| Administering Vaccines |
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| General Issues |
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| Note: Specific information nigh the administration of virtually vaccines is included in the Ask The Experts set for that vaccine. For additional questions and answers about routine vaccination during the COVID-19 pandemic, please meet the COVID-19 and Routine Vaccination section of Enquire the Experts, www.immunize.org/askexperts/experts_covid19.asp. For questions and answers virtually COVID-19 vaccination, please encounter the COVID-19 vaccine section of Ask the Experts, www.immunize.org/askexperts/experts_cov.asp. |
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| I was recently told by a colleague that pregnant healthcare personnel were not to administer alive vaccines to others. I had never heard that in schoolhouse or practice. Is that truthful? |
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| This is not true. Pregnant healthcare personnel may administer any vaccine except smallpox vaccine. |
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| Is it acceptable to administer vaccines in the nurses' station where vital signs and other patient intendance is performed? |
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| Yes. Vaccines tin can be administered in a patient care surface area. The recommendation from CDC's safe injection practices experts is that storing and preparing vaccines should non be washed in the same area where patient intendance is conducted. These activities should be done in a separate area. |
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| What is the appropriate anatomic site and needle length for intramuscular and subcutaneous vaccine injection? |
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| Appropriate site and needle length depends on age, route of injection, and body mass. Most injected vaccines are administered past the intramuscular route. |
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| Delight refer for details to the IAC 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. |
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| A summary of needle length and site selection past historic period is below. |
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| For intramuscular injections (use a 22- to 25-gauge needle for all ages): |
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| • | | For neonates (kickoff 28 days of life) and preterm infants the anterolateral thigh should be used. A ⅝-inch needle usually is acceptable to penetrate the thigh muscle if the skin is stretched flat between the pollex and forefinger and the needle is inserted at a 90-degree angle to the skin. | | | | | • | | The anterolateral thigh is preferred for infants younger than age 12 months. For the majority of infants a 1-inch needle is sufficient. | | | | | • | | For toddlers historic period 12 months through two years the anterolateral thigh musculus is preferred. The needle should be at to the lowest degree 1 inch long. The deltoid musculus can exist used if the musculus mass is acceptable. | | | | | • | | For children age 3 through 10 years, the deltoid muscle is preferred; the needle length for deltoid site injections can range from ⅝ to i inch on the basis of technique. The anterolateral thigh can also be used. In this case the needle length should be ane inch to 1.25 inches. | | | | | • | | For adolescents 11 through eighteen years, the deltoid musculus is preferred. The anterolateral thigh tin also be used. For injection into the anterolateral thigh, most adolescents will crave a 1-i.5-inch needle. | | | | | • | | For adults historic period nineteen years and older, the deltoid muscle is preferred. The anterolateral thigh also tin be used. | |
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| � | | For men and women who counterbalance less than 130 pounds (less than 60 kg), a ⅝-inch needle is sufficient to ensure intramuscular injection in the deltoid muscle if the injection is made at a xc-caste angle and the tissue is non bunched. | | | | | � | | For men and women who weigh 130–152 pounds (60–70 kg), a i-inch needle is sufficient. | | | | | � | | For women who weigh 152–200 pounds (70–xc kg) and men who counterbalance 152–260 pounds (seventy–118 kg), a ane- to ane�-inch needle is recommended. | | | | | � | | For women who counterbalance more than than 200 pounds (more than ninety kg) or men who weigh more than than 260 pounds (more than 118 kg), a 1�-inch needle is recommended. | |
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| For subcutaneous injections (use a 23- to 25-judge needle for all ages): |
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| 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. |
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| More data on injection technique is in the ACIP General All-time Practices Guidelines for Immunization, bachelor at www.cdc.gov/vaccines/hcp/acip-recs/full general-recs/administration.html. |
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| Why are some vaccinations given subcutaneously (SC) while others must exist given intramuscularly (IM)? |
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| In general, vaccines containing adjuvants (a component that enhances the antigenic response) are administered IM to avert irritation, induration, skin discoloration, inflammation, and granuloma germination if injected into subcutaneous tissue. This includes virtually 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 exist reduced if not given by the recommended road. |
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| A five twelvemonth old came in today for her preschool vaccines. She needed MMR and varicella. She has a broken arm which is in a cast. Can the anterolateral thigh be used to administer a subcutaneous vaccine in a 5 year old? |
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| Aye. There is no age limit for utilise of the anterolateral thigh for either subcutaneous or intramuscular vaccines. |
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| I have a 2-month-former child with a cast for hip dysplasia that completely covers the entire anterolateral thigh on both legs. She is not due to have it removed for ten weeks. What options do we have for her injectable vaccines? |
