| Administering Vaccines |
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| General Issues |
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| Note: Specific information about the administration of most vaccines is included in the Ask the Experts set for that vaccine. |
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| I was recently
told by a colleague that pregnant healthcare
personnel were not to administer live vaccines to others. I had never heard that in school or
practice. Is that true? |
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| This is not true. Pregnant healthcare personnel may administer any vaccine except the ACAM2000 smallpox vaccine. |
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| Is it
acceptable to administer vaccines in the
nurses' station where vital signs and other
patient care is performed? |
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| 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. |
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| What is the
appropriate anatomic site and needle length
for intramuscular and subcutaneous vaccine injection? |
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| Appropriate site and needle length depends on age, route of injection, and body mass. Most injected vaccines are administered by the intramuscular route. |
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| 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. |
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| A summary of needle length and site selection by age is below. |
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| For intramuscular injections (use a 22- to 25-gauge needle for all ages): |
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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. |
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The anterolateral thigh is preferred for infants younger than age 12 months. For the majority of infants a 1-inch needle is sufficient. |
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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. |
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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. |
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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. |
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For adults age 19 years and older, the deltoid muscle is preferred. The anterolateral thigh also can be used. |
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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. |
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For men and women who weigh 130–152 pounds (60–70 kg), a 1-inch needle is sufficient. |
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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. |
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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. |
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| For subcutaneous injections (use a 23- to 25-gauge needle for all ages): |
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| 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. |
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| 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. |
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| Why are some
vaccinations given subcutaneously (SC) while
others must be given intramuscularly (IM)? |
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| 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. |
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| 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? |
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| Yes.
There is no age limit for use of the
anterolateral thigh for either subcutaneous or
intramuscular vaccines. |
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| I have a
2-month-old child with a cast for hip
dysplasia that completely covers the entire
anterolateral thigh on both legs. She is not
due to have it removed
for 10 weeks. What options do we have for her
injectable vaccines? |
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| 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. |
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| I need
information about the administration of
vaccines to 3-month-old conjoined twins
(joined at the buttocks). For their routine
immunization, do we
provide one set of vaccinations or two, given
that they are conjoined at the buttock but
share no major organs? |
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| 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. |
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| If I need to
give more than 1 injection in a muscle, are
certain vaccines best given at different
anatomic sites? |
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| 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. |
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| How many
vaccines can be given during an office visit? |
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| 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. |
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| 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: |
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| For infants and toddlers:
www.eziz.org/assets/docs/IMM-718.pdf |
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| For
older children:
www.aimtoolkit.org/docs/Giving_all_the_doses_12mths.pdf |
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| For
adults:
www.eziz.org/assets/docs/IMM-718A.pdf |
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| For
details see ACIP's General Best Practices
Guidelines for Immunization, available at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. |
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*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. |
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| A 5-year-old
is in the office for vaccines and is due for
MMR, polio, varicella, and DTaP. Is there a
specific order I should be giving these
vaccines? |
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| 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. |
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| Do we need to wait for the vaccine to reach room temperature before we administer it to a patient? |
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| 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. |
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| 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. |
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| What is the
acceptable volume for a single dose of immune
globulin (IG) to inject into the deltoid
muscle of a normal-weight adult? What is the
acceptable
volume for a single dose of IG to inject into
the vastus lateralis of a normal-weight adult? |
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| Here
are the suggested volumes: |
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Deltoid: |
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Average 0.5 mL |
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Range 0.5–2 mL |
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Lateralis: |
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Average 1–4 mL |
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Range 1–5
mL |
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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. |
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| 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? |
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| 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. |
