Procedures for Vaccine Administration

Give the Patient or Caregiver the Vaccine Information Statement (VIS):

Vaccine information statements are required by federal law to be provided before administering a routinely recommended childhood vaccine. This document provides vaccine-specific information on the benefits and risks of the vaccine. The VIS must be given to every patient before vaccination, regardless of age, and must be given before every dose of a vaccine, even if the patient has received the same vaccine and VIS before. 
The Centers for Disease Control and Prevention encourages vaccine information statements to be given to patients before all vaccines, regardless of whether it is federally required or not, since they are informative documents that can help patients understand the risks and benefits of vaccination. Vaccine information statements are available in paper and electronic formats (CDC, 2021).

Hand Hygiene:

It is critical to perform hand hygiene before vaccine preparation, between patients, and when hands become soiled. Vaccine providers can use soap and water or an alcohol-based hand rub to clean hands. If hands become visibly dirty, they should be washed with soap and water (CDC, 2021).
Gloves are not required by the Occupational Safety and Health Administration (OSHA) unless the vaccine provider has open sores on their hands or it is likely that they will come in contact with infectious bodily fluids. In light of the COVID-19 pandemic, gloves are recommended when administering oral or nasal vaccines. If the vaccine provider chooses to wear gloves, they should be changed between patients and hand hygiene should be performed with each change (CDC, 2021).

Routes of Administration

The specifics of the route, site, and dosage amounts of various vaccines are derived from clinical trials, practical experience, and other considerations. This table outlines the normally recommended dosing and route information for common vaccines. The table below shows the Dose and Route Administration for Selected Vaccines

Vaccine	Dose	Route
DEN4CYD	0.5 mL          .	Subcut
DTaP, DT, Td, Tdap	0.5 mL          .	IM              .
DTaP-HepB-IPV	0.5 mL           .	IM                 .
DTaP/Hib	0.5 mL          .	IM              .
DTaP-IPV/Hib	0.5 mL               .	IM              .
DTaP-IPV	0.5 mL             .	IM                 .
Hib	0.5 mL            .	IM              .
Hib-MenCY	0.5 mL            .	IM              .

Routes of Administration:

Vaccine	Dose	Route
HepA        .	≤18 years: 0.5 mL  ≥19 years: 1.0 mL	IM         .
HepB            .	≤19 years: 0.5 mL(a)  ≥20 years: 1.0 mL	IM               .
HepA-HepB	≥18 years: 1.0 mL	IM             .
LAIV        .	0.2 mL divided dose between nares	Intranasal spray
IIV        .	6-35 months: 0.25 mL or 0.5 mL  ≥3 years: 0.5 mL(b)	IM                 .
MenB         .	0.5 mL             .	IM        .
MMR          .	0.5 mL           .	Subcut
MMRV             .	0.5 mL            .	Subcut

Abbreviations:

• DEN4CYD = dengue vaccine; DT = diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus toxoids and acellular pertussis; 
• HepA = hepatitis A; HepB = hepatitis B; Hib = Haemophilus influenzae type b; HPV = human papillomavirus; 
• IIV = inactivated influenza vaccine; IM = intramuscular; IPV = inactivated poliovirus; LAIV = live, attenuated influenza vaccine; 
• MenACWY = quadrivalent meningococcal conjugate vaccine; MenB = serogroup B meningococcal vaccine; MenCY = bivalent meningococcal conjugate vaccine component; MMR = measles, mumps, and rubella; MMRV = measles, mumps, rubella, and varicella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine;
• PCV13 = pneumococcal conjugate vaccine; PPSV23= pneumococcal polysaccharide vaccine; RV1 = live, attenuated monovalent rotavirus vaccine; RV5 = live, reassortment pentavalent rotavirus vaccine; RZV = recombinant adjuvanted zoster vaccine; Subcut = subcutaneous; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.
• Persons aged 11-15 years may be administered Recombivax HB (Merck), 1.0 mL (adult formulation) on a 2-dose schedule.
• Note that prefilled syringes of High-Dose Fluzone have a volume of 0.7 cc and the recommended volume of administration is 0.7 ccs.
• Do not withdraw more than 0.5 mL from the reconstituted product, even if some product is left in the vial. Stopper

Intramuscular Vaccine Administration

Many vaccines are recommended for intramuscular injection, including tetanus, pneumonia, hepatitis, meningococcal, and shingles. These vaccinations are injected into the muscle located under the skin and subcutaneous tissue.

Recommended Injection site:

The two muscles recommended for administering intramuscular injections are the vastus lateralis muscle found in the anterolateral thigh and the deltoid muscle in the upper arm. Using these muscles for intramuscular injections decreases the risk of inadvertently injecting into nerves or veins. 
Vaccinations for infants under 12 months of age should be given in the vastus lateralis muscle in the thigh. In toddlers 1-2 years of age, the vastus lateralis is preferred, though the deltoid muscle can be used if it has adequate muscle mass. The deltoid muscle is preferred in patients older than three, though the vastus lateralis can be used if the deltoid is insufficient or inaccessible (CDC, 2021).