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| Ideally, you can arrange to have the cast cut to administer vaccines in the anterolateral thighs. If that option is non bachelor, the gluteal region can be used if non covered by the cast. There are no other sites we recommend for vaccination; nevertheless, the inactivated polio vaccine could be given subcutaneously in either arm, if the child is large plenty. Rotavirus vaccine is given orally and should be administered. If vaccines cannot exist given for the 10 weeks, please advise the family unit to proceed people with any illness abroad from the child until she has been vaccinated. More than data run into ACIP'due south General All-time Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/full general-recs/administration.html. |
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| I need information about the administration of vaccines to 3-month-old conjoined twins (joined at the buttocks). For their routine immunization, exercise we provide 1 set of vaccinations or two, given that they are conjoined at the buttock but share no major organs? |
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| ACIP does not address this outcome. 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 claret supply, vaccination of each kid would also be indicated. The rationale is one cannot be certain, fifty-fifty in the latter case, that the common organs/claret 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 advisable, that is, one dose of each vaccine for each child. |
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| If I demand to give more than one injection in a musculus, are certain vaccines best given at different anatomic sites? |
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| Since DTaP and pneumococcal conjugate (PCV) are the vaccines nigh likely to cause a local reaction, it is prudent to give DTaP and PCV in split up limbs (if possible), and so at that place is no confusion about which vaccine caused the reaction. |
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| How many vaccines can be given during an office visit? |
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| 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 ane 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, xanthous fever, and oral typhoid) can be given at the aforementioned visit if indicated. If live vaccines are not administered during the aforementioned visit, they should be separated by iv weeks or more than. |
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| When giving several injections at a single visit, separate IM vaccines past at least 1 inch in the torso of the muscle if possible to reduce the likelihood of local reactions overlapping. Hither are some helpful site maps for unlike ages so you can tape where shots were given: |
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| For infants and toddlers: eziz.org/assets/docs/IMM-718.pdf |
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| For older children: www.aimtoolkit.org/docs/Giving_all_the_doses_12mths.pdf |
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| For adults: www.eziz.org/avails/docs/IMM-718A.pdf |
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| For details see ACIP'southward General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html. |
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| *At that place are iii exceptions to this general rule: i) if both pneumococcal conjugate vaccine (PCV13, Prevnar xiii, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) are indicated for a loftier-take chances patient, these vaccines should not be given at the same visit. The PCV13 should be given start followed by PPSV23 at least 8 weeks afterward. If PPSV23 has already been given, expect eight weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avert 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 commencement receive all recommended doses of PCV13 followed by Menactra at least four weeks later. Menveo (GSK) or MenQuadfi (Sanofi) MenACWY brands can be given at the same time or at any time before or subsequently PCV13. 3) Cholera vaccine should be administered before TY21a vaccine, and eight hours should separate cholera vaccine and the commencement dose of TY21a. |
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| A five-year-onetime is in the part for vaccines and is due for MMR, polio, varicella, and DTaP. Is there a specific order I should be giving these vaccines? |
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| The Advisory Commission on Immunization Practices (ACIP) does not address this outcome. 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 about pain (stinging, for example) terminal. For more than information on vaccine administration, please see the "Vaccine Administration" chapter of Epidemiology and Prevention of Vaccine-Preventable Diseases at www.cdc.gov/vaccines/pubs/pinkbook/capacity.html. |
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| Practise we need to wait for the vaccine to reach room temperature before we administer it to a patient? |
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| In that location is no recommendation to wait until a vaccine reaches room temperature before administration. The vaccine should be administered as presently as information technology is prepared. |
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| What is the acceptable volume for a single dose of immune globulin (IG) to inject into the deltoid muscle of a normal-weight developed? What is the acceptable volume for a single dose of IG to inject into the vastus lateralis of a normal-weight adult? |
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| Here are the suggested volumes: |
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| Deltoid: |
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| • | | Average 0.5 mL | | | | | • | | Range 0.5–2 mL | |
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| Vastus Lateralis: |
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| • | | Average 1–iv mL | | | | | • | | Range 1–5 mL | |
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| Infants and toddlers would autumn at the lower end of the range, whereas adolescents and adults would generally fall on the higher terminate of the range. |