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| 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. |
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| What does
"simultaneous administration" of vaccines
mean? Does it mean the same day, hour, or
what? |
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| 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. |
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| Some
manufacturers' package inserts state that a
vaccine should be used immediately after
reconstitution. In the context of
reconstitution and
administration of vaccines, how does CDC
define "immediately"? |
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| 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. |
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| 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. |
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| Does live oral cholera vaccine (Vaxchora, Emergent Travel Health) need to be administered at an interval from other live oral or injectable vaccines? |
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| 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. |
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| We have a
nurse in one of our clinics who gave separate
doses of hepatitis A and hepatitis B vaccine
in the gluteus. Are the doses of each antigen
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? |
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| 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. |
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| Is the
"Z-track" method recommended for IM
injections? |
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| 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. |
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| Is it safe to
give a vaccine directly into an area where
there is a tattoo? |
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| Both IM and SC
vaccines may be given through a tattoo. |
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| Do you need to
aspirate before giving a vaccination? |
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| 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. |
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| While giving
an injection, a nurse had blood return in the
syringe upon aspirating. What should she have done with the vaccine? |
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| 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. |
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| Is it
necessary to wear gloves when we administer
vaccinations? |
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| In general, 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. |
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| In 2020, in response to the COVID-19 pandemic, CDC temporarily recommended the use of gloves when administering oral and intranasal vaccines to patients in communities where SARS-CoV-2, the virus that causes COVID-19, is circulating. Gloves were recommended to prevent contact with the recipient's potentially infectious mucous membranes or respiratory secretions. In the setting of widely available and effective COVID-19 vaccines and treatments, CDC resumed recommending standard pre-pandemic infection control practices during vaccination. |
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| Is protective
eyewear needed for those who administer
vaccines so they can avoid blood spatter? |
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| ACIP does not
specifically recommend eye protection when
administering vaccines to prevent exposure to
blood spatter. |
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| In 2020, in response to the COVID-19 pandemic, CDC temporarily recommended the use of protective eyewear in areas where SARS-CoV-2 was circulating widely to reduce the risk of infection with SARS-CoV-2. In the setting of widely available and effective COVID-19 vaccines and treatments, CDC resumed recommending standard pre-pandemic infection control practices during vaccination. |
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| Where can I
find current information on how to protect
myself and my patients when administering vaccines during the COVID-19 pandemic? |
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| In 2020, in response to the COVID-19 pandemic, CDC temporarily recommended additional infection control steps to ensure the safety of people in vaccination clinics, including universal wearing of face masks to reduce the risk of transmission. In the setting of widely available and effective COVID-19 vaccines and treatments, CDC resumed recommending standard pre-pandemic infection control practices during vaccination. The use of face masks to protect patients or staff from respiratory viruses while administering vaccinations should be based on professional judgment in the specific circumstances and/or institutional policy. |
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| 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? |
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| 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. |
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| I've seen the
recommendation stating air bubbles in
manufacturer-filled syringes do not need to be expelled. Can you explain why those air
bubbles can
be injected but air bubbles in user-filled
syringes must be expelled? |
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| It is not wrong
to expel the air from syringes filled by
manufacturers, but typically it is such a
small amount of air (0.2cc–0.3cc) that it is
CDC's opinion
that it would not cause a problem. When the
syringe is inverted during an injection, that
small amount of air would typically just clear
the medication from
the needle. This is based on the recommendation that when the Z-track method is
used for intramuscular injection of irritating
medication (e.g., iron
preparations), the guidance is to leave
0.2cc–0.3cc in the syringe to be sure that all
of the medication leaves the needle and is not
tracked back through
subcutaneous tissue as the needle is
withdrawn. While the Z-track injection technique is not recommended for vaccine
administration, the Z-track method
demonstrates the acceptability of leaving a
very small amount of air in the syringe for
intramuscular injections. |
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| CDC
does, however, recommend that when drawing
vaccine from a vial into a regular syringe,
the air be expelled because the amount of air
drawn into
the syringe may be larger than the amount in a
manufacturer-filled syringe. Expelling the air
is part of general medication guidelines for
drawing
medication into a syringe. |
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| If a patient
is not able to receive rotavirus vaccine
orally, can we give it through a G-tube? |
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| You can give
rotavirus vaccine through a tube as long as
the child is otherwise eligible. |
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| If the lymph
nodes under a patient's arm were surgically
removed, should we avoid giving vaccines in
that arm? |
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| 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. |
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| What are the
special recommendations for administering
intramuscular injections in people with
clotting disorders? |
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| This issue is
discussed in ACIP's Best Practices Guidelines
for Immunization (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html).
