Patient Group Direction (PGD) for the administration of combined hepatitis A and hepatitis B vaccine

1. Clinical condition or situation to which the direction applies

Indication

• Pre-exposure immunisation against hepatitis A and B infection.

Objectives of care

• To reduce the incidence of hepatitis A and B infection for those individuals who are at

high risk of exposure to hepatitis A and B virus.

Inclusion criteria

• Valid consent has been obtained from the patient/carer who does not want to consult with their GP and would prefer to access vaccination from the PGD user.

• Individuals from 1 years of age at risk of hepatitis A and B, including (N.B. product specific age indications must be followed).

• Travellers visiting areas of medium or high endemicity, especially if sanitation and food hygiene are likely to be poor, who have not previously completed a course of hepatitis A and B vaccination.

• Patients originating from areas with high hepatitis A and B endemicity (adoptees, immigrants and refugees).

• Men who have sex with men (MSM) and whose sexual behaviour is likely to put them at risk.

• Patients for whom hepatitis A and B is an occupational hazard or for whom there is an increased risk of transmission. This includes, but not limited to, the following:

  ̵ Laboratory workers

  ̵ Employees in residential institutions and day-care facilities

  ̵ Nursing personnel

  ̵ Medical and paramedical personnel in hospitals and institutions

  ̵ Sewage workers

  ̵ Food packagers or handlers

• Individuals who continue to be at risk and require a booster dose of combined hepatitis A and B.

Exclusion criteria

(Refer to current and relevant

• Patients for whom no valid consent has been received.

• Hypersensitivity to the active substance(s) or to any of the excipients or trace residuals

SPC (Great Britain or

in the selected hepatitis A and B vaccine. See section 2 and 6.1 of the relevant Summary

Northern Ireland) and online

Green Book guidance for additional details)

of Product Characteristics (SPC).

• Hypersensitivity to neomycin.

• Confirmed anaphylactic reaction to a previous dose of the vaccine.

• A confirmed anaphylactic reaction to a previous dose of a vaccine containing hepatitis A

or B.

• Individuals under 1 years of age (N.B. product specific age exclusions must be followed –

see Description of treatment).

• Confirmed immunity due to natural infection or previous vaccination.

• Patients who require post-exposure immunisation against hepatitis A and B virus.

• Acute severe febrile illness – postpone administration until completely recovered.

• Has an evolving neurological condition. (With an evolving neurological condition,

immunisation should be deferred until the neurological condition has resolved or

stabilised).

1. Clinical condition or situation to which the direction applies – continued

Cautions

(including any relevant action to be taken)

Pregnancy and Breast-feeding

• Vaccines can be administered during pregnancy where there is a high risk of infection, and the benefits of vaccination outweigh the risks. It is recommended that the appropriate healthcare professional (e.g. GP, midwife) is consulted prior to injection (1) (2)

  (3) (4) (5) (6).

  Bleeding disorders

• Hepatitis A and B vaccine should be given with caution to patients with thrombocytopenia or any coagulation disorder (including those taking anticoagulants) since bleeding may occur following intramuscular administration to these patients (1) (2) (3)

  (4) (5) (6). It is recommended that the appropriate healthcare professional (e.g.GP) is consulted prior to injection, to determine if intramuscular injection is suitable and if vaccination should be scheduled shortly after the patient receives their medication/treatment to reduce bleeding. If the vaccine is offered, the patient/carer should be informed about the risk of bleeding from the injection.

• Patients on stable anticoagulation therapy, including patients on warfarin who are up- to-date with their scheduled International Normalised Ratio (INR) testing and whose latest INR was below the upper threshold of their therapeutic range, can receive intramuscular vaccination. If in any doubt, the clinician responsible for prescribing or monitoring the patient’s anticoagulant therapy should be consulted prior to injection (7).

• The vaccine may alternatively be administered by the subcutaneous (SC) route to individuals with bleeding disorders (1) (2) (3) (4) (5) (6). (N.B. There is a lack of evidence that SC injection is any safer than intramuscular injection in individuals taking anticoagulants, and injection by this route is more likely to cause local reactions) (8). Healthcare professionals who are not professionally competent to perform SC injections should refer the individual(s) to a suitable alternative provider.