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| If all needed vaccines aren't administered during the same visit, does one demand to wait a certain period of fourth dimension earlier administering the other needed vaccines? |
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| 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 on guidance from ACIP recommended against coadministration of COVID-19 vaccines with other vaccinations; all the same, ACIP updated its guidance in mid-2021 to state that these vaccines may be coadministered with other vaccinations when necessary. |
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| If two live vaccines are not given on the same day, they need to be spaced at least 4 weeks apart. As noted above, if both PCV13 and PPSV23 are indicated for a high-chance 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 i year (for an developed historic period 19 years or older) before giving PCV13 to avoid interference between the 2 vaccines. A person with anatomic or functional asplenia should receive both pneumococcal conjugate vaccine (PCV13) and meningococcal conjugate vaccines (MenACWY). If Menactra brand MenACWY is used the person should first receive all recommended doses of PCV13 then Menactra at least 4 weeks later. Menveo or MenQuadfi brands of MenACWY tin can be given at the aforementioned time or at any fourth dimension before or afterward PCV13. |
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| What does "simultaneous assistants" of vaccines mean? Does it mean the same day, 60 minutes, or what? |
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| Simultaneous ways the aforementioned day—the same clinic day. If someone receives a vaccine in the morning time and then another that same afternoon, it would be considered simultaneous administration. |
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| Some manufacturers' package inserts state that a vaccine should exist used immediately after reconstitution. In the context of reconstitution and administration of vaccines, how does CDC define "immediately"? |
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| At that place are various requirements for the apply of vaccines after reconstitution. Some manufacturers' package inserts crave that the vaccine be used or discarded in varying fourth dimension frames ranging from 24 hours subsequently reconstitution to immediately after reconstitution. While the specific timeframes are elementary to interpret, there can be some confusion as to what the requirement of "immediately" really ways. |
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| 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 whatsoever limited documentation that may be related to this process. It is up to the judgment of a provider to decide 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 exercise not have the data to put forth a full general fourth dimension frame every bit to what "immediately" means. CDC recommends that the provider contact the manufacturer any time (s)he has whatsoever question about whether or non the vaccine has been used in the advisable fourth dimension frame. |
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| Does live oral cholera vaccine (Vaxchora, PaxVax) need to be administered at an interval from other live oral or injectable vaccines? |
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| In full general, no. According to ACIP's Full general Best Practice Guidelines for Immunization, concerns about spacing between doses of live vaccines non given at the aforementioned 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, Berna) 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 get-go dose of Ty21a. |
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| Nosotros take a nurse in one of our clinics who gave split up doses of hepatitis A and hepatitis B vaccine in the gluteus. Are the doses of each antigen considered invalid? If so, tin they exist repeated at any time or do I demand to count the spacing between doses from the date when the invalid dose was administered? |
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| Although the gluteus musculus is not a recommended site for vaccination, in general, a dose given in that location can be considered valid. The exceptions to this full general dominion are hepatitis B and rabies vaccines, so the hepatitis B vaccine should not be counted in this state of affairs. The hepatitis B vaccine can exist repeated immediately. See the Advisory Commission on Immunization Do'due south (ACIP) General All-time Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/assistants.html. |
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| Is the "Z-track" method recommended for IM injections? |
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| ACIP does not address the utilize of this method for vaccination in its Best Practices Guidelines for Immunization (world wide web.cdc.gov/vaccines/hcp/acip-recs/general-recs/assistants.html). If you choose to use this method, yous should nonetheless adhere to the ACIP'south recommendations regarding needle length and anatomical site. |
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| Is information technology safety to requite a vaccine straight into an area where there is a tattoo? |
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| Both IM and SC vaccines may be given through a tattoo. |
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| Do you need to aspirate earlier giving a vaccination? |
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| No. ACIP does not recommend aspiration when administering vaccines because no data exist to justify the demand for this do. At that place are data that prove that aspiration is more than 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, information technology is difficult to cannulate a vessel without rupturing information technology and fifty-fifty 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. |
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| While giving an injection, a nurse had blood render in the syringe upon aspirating. What should she have done with the vaccine? |
