This is not true. Pregnant healthcare personnel may administer any vaccine except the ACAM2000 smallpox vaccine.
Ask the Experts: Administering Vaccines: General Issues
Yes. Vaccines can be administered in a patient care area. The recommendation from CDC’s safe injection practices experts is that storing and preparing vaccines should not be done in the same area where patient care is conducted. These activities should be done in a separate area.
Appropriate site and needle length depends on age, route of injection, and body mass. Most injected vaccines are administered by the intramuscular route.
Please refer for details to the Immunize.org handouts on administering intramuscular and subcutaneous vaccines to children and adults at www.immunize.org/catg.d/p2020.pdf and to adults only at www.immunize.org/catg.d/p2020a.pdf.
A summary of needle length and site selection by age is below.
For intramuscular injections (use a 22- to 25-gauge needle for all ages):
- 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 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 10 years, the deltoid muscle is preferred; the needle length for deltoid site injections can range from ⅝ to 1 inch on the basis of technique. The anterolateral thigh can also be used. In this case the needle length should be 1 inch to 1.25 inches.
- For adolescents 11 through 18 years, the deltoid muscle is preferred. The anterolateral thigh can also be used. For injection into the anterolateral thigh, most adolescents will require a 1-1.5-inch needle.
- For adults age 19 years and older, the deltoid muscle is preferred. 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.
For subcutaneous injections (use a 23- to 25-gauge needle for all ages):
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 needle length should be used for all ages.
More information on injection technique is in the ACIP “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
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 polysaccharide vaccines, which may be given either SC or IM). Vaccine efficacy may also be reduced if not given by the recommended route.
Yes. There is no age limit for use of the anterolateral thigh for either subcutaneous or intramuscular vaccines.
Ideally, you can arrange to have the cast cut to administer vaccines in the anterolateral thighs. If that option is not available, the gluteal region can be used if not covered by the cast. There are no other sites we recommend for vaccination; however, the inactivated polio vaccine could be given subcutaneously in either arm, if the child is large enough. Rotavirus vaccine is given orally and should be administered. If vaccines cannot be given for the 10 weeks, please advise the family to keep people with any illness away from the child until she has been vaccinated. More information see ACIP’s “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
ACIP does not address this issue. However, CDC recommends that these children should each be vaccinated, notwithstanding they are conjoined. We believe even in conjoined twins who share organs and/or blood supply, vaccination of each child would also be indicated. The rationale is one cannot be sure, even in the latter case, that the common organs/blood supply would eliminate vaccine antigens less quickly, or the immune system(s) would respond adequately, to one dose of each vaccine for the two children. Therefore two doses seems appropriate, that is, one dose of each vaccine for each child.
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.
With rare exceptions*, 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, live attenuated influenza, yellow fever, and oral typhoid) can be given at the same visit if indicated. 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: eziz.org/assets/docs/IMM-718.pdf
For older children: www.aimtoolkit.org/docs/Giving_all_the_doses_12mths.pdf
For adults: www.eziz.org/assets/docs/IMM-718A.pdf
For details see ACIP’s “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
*There are 3 exceptions to this general rule: 1) if both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) 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 two vaccines. 2) A person with anatomic or functional asplenia or HIV should receive both PCV13 and meningococcal ACWY (MenACWY) vaccines. If Menactra brand (Sanofi) MenACWY is used, the person should first receive all recommended doses of PCV13 followed by Menactra at least 4 weeks later. Menveo (GSK) or MenQuadfi (Sanofi) MenACWY brands can be given at the same time or at any time before or after PCV13. 3) Cholera vaccine should be administered before TY21a vaccine, and 8 hours should separate cholera vaccine and the first dose of TY21a.
The Advisory Committee on Immunization Practices (ACIP) does not address this issue. There is no recommended order in which the vaccines should be given. A best practice strategy to decrease injection or procedural pain is to administer the vaccine that causes the most pain (stinging, for example) last. For more information on vaccine administration, please see the “Vaccine Administration” chapter of Epidemiology and Prevention of Vaccine-Preventable Diseases at www.cdc.gov/vaccines/pubs/pinkbook/chapters.html.
With the exception of two vaccines used to prevent smallpox or mpox (previously known as monkeypox), there is no recommendation to wait until a vaccine reaches room temperature before administration. The vaccine should be administered as soon as it is prepared.
The live smallpox (vaccinia) vaccine, ACAM2000 (Emergent Product Development Gaithersburg, Inc.) and the non-replicating, live smallpox and mpox vaccine, Jynneos (Bavarian Nordic) should be brought to room temperature before use, according to the package inserts for these two products.
Here are the suggested volumes:
- Average 0.5 mL
- Range 0.5–2 mL
- Average 1–4 mL
- Range 1–5 mL
Infants and toddlers would fall at the lower end of the range, whereas adolescents and adults would generally fall on the higher end of the range.
All inactivated vaccines, including COVID-19 vaccines, can be given on the same day, or on any day before or after giving other inactivated or live vaccines. Early guidance from ACIP recommended against coadministration of COVID-19 vaccines with other vaccinations; however, ACIP updated its guidance in mid-2021 to state that these vaccines may be coadministered with other vaccinations when necessary.
If two live vaccines are not given on the same day, they need to be spaced at least 4 weeks apart. If both pneumococcal conjugate vaccine (PCV) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) are indicated for a high-risk patient, these vaccines should not be given at the same visit. The PCV 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 PCV to avoid interference between the 2 vaccines. A person with anatomic or functional asplenia should receive both PCV and meningococcal conjugate vaccines (MenACWY). If Menactra brand MenACWY is used the person should first receive all recommended doses of PCV then Menactra at least 4 weeks later. Menveo or MenQuadfi brands of MenACWY can be given at the same time or at any time before or after PCV.
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.
There are various requirements for the use of vaccines after reconstitution. Some manufacturers’ package inserts require that the vaccine be used or discarded in varying time frames ranging from 24 hours after reconstitution to immediately after reconstitution. While the specific timeframes are simple to interpret, there can be some confusion as to what the requirement of “immediately” actually means.
CDC considers “immediately” to be the reasonable time it takes to prepare and transport the vaccine to the patient to be administered. This would include any limited documentation that may be related to this process. It is up to the judgment of a provider to determine if a vaccine has not been used in the appropriate time. Some manufacturers have indicated to providers that “immediately” can be up to 30 minutes. The definition of “immediately” varies from manufacturer to manufacturer. Some do not have the data to put forth a general time frame as to what “immediately” means. CDC recommends that the provider contact the manufacturer any time (s)he has any question about whether or not the vaccine has been used in the appropriate time frame.
In general, no. According to ACIP’s “General Best Practice Guidelines for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. So live oral cholera vaccine may be administered simultaneously or at any interval before or after administration of most other vaccines. One exception is Ty21a oral typhoid vaccine (Vivotif, Emergent Travel Health) and oral cholera vaccine. Oral cholera vaccine should be administered before Ty21a vaccine, and at least 8 hours should separate the cholera vaccine and the first dose of Ty21a.
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 the Advisory Committee on Immunization Practice’s (ACIP) “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
ACIP does not address the use of this method for vaccination in its “Best Practices Guidelines for Immunization” (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html). If you choose to use this method, you should still adhere to the ACIP’s recommendations regarding needle length and anatomical site.
Both IM and SC vaccines may be given through a tattoo.
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.