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). |
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| We have a
question concerning delaying vaccinations for
an infant born to a heroin-addicted mother. We had a foster parent come into our health
department requesting only certain vaccines
for a 3-month-old, stating that the private
physician recommends delaying the schedule due
to the possible
residual effects of the heroin. The baby
appeared to be healthy. |
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| Heroin use or
addiction of the mother is not a reason to
delay vaccination of an otherwise healthy
infant. |
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| 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? |
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| 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. |
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| 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? |
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| 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/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf,
page 20. |
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| My nurse
removed the protective cap from a
preservative-free single dose vial, but the
vial was not used. How long can we keep a vial
of vaccine after we remove the protective cap
of a preservative-free vial of vaccine? |
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| Removing the
protective cap increases the likelihood the
septum or stopper could be punctured. The
puncture may not be visible. It is important
to ensure that the rubber seal on single-dose
vials is not punctured because single-dose
vials do not contain a preservative. Once the
protective cap has been removed, the vaccine
should be discarded at the end of the workday
because it may not be possible to determine if
the rubber seal has been punctured. For
additional details, see CDC's Vaccine Storage
& Handling Toolkit at
www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. |
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| Is it
necessary to allow alcohol to dry completely
on a patient's skin prior to injection? |
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| 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. |
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| 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? |
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| You should use
separate alcohol wipes to clean the vial top
and the patient's skin. |
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| 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? |
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| 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. |
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| 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? |
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| 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. |
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| Some single
dose vials (SDV) contain more than the
recommended dosage of the vaccine. 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? |
|
| In general 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. An
exception to this is recombinant zoster
vaccine (RZV; Shingrix, GSK). The RZV adjuvant
solution may contain up to 0.75 mL of liquid.
The entire volume of
the adjuvant solution should be withdrawn and
used to reconstitute the lyophilized vaccine.
After mixing, withdraw the recommended dose of
0.5 mL. Any
reconstituted vaccine left in the vial should
be discarded. |
|
| Where can I
obtain standing orders for vaccination? |
|
| Immunize.org 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. You can find the standing orders and protocols for medical management of vaccine reactions at www.immunize.org/standing-orders. |
|
| What is the
provider's liability when using standing order
protocols? |
|
| While you did not
say this explicitly, we assume the concern is
about a vaccine injury in a person who was vaccinated using a standing order. Of course,
as long as the person is properly screened for
contraindications and precautions, an injury
from a vaccine is very unlikely. In the event
that an injury does
occur, the National Vaccine Injury
Compensation Program (VICP) provides liability
protection for the vaccinator and the
clinician who signed the standing
order for any vaccine that is covered by the
vaccine injury compensation program (all
vaccines that are routinely administered to
children are covered by
the program for all ages of patients). More
information about the VICP is available on
their website at
www.hrsa.gov/vaccinecompensation/index.html. |
|
| 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? |
|
| Findings of 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 General Best Practices
Guidelines for 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 Methods for
Alleviating Discomfort and Pain Associated
with Vaccination at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. |
|
| 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. |
|
| Immunize.org has two pertinent educational pieces for healthcare professionals: "Medical Management of Vaccine Reactions in Children and Teens in a Community Setting" at www.immunize.org/catg.d/p3082a.pdf and "Medical Management of Vaccine Reactions in Adults in a Community Setting" at www.immunize.org/catg.d/p3082.pdf. |
|
