Contents

2 Processes for safe immunisation

2.3 Vaccine administration

The ‘Immunisation standards for vaccinators’ and the ‘Guidelines for organisations offering immunisation services’ apply to the delivery of all Schedule vaccines and those not on the Schedule. See Appendix 3.

The vaccinator is responsible for ensuring all the vaccines they are handling and administering have been stored at the recommended temperature range of +2oC to +8oC at all times (see Appendix 6 and the National Guidelines for Vaccine Storage and Distribution).1 Information on vaccine presentation, preparation and disposal can be found in Appendix 7.

Vaccinators are expected to know and observe standard occupational health and safety guidelines in order to minimise the risk of spreading infection and needle-stick injury (see Appendix 7).

All vaccinations on the New Zealand Immunisation Schedule are given parenterally (by injection) except for the rotavirus vaccine which is given non-parenterally (orally). For non-parenteral vaccine administration follow the manufacturer’s instructions.

2.3.1 Pre-vaccination checklist

Prior to immunisation with any vaccine, the vaccinator should ascertain if the vaccinee (child or adult):

The vaccinator will also need to determine which vaccines the vaccinee is due to have, assess the vaccinee’s overall current vaccination status and address parental concerns. The vaccinator will also need to advise the individual/parent/guardian they will need to remain for 20 minutes post-vaccination.

2.3.2 Additional precautions for live vaccinesTop

Prior to immunisation with a live vaccine, the vaccinator should know whether the vaccinee (child or adult):

2.3.3 Conditions that are not contraindications to immunisationTop

The following conditions are not contraindications to the immunisation of children and adults (see chapter 3 for further detail):

See section 1.4.1 for information on general contraindications to immunisation, or the relevant disease chapter section for more specific vaccine contraindications.

2.3.4 Preparing for vaccine administrationTop

Key points for administering injectable vaccines

Vaccines should not be mixed in the same syringe, unless the prescribing information sheet specifically states it is permitted or essential (eg, DTaP-IPV-HepB/Hib).

Careful use of a longer needle will cause less damage than a short needle.

To avoid tracking, make sure all the vaccine has been injected before smoothly withdrawing the needle.

Correct vaccine administration is vitally important, and vaccinators have a responsibility to see that vaccines are given:

The use of alternative sites will be based on professional judgement, including knowledge of the potential risks at each site and recommendations in the manufacturer’s data sheet.

The guidelines below will help to make the experience less distressing for the individual, parent/guardian and/or whānau, and vaccinator.

Table 2.2: Guidelines for vaccine administration

Preparation Immunisation event
Vaccinate in a private and appropriate setting. Draw up injections out of sight, if possible. Medical paraphernalia is commonplace to vaccinators, but it may heighten the anxiety of some individuals.
Prepare the area/room layout to suit the vaccinator and vaccination event. Ensure the individual or parent/guardian has had the opportunity to discuss any concerns and has given informed consent.
Be familiar with the vaccines (eg, their correct preparation, administration and the potential for adverse events). Be prepared to include other family members and whānau in the discussion, and explain to older children accompanying infants why the injections are being given and what will happen.
Be aware of the individual’s immunisation history (eg, submit an NIR status query if the history is unknown). Give the appropriate immunisations due and advise when the next immunisation event is due.
Ensure there are age-appropriate distractions available. Talk quietly to the child before and during immunisation. Make eye contact and explain what is going to happen. Even when a child is unable to understand the words, an unhurried, quiet approach has a calming effect and reassures the parent/guardian.
Ensure the relevant immunisation health education resources are available. Give written and verbal advice to the individual and parent/guardian. The advice should cover what may be expected after immunisation, and what to do in the event of an adverse event, along with advice on when to notify the vaccinator.

Skin preparation

Skin preparation or cleansing when the injection site is clean is not necessary. However, if an alcohol swab is used, it must be allowed to dry for at least two minutes, otherwise alcohol may be tracked into the muscle, causing local irritation. Alcohol may also inactivate a live attenuated vaccine such as MMR.

A dirty injection site may be washed with soap and water and thoroughly dried before the immunisation event.

Needle angle, gauge and length (see Table 2.3)

All schedule vaccines (with the exception of MMR, which is administered subcutaneously, and rotavirus, which is administered orally) are administered by intramuscular injection. Intramuscular injections should be administered at a 90 degree angle to the skin plane. The needle length used will be determined by the size of the limb and muscle bulk, whether the tissue is bunched or stretched, and the vaccinator’s professional judgement.

