Home
|
About IAC
|
Contact
|
A-Z Index
|
Donate
|
Shop
|
SUBSCRIBE
Immunization Action Coalition
IAC Home
|
Ask the Experts
|
Topic Index
|
Administering Vaccines

Ask the Experts: Topics

Administering Vaccines

Make a Donation Ask the Experts Home
Administering Vaccines
-- Vaccine Administration Errors
Billing and Reimbursement
Documenting Vaccination
Precautions and Contraindications
Scheduling Vaccines
Storage and Handling
-- Vaccine Storage Units
-- Temperature Monitoring & Controls
-- Troubleshooting & Follow-Up
-- Vaccine Viability & Expiration
-- Resources
Vaccine Recommendations
Vaccine Safety
 
More Ask the Experts
What's New
Question of the Week
Vaccine Index
View All
 
Administering Vaccines
What is the appropriate anatomic site and needle length for intramuscular and subcutaneous vaccine injection?
Appropriate site and needle length depends on age and body mass. Most injected vaccines are administered by the intramuscular route.
For neonates (first 28 days of life) and preterm infants the anterolateral thigh should be used. A ⅝-inch needle usually is adequate to penetrate the thigh muscle if the skin is stretched flat between the thumb and forefinger and the needle is inserted at a 90-degree angle to the skin.
The anterolateral thigh is preferred for infants younger than age 12 months. For the majority of infants a 1-inch, 22- to 25-gauge needle is sufficient.
For toddlers age 12 months through 2 years the anterolateral thigh muscle is preferred. The needle should be at least 1 inch long. The deltoid muscle can be used if the muscle mass is adequate.
For children age 3 through 19 years, the deltoid muscle is preferred. The anterolateral thigh also can be used. Needle size for deltoid muscle injections can range from 22 to 25 gauge and from ⅝ to 1 inch depending on the technique used.
For adults age 19 years and older, the deltoid muscle is preferred for routine intramuscular vaccinations. The anterolateral thigh also can be used. For men and women who weigh less than 130 pounds (less than 60 kg), a ⅝-inch needle is sufficient to ensure intramuscular injection in the deltoid muscle if the injection is made at a 90-degree angle and the tissue is not bunched. For men and women who weigh 130–152 pounds (60–70 kg), a 1-inch needle is sufficient. For women who weigh 152–200 pounds (70–90 kg) and men who weigh 152–260 pounds (70–118 kg), a 1- to 1½-inch needle is recommended. For women who weigh more than 200 pounds (more than 90 kg) or men who weigh more than 260 pounds (more than 118 kg), a 1½-inch needle is recommended.
Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants younger than age 12 months and in the upper-outer triceps area of people age 12 months and older. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. A ⅝-inch, 23- to 25-gauge needle should be used for all ages. More information on injection technique is in the ACIP General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 13-16.
Why are some vaccinations given subcutaneously (SC) while others must be given intramuscularly (IM)?
In general, vaccines containing adjuvants (a component that enhances the antigenic response) are administered IM to avoid irritation, induration, skin discoloration, inflammation, and granuloma formation if injected into subcutaneous tissue. This includes most of the inactivated vaccines, with a few exceptions (such as IPV and pneumococcal vaccines, which may be given either SC or IM). Vaccine efficacy may also be reduced if not given by the recommended route.
A 5 year old came in today for her preschool vaccines. She needed MMR and varicella. She has a broken arm which is in a cast. Can the anterolateral thigh be used to administer a subcutaneous vaccine in a 5 year old?
Yes. There is no age limit for use of the anterolateral thigh for either subcutaneous or intramuscular vaccines.
If I need to give more than 1 injection in a muscle, are certain vaccines best given at different anatomic sites?
Since DTaP and pneumococcal conjugate (PCV) are the vaccines most likely to cause a local reaction, it is prudent to give DTaP and PCV in separate limbs (if possible), so there is no confusion about which vaccine caused the reaction.
How many vaccines can be given during an office visit?
