Vaccine Administration: During Vaccination

Vaccine Preparation

To ensure proper vaccine preparation, use aseptic technique and follow infection prevention guidelines. This includes:

• Ensure that your practice, clinic, or pharmacy has the supplies needed to administer vaccines.
• Perform hand hygiene before preparing vaccines.
• Before using a vaccine, carefully inspect the vial for damage, particulate matter, or contamination.
• Verify the vaccine has been stored at proper temperatures.

• Prepare vaccines in a clean, designated area away from where the patient is being vaccinated and away from any potentially contaminated items.
  • If possible, declare the preparation area a "Quiet Zone" or "No Interruptions Area." Distractions during the preparation process have been identified as a contributing factor to vaccination errors.

• Follow the vaccine manufacturer's directions, located in the package inserts.

• Check the expiration dates on the vaccine and any diluent (if needed). Some syringes and needles have expiration dates, so also check those, too. NEVER use expired vaccine, diluent, or equipment.

• Use a separate needle and syringe for each injection.

• Prepare vaccines only when you are ready to administer them.

• Only administer vaccines you have prepared.

• Discard all used syringe/needle in a puncture-proof sharps container in immediate area where vaccine is administered.

Vaccine Presentations

Vaccines are available in different presentations, including:

Single-dose Vial (SDV)

Most vaccines are available in SDVs. Since SDVs do not contain preservatives that help prevent microorganism growth, SDVs are intended to be punctured only once for one patient. Once the appropriate dosage has been withdrawn, the vial and any leftover contents should be discarded appropriately. Never use an SDV for more than one patient.

Manufacturer-Filled Syringe (MFS)

MFSs are prepared by the manufacturer with a single dose of vaccine and sealed under sterile conditions. Like SDVs, MFSs do not contain a preservative to help prevent the growth of microorganisms. MFSs are intended for one injection for one patient. Once the sterile seal has been broken, the vaccine should be used or discarded by the end of the workday.

Multidose Vial (MDV)

An MDV contains more than one dose of a vaccine. To prevent inadvertent contamination of the vial, MDVs are labeled by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of microorganisms. Because MDVs contain a preservative, they can be punctured more than once. MDVs used for more than one patient should only be kept and accessed in a dedicated, clean medication preparation area, away from patient treatment areas. Only the number of doses indicated in the manufacturer's package insert should be withdrawn from the vial. Partial doses from two or more vials should never be combined to make a dose of vaccine.

Oral Applicator and Nasal Sprayer

An oral applicator is used with oral vaccines and contains only one dose of medication. Oral vaccines do not contain a preservative. In the US, Rotavirus vaccine is administered using an oral applicator. An intranasal sprayer is used for the live, attenuated influenza vaccine.

Needle Selection

Vaccines must reach the desired tissue to provide an optimal immune response and reduce the likelihood of injection-site reactions. Needle selection should be based on the:

• Route of administration

• Patient age

• Sex and weight (for adults aged 19 years and older)

• Injection site

• Injection technique

The following table outlines recommended needle gauges and lengths. In addition, clinical judgment should be used when selecting needles to administer injectable vaccines.

Needle Length and Gage Charts

 Subcutaneous Injection

 Intramuscular Injection for Children and Adolescents (birth–18 years)

 Intramuscular Injection for Adults (age 19 years or older)

Site and Route Selection

There are five routes used to administer vaccines. The recommended route and site for each vaccine is based on clinical trials, practical experience, and theoretical considerations. Deviation from the recommended route may reduce vaccine effectiveness or increase local adverse reactions. Some vaccine doses are not valid if administered using the wrong route, and revaccination is recommended.

Oral Route (PO)

• Oral vaccine is administered through drops to the mouth.
• Rotavirus vaccine (RV1 [Rotarix], RV5 [RotaTeq]) is the only routinely recommended vaccine administered orally. Rotavirus vaccine should never be injected.
• For further guidance view the following demonstrations:
  • Rotarix Digital Demonstration
  • RotaTeq (RV5) – YouTube

Intranasal Route (NAS)

• Intranasal vaccine is administered into each nostril using a manufacturer-filled nasal sprayer.
• Live, attenuated influenza (LAIV [FluMist]) vaccine is the only vaccine administered by the intranasal route
• For further guidance view the following demonstration:
  • Live, Attenuated Influenza Vaccine (LAIV)

Subcutaneous Route (Subcut)

• Subcutaneous injections are administered into the fatty tissue found below the dermis and above muscle tissue.
• Routinely recommended vaccines administered by subcutaneous injection include:
  • DEN4CYD (Dengvaxia)
  • IPV (IPOL)
  • MMR (MMR-II, Priorix)
  • MMRV (ProQuad)
  • PPSV23 (Pneumovax 23)
  • VAR (Varivax)

• Note: MMRII, IPOL, Pneumovax 23, and ProQuad can be administered by intramuscular (IM) or subcutaneous injection

• For further guidance view the following factsheet and video demonstration:
  • Subcutaneous (SUBCUT) Injection Factsheet
  • Subcutaneous (SUBCUT) Injection: Administration

Intradermal Injection

• Intradermal administration involves injecting the vaccine superficially between the epidermis and the hypodermis layers of the skin, typically of the volar aspect (inner side) of the forearm.