  Syncope

• Syncope (fainting) can occur following, or even before, any vaccination as a psychogenic response to the needle injection. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints

(9).

1. Clinical condition or situation to which the direction applies – continued

Cautions

(including any relevant action to be taken)

Protection advice

• The vaccine will not prevent infection caused by other agents such as hepatitis C and hepatitis E and other pathogens known to infect the liver (1) (2) (3) (4) (5) (6).

  Individuals in the incubation period of a hepatitis infection

• It is possible that subjects may be in the incubation period of a hepatitis A or hepatitis B infection at the time of vaccination. It is not known whether vaccination will prevent hepatitis A and hepatitis B in such cases. Refer to healthcare professional if a hepatitis infection is suspected (1) (2) (3) (4) (5) (6).

  Immunosuppressed patients

• Patients that are immunosuppressed due to disease or treatment, including asplenia or dysfunction of the spleen, or HIV infection (regardless of CD4 count), may not produce a sufficient protective antibody response following vaccination (10).

• Specialist advice may be required - see the Green Book chapters 6 & 7:

  ̵ https://www.gov.uk/government/publications/contraindications-and-special- considerations-the-green-book-chapter-6

  ̵ https://www.gov.uk/government/publications/immunisation-of-individuals- with-underlying-medical-conditions-the-green-book-chapter-7

  Other considerations

• Healthcare professionals must not delegate their responsibility and they have the right to refuse vaccination to eligible patients based on their own clinical judgement. Where there is doubt, vaccination should not be initiated until the patient has sought advice

from the appropriate healthcare professional.

1. Clinical condition or situation to which the direction applies – continued

Product interactions

• Prior to administration and where indicated, medication that the patient is using should be checked for product interactions using the British National Formulary (BNF) and SPC. This includes checking that the patient’s medication does not suggest conditions that are excluded from vaccination under this PGD.

• Only the concomitant administration of Twinrix Paediatric® with Cervarix® has been specifically studied. It is advised that vaccines other than Cervarix® should not be administered at the same time as Twinrix Paediatric® (2) (5).

• Ambirix® can be administered concomitantly with, but as a separate injection to a combined diphtheria, tetanus, acellular pertussis, inactivated poliomyelitis and Haemophilus influenzae type b vaccine (DTPa-IPV+Hib) or with a combined Measles- Mumps-Rubella vaccine in the second year of life (3) (6).

• Concomitant administration of Ambirix® and other vaccines than those listed above has not been studied. It is advised that Ambirix® should not be administered at the same time as other vaccines unless absolutely necessary.

• Concomitant vaccines should always be administered at separate injection sites and

preferably into different limbs (3) (6).

Action if patient is excluded from the service

• The risk to the patient of not being vaccinated must be considered.

• If administration is postponed, arrange a future date for vaccination as appropriate.

• Discuss with patient and document the reasons for exclusion from vaccination under the PGD.

• If the patient has consented, refer them to their GP and/or inform their GP.

• Signpost to other services if appropriate.

• Refer patient back to employer’s occupational health service if appropriate.

• Give appropriate food, water and personal hygiene advice if travelling. Advise travellers that they should avoid contact with blood and bodily fluids to reduce their risk of hepatitis B.

Action if patient declines the service

• Ensure patient/carer fully understands the risks of declining vaccination.

• Advise the patient/carer about the protective effects of the vaccine.

• Explain NHS eligibility for vaccination where appropriate.

• Reschedule vaccination if appropriate.

• Document the reasons for declining vaccination and any action taken, including advice given to the patient in their medication record.

• Give appropriate food, water and personal hygiene advice if travelling. Advise travellers that they should avoid contact with blood and bodily fluids to reduce their risk of hepatitis B.

• Refer patient back to employer’s occupational health service if appropriate.

2. Description of vaccine

Name, strength & formulation of drug

Supplier

Name of product

Composition

Pharmaceutical

form

*Excipients

Age indications

GlaxoSmithKline UK

Twinrix Paediatric® Vaccine

Hepatitis A (inactivated) and hepatitis B (rDNA) (HAB) vaccine (adsorbed)

Suspension for injection

• Sodium chloride

• Water for injections

Between 1-15 years

Twinrix Adult® Vaccine

Hepatitis A (inactivated) and hepatitis B (rDNA) (HAB) vaccine (adsorbed)

Suspension for injection

• Sodium chloride

• Water for injections

16 years and over

Ambirix®

Hepatitis A (inactivated) and hepatitis B (rDNA) (HAB) vaccine (adsorbed)

Suspension for injection

• Sodium chloride

• Water for injections

Between 1-15 years

• * Twinrix Paediatric® and Twinrix Adult® vaccines may contain traces of neomycin which is used during the manufacturing process.

