Vaccine AdministrationDonna L. Weaver, RN, MN, Nurse Educator

National Center for Immunization and Respiratory Diseases

TennesseeApril, 2010

Be Prepared to Administer Vaccines Correctly

Adhere to OSHA guidelines for employee safety

Provide staff with easy to use resources and guidelines Document immunizations correctly

Ensure staff is adequately trainedProvide current immunization education

Vaccine Administration Errors

• The Right Drug

• The Right Dose

• The Right Route

• The Right Technique

• The Right Time

• The Right Patient

• The Right Documentation

Right Vaccine or Formulation

• Errors occur because both types of vaccine stored in the same refrigerator, similarity of appearance of packaging, and small print

Right VaccineCheck Your Vial 3 TIMES

• DTaP

• Tdap

Right Vaccine

• DTaP

– 6 weeks – 6 years

– Schedule = 5 doses

– Main contents• Diphtheria toxoid

• Tetanus toxoid

• aPertussis antigens

• Tdap

– 10 – 64 years

– Schedule = 1 dose ONLY

– Main contents• diphtheria toxoid = 1/3 amount in

DTaP• Tetanus toxoid = same as

amount in DTaP• apertussis antigens = less than

amount in DTaP

Right VaccineCheck Your Vial 3 TIMES

• PPD (tuberculin skin test)

• DT

• Td (dT)

Produced byCalifornia

ImmunizationBranch

Produced byCalifornia

ImmunizationBranch

Available at http://www.cdph.ca.gov/HealthInfo/discond/Documents/check_your_vials_508_.pdfAvailable at http://www.cdph.ca.gov/HealthInfo/discond/Documents/check_your_vials_508_.pdf

Right VaccineCheck Your Vial 3 TIMES

• Varicella vaccine

• Zoster vaccine

Right Vaccine

• Varicella

– 12 months and older

– Schedule = 2 doses

– Main contents• Live attenuated varicella

vaccine virus

• Zoster

– 60 years and older

– Schedule = 1 dose ONLY

– Main contents• Live attenuated varicella

vaccine virus – 14 times as much as in varicella vaccine

Right Vaccine

• Label clearly

• Include age indications

• Separate look-alike and sound-alike vaccines as much as possible

Right FormulationHepatitis A, Hepatitis B, & Twinrix

Remember – always use the age-appropriate dose!!!

Vaccine Age Dose

Hepatitis A 12 mos thru 18 yrs 0.5 mL

19 yrs and older 1 mL

Hepatitis B Birth thru 19 yrs 0.5 mL

20 yrs and older 1 mL

Twinrix 18 yrs and older 1 mL

CDC

Right Diluent

ActHIB® + 0.4% Sodium chloride

Hiberix + 0.9% Sodium chloride

TriHIBit = ActHIB® + Tripedia®

Pentacel = ActHIB + DTaP(Daptacel)/IPV

Rotarix = RV1 + Sterile water/ calcium carbonate/ xanthan

M-M-R + Sterile water

Varivax + Sterile water

ProQuad® = MMRV + Sterile water

Zostavax® + Sterile water

Menomune® + Sterile water/ Thimerosal

Menveo = Serogroup A + Serogroups C/Y/W-135

Vaccine + Diluent

Do NOT Split Pentacel

• Do NOT give DTaP/IPV solution separately without the ActHIB++

Hib DTaP/IPV

Only Combine Vaccines if FDA Approved

• Vaccines should NEVER be combined in the same syringe unless FDA approved for this purpose

++

Right Route for Vaccine

Rotavirus VaccineOral Route

LAIV VaccineIntranasal Route

Subcutaneous (subQ) Injections

Needle size23 - 25 gauge

5/8” length

Muscle tissueMuscle tissue

Fatty tissue (subQ)Fatty tissue (subQ)

DermisDermis

45° Angle45° Angle

Intramuscular (IM) Injections

Needle length & Site depend on:Muscle size, Fatty tissue thickness,

Vaccine volume, Injection technique Aspiration is NOT required

Fatty tissue (SubQ)Fatty tissue (SubQ)

DermiDermissFatty tissue Fatty tissue (subQ)(subQ)

Muscle Muscle tissuetissue

90° 90° AngleAngle

Acromial Process

Axillary FoldAxillary Fold

Correct!Correct!Incorrect!Incorrect!NO!!!

www.reuters.com/article/idUSTRE61733Z20100208

Right Needle Length

Intramuscular (IM) Injections

Sex/

Weight

Needle Length

Injection Site

M & F <130 lbs 1”* Deltoid Muscle

F 130 lbs - 200 lbs 1” - 1½”

M 130 lbs - 260 lbs

F >200 lbs 1½”

M >260 lbs*Some experts allow for use of a 5/8” needle

Multiple Vaccinations• Use the thigh for multiple IM injections in infants and young children

