Vaccine Administration

• Vaccine Administration
• Preparing the vaccine
• Injection sites
• Factors that contribute to optimal intramuscular vaccine delivery
• Documentation

Vaccine Administration

• Any inactivated vaccines containing Diphtheria, Tetanus, Pertussis, IPV, Haemophilus Influenzae Type B and Hepatitis B components must be injected deep intramuscular (IM).
• BCG is delivered intradermally.
• MMR is injected subcutaneously.
• Check the datasheet for administration of other vaccines.
• Incorrectly administered vaccines (incorrect sites and poor administration techniques) are a contributing factor to vaccine failure and can lead to injection site nodules or lumps and local reactions.

Preparing the Vaccine

Drawing up

• Check the colour and appearance of the vaccine for indications of vaccine damage (sediment or colour change).
• Inactivated vaccines contain adjuvants, stabilisers and preservatives and therefore must be shaken vigorously before drawing up to obtain uniform suspension.
• Expel air from the syringe until vaccine is visible at the needle connection part of the syringe.  Check the vaccine volume, as the vial is usually overfilled.

Needle gauge and length

• Most vaccines are given via the intramuscular route into the deltoid or the lateral aspect of the thigh.  This optimises the immunogenicity of the vaccine and minimises adverse reactions at the injection site. 
• Injecting a vaccine into the layer of subcutaneous fat, where poor vascularity may result in slow mobilisation and processing of antigen, is a cause of vaccine failure.
• In the case of vaccines in which the antigen is adsorbed to an aluminium salt adjuvant such as hepatitis B, and diphtheria, tetanus, and Pertussis vaccines, the intramuscular route is strongly preferred because superficial administration leads to an increased incidence of local reactions such as irritation, inflammation, granuloma formation and necrosis.
  

Skin preparation

• Skin preparation or cleansing the injection site prior to vaccination is not necessary. However, if an alcohol swab is used the area needs to be cleaned for >30 seconds and it must be allowed to dry (at least 2 minutes), otherwise alcohol may be tracked into the muscle causing local irritation.
• Alcohol may also inactivate a live attenuated vaccine such as MMR.
  

Injection sites

The injectable vaccines should be administered in a site (healthy well-developed muscle) that is as free as possible from the risk of local, neural, vascular and tissue injury.

For IM injections in infants under 15 months of age, the recommended and safest site is the Vastus Lateralis (lateral thigh). Use of the anterior thigh or rectus femoris muscle is not recommended because what appears to be a bulky muscle anteriorly is predominantly subcutaneous fat. Immediately underlying the rectus femoris muscle is a neurovascular bundle. Vaccine deposition within the neurovascular bundle increases the potential for local reaction and chronic injection site nodules. 

Positioning for Vastus Lateralis injection - Infant

Infants six months and under do not need to be as firmly grasped / restrained as toddlers.  At this age excessive restraint increases their fear as well as muscle-tautness / tension.  An infant can be placed lying on their back on the bed or in the cuddle position (semi-recumbant) on the parents/caregivers lap.  Placing the infant on the bed minimises delay between injections.  Some vaccinators consider it is easier this way – others consider the cuddle position offers better support for both the infant and their parent.

To locate the vastus lateralis site:

• Have the infant on their back, with the napkin undone.
• Gently adduct the flexed leg – locate the trochanter as the upper marker and the lateral femoral condyle as the lower marker.
• Section into thirds and run an imaginary line from the centre of the lower marker to the centre of the upper marker.  (Look for the dimple along the lower portion of the fascia lata)
• The injection site is just above the junction of the upper and middle thirds i.e. the vaccine must be deposited no lower than the junction of the upper and middle thirds.

Administering the vaccine:

Immobilise the limb as above either by controlling the infant’s knee in the palm or the v-shape made when the vaccinator’s index finger and thumb are splayed.
For IM injection the needle should be inserted smoothly, at a 90-degree angle to the long axis of the leg and at least 1.5cm, i.e. one finger width above the junction of the upper and middle thirds.

If right handed, the vaccinator should consider giving the composite injection eg those containing the pertussis into the left thigh and vice versa – if left handed, administer the composite vaccine in the right thigh. The composite vaccines are potentially more reactogenic, so administering these vaccines into the thigh that the vaccinator finds the easiest facilitates smooth penetration of the muscle, reduces tissue trauma and reduces the likelihood of local reactions.