• For a full list of excipients, see section 2 and 6.1 of the relevant SPC.

Legal status

• POM – Prescription Only Medicine

Dose/dose range

• Twinrix adult: 1 ml (1) (4)

• Twinrix Paediatric: 0.5 ml (2) (5)

• Ambirix: 1 ml (3) (6)

Use of PGD outside terms of SPC

• This PGD covers vaccination in England, Scotland, Wales and Northern Ireland. Please note that Northern Ireland may have a separate SPC from Great Britain and guidance may differ. Please refer to the relevant SPC for more information.

• Although healthcare professionals have the right to refuse vaccination even where a

patient is eligible, they cannot override PGD exclusions.

Route/method of administration

• The vaccine should be inspected for any foreign particulate matter and /or for any variation of physical aspect prior to administration. If either is observed the vaccine should not be administered (1) (2) (3) (4) (5) (6).

• For intramuscular injection. The vaccine must not be injected intravenously or intradermally and must not be mixed with other vaccines in the same syringe (1) (2) (3) (4) (5) (6).

• For patients with bleeding disorders, a fine needle (equal to 23 gauge or finer calibre) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes. Alternatively, vaccination can be given by SC injection to reduce risk of bleeding (see cautions) (7).

• The preferred site of injection is the deltoid muscle of the upper arm (1) (2) (3) (4) (5) (6).

• In children 12 months through to 35 months, the preferred sites for intramuscular injection are the anterolateral aspect of the thigh (if suitably trained), or the deltoid muscle if muscle mass is adequate (11).

• Where two or more injections need to be administered at the same time, they should be given at separate sites, preferably in different limbs. If more than one injection is to be

given in the same limb, they should be administered at least 2.5cm apart (11).

2. Description of vaccine – continued

Frequency of administration

Primary Course: Ambirix®

Dose

Conventional schedule

Accelerated Schedule

1st injection

1.0mL

Elected date

N/A

2nd injection

1.0mL

6 – 12 months after 1st

injection

N/A

Primary Course: Twinrix®

Paediatric

Dose

Conventional schedule

Accelerated Schedule

1st injection

0.5mL

Elected date

N/A

2nd injection

0.5mL

1 month after 1st injection

N/A

3rd injection

0.5mL

6 months after 1st dose

N/A

Primary Course: Twinrix®

Dose

Conventional schedule

Accelerated Schedule*

1st injection

1.0mL

Elected date

Elected date

2nd injection

1.0mL

1 month after 1st injection

7 days after 1st injection

3rd injection

1.0mL

6 months after 1st injection

21 days after 1st injection

• *In exceptional circumstances in adults, when travel is anticipated within one month or more after initiating the vaccination course, but where insufficient time is available to allow the standard schedule to be completed. When this schedule is applied, a fourth dose is recommended 12 months after the first dose (1) (4).

• Ambirix® should be used only when there is a relatively low risk of hepatitis B infection during the vaccination course as protection against hepatitis B infections may not be obtained until after the second dose. It is therefore recommended that Ambirix® should be administered in settings where completion of the two-dose vaccination course can be assured (3) (6).

• Once initiated, the primary course of vaccination should be completed with the same vaccine (1) (2) (3) (4) (5) (6).

Follow up / minimum or maximum period

• Hepatitis A & hepatitis B combination vaccines should not be used to complete primary courses of either hepatitis A or hepatitis B that were started using single antigen vaccines. N.B Refer to Public Health England guidelines in times of shortage.

• For travellers who have completed a primary course of vaccination, a single booster dose of vaccine at five years is not required, unless they are considered to be at continuing risk of infection (12).

• In situations where a booster dose of hepatitis A and/or hepatitis B is desired, a monovalent or combined vaccine can be given (2) (5).

• For travellers who have completed an accelerated primary course of vaccination, a single booster dose of vaccine is recommended at 12 months after the first dose (1) (4).

