​Inf​luenza Implementation Guidance

Updated September 2020


​Registered nurses and medical assistants are the health care professionals most commonly administering immunizations. There are a few states that do not allow medical assistants to administer injections, so it is important to check state statutes. Many medical practices require that medical assistants be certified or registered and have graduated from an accredited medical assisting program to administer immunizations or any type of injections.

Administering immunizations correctly is a critical part of the health care professional's job. The flu vaccine is required to be administered either intramuscularly (IM), intradermally (in the case of Fluzone Intradermal) or intranasally (in the case of nasal flu vaccine). Following the most current influenza vaccine policies from the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) is another important factor. It is important that health care professionals are knowledgeable and have been well-trained prior to administering immunizations. If immunizations are given improperly, the patient may not develop immunity.

It is helpful to provide staff with an annual refresher on vaccine administration and safety, ideally just prior to receipt of flu vaccine in the late summer/early fall. Remember the following:

  • Review the Vaccine Information Statements (VIS) for the current flu vaccine season
  • Review dosage recommendations, administration requirements and package inserts for the different flu vaccines your practice will be receiving
  • Review IM placement locations
    • On the thigh (vastus lateralis is the preferred muscle)—the preferred spot for infants (newborn to infants younger than age 12 months) and young children (age 12 months through 2 years)
    • Arm (Deltoid muscle)—older children (age 3 through 19 years) and adults
    • Choose the right needle size. Usual choices in the pediatric setting are 5/8", 1", and 1 & 1/2"; ensure the needle length is sufficient to administer vaccine in the muscle mass, as opposed to deep subcutaneous (SQ) tissue.
      • For infants up to age 1 year, a 1" needle is usually used in the vastus lateralis muscle of the upper thigh. Examine the 6-month child well; sometimes a 5/8" needle may be appropriate. The appropriate needle length, especially in infants, is very much patient dependent.
      • For toddlers and older children, needle length will vary based on injection site (vastus lateralis or deltoid) and weight of the patient (1" – 1.5").
  • For Injectable Flu vaccine
    • Insert the needle at a 90-degree angle quickly. Do not aspirate after needle insertion.
    • Remember multiple immunizations given on the same day should be given a minimum of 1" apart.
  • For Nasal Flu Vaccine
    • Administer intranasally; sniffing is not required by the patient.
    • Each FluMist unit contains one dose with1/2 administered into each nostril.
  • For Intradermal Flu Vaccine (see administration guide)
    • Fluzone Intradermal vaccine is given in the upper arm—the same spot you would administer an IM vaccine
    • First shake the vial
    • Insert the needle perpendicular to the skin above the deltoid
    • Do not aspirate. Push the plunger to inject
    • Remove the needle and dispose

Review Infection Prevention & Quality Control Recommendations 

  • Interim AAP guidance during a pandemic:
    • For administration of inactivated influenza vaccine, a surgical/medical mask should always be worn as well as eye protection.

    • For administration of live attenuated influenza vaccine (LAIV), gloves are recommended in addition to use of a surgical/medical facemask and eye protection.

  • Remind staff to wash hands prior to vaccine preparation and between each patient. Handwashing is the most important way to prevent the spread of infection. Handwashing is especially important during a busy flu-shot clinic when harried staff may be likely to forget.

  • Always check expiration dates before drawing up the vaccine.

  • Document the vaccine administered in the patient’s chart accurately. See the Liability and Risk Management section of this document for details.

  • Give each patient the appropriate VIS for the current flu vaccine season before the vaccine is administered.

Tools and Resources


Immunization Action Coalition 
  • Interim Guidance for Immunization Services During the COVID-19 Pandemic 

  • Vaccine Administration e-Learn
    The CDC offers Vaccine Administration e-Learn, a free, interactive, online educational program that serves as a useful introductory course or a great refresher on vaccine administration.

  • Vaccine Administration Videos
    The Centers for Diseases Control and Prevention has developed videos that demonstrate appropriate vaccine administration techniques, as part of the One and Only Campaign. The videos include, "Check Your Steps! Make Every Injection Safe," "Managing Patient Safety, One Injection at a Time," and "Safe Injection Practices - How to Do It Right."

  • 2020 Pink Book Webinars
    This online series of 15 webinars provides an overview of the principles of vaccination, general recommendations, immunization strategies for providers, and specific information about vaccine-preventable diseases and the vaccines that prevent them. Each one-hour webinar explores a chapter from the 13th edition of “Epidemiology and Prevention of Vaccine-Preventable Diseases,” also known widely as “The Pink Book.”

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