCNOCDOCSOCPhA-SALEMED3. 22 Dec 2000.
- Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001. www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
- UKCC. Code of Professional Conduct for the Nurse, Midwife and Health Visitor. 3rd edn. London: UKCC, 1992.
- UKCC. Standards for the Administration of Medicines. London: UKCC, 2000.