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| 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. |
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| Is information technology necessary to wear gloves when we administer vaccinations? |
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| In general, no. Occupational Safety and Wellness Administration (OSHA) regulations do not crave 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 alter them between each patient come across. |
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| In response to the 2020 COVID-19 pandemic, CDC has recommended the employ of gloves when administering oral and intranasal vaccines to patients in communities where SARS-CoV-2, the virus that causes COVID-nineteen, is circulating. Gloves are recommended to forbid contact with the recipient's potentially infectious mucous membranes or respiratory secretions. For more guidance on prophylactic vaccination practices during the COVID-19 pandemic, see www.cdc.gov/vaccines/pandemic-guidance/alphabetize.html. |
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| The Immunization Action Coalition (IAC) has developed a handout on protective measures to take when vaccinating during the COVID-19 pandemic, available at www.immunize.org/catg.d/p2009.pdf. |
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| Is protective eyewear needed for those who administer vaccines and so they can avoid blood spatter? |
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| ACIP does not specifically recommend middle protection when administering vaccines to forestall exposure to blood spatter. |
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| In response to the COVID-nineteen pandemic, CDC has made recommendations concerning the use of protective eyewear by immunization providers in communities where SARS-CoV-2, the virus that causes COVID-nineteen, is circulating. In areas with moderate to substantial community transmission of SARS-CoV-2, healthcare providers should vesture middle protection given the increased likelihood of encountering asymptomatic COVID-nineteen patients. In areas with no or minimal community transmission of SARS-CoV-two, universal eye protection is considered optional, unless otherwise indicated as a part of standard precautions. For more guidance on safety vaccination practices during the COVID-19 pandemic, see www.cdc.gov/vaccines/pandemic-guidance/index.html. |
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| The Immunization Action Coalition (IAC) has adult a handout on protective measures to take when vaccinating during the COVID-19 pandemic, bachelor at world wide web.immunize.org/catg.d/p2009.pdf. |
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| It is fall 2021 and we are preparing our supplies for an immunization clinic in the context of COVID-xix. Practise surgical masks or material face coverings demand to exist worn in immunization settings while COVID-19 is circulating? Are N95 respirators recommended to be worn while administering any vaccinations? |
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| In order to reduce the risk of exposure to SARS-CoV-2, the virus that causes COVID-19, CDC recommends that all health care providers administering vaccines in any setting wear a medical face mask at all times and that they implement policies for the employ of cloth face coverings by all patients age 2 years and older who can tolerate them. |
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| Administration of oral or nasal spray vaccines is not considered to exist an aerosol generating process and N95 respirators are not recommended for vaccine assistants. Run into the next question for links to more information. |
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| Where can I find current information on how to protect myself and my patients when administering vaccines during the COVID-19 pandemic? |
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| CDC has published guidelines for safe vaccine administration during the COVID-19 pandemic that will be updated as needed. These guidelines focus on reducing the risk of SARS-CoV-ii transmission while in the location where immunizations are beingness given and during vaccine administration and can be institute here: world wide web.cdc.gov/vaccines/pandemic-guidance/alphabetize.html. |
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| IAC has assembled key resources, handouts and links related to COVID-19 and vaccination on our Vaccination and COVID-19 page, world wide web.immunize.org/vax-and-covid-nineteen/, and in our Ask the Experts section on COVID-19 and Routine Vaccination, at www.immunize.org/askexperts/experts_covid19.asp. |
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| Some single-dose manufacturer-filled vaccines come with an air pocket in the syringe chamber. Practice we need to expel the air pocket before vaccinating? |
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| No. You do not demand to miscarry the air pocket. The air will be absorbed. This is not true for syringes that you fill up yourself; yous should expel air bubbles from these syringes prior to vaccination to the extent that you can exercise so. |
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| I've seen the recommendation stating air bubbles in manufacturer-filled syringes do not need to be expelled. Tin can you explain why those air bubbles can exist injected just air bubbles in user-filled syringes must be expelled? |
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| It is not wrong to miscarry the air from syringes filled by manufacturers, only typically it is such a small-scale amount of air (0.2cc–0.3cc) that it is CDC's stance 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-rails method is used for intramuscular injection of irritating medication (e.grand., 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-rails injection technique is not recommended for vaccine assistants, the Z-track method demonstrates the acceptability of leaving a very pocket-size amount of air in the syringe for intramuscular injections. |
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| CDC does, nevertheless, recommend that when drawing vaccine from a vial into a regular syringe, the air exist 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. |