| CDC studies have shown that about 80% of fainting episodes occur within 15 minutes of receiving the vaccine. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination in accordance with ACIP's General Best Practices Guidance for Immunization (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html). This is particularly important when vaccinating adolescents and young adults. CDC has posted additional information on this topic at www.cdc.gov/vaccinesafety/concerns/fainting.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), and varicella 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. |
|
| Immunize.org has produced a printable document with details about vaccines that require diluents and how to use them: www.immunize.org/catg.d/p3040.pdf. |
|
| 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 needle
came loose while I was injecting a dose of
vaccine, and approximately half the dose was
lost. Should we revaccinate the patient? 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. Use
your discretion to determine whether an
adequate dose was given. 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. In the case of
Shingrix (RZV; GSK) if the person is still in
the office the dose can be repeated immediately; however, if the repeat Shingrix dose cannot be
given on the same day CDC recommends that it
should be given 4 weeks after the invalid
dose. |
|
| 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 by
an infant, count the dose and do not
administer a second dose. If a person sneezes
after live attenuated influenza vaccine (Flumist;
AstraZeneca) the dose can be counted as valid. |
|
| If a patient
pulls away during administration of a vaccine
and the needle comes out, is it okay to
reintroduce the same needle and finish the
injection? |
|
| No. The needle
should be considered to be contaminated. The
needle and syringe should be discarded. A new
syringe, needle, and dose of vaccine should be
used. Generally, a full repeat dose should be
given, but you may use your clinical judgment
to decide whether an adequate dose was
administered before the patient pulled away. |
|
| 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. |
|
|
|
|
|
| We received a
report of an infant who received rotavirus
vaccine intramuscularly rather than orally. Is
this dose valid? If not, when should it be
repeated? |
|
| The
rotavirus vaccine dose given by the
intramuscular route is not valid and should be
repeated by the oral route as soon as
possible. In a review of such
rotavirus vaccine administration errors, there
usually were not adverse reactions, and those
documented were limited to local reactions and
general, brief
irritability. Please see
www.cdc.gov/mmwr/pdf/wk/mm6304.pdf,
page 81, for more information. |
|
| Please take steps
to ensure that such vaccine administration
errors are avoided in the future. This event
should be reported to the Vaccine Adverse
Event
Reporting System at
https://vaers.hhs.gov even
if an adverse reaction does not result from
it. |
|
| 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. Although simply
repeating the dose is
preferred, serologic testing to check for immunity after certain vaccinations (e.g.,
measles, rubella, varicella, hepatitis A) may
be accepted. |
|
| MMRV was
mistakenly given to a 31-year-old instead of
MMR. Can this be considered a valid dose? |
|
| Yes, however,
this issue is not addressed in the 2010 MMRV
ACIP recommendations. Although this is
off-label use, CDC recommends that when a dose
of MMRV is inadvertently given to a patient
age 13 years and older, it may be counted
towards completion of the MMR and varicella
vaccine series and
does not need to be repeated. |
|
| An expired
dose of ProQuad (MMRV, Merck) was given to a
patient. We assume that the repeat dose should be given in three months because the
spacing between doses of a combination vaccine
depends on the longest minimum interval of a
component (in this case the varicella vaccine
component).
Is this correct? |
|
| In the case of an
expired live vaccine, the issue is not
necessarily the routine minimum interval
(three months in the case of varicella and ProQuad
vaccines), but the interval that would prevent
viral interference if the expired vaccine
happened to be still viable. This interval is
considered to be four
weeks (28 days). The repeat dose should be
administered four weeks after the expired
dose. |
|
| What should we
do if we give an injection by the wrong route
(SC instead of IM)? |
|
| 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 and/or
CDC recommends that if hepatitis B, rabies,
HPV and inactivated
influenza vaccines are administered subcutaneously the doses should not be counted
as valid and should be repeated. |
|
| ACIP states that
If PCV13, Hib, and/or DTaP are administered by
the subcutaneous route, providers have the discretion to repeat the doses. There is no
minimum interval between the invalid dose and
the repeat dose. ACIP and/or CDC recommends
that if HepA, MenACWY, IPV, PPSV23, COVID-19,
and
RZV vaccines are administered subcutaneously,
the doses can count and do not need to be
repeated. ACIP/CDC has no recommendation for
Tdap, Td,
MenB, Typhim VI, or JE-VC. |
|
| 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
the error is discovered on the same clinic
day, you can administer the other "half" of
the dose on that same day. If the error is
discovered
later, the dose should not be counted, and
then the person should be recalled to the
office and given a full age-appropriate repeat
dose. |
|
| 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. |
| |
| A dose of
Kinrix (DTaP-IPV; GSK) should have been
administered to a 4-year-old, but Pentacel
(DTaP-IPV-Hib; Sanofi Pasteur) was
administered instead.