All vaccines can be administered at the same visit*. There is no upper limit for the number of vaccines that can be administered during one visit. ACIP and AAP consistently recommend that all needed vaccines be administered during an office visit. Vaccination should not be deferred because multiple vaccines are needed. All live vaccines (MMR, varicella, zoster, live attenuated influenza, yellow fever, and oral typhoid) can be given at the same visit. If live vaccines are not administered during the same visit, they should be separated by 4 weeks or more.
When giving several injections at a single visit, separate IM vaccines by at least 1 inch in the body of the muscle if possible to reduce the likelihood of local reactions overlapping. Here are some helpful site maps for different ages so you can record where shots were given:
For infants and toddlers: http://eziz.org/assets/docs/IMM-718.pdf
For adolescents: http://www.aimtoolkit.org/pdf/7_Givingallthedoses_adolescent_013113.pdf
For adults: www.eziz.org/assets/docs/IMM-718A.pdf
For details, consult CDC's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 27-28.
*There are 2 exceptions to this general rule: 1) if both PCV13 and PPSV23 are indicated for a high-risk patient, these vaccines should not be given at the same visit. The PCV13 should be given first followed by PPSV23 at least 8 weeks later. If PPSV23 has already been given, wait 8 weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avoid interference between the 2 vaccines. 2) A person with anatomic or functional asplenia should receive both pneumococcal conjugate vaccine (PCV13) and meningococcal conjugate vaccines (MCV4). If Menactra brand MCV4 is used the person should first receive all recommended doses of PCV13 then Menactra at least 4 weeks later. Menveo brand MCV4 can be given at the same time or at any time before or after PCV13.
If all needed vaccines aren't administered during the same visit, does one need to wait a certain period of time before administering the other needed vaccines?
All inactivated vaccines can be given on the same day, or on any day before or after giving other inactivated or live vaccines. However, if two live vaccines are not given on the same day, they need to be spaced at least 4 weeks apart.
What does “simultaneous administration” of vaccines mean? Does it mean the same day, hour, or what?
Simultaneous means the same day—the same clinic day. If someone receives a vaccine in the morning and then another that same afternoon, it would be considered simultaneous administration.
We have a nurse in one of our clinics that gave separate doses of hepatitis A and hepatitis B vaccine in the gluteus. Are the doses of each antigen are considered invalid? If so, can they be repeated at any time or do I need to count the spacing between doses from the date when the invalid dose was administered?
Although the gluteus muscle is not a recommended site for vaccination, in general a dose given there can be considered valid. The exceptions to this general rule are hepatitis B and rabies vaccines, so the hepatitis B vaccine should not be counted in this situation. The hepatitis B vaccine can be repeated immediately. See ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 17.
Is the “Z-track” method recommended for IM injections?
ACIP does not address the use of this method for vaccination in its General Recommendations on Immunization (www.cdc.gov/mmwr/pdf/rr/rr6002.pdf). If you choose to use this method, you should still adhere to the ACIP's recommendations regarding needle length and anatomical site.
Is it safe to give a vaccine directly into an area where there is a tattoo?
Both IM and SC vaccines may be given through a tattoo.
Do you need to aspirate before giving a vaccination?
No. ACIP does not recommend aspiration when administering vaccines because no data exist to justify the need for this practice. There are data that show that aspiration is more painful for the vaccine recipient. IM injections are not given in areas where large vessels are present. Given the size of the needle and the angle at which you inject the vaccine, it is difficult to cannulate a vessel without rupturing it and even more difficult to actually deliver the vaccine intravenously. We are aware of no reports of a vaccine being administered intravenously and causing harm in the absence of aspiration.
While giving an injection, a nurse had blood return in the syringe upon aspirating. What should she have done with the vaccine?
Although aspiration is not recommended, if you do aspirate and get a flash of blood, then the procedure is to withdraw the needle and start over. The syringe, needle, and contaminated dose of vaccine should be discarded in a sharps container, and a new syringe and needle should be used to draw up and administer another dose of vaccine. This is a waste of expensive vaccine that could be avoided by simply not aspirating.
Is it necessary to wear gloves when we administer vaccinations?
