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Vaccine Administration

Updated 10/2015

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Immunizations need to be administered according to the 7 rights: 

  • All patients should be screened for contraindications and precautions every time a vaccine is administered, even if the patient has previously received a dose of that vaccine. The patient's status can change from one visit to the next or a new contraindication or precaution may have been added. ​​Screening questions are available here.

  • Some vaccines need to be reconstituted; a specific diluent will be provided by the manufacturer. It is important to follow manufacturer guidelines in reconstituting the vaccine. See Vaccines with Diluents: How to Use Them. Measles, mumps, rubella (MMR); varicella; zoster; meningococcal polysaccharide (MPSV); and rotavirus vaccines all require reconstitution

  • This includes administering at the correct age, the appropriate interval, and before vaccine or diluent expires.

    Check the schedule to ensure the patient is getting the vaccine at the right time, and the appropriate interval (Log-in required).  Each vaccine vial should be checked for the expiration date. A vaccine should never be used if it is expired. Once reconstituted, the vaccine must be administered according to the guidelines or discarded. In most cases, if not used within 30 minutes, the vaccine will lose its potency and the patient will not be properly immunized.
  • Vaccine administrators need to make sure they draw the correct amount of immunization when drawing from multidose vials. See Administering Vaccines: Dose, Route, Site, and Needle Size.

  • Immunizations are administered through the following routes: intramuscular (IM), subcutaneous (SQ), oral, nasal, and intradermal. The majority of immunizations are administered IM, but MMR, varicella, zoster, and MPSV are administered SQ. In administering IM injections, it is important to use a needle with the correct length to reach the muscle mass and not seep into SQ tissue. (see Table 1 below)

    When administering IM injections, the needle should be inserted at a 90° angle—and quickly. It is not necessary to aspirate after needle insertion. SQ injections are administered at a 45° angle, and the SQ tissue is pinched up to prevent injection into the muscle. It is not necessary to aspirate after needle insertion. Multiple immunizations should be a minimum of 1 inch apart. Another method of immunization is nasal spray, which has recently become available for live attenuated influenza vaccine. Intradermal is now available for Fluzone, an influenza vaccine. Oral polio vaccine has not been used in the United States since 2000 but is still used in other countries. In the United States, inactivated polio vaccine is given and can be administered SQ or IM.
  • Children of different sizes and ages will need vaccines administered in different locations on the body. (see Table 2 below).

  • Document the following:
    • Vaccine manufacturer,
      • ​Required under the National Childhood Vaccine Injury Act
    • ​Lot number,
      • Required under the National Childhood Vaccine Injury Act
    • Date of administration,
      • Required under the National Childhood Vaccine Injury Act
    • Name and business address of the health care professional administering the vaccine,
      • Required under the National Childhood Vaccine Injury Act
    • Date that VIS is provided (and VIS publication date),
      • Required by Centers for Disease Control and Prevention (CDC) regulations for vaccines purchased through CDC contract. See the VIS Web site for current versions.
    • Site (eg, deltoid area) ,
      • Recommended by the American Academy of Pediatrics
    • Route (eg, intramuscular) of administration , and
      • Recommended by the American Academy of Pediatrics
    • ​Expiration date of the vaccine.
      • Recommended by the American Academy of Pediatrics​​
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Other important vaccine administration tips:

Dos

  • Do use a separate anatomic site for each injection.
  • Do label vaccines if more than one are drawn up together. This will help with documenting which vaccines were given in which site.
  • Do ensure that the person who drew up the vaccine administers it. This will reduce errors.
  • Do wash hands between patient encounters and before preparing vaccines.
  • ​Do wear gloves to administer a vaccine if there is a risk coming into contact with body fluids or if the administrator has open sores or cuts on the hands.
  • Do consider immunizations for those with only a mild illness. If a child has a moderate or severe illness – rescheduled their immunizations.
  • Do always screen for other contraindications.
  • Do use safety syringes to reduce the incidence of needle sticks and disease transmission.
  • Do check to see what size needle, route and location should be used. 

Don'ts

  • Do not mix separate vaccines in the same syringe. If more than one vaccine is being administered to the same limb, injection sites should be 1 to 2 inches apart so that any reactions can be determined.
  • Do not pre-draw your own syringes – these are vaccines that are drawn up in syringes and laid out at the beginning of the day or significantly before administration. It is ok to use prefilled syringes that come as single doses from the manufacturer.

Some immunizations come with a diluent and must be reconstituted, whereas others do not. Always follow the current recommended immunization schedule.

Table 1

Adapted From AAP RedBook 

Common Pediatric Vaccines Administered in the United States and Their Routes of Administration​

   
Diphtheria-tetanus (DT, Td)ToxoidsIM
DTaPToxoids and inactivated bacterial componentsIM
DTaP, hepatitis B, and IPVToxoids and inactivated bacterial components, recombinant viral antigen, inactivated virusIM
DTaP-IPVToxoids and inactivated bacterial components, inactivated virusIM
DTaP-IPV/Hib (PRP-T reconstituted with DTaP-IPV)Toxoids and inactivated bacterial components, polysaccharide-protein conjugate, inactivated virusIM
Hepatitis AInactivated virusIM
Hepatitis BRecombinant viral antigenIM
Hepatitis A-hepatitis BInactivated virus and recombinant viral antigensIM
Hib conjugate (tetanus toxoid) b Bacterial polysaccharide-protein conjugateIM
Hib conjugate (PRP-OMP b ) hepatitis BBacterial polysaccharide-protein conjugate with recombinant viral antigenIM
Human papillomavirus (HPV2 and HPV4)Recombinant viral antigensIM
InfluenzaInactivated viral componentsIM
InfluenzaLive-attenuated virusesIntranasal
Meningococcal polysaccharide (MPSV4)Bacterial polysaccharideSC
Meningococcal conjugate (MCV4)Bacterial polysaccharide-protein conjugateIM
MMRLive-attenuated virusesSC
MMRVLive-attenuated virusesSC
Pneumococcal polysaccharide (PPSV)Bacterial polysaccharideIM or SC
Pneumococcal conjugate (PCV)Bacterial polysaccharide-protein conjugateIM
Poliovirus (IPV)Inactivated virusesSC or IM
Rotavirus (RV1 and RV5)Live-attenuated virusOral
TdapToxoids and inactivated bacterial componentsIM
TetanusToxoidIM
VaricellaLive-attenuated virusSC

 

Table 2

From AAP Red Book: Site and Needle Length by Age for Intramuscular Immunization​

Age Group Needle Length, inches (mm) a Suggested Injection Site
Newborns (preterm and term) and infants <1 mo of age⅝ (16) b Anterolateral thigh muscle
Term infants, 1–12 mo of age1 (25)Anterolateral thigh muscle
Toddlers and children⅝ –1 (16–25) b Deltoid muscle of the arm
 1–1¼ (25–32)Anterolateral thigh muscle
Adults  
 Female and male, weight <60 kg1 (25) c Deltoid muscle of the arm
 Female and male, weight 60–70 kg1 (25)Deltoid muscle of the arm
 Female, weight 70–90 kg1 (25)–1½ (38)Deltoid muscle of the arm
 Male, weight 70–118 kg1 (25)–1½ (38)Deltoid muscle of the arm
Female, weight >90 kg1½ (38)Deltoid muscle of the arm
 Male, weight >118 kg1½ (38)Deltoid muscle of the arm​​

a Assumes that needle is inserted fully.

b If the skin is stretched tightly and subcutaneous tissues are not bunched.

c Some experts recommend a ⅝-inch needle for men and women who weigh less than 60 kg.

Vaccine Administration Resources

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