• For further information regarding interrupted courses and the need for further doses

and, see the SPC and official recommendations.

3. Further aspects of vaccination

Adverse Reactions and their Management

• Follow local SOP on adverse reactions and their management.

• Very common side effects include (≥1/10): Headache, pain and redness at the injection site and fatigue (1) (4).

• Common side effects include (≥1/100 to <1/10): Gastrointestinal symptoms, diarrhoea, nausea, swelling at the injection site, injection site reactions (such as haematoma, pruritus and bruising) and malaise (1) (4).

• Uncommon side effects include (≥1/1,000 to <1/100): Dizziness, vomiting, abdominal pain, myalgia and fever (1) (4).

• Rare side effects include (≥1/10,000 to <1/1,000): Lymphadenopathy, decreases appetite, hypoaesthesia, paraesthesia, hypotension, rash, pruritus, arthralgia, influenza like illness and chills (1) (4).

• Frequency of adverse reactions may differ from the above with Twinrix Paediatric® and Ambirix® vaccines. Please refer to section 4.8 of the relevant SPC.

• Emergency equipment must be available including immediate access to epinephrine (adrenaline) 1:1000 for intramuscular (IM) injection. Please refer to resuscitation council guidelines.

• Healthcare professionals should confirm with patients that they are fit to leave the premises after a period of observation. Patients should not leave if they are feeling at all unwell without speaking to the healthcare professional.

• The onset of anaphylaxis is rapid, typically within minutes, and its clinical course is unpredictable with variable severity and clinical features. Due to the unpredictable nature of anaphylactic reactions, it is not possible to define a particular time period over which all patients should be observed following immunisation to ensure they do not develop anaphylaxis.

• In the event that the patient exhibits signs of anaphylaxis after injection, healthcare professionals must seek urgent medical attention.

• Advise the patient to consult their GP if there is a severe local reaction at the injection site, if they have a fever or if any other serious symptoms develop.

• For a comprehensive list of all warnings, cautions and potential adverse reactions, refer

to the current BNF, current and relevant SPCs (Great Britain or Northern Ireland) and the Green Book - Immunisation against infectious disease.

Reporting procedure of adverse reactions

• Report to GP if appropriate & document in patient’s medication records.

• Follow local SOP for reporting of adverse events.

• All suspected adverse reactions must be reported via the Yellow Card scheme to the MHRA or on the website at https://yellowcard.mhra.gov.uk/

• An adverse reaction should be reported even if it is not certain that the medicine has caused it, if it is well recognised, or if other drugs were given at the same time.

• Further information is available online from https://yellowcard.mhra.gov.uk/

3. Further aspects of vaccination – continued

Advice to patient / carer

Vaccine protection

• Explain protection level expected from vaccine. Advise patients that not all those who receive the vaccine will be fully protected, and the vaccine only protects against infections for which it has been developed.

  Patient information

• Provide a patient information leaflet and discuss as required.

• Provide advice on and explain potential warnings.

• Advise on possible side effects and their management. If the symptoms do not resolve and/or the patient experiences other severe symptoms, they should be advised to contact their GP, NHS 111 or visit A&E.

• Give appropriate food, water and personal hygiene advice if travelling with additional advice that all travellers should avoid contact with blood and bodily fluids to reduce their risk of hepatitis B and other blood borne viruses.

• MSM with multiple sexual partners need to be informed about the risks of hepatitis A & B, and about the need to maintain high standards of personal hygiene.

• It is important that immunisation does not encourage relaxation of other measures designed to prevent hepatitis exposure, for example condom use and needle exchange. Vaccine record

• Provide patient with a record of vaccination.

Records to be kept

• In all cases manual records including any risk assessment forms or computerised records should include:

  ̵ Patient’s name, address and date of birth;

  ̵ Name of immuniser;

  ̵ Dose, site and route of injection;

  ̵ Date of administration;

  ̵ Brand name, batch number & expiry date of vaccine;

  ̵ Confirmation that there are no contraindications; that side effects have been discussed; support literature given (if applicable) and any other advice given;

  ̵ That valid informed consent was given prior to administration;

  ̵ Details of any adverse reactions and actions taken;

  ̵ Signature and printed name and designation (in black ink) for paper records. For computer records, ensure data authentication of practitioner delivering care.

