This is not true. Pregnant healthcare personnel may administer any vaccine except the ACAM2000 smallpox vaccine.
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 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 vaccine administration section of CDC’s “General Best Practices for Immunization”, available at www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html.
In general, vaccines containing adjuvants (a component that enhances the antigenic response) are administered IM to avoid the risk of irritation, swelling, skin discoloration, inflammation, or granuloma formation if injected into subcutaneous tissue. This includes most of the inactivated vaccines, with a few exceptions (such as inactivated polio vaccine and pneumococcal polysaccharide vaccine, which may be given either subcut 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 recommended 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. For more information see the vaccine administration section of CDC’s “General Best Practices for Immunization”, available at www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html.
ACIP does not address this issue. However, CDC experts have previously recommended 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, administering a dose to each child, as if they were not conjoined, seems appropriate.
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 injectable or intranasal 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: www.eziz.org/PDF/IMM-718.pdf
For older children: www.aimtoolkit.org/docs/Giving_all_the_doses_12mths.pdf
For adults: eziz.org/assets/docs/ADA/IMM-718A.pdf
For details see the vaccine administration section of CDC’s “General Best Practices for Immunization”, available at www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html.
*There are 2 exceptions to this general rule:
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 general information on vaccine administration, please see the vaccine administration chapter of Epidemiology and Prevention of Vaccine-Preventable Diseases at www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-6-vaccine-administration.html.
The live smallpox (vaccinia) vaccine, ACAM2000 (Emergent BioSolutions) 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.
With the exception of these two vaccines, 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.
There are no precise volume limits published by CDC or professional organizations. Professional judgment is required. Here are CDC’s suggested volumes:
Deltoid:
Vastus Lateralis:
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.
The same injection volume ranges above also apply when considering administration of multiple vaccinations or a combination of an antibody product and vaccination (e.g., nirsevimab and vaccine) in the same muscle.
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, with one exception. The exception is when the 15-valent pneumococcal conjugate vaccine (PCV15, Vaxneuvance, Merck) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) are indicated for a high-risk patient. These vaccines should not be given at the same visit. PCV15 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 PCV15 to avoid interference between the 2 vaccines.
If two or more injectable or nasally administered live vaccines are not given on the same day, they need to be spaced at least 4 weeks apart. If two such vaccines are administered less than 4 weeks apart, the second vaccine administered should not be counted and the dose should be repeated at least 4 weeks later. The 4-day grace period, which may be used to shorten the minimum interval between two doses of the same vaccine in a series, should not be applied to the 4-week minimum interval between two different live vaccines.
Oral typhoid vaccine (Vivotif, Bavarian Nordic) and oral rotavirus vaccine can be administered simultaneously with or at any interval before or after other live vaccines (injectable or intranasal) if indicated. If administering oral cholera and oral typhoid vaccines on the same day, ACIP recommends that the recipient should ingest the oral cholera vaccine first and wait at least 8 hours before ingesting the first dose of oral Ty21a typhoid vaccine (Vivotif, Bavarian Nordic) because the oral cholera vaccine buffer solution could interfere with the enteric-coated Ty21a vaccine.
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, it may be unclear what the requirement of “immediately” actually means.
CDC experts have considered “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” may 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. Contact the manufacturer any time there is any question about whether or not the vaccine has been used within an appropriate time frame.
According to CDC’s “General Best Practices for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. Therefore, live oral cholera vaccine may be administered simultaneously or at any interval before or after administration of most other vaccines.
One exception is when Ty21a oral typhoid vaccine (Vivotif, Bavarian Nordic) and oral cholera vaccine are both indicated. ACIP recommends that 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 to avoid the potential for interference between the oral cholera vaccine buffer solution and the enteric-coated Ty21a vaccine dose.
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. Hepatitis B vaccine is not considered valid if administered by any route other than intramuscular, or, if given to an adult, if given in any site except the deltoid or anterolateral thigh. So, the hepatitis A vaccine may be counted as valid, but the hepatitis B vaccine should not be counted in this situation. The hepatitis B vaccine can be repeated immediately. See the vaccine administration section of CDC’s “General Best Practices for Immunization” for details, available at www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html.
