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 ACIP “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
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.
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 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.
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.
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 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 ACIP’s “General Best Practices Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
*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.
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/pinkbook/hcp/table-of-contents/chapter-6-vaccine-administration.html.
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.
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.
Here are the 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.
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.
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.
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, there can be some confusion as to what the requirement of “immediately” actually means.
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.
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.
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.
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.
Both IM and SC vaccines may be given through a tattoo.
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.
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 setting of widely available and effective COVID-19 vaccines and treatments, CDC 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 setting of widely available and effective COVID-19 vaccines and treatments, CDC resumed recommending standard pre-pandemic infection control practices during vaccination.
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.
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 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 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).
Heroin use or addiction of the mother is not a reason to delay vaccination of an otherwise healthy infant.
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.
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.
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.
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 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.
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 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.
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.
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.
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.
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” at www.immunize.org/catg.d/p3082a.pdf and “Medical Management of Vaccine Reactions in Adult Patients” 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.
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.
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 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.