• The deltoid muscle can be used for older children and adults

• Separate each injection by at least 1”

• Administer vaccine and immune globulin at separate sites

• Combination vaccines can reduce the number of injections needed

Recommended Volume for Site

Muscle

Volume Injected

Average Range

Deltoid 0.5 mL 0.5 - 2 mL

Vastus lateralis(anterolateral thigh)

1 - 4 mL 1 - 5 mL

Syncope Following Vaccination

• An increase in the number of reports of syncope has been detected by the Vaccine Adverse Event Reporting System (VAERS)

• 11-18 year old females have contributed most of the increase

• Serious injuries have resulted

www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm?s_cid=mm5717a2_e

Administer Immunizations SAFELY!

• Have patients seated for vaccination

• Strongly consider observing patients for 15 minutes after they are vaccinated

• If syncope develops, patients should be observed until symptoms resolve

Handle Vaccines with Care

• Do NOT refreeze vaccines after thawing – Unreconstituted varicella and MMRV may

be stored for up to 72 hours at 35º-46ºF (2º -8º C)

– Unreconstituted zoster vaccine may not be stored in this manner

• Do NOT uncap vials until ready for use

• Remember, the clock is ticking once a lyophilized vaccine is reconstituted

Provider Prefilled Syringes

• Prefilling syringes from a multidose vial is STRONGLY DISCOURAGED by CDC

• May result in vaccine administration errors and wastage

• Consider using manufacturer-supplied prefilled syringes (if available) for large immunization events

Provider Prefilled Syringes

• Provider prefilled syringes should be discarded after 30 minutes (total) exposure to room temperature

• Provider prefilled syringes should be discarded at end of the clinic day

Manufacturer Prefilled Syringes

• Do not contain a preservative

• Removing the syringe cap or attachment of a needle breaks the sterile seal

• Do NOT remove the cap or attach a needle until ready to use

• Manufacturer prefilled syringes with a needle attached should be discarded at end of the clinic day

Do NOT Administer Expired Vaccine

IMPORTANT RULE: Vaccine doses should not be administered at intervals less than the recommended minimal

intervals or earlier than the minimal ages.

But, there is no maximum interval!(Except for oral typhoid vaccine in some circumstances.)

Scheduling Errors

• Giving TriHIBit (DTaP+Hib) at 2, 4, and 6 months

• Giving rotavirus vaccine after 8 months 0 days

• Giving PPSV23 every 5 years

• Not allowing 6 months between the next-to-last and last doses of IPV

• Using Kinrix other than for the 5th dose of the DTaP and the 4th dose of IPV in children age 4-6 years

• Giving live vaccines not administered at the same visit less than 4 weeks apart

Doses administered 5 or more days before the minimum age should be repeated on or after the patient reaches the minimum age and 4 or more weeks after the invalid dose. Doses administered 5 or more days earlier than the recommended minimum interval between doses are not valid and must be repeated. The repeat dose should be spaced after the invalid dose by the recommended minimum interval

Right Interval

Vaccine doses administered up to 4 days before the minimum interval or age can be counted as valid

This grace period should not be used when scheduling future vaccination visits, or applied to the 28-day interval between live parenteral vaccines of two different vaccines not administered at the same visit

Use of the grace period may conflict with state daycare or school entry vaccination requirements

The 4-day “Grace Period”

Scheduling errors: giving doses without the minimum spacing

• Giving 2nd dose of hepatitis A vaccine less than 6 months after the first dose

• Giving the hep B vaccine series without at least 4 wks between doses 1 and 2; 8 wks between doses 2 and 3; and 16 wks between doses 1 and 3

• Giving the HPV vaccine series without at least 4 wks between doses 1 and 2; 12 wks between doses 2 and 3; and 24 wks between doses 1 and 3

Scheduling errors: giving doses at too young an age

• Giving the 1st dose of MMR before age 12 months

• Giving the 3rd dose of Comvax before age 12 months

• Giving the 4th dose of DTaP before age 12 months or less than 6 months after 3rd dose

• Finishing infant’s hepB series before 24 wks

• Giving any vaccine (except hepatitis B) before age 6 weeks

Vaccine Administration Resources

CDCwww.cdc.gov/vaccines/recs/vac-admin/default.htm

Imz Action Coalitionwww.immunize.org/printmaterials/topic.asp#services

CA Imz Programwww.eziz.org/pages/vaccineadmin.htmlndhandling.html

Michigan Imz Programwww.aimtoolkit.org/

CDC Vaccines and ImmunizationContact Information

• Telephone 800.CDC.INFO (for patients and parents)

• Email nipinfo@cdc.gov(for providers)

• Website www.cdc.gov/vaccines/

• Vaccine Safety

www.cdc.gov/od/science/iso/