No. Occupational Safety and Health Administration (OSHA) regulations do not require the wearing of gloves when administering vaccinations, unless the person administering the vaccine is likely to come into contact with potentially infectious body fluids or has an open lesion on their hand. If a healthcare worker chooses to wear gloves, he or she must change them between each patient encounter.
Some single-dose manufacturer-filled vaccines come with an air pocket in the syringe chamber. Do we need to expel the air pocket before vaccinating?
No. You do not need to expel the air pocket. The air will be absorbed. This is not true for syringes that you fill yourself; you should expel air bubbles from these syringes prior to vaccination to the extent that you can do so.
If a patient is not able to receive rotavirus vaccine orally, can we give it through a G-tube?
You can give rotavirus vaccine through a tube as long as the child is otherwise eligible.
If the lymph nodes under a patient’s arm were surgically removed, should we avoid giving vaccines in that arm?
We are aware that some surgeons advise against vaccination in an arm where lymph nodes were dissected. ACIP does not address this, so feel free to use your professional judgment in determining whether to use the arm that was operated on, the other arm (if not affected), or the anterolateral aspect of the thigh, which is an acceptable secondary route for adult immunization.
What are the special recommendations for administering intramuscular injections in people with clotting disorders?
This issue is discussed in ACIP's "General Recommendations on Immunization" (www.cdc.gov/mmwr/pdf/rr/rr6002.pdf (pages 29-30). Intramuscular (IM) injections should be scheduled shortly after antihemophilia therapy or prior to a dose of anticoagulant. For both IM and subcutaneous (SC) injections, a fine needle (23 gauge or smaller) should be used and firm pressure applied to the site, without rubbing, for at least 2 minutes. Providers should not administer a vaccine by a route that is not approved by the FDA for that particular vaccine (e.g., administration of IM vaccines by the SC route).
Is it okay to draw up vaccines at the beginning of the shift? If it isn't, how much in advance can this be done?
The ACIP discourages the practice of prefilling vaccine into syringes, primarily because of the increased possibility of administration and dosing errors. An exception may be considered when only a single type of vaccine is to be administered during a clinic (e.g., influenza). Another reason to discourage the practice in general is that some vaccines have a very limited shelf life after reconstitution. If the reconstituted vaccine is not used within the designated time period, it must be discarded. A chart of the time allowed between reconstitution and use, "Vaccines with Diluents: How to Use Them," is available at www.immunize.org/catg.d/p3040.pdf. For more information on prefilling syringes, please read www.immunize.org/technically-speaking/20110901.asp.
If you place a needle on a manufacturer-filled syringe and then don't administer the vaccine, how long can you store the syringe with the needle attached?
In general, a vaccine should not be prepared until the provider is ready to administer it to a patient. This is because once the syringe cap is removed or a needle is attached, the sterile seal is broken. However, if a sterile seal has been broken, staff should be sure to maintain the syringe at the appropriate temperature and either use it or discard it at the end of the clinic day. This issue is addressed in the CDC Storage and Handling Toolkit, available at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf, pages 102-103.
The cap of a single dose vial (SDV) was removed and the stopper cleaned, but before the needle was inserted it was discovered to be the incorrect vaccine. Can a SDV be stored and used at a later time when no needle was inserted into the vial stopper, even though the cap has been removed?
The current CDC recommendation is that when a single dose vial or syringe has been "activated," meaning the protective cap removed, the dose must be used during that clinic session or else it should be discarded, even if the vial has not been punctured with a needle.
Is it necessary to allow alcohol to dry completely on patients skin prior to injection?
It is prudent to allow the alcohol to evaporate, but it is unlikely that the small amount residual alcohol on the skin will affect the vaccine or increase the risk of an adverse reaction.
Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial?
You should use separate alcohol wipes to clean the vial top and the patient’s skin.
I know that it is advisable to clean the vaccine vial stopper with an alcohol wipe after removing the protective cap from a vaccine or diluent vial. Do you have to wait for the alcohol to dry before you insert the needle in to the stopper?