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| If a patient is not able to receive rotavirus vaccine orally, tin nosotros give it through a Yard-tube? |
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| You can give rotavirus vaccine through a tube as long as the child is otherwise eligible. |
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| If the lymph nodes under a patient's arm were surgically removed, should we avoid giving vaccines in that arm? |
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| We are enlightened that some surgeons advise confronting vaccination in an arm where lymph nodes were dissected. ACIP does not accost this, and then feel gratis to employ your professional judgment in determining whether to employ the arm that was operated on, the other arm (if not afflicted), or the anterolateral aspect of the thigh, which is an acceptable secondary route for adult immunization. |
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| What are the special recommendations for administering intramuscular injections in people with clotting disorders? |
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| This issue is discussed in ACIP's Best Practices Guidelines for Immunization (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/assistants.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 past a route that is not canonical by the FDA for that detail vaccine (east.g., administration of IM vaccines past the SC road). |
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| We have a question concerning delaying vaccinations for an infant born to a heroin-addicted female parent. We had a foster parent come into our health department requesting only certain vaccines for a 3-month-old, stating that the private doctor recommends delaying the schedule due to the possible residual effects of the heroin. The baby appeared to be healthy. |
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| Heroin use or addiction of the mother is not a reason to delay vaccination of an otherwise good for you infant. |
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| Is it okay to describe up vaccines at the beginning of the shift? If it isn't, how much in advance can this exist done? |
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| 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 merely a single blazon of vaccine is to be administered during a clinic (e.thou., influenza). Another reason to discourage the exercise in full 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. |
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| If you place a needle on a manufacturer-filled syringe and then don't administer the vaccine, how long tin can you store the syringe with the needle attached? |
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| In full general, a vaccine should not be prepared until the provider is prepare to administer it to a patient. This is because one time the syringe cap is removed or a needle is attached, the sterile seal is broken. Nonetheless, if a sterile seal has been broken, staff should be sure to maintain the syringe at the appropriate temperature and either apply it or discard it at the end of the clinic day. This issue is addressed in the CDC Storage and Handling Toolkit, bachelor at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, page xx. |
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| My nurse removed the protective cap from a preservative-free single dose vial, merely the vial was not used. How long can we keep a vial of vaccine after nosotros remove the protective cap of a preservative-free vial of vaccine? |
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| Removing the protective cap increases the likelihood the septum or stopper could be punctured. The puncture may non be visible. It is important to ensure that the condom seal on single-dose vials is non 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, encounter CDC'south Vaccine Storage & Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. |
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| Is it necessary to allow booze to dry completely on a patient�s skin prior to injection? |
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| Information technology is prudent to allow the alcohol to evaporate, simply it is unlikely that the minor amount residuum alcohol on the skin volition bear on the vaccine or increment the hazard of an agin reaction. |
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| Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or tin can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial? |
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| You should apply separate booze wipes to clean the vial top and the patient's peel. |
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| I know that it is advisable to make clean the vaccine vial stopper with an alcohol wipe after removing the protective cap from a vaccine or diluent vial. Do y'all have to look for the booze to dry earlier you insert the needle in to the stopper? |
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| The stopper of a single-dose vial is oft causeless 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 assistance to assure aseptic technique in preparing the single-dose vial prior to inserting a sterile syringe. Alcohol evaporates rapidly and will dry while the needle is being prepared for insertion into the vial. |
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| In cleaning the vaccine vial stopper or the patient'due south peel, is it okay to use a not-sterile cotton brawl or do we demand to use a pre-packaged sterile booze prep pad? |
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| Using a pre-packaged sterile booze prep pad is recommended to maintain aseptic technique. Not only are cotton balls not sterile, but neither is a canteen of sterile alcohol, one time it'south opened. |
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| Some single dose vials (SDV) contain more the recommended dosage of the vaccine. Should we administer the recommended dose of the vaccine, or the entire contents of the vial fifty-fifty if it contains more than the recommended dose? |