Table 2.3: Needle gauge and length, by site and age

Age Site Needle gauge and length Rationale
Intramuscular injection      
Birth Vastus lateralis 23–25 G x 16 mm  
6 weeks Vastus lateralis 23–25 G x 16 or 25 mm Choice of needle length will be based on the vaccinator’s professional judgement.
3–14 months Vastus lateralis 23–25 G x 25 mm A 25 mm needle will ensure deep IM vaccine deposition.
15 months–
3 years
Deltoid
or
23–25 G x 16 mm The vastus lateralis site remains an option in young children when the deltoid muscle bulk is small and multiple injections are necessary.
Vastus lateralis 23–25 G x 25 mm  
3–7 years Deltoid 23–25 G x 16 mm A 16 mm needle should be sufficient to effect deep IM deposition in the deltoid in most children.
Vastus lateralisa 21–22 G x 25 mm  
Older children (7 years and older), adolescents and adults Deltoidb 23–25 G x 16 mm, or 23–25 G x 25 mm, or
21–22 G x 38 mm
Most adolescents and adults will require a 25 mm needle to effect deep IM deposition.
Vastus lateralisa 21–22 G x 38 mm  
Subcutaneous injection      
Subcutaneous injection Deltoid 25–26 G x 16 mm An insertion angle of 45 degrees is recommended. The needle should never be longer than 16 mm or inadvertent IM administration could result.
a Consideration may be given to the vastus lateralis as an alternative vaccination site, providing it is not contraindicated by the manufacturer’s data sheet.
b For females weighing <60 kg use a 23–25 G x 16 mm needle; for 60–90 kg use a 23–25 G x 25mm needle; for >90 kg use a 21–22 G x 38 mm needle. For adolescent and adult males, a 23–25 G x 25 mm needle is sufficient.3, 4

2.3.5 Intramuscular injection sitesTop

Injectable vaccines should be administered in healthy, well-developed muscle, in a site as free as possible from the risk of local, neural, vascular and tissue injury. Incorrectly administered vaccines (incorrect sites and poor administration techniques) contribute to vaccine failure, injection site nodules or sterile abscesses, and increased local reactions.

Careful use of a longer needle will cause less damage than a shorter needle.

The recommended sites for intramuscular (IM) vaccines (based on proven uptake and safety data) are:

In infants and young children aged under 15 months, the deltoid muscle does not provide a safe IM injection site due to the superficiality of the radial nerve and the deltoid muscle being insufficiently developed to absorb medication adequately.

The buttock should not be used for the administration of vaccines in infants or young children, because the buttock region is mostly subcutaneous fat until the child has been walking for at least 9 to 12 months. Use of the buttock is not recommended for adult vaccinations either, because the buttock subcutaneous layer can vary from 1 to 9 cm and IM deposition may not occur.

Consideration may be given to using the vastus lateralis as an alternative site to the deltoid, providing it is not contraindicated by the manufacturer’s data sheet.

2.3.6 Infant vaccination (vastus lateralis)Top

Infants aged under 6 months do not need to be grasped or restrained as firmly as toddlers. At this age, excessive restraint increases their fear as well as muscle tautness. An infant can be placed lying on his or her back on the bed, or in the cuddle (semi-recumbent) position on the parent’s/guardian’s lap. Placing the infant on the bed minimises delay between injections and makes the injection process easier, although some vaccinators believe the cuddle position offers better psychological support and comfort for both the infant and the parent/guardian.

Ideally, the parent/guardian should be asked if they wish to hold the infant or child for the injections. Some will prefer not to be involved with the procedure – some do not even wish to be present. If the parent/guardian is helping to hold the infant or child, ensure they understand what is expected of them and what will take place. Most vaccinators choose to administer all the injections due quickly and soothe the infant or child afterwards (see section 2.3.13 for soothing measures).

To locate the injection site, undo the nappy, gently adduct the flexed knee and (see Figure 2.1):

  1. find the greater trochanter
  2. find the lateral femoral condyle
  3. section the thigh 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 at the junction of the upper and middle thirds and slightly anterior to (above) the imaginary line, in the bulkiest part of the muscle.

Figure 2.1: Photo showing the infant lateral thigh injection site

Figure 2.1: Photo showing the infant lateral thigh injection site

The needle should be directed at a 90 degree angle to the skin surface and inserted at the junction of the upper and middle thirds. Inject the vaccine at a controlled rate. To avoid tracking, make sure all the vaccine has been injected before smoothly withdrawing the needle. Do not massage or rub the injection site afterwards.

