Administer the Vaccine(s)

Each vaccine has a recommended administration route and site. This information is included in the manufacturer’s package insert for each vaccine. Deviation from the recommended route may reduce vaccine efficacy or increase local adverse reactions.

Health care personnel should always perform hand hygiene before administering vaccines by any route. Vaccine administration routes include:

• Oral route: administered by mouth
• Subcutaneous route: injected into the area just beneath the skin into the fatty, connective tissue
• Intramuscular route: injected into muscle tissue
• Intradermal route: injected into layers of the skin
• Intranasal route: administered into the nose

VACCINES	ROUTE
Rotavirus (RV1, RV5)	Oral
DTaP, DT, HepA, HepB, Hib, HPV, IIV3, IIV4, RIV3, ccIIV3, IPV,* MenACWY, MenB, PCV13, PPSV23,* Td, Tdap, TT	Intramuscular injection
HZV, IPV,* MMR, PPSV23,* VAR	Subcutaneous injection
Fluzone ID	Intradermal injection
COMBINATION VACCINES	ROUTE
DTaP-IPV, DTaP-IPV-HepB, DTaP-IPV/Hib, HepA-HepB	Intramuscular injection
MMRV	Subcutaneous injection

*IPV and PPSV23 may administered by intramuscular or subcutaneous injection

When administering a vaccine by injection, choose the correct needle size based on the route, age, patient size, and injection technique.

Some vaccines are approved by the Food and Drug Administration (FDA) for administration by the Pharmajet Stratis needle-free injection system. This system administers vaccines by creating a narrow stream capable of penetrating the skin. For more information, see the manufacturer’s website.

Multiple Injections

Often, more than one vaccine is needed during the same doctor’s visit, requiring more than one shot. If multiple vaccines are administered at a single visit, administer each injection in a different injection site. For infants and younger children receiving more than two injections in a single limb, the thigh is the preferred site because of the greater muscle mass. For older children and adults, the deltoid muscle can be used for more than one intramuscular injection. Best practices for multiple injections include:

• Label each syringe to identify the vaccine it contains.
• Separate injection sites by 1 inch or more, if possible.
• Administer vaccines that may be more likely to cause a local reaction (e.g., tetanus-toxoid-containing and PCV13) in different limbs, if possible.
• Use combination vaccines (e.g., DTaP-IPV-HepB or DTaP-IPV/Hib), if appropriate, to decrease the number of injections.

Managing Acute Vaccine Reactions

Severe, life-threatening reactions following vaccinations are rare. However, all vaccination providers should be familiar with the office emergency plan and currently certified in cardiopulmonary resuscitation.

Procedural Pain Management

Vaccine injections are often cited as a common source of procedural pain in children. The pain associated with injections is a source of distress for children and their parents and/or guardians. Although pain from injections is, to some extent, unavoidable, there are some things that parents and health care providers can do to help prevent distress and decrease fear. Evidence-based strategies to reduce procedural pain include:

• Breastfeeding
• Giving sweet-tasting liquids (orally)
• Injecting vaccines rapidly without aspiration
• Injecting the most painful vaccine last
• Using tactile stimulation (rubbing/stroking near the injection site before and during injection)
• Distracting the patient (done by either the parent or clinician)
• Having the patient seated rather than lying down
• Using topical anesthetics

Fear of injections is often a reason why adults, including health care personnel, decline vaccines. Some of the evidence-based strategies for reducing procedural pain in children can also be used to help prevent distress and alleviate fear in adults.