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| In general the entire volume should be used fifty-fifty if information technology is a little more than 0.five mL. Discarding the excess vaccine is non 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. |
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| Where can I obtain standing orders for vaccination? |
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| The Immunization Action Coalition (IAC) has adult suggested standing orders for all vaccines normally 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 world wide web.immunize.org/continuing-orders. |
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| What is the provider'south liability when using standing order protocols? |
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| While you lot did not say this explicitly, we assume the concern is about a vaccine injury in a person who was vaccinated using a continuing 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 Bounty 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 plan for all ages of patients). More than information about the VICP is available on their website at www.hrsa.gov/vaccinecompensation/index.html. |
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| A 2009 article in The Lancet reported that infants who received 3 doses of paracetamol post-obit immunization had reduced allowed responses to certain vaccines. Based on these findings, should we finish recommending acetaminophen for fever or discomfort after baby immunizations? |
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| Findings of this study discourages the prophylactic apply of paracetamol (similar to acetaminophen) prior to or immediately following vaccination. Acetaminophen can be used to care for hurting or fever if it should occur following vaccination. ACIP'southward General All-time Practices Guidelines for Immunization country: "Testify does non support use of antipyretics before or at the fourth dimension of vaccination; still, they can be used for the handling of fever and local discomfort that might occur following vaccination. Studies of children with previous febrile seizures take not demonstrated antipyretics to be effective in the prevention of delirious seizures." For more information on this result, encounter Methods for Alleviating Discomfort and Hurting Associated with Vaccination at www.cdc.gov/vaccines/hcp/acip-recs/full general-recs/administration.html. |
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| What guidance is there for preventing patients from fainting after vaccination? |
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| All providers who administer vaccinations should be aware of the potential for syncope (fainting) after vaccination and take appropriate measures to preclude it. Thus, clinicians should (1) make sure that people who are being vaccinated are always seated; (2) exist aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.); and (three) accept appropriate measures to prevent injuries if such symptoms occur. |
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| IAC has ii 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. |
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| Since 2005, VAERS has received an increasing number of reports of syncope, coinciding with the licensure of three vaccines for adolescents—HPV, meningococcal conjugate, and Tdap. Fainting among girls and young women ages eleven–18 deemed for virtually of the increase. Serious injuries take occurred, including one fatality from intracranial hemorrhage caused by head trauma. The May two, 2008, MMWR included a summary of findings on the increase in fainting subsequently vaccination (see world wide web.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm). In people for whom vaccination fourth dimension and fainting fourth dimension were reported, it was discovered that eighty% occurred within 15 minutes of receiving the vaccine. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination in accordance with ACIP'due south General All-time Practices Guidance for Immunization (run into www.cdc.gov/vaccines/hcp/acip-recs/general-recs/assistants.html). This is particularly of import when vaccinating adolescents and immature adults. CDC has posted often asked questions on this topic at www.cdc.gov/vaccinesafety/Concerns/syncope_faqs.html. |
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| Are vaccine diluents interchangeable? |
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| Diluents are non 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 exist used to reconstitute any other lyophilized vaccine. |
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| If the incorrect 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 exist repeated as before long as possible. If a live vaccine is reconstituted with the incorrect diluent and is administered, the dose is invalid. If the dose can't be repeated on the same clinic twenty-four hour period, it needs to be repeated no earlier than 4 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 aforementioned live vaccine. |
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| Is it recommended to change needles later a vaccine dose has been drawn into a syringe? |
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| No. It is as well unnecessary to alter the needle if it has passed through two stoppers, which is done when a lyophilized vaccine is reconstituted. Irresolute needles is a waste of resources and increases the risk of needle stick injury. |
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| When patients need multiple vaccines (such as influenza and pneumococcal), can we just combine them in the aforementioned syringe? |
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| Absolutely not. No vaccines should ever be mixed in the same syringe unless the combination has been specifically approved by the FDA. |
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| The needle came loose while I was injecting a dose of vaccine, and approximately half the dose was lost. Should we revaccinate the patient? If so, when? |