Intramuscular Injection Technique:

When administering an intramuscular injection, proper hand hygiene should be performed first. The muscle used for injection should then be identified, and the area should be cleaned with a sterile alcohol swab and allowed to dry. 
The skin should be spread tight to isolate the muscle, and the needle can then be inserted into the middle of the muscle at a 90-degree angle. The vaccine is then injected, the needle is withdrawn, and a bandage can be applied to stop any bleeding (CDC, 2021).

Subcutaneous Vaccine Administration

Subcutaneous vaccines are injected into the fatty tissue located just below the dermis and above the muscle tissue.

• Patients 1 year and older are given subcutaneous vaccine injections in the fatty tissue found above the upper outer triceps in the arm. 
• Infants younger than one year of age are typically given subcutaneous vaccinations in the fatty tissue of the thigh. Vaccines administered by subcutaneous injection include MMR (measles, mumps, and rubella) and varicella (CDC, 2021).
• In order to administer a subcutaneous vaccination, proper hand hygiene must be performed first. Then the skin must be cleaned using a sterile alcohol swab and allowed to dry. 
• Next, the skin and underlying fatty tissue should be pinched up, and the needle should be inserted at a 45-degree angle into the subcutaneous tissue. 
• The vaccine is then injected quickly, and the needle is withdrawn afterward. A bandage can then be applied to stop any bleeding (CDC, 2021).

Intranasal Vaccine Administration

Only one vaccine is administered through the intranasal route: the live attenuated influenza vaccine (LAIV). This vaccine is sprayed into each nostril using a prefilled nasal sprayer.

To administer the live attenuated influenza vaccine, hand hygiene should be performed first. Next, the rubber stopper on the nasal sprayer should be removed, and the tip of the applicator should be placed just inside the patient’s nostril.

Then the plunger should be pushed in a single, rapid motion until up to the dose divider clip. The dose divider clip is then removed, and the remaining vaccine can be administered in the other nostril. If the patient coughs or sneezes, the dose does not need to be repeated (CDC, 2021).

What Would You Do?

Your 6-year-old patient is behind on vaccinations. To help your patient get up to date, you are going to have to administer multiple vaccines during one visit. What is the best way to accomplish this to decrease the number of injections that have to be performed?

Multiple Vaccinations at Once

Administering multiple vaccines in one clinical visit is ideal for helping keep patients up to date with the vaccination schedule. Combination vaccines can help to decrease the number of injections performed at once, but even with a variety of combination vaccines available, it is often necessary to administer two or more vaccines in one visit. When giving multiple vaccinations at once, each vaccine should be given at a different injection site. Both the deltoid and vastus lateralis muscles have more than one injection site in each muscle. Injection sites should be separated by an inch or more to allow providers to identify injection site reactions if they occur (CDC, 2021).

Considerations for Multiple Injections in a Limb:

For children receiving more than one intramuscular injection in the same limb, the vastus lateralis muscle is preferred due to its greater muscle mass and ability to separate injections from one another. Older children and adults with adequate muscle mass can use the deltoid muscle for multiple injections. Vaccines more likely to cause pain or an injection site reaction, such as MMR or tetanus, should be administered in different limbs if possible (CDC, 2021).

Disposal of Supplies:

All syringes and needles should be discarded immediately after use in a sharp’s container. These puncture-resistant, closeable containers help to prevent accidental needlestick injuries and the reuse of needles. Vaccine vials that are empty or expired should be discarded according to state regulations for medical waste set by each state’s environmental agency (CDC, 2021).

Safety Considerations During Vaccine Administration

When administering vaccines, general precautions should be followed to reduce the risk of exposure to disease. Since the most significant risk of disease spread during vaccination is through person-to-person contact, proper hand hygiene should be performed before preparing vaccines and between each patient (CDC, 2021; CDC, 2022B).

Exposure of Vaccine Component:

Vaccine providers may have concerns when they have contraindications or precautions to the vaccines they are administering. There is no evidence showing any risk to the vaccine provider when administering routinely recommended vaccinations. 
Therefore, allergies, contraindications, or precautions present in the vaccine provider should not be considered a reason to avoid administering vaccinations (CDC, 2022B).

Preventing Bloodborne Disease:

Bloodborne illnesses, such as hepatitis and HIV, are occupational hazards for vaccine providers. In 2000, the Needlestick Safety and Prevention Act was passed to reduce the risk of needlestick injuries and the subsequent spread of bloodborne illnesses. 
This act requires the use of engineered safety devices, such as self-sheathing needles and sharps containers, that prevent needlesticks. It also requires documentation of needlestick injuries (CDC, 2022B).

Preventing Needlestick Injuries:

Preventing needlestick injuries requires consistent use of needle safety mechanisms every time a vaccine is administered. Once the needle is uncapped, the person administering the vaccine should never take their eye off the needle until it is safely disposed of in a sharps container. 
After injection, safety mechanisms that shield the needle should be used immediately, and used syringes should be immediately discarded in puncture-resistant sharps containers located in the same room used for vaccine administration. Caps should never be replaced on used needles (CDC, 2022B).