• GP may be notified, if the patient has consented for personalised information to be shared.

• Pharmacy/clinic records should be stored in line with relevant legislation and local policies. Generally, records should be kept for 8 years in adults and until 25 years of age

in children.

3. Further aspects of vaccination – continued

Additional facilities / requirements

• Policies and procedures must be in place for providing a private vaccination service including cold chain management, sharps disposal, needlestick injury, consent, record keeping and training requirements.

• Pharmaceutical refrigerator (or validated cool box for storing vaccines if running an

  “offsite” clinic).

• Resuscitation kit, including immediate access to 1:1000 epinephrine (adrenaline).

• Access to medical support (this may be via telephone).

• Disposal - equipment used for vaccination, including used vials or ampoules, should be disposed of at the end of a session by sealing in a proper, appropriately sized puncture-

resistant ‘sharps’ box (UN-approved, BS 320).

3. Further aspects of vaccination – continued

Additional facilities / requirements

PGD users must:

• Be familiar with and have online access to the latest edition of the Green Book, noting that clinical guidance may change and that the Green Book is frequently updated.

• Be aware of current clinical recommendations and be able to undertake administration (where applicable) and discuss any issues that may arise.

• Have been trained and assessed as being competent in the delivery of this medicine covered by this PGD.

• Maintain their skills, knowledge and professional level of competence in this area according to their individual code of professional conduct.

• Possess appropriate professional indemnity.

• Agree to work within the terms of the implementing PGD.

• Be aware of medicine handling, storage and administration guidelines.

• Regularly check BNF/BNFC / Green Book for contraindications, cautions and interactions. The superintendent/clinical lead of the implementing pharmacy/clinic will be responsible for:

• Providing adequate up-to-date clinical resources.

• Ensuring that staff using the PGD, have access to up-to-date resources.

• Ensuring that staff have received adequate training in all areas relevant to this PGD.

  Requirements for Continuing Professional Development (CPD)

• All staff involved in the implementation of this PGD should participate in adequate and appropriate Continual Professional Development to ensure procedures follow the most up to date clinical guidance.

  Facilities and supplies to be available

• Consultations carried out under the authorisation of this PGD should be completed in a private space, physically closed off from interruption such as a pharmacy consultation room, in order to ensure patient confidentiality.

• The following should be available:

  1. Safe storage areas for medicines and equipment

  2. Clean and tidy clinical rooms that allow confidentiality and patient privacy.

  3. Copies of the current PGD

  4. Access to a current BNF and Green Book

     Audit

• All health risk assessment, advice and medicine supply record forms should be stored in the pharmacy/clinic and will be audited by the implementing pharmacy/clinic in order to analyse service delivery. If the service is deemed insufficient, management staff, the superintendent/clinical lead and implementing healthcare professional will be informed

and an action plan drawn up to remedy the service.

3. Further aspects of vaccination – continued

Consent

• Prior to the administration and/or supply of a medicine, consent must be obtained, preferably written, from the patient, and documented either in the patient’s medical records/notes or on an administration form.

  The key points include:

• If a patient’s fitness and suitability cannot be established, supply should be deferred.

• There is no legal requirement for consent to be in writing but written consent serves to record the decision and the discussions that have taken place.

• Consent - either written or verbal - is required at the time of each supply.

• Consent remains valid unless the patient who gave it withdraws it. If there is new information between the time consent was given and when the supply is offered, including new evidence of risk, new medicines becoming available or where there is a significant change in the patient’s condition, it may be necessary for the patient to reconfirm their consent.

• Written and verbal information should be available in a form that can be easily understood by the person who will be giving the consent. Where English is not easily understood, translations and properly recognised interpreters should be used in order that they can make informed consent.

• The attendance of a patient for the supply/administration of treatment after an invitation to attend for this purpose may be viewed as acceptance that the patient may have the treatment/administration.

• Patients should also be informed about how data on the supply will be stored, who will be able to access that information and how that data may be used.

• Where consent is either refused or withdrawn, this decision must be documented.

• Consent obtained before the occasion upon which a patient attends for the

supply/administration is only an agreement for the patient to be included in this instance and does not mean that consent is in place for each future supply/administration.

4. References & Resources

For a comprehensive list of all warnings, cautions and potential adverse reactions, refer to the current BNF and SPCs.