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| When injectable vaccine volume is lost (patient moves, syringe leaks), it may be difficult to judge how much vaccine the patient really 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 information technology was an inactivated vaccine, you should re-immunize the person as before long every bit possible. In the example of Shingrix (RZV; GSK) if the person is all the same in the function the dose tin exist repeated immediately. If the echo dose cannot be given on the aforementioned twenty-four hour period CDC recommends that information technology should be given 4 weeks subsequently the invalid dose. |
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| If it was a live vaccine, you can requite another dose if y'all detect the error on the aforementioned clinic solar 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 later on live attenuated influenza vaccine (Flumist; AstraZeneca) the dose tin be counted as valid. |
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| If a patient pulls away during assistants of a vaccine and the needle comes out, is it okay to reintroduce the same needle and finish the injection? |
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| 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 exist used. Mostly, a full echo dose should exist given, just you may use your clinical judgment to determine whether an adequate dose was administered before the patient pulled away. |
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| We run a educatee wellness middle and are wondering what the position is on discarding empty vaccine vials. Do they need to go in a sharps container afterward they are drawn up or can they become in the trash? |
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| Empty or expired vaccine vials are considered medical waste product and should be disposed of according to land regulations. |
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| Vaccine Administration Errors | Back to top | |
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| We received a study of an infant who received rotavirus vaccine intramuscularly rather than orally. Is this dose valid? If not, when should it exist repeated? |
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| The rotavirus vaccine dose given by the intramuscular route is not valid and should be repeated by the oral route as soon as possible. In a review of such rotavirus vaccine administration errors, in that location commonly were not adverse reactions, and those documented were express to local reactions and full general, brief irritability. Please see www.cdc.gov/mmwr/pdf/wk/mm6304.pdf, page 81, for more information. |
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| Please take steps to ensure that such vaccine assistants errors are avoided in the future. This event should be reported to the Vaccine Adverse Event Reporting System at https://vaers.hhs.gov fifty-fifty if an adverse reaction does not consequence from it. |
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| What should we do if a dose of expired vaccine is given to a patient? |
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| The dose should be repeated. If the expired dose is a live virus vaccine, you should await at least 4 weeks afterward the previous (expired) dose was given before repeating it. If the expired dose is not a live vaccine, the dose should be repeated equally soon as possible. Although simply repeating the dose is preferred, serologic testing to check for immunity after certain vaccinations (due east.g., measles, rubella, varicella, hepatitis A) may be accustomed. |
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| MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose? |
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| Yes, however, this consequence is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label use, CDC recommends that when a dose of MMRV is inadvertently given to a patient age xiii years and older, information technology may be counted towards completion of the MMR and varicella vaccine series and does not demand to exist repeated. |
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| An expired dose of ProQuad (MMRV, Merck) was given to a patient. We assume that the repeat dose should exist given in three months because the spacing between doses of a combination vaccine depends on the longest minimum interval of a component (in this case the varicella vaccine component). Is this correct? |
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| In the case of an expired live vaccine, the issue is not necessarily the routine minimum interval (3 months in the example of varicella and ProQuad vaccines), merely the interval that would forbid viral interference if the expired vaccine happened to exist still viable. This interval is considered to be four weeks (28 days). The repeat dose should exist administered four weeks afterwards the expired dose. |
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| What should we practise if we give an injection past the incorrect route (SC instead of IM)? |
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| Your practise should put procedures in place to ensure that y'all ever requite vaccines by the recommended route considering data regarding rubber and efficacy of alternate routes are express. If this does inadvertently happen, ACIP and/or CDC recommends that if hepatitis B, rabies, HPV and inactivated influenza vaccines are administered subcutaneously the doses should not be counted equally valid and should be repeated. |
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| ACIP states that If PCV13, Hib, and/or DTaP are administered by the subcutaneous route, providers take the discretion to repeat the doses. At that place is no minimum interval between the invalid dose and the repeat dose. ACIP and/or CDC recommends that if HepA, MenACWY, IPV, PPSV23, COVID-nineteen, and RZV vaccines are administered subcutaneously, the doses can count and exercise not demand to exist repeated. ACIP/CDC has no recommendation for Tdap, Td, MenB, Typhim Half-dozen, or JE-VC. |
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| I of our staff gave a dose of pediatric hepatitis A vaccine to an adult patient by mistake. How do we remedy this fault? |