• The routinely recommended vaccine administered by ID injection is:
  • Mpox (Jynneos)
  • The standard regimen for Jynneos involves a subcutaneous (Subcut) route of administration. An alternative regimen involving intradermal (ID) administration with an injection may be used under an Emergency Use Authorization (EUA).

• For further guidance view the following demonstration:
  • How to Administer Intradermal Vaccine in Forearm, Deltoid, and Scapula

Intramuscular Route (IM)

• Intramuscular injections are administered into the muscle through the skin and subcutaneous tissue. The recommended site is based on age. Use the correct needle length and gauge based on the patient's, age, weight, and gender.

• Routinely recommended vaccines administered by IM injection include:
  • COVID-19 (Comirnaty, Spikevax)
  • DTaP (Daptacel, Infanrix)
  • DTaP-IPV-HepB (Pediarix)
  • DTaP-IPV/Hib (Pentacel)
  • DTaP-IPV (Kinrix, Quadracel)
  • Hib (PedvaxHIB, ActHIB, Hiberix)
  • HepA (Havrix, Vaqta)
  • HepB (Engerix B, Heplisav-B, Recombivax HB)
  • HepA-HepB (Twinrix)
  • HPV (Gardasil 9)
  • IIV (multiple brands)
  • IPV (IPOL)
  • MenABCWY (Penbraya, Penmenvy)
  • MenACWY (MenQuadfi, Menveo)
  • MenB (Bexsero, Trumenba)
  • MMR (MMRII)
  • PCV 15 (Vaxneuvance)
  • PCV 20 (Prevnar 20)
  • PCV 21 (Capvaxive)
  • PPSV23 (Pneumovax 23)
  • RSV monoclonal antibody (Beyfortis, Clesrovimab)
  • RSV (Abrysvo, Arexvy, mRESVIA)
  • RZV (Shingrix)
  • Td (Tenivac)
  • Tdap (Adacel, Boostrix)

Note: IPOL, MMRII and Pneumovax 23 can be administered by IM or subcut injection.

• For further guidance view the following videos and job aids:
  • Intramuscular (IM) Injection: Sites
  • Intramuscular (IM) Injection: Supplies (Children Birth Through 18 Years of Age)
  • Intramuscular Injection: Supplies (Adults 19 Years of Age and Older)
  • Intramuscular (IM) Injection Children 7 through 18 years of age
  • Intramuscular (IM) Injection Adults 19 years of age and older

Filling Syringes

Follow standard medication preparation guidelines when drawing a dose of vaccine into a syringe. The cap on the top of an unopened vaccine vial functions as a dust cover. However, not all vaccine manufacturers guarantee the tops of unused vials are sterile, and the way the cover over the stopper is removed can potentially contaminate the stopper. Therefore, use friction and a sterile alcohol swab to wipe the stopper. Alcohol evaporates quickly and will dry while the needle is being prepared for vial insertion.

Before withdrawing each dose, the vial should be agitated to mix the vaccine thoroughly to obtain a uniform suspension. Do not shake vaccine, unless instructed by the manufacturer. The vaccine should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not administer the vaccine if it's discolored or contains particulate matter.

When filling a syringe:

• Never enter a vial with a previously used syringe or needle.

• Never mix different vaccine products in the same syringe.

• Never transfer vaccine from one syringe to another.

• Never combine partial doses from separate vials to obtain a full dose.

More than one vaccine may be administered at the same visit; however, they may look similar once drawn into a syringe. By immediately labeling the syringe with the name of the vaccine, health care providers will know the route to administer the vaccine correctly.

Multiple Vaccinations / Coadministration

Often, more than one vaccine is given during the same visit. This can be referred to as coadministration, or simultaneous administration. For infants and younger children receiving more than two injections in a single limb, the thigh is the preferred anatomic site because of the greater muscle mass. For older children and adults, the deltoid muscle can be used for more than one intramuscular injection.

Additional best practices for multiple injections include:

• Prepare each injectable vaccine using a separate syringe.

• When appropriate, use combination vaccines (e.g., DTaP-IPV-HepB or DTaP-IPV/Hib) to reduce the number of injections.
  • Do NOT mix more than one vaccine in the same syringe in an effort to create your own "combination vaccine."

• Administer each vaccine in a different injection site. Separate injection sites by 1 inch or more, if possible.

• Administer vaccines that are known to be painful when injected (e.g., MMR, HPV) last.

• If possible, administer vaccines that may be more likely to cause a local reaction (e.g., tetanus-toxoid-containing and PCV or RZV) in different limbs.

Find additional information about vaccine coadministration in Chapter 6: Vaccine Administration | Pink Book | CDC

Procedural Pain Management

Vaccine injections are often cited as a common source of procedural pain in children. Pain associated with injections can be a source of anxiety for children and their parents or guardians. Although pain from injections is somewhat 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

• Using topical anesthetics before vaccination

• Breastfeeding during vaccination

• Giving sweet-tasting liquids (orally) during vaccination

• Injecting vaccines rapidly without aspiration

• Administration technique

• Administer the vaccine quickly without aspirating. Studies have found aspiration can increase pain because of the combined effects of a longer needle-dwelling time in the tissues and wiggling of the needle.

• Distraction

• Breathing technique: Taking slow, deep breaths can calm people and reduce the body's reaction to pain.

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

A detailed discussion of strategies to reduce procedural pain can be found in the Pink Book.