The stopper of a single-dose vial is often assumed to be sterile. However, not all vaccine manufacturers guarantee the tops of unused vials are sterile, and the manner in which the cover over the stopper is removed can potentially contaminate the stopper. Therefore, using friction and a sterile alcohol pad to swab the stopper may help to assure aseptic technique in preparing the single-dose vial prior to inserting a sterile syringe. Alcohol evaporates quickly and will dry while the needle is being prepared for insertion into the vial.
In cleaning the vaccine vial stopper or the patient’s skin, is it okay to use a non-sterile cotton ball or do we need to use a pre-packaged sterile alcohol prep pad?
Using a pre-packaged sterile alcohol prep pad is recommended to maintain aseptic technique. Not only are cotton balls not sterile, but neither is a bottle of sterile alcohol, once it's opened.
Some single dose vials (SDV) contain more than the recommended dosage of the vaccine. For example, a SDV of HPV4 contains about 0.6mL when drawing up the entire vial. Should we administer the recommended dose of the vaccine, or the entire contents of the vial even if it contains more than the recommended dose?
The entire volume should be used even if it is a little more than 0.5 mL. Discarding the excess vaccine is not required or recommended.
Where can I obtain standing orders for vaccination?
The Immunization Action Coalition (IAC) has developed suggested standing orders for all vaccines commonly given to children and adults. They are based on CDC's Advisory Committee on Immunization Practices (ACIP) recommendations and are reviewed for technical accuracy by CDC staff. You can find the standing orders and protocols for medical management of vaccine reactions at www.immunize.org/standing-orders.
A 2009 article in The Lancet reported that infants who received 3 doses of paracetamol following immunization had reduced immune responses to certain vaccines. Based on these findings, should we stop recommending acetaminophen for fever or discomfort after infant immunizations?
Evidence from this study discourages the prophylactic use of paracetamol (similar to acetaminophen) prior to or immediately following vaccination. Acetaminophen can be used to treat pain or fever if it should occur following vaccination. ACIP's 2011 General Recommendations on Immunization state: "Evidence does not support use of antipyretics before or at the time of vaccination; however, they can be used for the treatment of fever and local discomfort that might occur following vaccination. Studies of children with previous febrile seizures have not demonstrated antipyretics to be effective in the prevention of febrile seizures." For more information on this issue, see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 16.
What guidance is there for preventing patients from fainting after vaccination?
All providers who administer vaccinations should be aware of the potential for syncope (fainting) after vaccination and take appropriate measures to prevent it. Thus, clinicians should (1) make sure that people who are being vaccinated are always seated; (2) be aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.); and (3) take appropriate measures to prevent injuries if such symptoms occur. [Note: IAC has two pertinent educational pieces for healthcare professionals: "Medical Management of Vaccine Reactions in Children and Teens" and "Medical Management of Vaccine Reactions in Adult Patients"].
Since 2005, VAERS has received an increasing number of reports of syncope, coinciding with the licensure of three vaccines for adolescents—HPV, meningococcal conjugate, and Tdap. Fainting among girls and young women ages 11-18 accounted for most of the increase. Serious injuries have occurred, including one fatality from intracranial hemorrhage caused by head trauma. The May 2, 2008, MMWR included a summary of findings on the increase in fainting after vaccination (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm). In people for whom vaccination time and fainting time were reported, it was discovered that 80% occurred within 15 minutes of receiving the vaccine. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination in accordance with ACIP General Recommendations on Immunization (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 12). This is particularly important when vaccinating adolescents and young adults.
CDC has posted frequently asked questions on this topic at www.cdc.gov/vaccinesafety/Concerns/syncope_faqs.html.
Are vaccine diluents interchangeable?
Diluents are not interchangeable, except for the sterile water used in Merck’s measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV), varicella, and zoster vaccines. No other diluent can be used for these vaccines, and these diluents must not be used to reconstitute any other lyophilized vaccine.
If the wrong diluent is used, the vaccination should always be repeated. If an inactivated vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid and should be repeated as soon as possible. If a live vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid. If the dose can't be repeated on the same clinic day, it needs to be repeated no earlier than four weeks after the invalid dose. This spacing is due to the effects of generating a partial immune response that could suppress the live replication of subsequent doses, even of the same live vaccine.