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| In general, if the error is discovered on the same dispensary day, you can administer the other "half" of the dose on that same day. If the error is discovered after, the dose should not be counted, and then the person should be recalled to the office and given a full age-advisable repeat dose. |
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| There are, however, 2 exceptions to the full general rule: (1) If a patient sneezes after receiving nasal-spray alive adulterate influenza vaccine, count the dose every bit valid. (2) If an baby regurgitates, spits, or vomits during or after receiving oral rotavirus vaccine, count the dose as valid. |
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| If y'all requite more than than an age-appropriate dose, count the dose as valid and notify the patient/parent nearly the error. Using larger than recommended dosages can be hazardous because of excessive local or systemic concentrations of antigens or other vaccine constituents. Avert such errors by checking the vaccine vial label three times. |
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| A dose of Kinrix (DTaP-IPV; GSK) should have been administered to a 4-twelvemonth-onetime, but Pentacel (DTaP-IPV-Hib; Sanofi Pasteur) was administered instead. Does the dose of DTaP count? |
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| Yes. The DTaP in the Pentacel can be counted. Although Pentacel is licensed as a iv-dose series and this may correspond a fifth dose of Pentacel (in which case it would be off-characterization employ), the dose of DTaP counts as the fifth dose of DTaP. |
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| A dose of pneumococcal conjugate vaccine was administered into my patient's dialysis port. Does this dose count? |
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| In that location are no data on the effectiveness of pneumococcal conjugate vaccine given past the intravenous route. The patient has renal disease, then it is important to ensure that the dose they receive is effective. CDC recommends repeating the dose. |
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| A 2-month-old was mistakenly given PPSV23 instead of PCV13. What should be done? |
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| PPSV23 is not effective in children younger than 24 months of age. PPSV23 given at this age should not be considered to be part of the pneumococcal vaccination series. PCV13 should be administered as soon every bit the error is discovered. Whatever fourth dimension the incorrect vaccine is given, the parent/patient should be notified. |
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| Rather than giving PCV13 first and waiting eight weeks to give PPSV23 equally recommended for an immunocompromised child (2 years or older) or adult patient, nosotros inadvertently gave both vaccines at the aforementioned visit. Nosotros are looking for guidance. |
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| Although PCV13 and PPSV23 should not be administered at the same visit, CDC does non recommend repeating either vaccine dose should this occur. You should inform the patient of the error and let them know that they will not need to repeat either dose. |
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| A 60-twelvemonth-old patient was inadvertently given varicella vaccine instead of zoster vaccine. Should the patient withal be given the zoster vaccine? If then, how long an interval should occur betwixt the 2 doses? |
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| CDC recommends that if a provider mistakenly administers varicella vaccine to a person for whom zoster vaccine is indicated, no specific safety concerns exist, simply the dose should not be considered valid. Recombinant zoster vaccine (RZV; Shingrix, GSK) should be administered at least viii weeks after receipt of the varicella vaccine. However, if RZV is administered less than 8 weeks later on the varicella vaccine, it does not demand to exist repeated. A second dose of RZV should exist given 2–6 months later the showtime dose of RZV. Avoid such errors by checking the vial label iii times to brand sure you lot're administering the production y'all intended. |
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| If RZV (Shingrix) is erroneously given to a child for prevention of varicella, the dose is invalid, but is in that location a waiting period before a valid dose of varicella vaccine can exist given? Is it OK to give a dose of varicella vaccine as soon equally the fault is discovered? |
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| There is no waiting period. The varicella vaccine dose can be given at whatever time afterwards the RZV dose. |
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| While giving a dose of RZV (Shingrix) the syringe came loose from the needle and part of the dose was lost. Will the patient exist protected with this fractional dose or does it demand to be repeated? |
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| A dose less than the full 0.5 mL dose is not valid and should be repeated. If the patient is still in the office the dose can be repeated immediately. If the echo dose cannot be given on the aforementioned day CDC recommends that it should be given iv weeks after the invalid dose. |
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| My medical assistant inadvertently administered a 0.5 mL dose of the RZV (Shingrix) diluent only. The dose did non comprise any antigen. When tin nosotros administer a properly reconstituted dose? |
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| The CDC zoster subject matter experts recommend that in this situation you lot should await four weeks before giving a repeat dose. |
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| Several doses (antigen and diluent) of RZV (Shingrix) were mistakenly stored in our office freezer. I of these doses was administered to a patient. Is this dose valid and if not, when can it be repeated? |
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| Any RZV, either antigen or diluent, that is exposed to freezing temperature should non be used. If a dose exposed to freezing temperature is given to a patient the dose should exist considered invalid and should exist repeated 4 weeks later on the invalid dose. |
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