References

1. Summary of Product Characteristics; Twinrix Adult Vaccine, suspension for injection. emc (Great Britain). [Online] March 30, 2021. [Cited: December 19, 2022.] https://www.medicines.org.uk/emc/product/1163.

1. Summary of Product Characteristics; Twinrix Paediatric, suspension for injection in pre-filled syringe. emc (Great Britain). [Online] April 20, 2021. [Cited: December 19, 2022.] https://www.medicines.org.uk/emc/product/1164.

2. Summary of Product Characteristics; Ambirix suspension for injection in pre-filled syringe. emc (Great Britain). [Online] March 12, 2021. [Cited: December 19, 2022.] https://www.medicines.org.uk/emc/product/6172.

3. Summary of Product Characteristics; Twinrix Adult, suspension for injection in pre-filled syringe. emc (Northern Ireland). [Online] May 13, 2022. [Cited: December 19, 2022.] https://www.emcmedicines.com/en-gb/northernireland/medicine?id=f133973f-9786-4713-b515- b045eae60195&type=smpc.

4. Summary of Product Characteristics; Twinrix Paediatric Vaccine suspension for injection. emc (Northern Ireland). [Online] March 26, 2020. [Cited: December 19, 2022.] https://www.emcmedicines.com/en-gb/northernireland/medicine?id=0b03df3f-5543-4d45-a99a- f1c4f275cb85&type=smpc.

5. Summary of Product Characteristics; Ambirix, suspension for injection in pre-filled syringe. emc (Northern Ireland). [Online] March 26, 2020. [Cited: December 19, 2022.] https://www.emcmedicines.com/en-gb/northernireland/medicine?id=6a3f632b-13e4-4b83-8034- 27557838145f&type=smpc.

6. Chapter 14a; COVID-19 - SARS-CoV-2. The Green Book. [Online] September 04, 2022. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1057798/Greenbook-chapter-14a- 28Feb22.pdf.

7. Chapter 19; Influenza. The Green Book. [Online] September 16, 2022. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/931139/Green_book_chapter_19_ influenza_V7_OCT_2020.pdf.

8. Chapter 8: Vaccine safety and the management of adverse events following immunisation. The Green Book. [Online] August 2012. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147868/Green-Book-Chapter-8- v4_0.pdf.

9. Chapter 7; Immunisation of individuals with underlying medical conditions. The Green Book. [Online] January 2020. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/857279/Greenbook_chapter_7_I mmunsing_immunosupressed.pdf.

10. Chapter 4; Immunisation procedures. The Green Book. [Online] June 2021. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147915/Green-Book-Chapter- 4.pdf.

11. Chapter 18; Hepatitis B. The Green Book. [Online] February 04, 2022. [Cited: December 19, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1052889/Greenbook-chapter-18- 4Feb22.pdf.

4. References & Resources – continued

Additional resources

1. Chapter 17; Hepatitis A. The Green Book. [Online] February 07, 2022. [Cited: April 28, 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1053507/Greenbook - chapter-17-7Feb22.pdf.

2. Hepatitis A. Travel Health Pro. [Online] January 03, 2019. [Cited: April 28, 2022.] https://travelhealthpro.org.uk/factsheet/21/hepatitis-a.

3. Hepatitis B. Travel Health Pro. [Online] November 28, 2019. [Cited: April 28, 2022.] https://travelhealthpro.org.uk/factsheet/50/hepatitis-b.

4. Hepatitis A. NHS. [Online] March 11, 2019. [Cited: April 28, 2022.] https://www.nhs.uk/conditions/hepatitis- a/vaccination/.

5. Hepatitis B vaccine overview. NHS. [Online] November 02, 2021. [Cited: April 28, 2022.] https://www.nhs.uk/conditions/vaccinations/hepatitis-b-vaccine/.

6. Patient Group Direction; Medicines practice guideline [MPG2]. National Institute for Health and Care Excellence. [Online] March 27, 2017. [Cited: February 11, 2022.] https://www.nice.org.uk/Guidance/MPG2.

7. Competency framework for health professionals using Patient Group Directions. National Insti tute for Health and Care Excellence. [Online] January 4, 2018. [Cited: February 11, 2022.] https://www.nice.org.uk/guidance/mpg2/resources.