Is it recommended to change needles after a vaccine dose has been drawn into a syringe?
No. It is also unnecessary to change the needle if it has passed through two stoppers, which is done when a lyophilized vaccine is reconstituted. Changing needles is a waste of resources and increases the risk of needle stick injury.
When patients need multiple vaccines (such as influenza and pneumococcal), can we just combine them in the same syringe?
Absolutely not. No vaccines should ever be mixed in the same syringe unless the combination has been specifically approved by the FDA. The diluent for Pentacel (DTaP/IPV/Hib) and Menveo brand meningococcal conjugate vaccines contains an antigenic component of the vaccine and should always be combined as directed by the manufacturer.
If some portion of a vaccine leaks out of the syringe while it is injected into a patient, does the dose need to be repeated and if so, when?
When this happens, it is difficult to judge how much vaccine the person received. This would be a nonstandard dose and should not be counted. You should go ahead and re-immunize the individual at that time.
A child wiggled when we were injecting a dose of vaccine, and approximately half the dose was lost. Should we revaccinate the child? If so, when?
When injectable vaccine volume is lost (patient moves, syringe leaks), it may be difficult to judge how much vaccine the patient actually received. In general, you should treat this as a nonstandard injectable dose and should not count it. If it was an inactivated vaccine, you should re-immunize the person as soon as possible. If it was a live vaccine, you can give another dose if you detect the error on the same clinic day; otherwise you should wait 28 days to give the next dose. However, if part of a dose of an oral vaccine (rotavirus) was spit out, count the dose and do not administer a second dose.
We run a student health center and are wondering what the position is on discarding empty vaccine vials. Do they need to go in a sharps container after they are drawn up or can they go in the trash?
Empty or expired vaccine vials are considered medical waste and should be disposed of according to state regulations.
Vaccine Administration Errors Back to top
What should we do if a dose of expired vaccine is given to a patient?
The dose should be repeated. If the expired dose is a live virus vaccine, you should wait at least 4 weeks after the previous (expired) dose was given before repeating it. If the expired dose is not a live vaccine, the dose should be repeated as soon as possible. If you prefer, you can perform serologic testing to check for immunity for certain vaccinations (e.g., measles, mumps, rubella, varicella, and hepatitis A).
What should we do if we give an injection by the wrong route (e.g., IM instead of SC)?
Your practice should put procedures in place to ensure that you always give vaccines by the recommended route because data regarding safety and efficacy of alternate routes are limited. If this does inadvertently happen, ACIP recommends that vaccines given by the wrong route be counted as valid with two exceptions: hepatitis B or rabies vaccine given by any route other than IM should not be counted as valid and should be repeated. This and other information on vaccine administration is discussed in the ACIP General Recommendations on Immunization available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf. In addition, CDC and the manufacturers recommend that a dose of HPV vaccine given by any route other than intramuscular be repeated. There is no minimum interval between the invalid (subcutaneous) dose and the repeat dose.
A vaccine given intradermally (except the intradermal influenza vaccine) should not be counted as valid, and should be repeated.
One of our staff gave a dose of pediatric hepatitis A vaccine to an adult patient by mistake. How do we remedy this error?
In general, if you give less than a full age-appropriate dose of any vaccine, the dose is invalid. You should revaccinate the person with the appropriate dose as soon as feasible.
There are, however, two exceptions to the general rule: (1) If a patient sneezes after receiving nasal-spray live attenuated influenza vaccine, count the dose as valid. (2) If an infant regurgitates, spits, or vomits during or after receiving oral rotavirus vaccine, count the dose as valid.
If you give more than an age-appropriate dose, count the dose as valid and notify the patient/parent about the error. Using larger than recommended dosages can be hazardous because of excessive local or systemic concentrations of antigens or other vaccine constituents. Avoid such errors by checking the vaccine vial label 3 times.
 
This page was reviewed on May 1, 2014
Immunization Action Coalition  •  2550 University Avenue West  •  Suite 415 North  •  Saint Paul, Minnesota  •  55114
tel 651-647-9009  •  fax 651-647-9131
 
This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.