Does the dose of DTaP count? |
|
| Yes. The DTaP in
the Pentacel can be counted. Although Pentacel
is licensed as a 4-dose series and this may represent a fifth dose of Pentacel (in which
case it would be off-label use), the dose of
DTaP counts as the fifth dose of DTaP. |
|
| A dose of
pneumococcal conjugate vaccine was
administered into my patient's dialysis port.
Does this dose count? |
|
| There are no data
on the effectiveness of pneumococcal conjugate
vaccine given by the intravenous route. The patient has renal disease, so it is
important to ensure that the dose they receive
is effective. CDC recommends repeating the
dose. |
|
| A 2-month-old was mistakenly given PPSV23. What should be done? |
|
| PPSV23 is not effective in children younger than 24 months of age. PPSV23 given at this age should not be considered to be part of the pneumococcal vaccination series. Pneumococcal conjugate vaccine should be administered as soon as the error is discovered. Any time the wrong vaccine is given, the parent/patient should be notified. |
|
| We inadvertently gave both pneumococcal conjugate (PCV) and pneumococcal polysaccharide (PPSV) vaccines at the same visit. We are looking for guidance. |
|
| Although PCV and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur. You should inform the patient of the error and let them know that they will not need to repeat either dose. |
|
| A 60-year-old
patient was inadvertently given varicella
vaccine instead of zoster vaccine. Should the patient still be given the zoster vaccine? If
so, how
long an interval should occur between the 2
doses? |
|
| CDC recommends
that if a provider mistakenly administers
varicella vaccine to a person for whom zoster
vaccine is indicated, no specific safety
concerns exist, but the dose should not be
considered valid. Recombinant zoster vaccine (RZV;
Shingrix, GSK) should be administered at least
8 weeks
after receipt of the varicella vaccine. However, if RZV is administered less than 8
weeks after the varicella vaccine, it does not
need to be repeated. A
second dose of RZV should be given 2–6 months
after the first dose of RZV. Avoid such errors
by checking the vial label 3 times to make
sure you're
administering the product you intended. |
|
| If RZV (Shingrix)
is erroneously given to a child for prevention
of varicella, the dose is invalid, but is
there a waiting period before a valid dose of
varicella
vaccine can be given? Is it OK to give a dose
of varicella vaccine as soon as the error is
discovered? |
|
| There is no
waiting period. The varicella vaccine dose can
be given at any time after the RZV dose. |
|
| While giving a
dose of RZV (Shingrix) the syringe came loose
from the needle and part of the dose was lost. Will the patient be protected with this
partial
dose or does it need to be repeated? |
|
| A dose less than
the full 0.5 mL dose is not valid and should
be repeated. If the patient is still in the
office the dose can be repeated immediately.
If the
repeat dose cannot be given on the same day
CDC recommends that it should be given 4 weeks
after the invalid dose. |
|
| My medical
assistant inadvertently administered a 0.5 mL
dose of the RZV (Shingrix) diluent only. The dose did not contain any antigen. When can we
administer a properly reconstituted dose? |
|
| The CDC zoster
subject matter experts recommend that in this
situation you should wait 4 weeks before
giving a repeat dose. |
|
| Several doses
(antigen and diluent) of RZV (Shingrix) were
mistakenly stored in our office freezer. One
of these doses was administered to a patient.
Is
this dose valid and if not, when can it be
repeated? |
|
| Any RZV, either
antigen or diluent, that is exposed to
freezing temperature should not be used. If a
dose exposed to freezing temperature is given
to a
patient the dose should be considered invalid
and should be repeated 4 weeks after the
invalid dose. |
|
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ACIP Recommendations
Vaccine Information Statements 