Multiple injections in the same muscle

In general, the best-practice recommendation is only one injection per site (eg, vastus lateralis), although with the introduction of new vaccines and the need for best protection (eg, catch-ups), two injections in one muscle may be required. Unless the manufacturer’s data sheet states otherwise, this is considered safe and acceptable.

A well-prepared and confident vaccinator will reassure the parent/guardian or whānau that giving concurrent vaccines is a safe and appropriate practice, avoiding multiple visits.

When it is necessary for two vaccines to be given in the same limb, the vastus lateralis is preferred because of its greater muscle mass (see Figure 2.2). The injection sites should be on the long axis of the thigh and separated by at least 2 cm so that localised reactions will not overlap.

Figure 2.2: Diagram showing suggested sites for multiple injections in the lateral thigh

Figure 2.2: Diagram showing suggested sites for multiple injections in the lateral thigh

Multiple vaccines should not be mixed in a single syringe unless specifically licensed and labelled for administration in one syringe. A different needle and syringe should be used for each injection.

If all scheduled vaccines are not administered concurrently, there is no minimum interval necessary between visits (ie, it could be the next day). However, there must be at least four weeks between:

2.3.7 Young child vaccination (vastus lateralis or deltoid)Top

The choice between the two sites for IM injections from 15 months of age will be based on the vaccinator’s professional judgement, such as knowledge of the child and ease of restraint. Some vaccinators consider the vastus lateralis preferable for young children when the deltoid muscle bulk is small and because of the superficiality of the radial nerve. Discuss the options with the parent/guardian when making your decision.

The easiest and safest way to position and restrain a young child for a lateral thigh and/or deltoid injection is to sit the child sideways on their parent’s or guardian’s lap. The parent’s/guardian’s hand restrains the child’s outer arm and the child’s legs are either restrained between the parent’s/guardian’s legs or by placing a hand on the child’s outer knee or lower leg. Alternatively, the child may face their parent/guardian while straddling the parent’s/guardian’s legs (see Figures 2.3 and 2.4).

Figure 2.3: Photo showing cuddle positions for vastus lateralis or deltoid injections in children

Figure 2.3: Photo showing cuddle positions for vastus lateralis or deltoid injections in children

Figure 2.4: Photo showing the straddle position for vastus lateralis or deltoid injections in children

Figure 2.4: Photo showing the straddle position for vastus lateralis or deltoid injections in children

If using the straddle position, both the deltoid and vastus lateralis muscle are likely to be more tense or taut, and the injection may therefore be more painful.

2.3.8 Older child, adolescent and adult vaccination (deltoid)Top

The deltoid muscle is located in the lateral aspect of the upper arm. The entire deltoid muscle must be exposed to avoid the risk of radial nerve injury (an injection at the junction of the middle and upper thirds of the lateral aspect of the arm may damage the nerve) (see Figure 2.5).

Figure 2.5: Line drawing showing surface landmarks and structures potentially damaged by intramuscular injection in the upper limb

Figure 2.5: Line drawing showing surface landmarks and structures potentially damaged by intramuscular injection in the upper limb

Reproduced with permission: Cook IF. 2011. An evidence based protocol for the prevention of upper arm injury related to vaccine administration (UAIRVA). Human Vaccines 7(8): 845–8.

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

The vaccinee should be seated with their arm removed from the garment sleeve and hanging relaxed at their side. The vaccinator places their index finger on the vaccinee’s acromion process (the highest point on the shoulder) and their thumb on the vaccinee’s deltoid tuberosity (the lower deltoid attachment point).5

The injection site is at the axilla line, between these anatomical landmarks. The vaccine should be deposited at the bulkiest part of the muscle (Figure 2.6).

Figure 2.6: Diagram showing how to locate the deltoid site

Figure 2.6: Diagram showing how to locate the deltoid site

If multiple injections in the deltoid are required, the sites should be separated by at least 2 to 3 cm.6

2.3.9 Subcutaneous injection sitesTop

A subcutaneous (SC) injection should be given into healthy tissue that is away from bony prominences and free of large blood vessels or nerves. The recommended site for subcutaneous vaccine administration is the upper arm (overlying the deltoid muscle).

The principles for locating the upper arm site for an SC injection are the same as for an IM injection. However, needle length is more critical than angle of insertion for subcutaneous injections. An insertion angle of 45 degrees is recommended and the needle should never be longer than 16 mm, or inadvertent IM administration could result. The thigh may be used for SC vaccines unless contraindicated by the manufacturer’s data sheet. See also section 1.4.2 for information about thrombocytopenia and bleeding disorders.