CDC does not address the use of this method for vaccination in the vaccine administration section of its “Best Practices for Immunization” (www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html). If you choose to use this method, you should still adhere to CDC’s recommendations regarding needle length and anatomical site.
Both intramuscular and subcutaneous vaccines may be given through a tattoo.
No. CDC 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. Intramuscular injections are not given in areas where large blood 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.
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.
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.
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 current setting of widely available and effective COVID-19 vaccines and treatments, CDC has resumed recommending standard pre-pandemic infection control practices during vaccination.
ACIP does not specifically recommend eye protection when administering vaccines to prevent exposure to blood spatter.
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 current setting of widely available and effective COVID-19 vaccines and treatments, CDC has resumed recommending standard pre-pandemic infection control practices during vaccination.
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.
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.
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.
You can give rotavirus vaccine through a G-tube as long as the child is otherwise eligible.
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.
This issue is discussed in the special populations section of CDC’s “General Best Practices for Immunization” (www.cdc.gov/vaccines/hcp/imz-best-practices/special-situations.html#cdc_report_pub_study_section_8-vaccinating-persons-with-increased-bleeding-risk). Intramuscular (IM) injections should be scheduled shortly after antihemophilia therapy or prior to a dose of anticoagulant, if the patient receives this treatment. For both IM and subcutaneous (subcut) 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. Provide information to the recipient or caregiver about the risk for hematoma from the injection. 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 subcut route).
Heroin use or addiction of the mother is not a reason to delay vaccination of an otherwise healthy infant.
CDC 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 the 2011 Technically Speaking column written by Immunize.org founder, Dr. Deborah Wexler, www.immunize.org/about/pub-archives/guidance-for-busy-clinics-on-prefilling-your-own-syringes/.
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. Once 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 by 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 21.
Removing the protective cap increases the likelihood the septum or stopper of the SDV could be punctured. The puncture may not be visible. It is important to ensure that the rubber seal on an SDV is not punctured before use because SDVs do not contain a preservative. Discard any unused SDVs without a protective cap at the end of the workday. For additional details, see page 21 of CDC’s Vaccine Storage & Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.
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.
You should use separate alcohol wipes to clean the vial top and the patient’s skin.
The stopper of a single-dose vial (SDV) 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 SDV prior to inserting a sterile syringe. Alcohol evaporates quickly and will dry while the needle is being prepared for insertion into the vial.
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.
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 Shingrix 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 Shingrix dose of 0.5 mL. Any reconstituted vaccine left in the vial should be discarded.
Immunize.org has developed suggested standing orders templates for all vaccines routinely given to children and adults. We do not produce standing orders templates for combination products (products that combine vaccines that also are given separately). We also do not routinely produce standing orders templates for vaccines that are infrequently indicated or require clinical risk assessment (by definition, the need for clinical assessment precludes use of a simple standing order for routine administration). These standing orders templates 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/clinical/topic/standing-orders-templates/.
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. Some vaccines used in response to a public health emergency, including COVID-19, are included in the Countermeasures Injury Compensation Program (CICP). More information about the CICP is available at www.hrsa.gov/cicp.
Findings of this study discourages the prophylactic use of paracetamol (which is similar to acetaminophen) before or immediately following vaccination. Acetaminophen may be used to treat pain or fever if either symptom should occur following vaccination. CDC’s “General Best Practices for Immunization” states: “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/imz-best-practices/vaccine-administration.html.
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 or lying down; (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 clinical resources specifically addressing vaccination-related syncope:
These two resources are also relevant:
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 CDC’s General Best Practices for Immunization (see www.cdc.gov/vaccines/hcp/imz-best-practices/vaccine-administration.html). This is particularly important when vaccinating adolescents and young adults or those with a history of injection-related syncope. CDC has posted additional information on this topic at www.cdc.gov/vaccinesafety/concerns/fainting.html.
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/wp-content/uploads/catg.d/p3040.pdf.
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.
Absolutely not. No vaccines should ever be mixed in the same syringe unless the combination has been specifically approved by the FDA.
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, then 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.
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.
Empty or expired vaccine vials are considered medical waste and should be disposed of according to state regulations.