Vastus Lateralis – Toddlers

The principles for a toddler lateral thigh injection are the same for an infant, except they will be preferably sitting on a parent / caregiver’s lap. It is easier to safely position and restrain the toddler / preschooler if they are sitting sideways on their parent’s lap or facing their parent while straddling the parent’s legs.

If the child is sitting sideways, the child’s right arm should be placed behind its parent’s back.  The parent’s left arm is placed over the child’s left arm and chest ant their right arm should lie across the child’s legs and tuck under the child’s knee.  If the child is in the straddle position, both the child’s arms should be behind their parent’s back and the parent then wraps his/her arms around the child’s body.

It should be noted that if using the straddle position, the vastus lateralis muscle becomes more tense / taut and the injection may then be more painful.

To administer two intramuscular injections in the same vastus lateralis muscle:

• When two intramuscular injections are to be given in the same vastus lateralis, the vaccinator’s injection technique needs to be very precise.
• Locate the correct anatomical landmarks as if administering one injection.
• Using a 90 degree angle, the first injection/needle insertion should be slightly above the junction of the upper and middle third as described.
• Ensuring that the second injection is at a 90-degree angle, needle insertion for the second injection should be 1-2cm distal of the junction.
• Injection sites should be separated by at least 2 cm, so that local reactions will not overlap.
• When giving two vaccinations in one limb both needle angles need to be the same, i.e. parallel. This will ensure vaccines do not mix within the muscle tissue.
  Giving vaccines simultaneously has been found to be safe and effective. Providers tend to be more reluctant than parents to give several vaccinations at one visit. Internationally, higher coverage rates have been achieved when clinicians strongly recommended all possible injections at one visit compared to those who offered parents the choice of deferring some vaccines to a subsequent visit.

Deltoid

The deltoid muscle is recommended and safest site for intramuscular injections in older children, adolescents and adults.

The entire deltoid muscle must be exposed otherwise the vaccinator will expose only the lower portion of the deltoid. The radial nerve is very superficial in the middle third of the upper arm, especially in children. An injection at the junction of the middle and upper thirds of the lateral aspect of the arm may damage the nerve.

To locate the deltoid site:

• Make sure the whole shoulder is exposed, e.g. by removing the arm from the garment sleeve.
• Find the acromion process as the upper marker. Find the deltoid tuberosity (in line with the axilla) as the lower marker.
• Draw an imaginary triangle pointing downward from the acromion.
• The injection site is in the centre of the triangle or the point halfway between the markers (it will be from one to four finger widths from the acromion, depending on the size of the arm).

Administering the vaccine:

The volume injected into the deltoid should not exceed 0.5ml in children and 1.0ml in adults.

Vaccinators need to be aware of the superficiality of the radial nerve and small deltoid muscle bulk if using the deltoid site for young children, i.e. over 15 months and up to 5 years of age. The vastus lateralis remains an option and it may be preferable to use this site for very small children. Consideration may be given to the vastus lateralis as an alternative site for adults, providing it is not contraindicated by the manufacturer’s information sheet.

Subcutaneous Injection

A subcutaneous injection should be given into healthy tissue, which is away from bony prominences and free of large blood vessels or nerves. Subcutaneous tissue is found all over the body, but the most commonly used site is the upper arm, based on its accessibility and proven good vaccine uptake.

The principles for locating the deltoid site for a subcutaneous injection are the same as for an intramuscular injection, however needle length is more critical than angle of insertion for subcutaneous injections.  While an insertion angle of 45 degrees is recommended, the needle should never be longer than 16mm or inadvertent intramuscular administration may result.

Factors that contribute to optimal intramuscular vaccine delivery 

The following steps or measures will help reduce the incidence of local reactions:

1. Correctly stored vaccines
2. Relaxed muscle
3. Correct route
4. Correct needle length (careful use of a longer needle will cause less damage than a short needle)
5. Changing and not priming the new needle.
6. Needles should be routinely changed after drawing up because:
7. Most inactivated vaccines contain adjuvant and some contain thiomersal, both of which are very irritating to tissue.
8. A needle that has passed through a rubber stopper may be blunted and could possibly increase tissue trauma.  In addition, minute rubber fragments may be caught in the drawing up needle and be injected into the muscle, contributing to local reactions.
9. Controlled injection rate.  Use of a 1ml (e.g. tuberculin) syringe allows for greater control of the rate of plunger depression.  The plunger on a 1ml syringe has less resistance than a 2 – 3ml syringe and therefore requires less force to depress it. Forceful depression of the plunger can cause vaccine to backtrack along the needle shaft to the skin surface.  If a drop of vaccine is frequently seen at the skin surface following intramuscular injections, the vaccinator may be / is injecting too forcibly.
   If using alcohol swabs, allow drying, otherwise alcohol can be tracked in with the needle.
10. Vaccines should not be mixed in the same syringe, unless the prescribing information sheet specifically states it is permitted e.g. Infanrix/Hib

Disposal of vaccination equipment

• Do not separate needles from syringes or recap needles (unless a recapping device is used). All empty partly used vials/ampoules, syringes; needles should be discarded in the sharps container.
• Sharps containers should comply with local Health and Safety guidelines i.e. must be made of rigid, leak and puncture proof material with an opening wide enough to allow disposable material to be dropped into the container with one hand but prevent removal of the contents.
• There should be a sharps container available in every area where vaccination takes place.
• Sharps containers should be only filled to the line indicated, then sealed and given to an approved hazardous waste disposal person for incineration.

Safety for vaccinators

• If you get a blood or vaccine splash on the skin, thoroughly wash the area with soap and water. 
• When cleaning up blood spills on work surfaces, put on some gloves, and initially soak up the spill with a cloth or paper towel, which should then be disposed into the hazardous waste bin. Then wipe the surface with a cloth and some 0.5% Hypochlorite (household bleach diluted to 1 part bleach to 9 parts water).
• Let the surface dry before using it again. Alternatively, granular hypochlorite can be used for liquid spills. Once used, carefully seal in approved biohazard bag and dispose into the hazardous waste for collection by an approved hazardous waste disposal provider. Once you have removed the gloves, make sure you wash your hands.

In the event of a needlestick or blood and body fluid accident:

1. Wash needlestick injuries and cuts with copious amounts of soap and water.
2. Flush splashes to the mouth and nose with copious amount of clear, clean water.
3. Irrigate eyes with clean water, normal saline, or a sterile irrigant.
4. Immediately Advise your supervisor, i.e.: GP or Practice Manager, Occupational Health or Infection Control person. They will arrange for blood samples to be taken from both you and the person who is the source of the blood/body fluid. Bloods will be taken to test for HBV, HCV and HIV.

Documentation

When client notes are held up for legal scrutiny, it is difficult to prove what action / care was or was not taken / delivered, if you have not recorded accurately. Accurate documentation is essential. The following are a few simple rules you should follow:

• Do:
   
  Write legibly
  Use permanent ink
  Identify date, time, signature and title
  Record in consecutive and chronological order
  Write objectively
  Record entries as soon as possible
  Be specific and factual
  Accurately record findings and evaluations
  Document all complaints from the client.  Record the resolution of any complaints
• Don’t:
   
  Rely on memory
  Erase entries
  Make assumptions
  Leave blank spaces
  Use abbreviations
  Add comments to the notes at a later date
  Use generalisations

Correcting errors:
 

• Draw a single line through the incorrect entry, while ensuring the incorrect entry is still readable
• Describe the error - e.g. wrong date, wrong client
• Correct the data
• Add the date, time, signature and title

Vaccinators are advised to record the following:

Date
Client name
Consent given
Vaccine type and number in the series
Batch number and expiry date
Dose, injection site (be specific) and injection route
Needle length used
The patient was observed for the recommended time
No adverse events occurred during the observation period
Vaccinators signature and title
Recall date when applicable

Only by documenting all relevant information can you ensure that others will know what you observed, discussed and any action taken / treatments given.

Unfortunately if care is not recorded then the assumption can be / is often made that the care was not delivered.

Selected references:
Bartlett MJ, Burgess MA, McIntyre PB (1999) Parent and general practitioner preferences for infant immunisation. Aust Fam Physician. 28 (suppl 1): S22-7
Woodin KA et al. (1995) Are children becoming pincushions from immunisations? Arch Pediatr Adolesc Med. 149 (8): 845-84
Lieu T et al (2001) Variation in clinician recommendations for multiple injections during adoption of inactivated polio vaccine. Pediatrics. 107 (4) e49

Contraindications and precautions to vaccination

The immunisation session