2.3.10 Intradermal injectionsTop

The intradermal injection technique for BCG vaccine requires special training, and should only be performed by a gazetted BCG vaccinator. (See chapter 20 and the Technical Guidelines for Mantoux Testing and BCG Vaccination 19967 [or the current edition]).

Some other non-funded vaccines (eg, Intanza, an influenza vaccine) are administered by the intradermal route. Vaccinators should refer to the manufacturer’s data sheet for instructions on administration.

2.3.11 Oral vaccine administrationTop

The rotavirus vaccine is administered orally. Administer the dose by gently squeezing the liquid into the infant’s mouth, towards the inner cheek, until the dosing tube is empty. Do not inject oral vaccines.

For specific oral vaccine administration instructions, refer to the manufacturer’s vaccine package insert or to the vaccine data sheet (available on the Medsafe website: www.medsafe.govt.nz).

2.3.12 Post-vaccination adviceTop

Post-vaccination advice should be given both verbally and in writing. The advice should cover:

Table 2.4: Common vaccine responses

Vaccine Common vaccine responses
DTaP- or Tdap-containing vaccine Localised pain, redness and swelling at injection site.
Mild fever.
Being grizzly and unsettled – this may persist for 24–48 hours.
Drowsiness.
Extensive limb swelling after the 4th dose of a DTaP-containing vaccine.
Hepatitis B Very occasionally soreness and redness at the injection site.
Mild fever.
Hib Localised pain, redness and swelling at the injection site.
Mild fever.
MMR Discomfort at injection site.
5–12 days after vaccination:
  • mild fever with faint rash (not infectious)
  • head cold and/or runny nose
  • cough and/or puffy eyes
  • ​swelling of salivary glands.
Adult Td Localised discomfort, redness and swelling at the injection site.
Influenza Mild fever.
Occasional discomfort, redness and swelling at the injection site.
Pneumococcal Pain at the injection site.
Mild fever.
HPV Localised discomfort, redness and swelling at the injection site.
Heavy arm.
Mild fever.
Nausea.
Dizziness.
Headache.
Rotavirus Diarrhoea may occur after the first dose.

2.3.13 Recommendations for fever and pain managementTop

Fever

General fever-relieving measures include:

The use of paracetamol during paediatric immunisation (including influenza vaccine) may affect the antibody response.8 While a high fever alone does not need treatment, antipyretic analgesics (paracetamol or ibuprofen) may be used for distress or pain in a febrile child who has not responded to the cooling measures described above.

Pain management and soothing measures

For infants aged under 12 months, breastfeeding before, during and after the injection can provide comfort and pain relief.9

Using age-appropriate distraction has been shown to reduce pain and distress.9 Examples include showing an interesting or musical toy to an infant, or encouraging an older child to blow using a windmill toy or bubbles. Electronic games/phone games can be useful for older children and teenagers. For children aged over 12 months, tactile stimulation may create ‘white noise’. Paediatric and adult studies found rubbing or applying pressure to the injection site before and during injection reduced pain.10 Vibration devices can also be used.11 Do not rub the injection site after the injection as it increases the risk of vaccine reactogenicity.

For infants aged under 6 months the 5 S’s (swaddling, side/stomach position, shushing, swinging and sucking) have been found to be effective for soothing and reducing pain after immunisations.12

For infants aged under 12 months, giving a sugar solution immediately before the injection provides pain relief and may last for up to 10 minutes.9 Rotavirus vaccines contain sucrose at a similar concentration and volume to the sugar solution doses shown to reduce pain, although rotavirus vaccines have not been directly evaluated. Give the rotavirus vaccine 1–2 minutes before the other immunisations. Do not give additional sucrose if giving a rotavirus vaccine. The infant can then be breastfed or held comfortably while the immunisations are given.

For infants and children, the use of a topical anaesthetic cream or patch has been found to be effective for immunisation pain management.9 Parents/guardians and those administering the vaccine should check the manufacturers’ recommendations before using topical anaesthetics. The correct dose for infants needs to be followed particularly carefully due to risk of methaemoglobinaemia. Topical anaesthetics may have a role in managing immunisation pain and anxiety, particularly for children who have had previous multiple medical interventions or needle phobias.

Only use antipyretic analgesics such as paracetamol for relief of post-vaccination pain and significant discomfort. Because they may affect the antibody response,8 antipyretic analgesics should not be used before immunisations or for fever prevention.