1.4 Administration of vaccines

Please note: due to continuous updates being made to the Immunisation Handbook, the page number on the electronic version will not always match the hard copy version.

IM injection technique^10,11

• For IM injection, a 25 mm needle should be used in most cases (see Table 1.4.2 below).
• Depending on the injection site, the limb should be positioned so as to relax the muscle into which the vaccine is to be injected.
• The 25 mm needle should pierce the skin at an angle of 90° to the skin, and can be safely inserted to the hub.12 Provided an injection angle of >70° is used, the needle should reach the muscle layer.¹³
• Studies have demonstrated that, for most vaccines, local adverse events are minimised and immunogenicity enhanced by ensuring vaccine is deposited into the muscle and not into the subcutaneous layer.^5,14-17 However, some vaccines, eg. inactivated poliomyelitis, varicella and meningococcal polysaccharide vaccines, are only licensed for SC administration.
• A recent clinical trial demonstrated that long (25 mm) needles (with the skin stretched flat and the needle inserted at 90°) for infant vaccination were associated with significantly fewer local adverse events while achieving comparable immunogenicity. Little difference was found between needles the same length but with different gauges in local adverse events or immune response.¹²
• If using a 25 gauge needle for an IM vaccination, ensure the vaccine is injected slowly over a count of 5 seconds to avoid injection pain and muscle trauma.
• It is not considered necessary to draw back on the syringe plunger before injecting a vaccine.⁵ However, if this is done, and a flash of blood appears in the needle hub, the needle should be withdrawn and a new site selected for injection.¹⁸
• After completing the injection, perform post-vaccination care (see Chapter 1.5, Post-vaccination procedures).

SC injection technique

• SC injections are usually administered at a 45° angle to the skin.
• The standard needle for administering vaccines by SC injection is a 25 or 26 gauge needle, 16 mm in length.

Intradermal injection technique

For intradermal injection of BCG vaccine or Q fever skin test vaccine, a 26 or 27 gauge, 10 mm needle is recommended. The intradermal injection technique requires special training, and should be performed only by a trained provider (see Chapter 3.22, Tuberculosis and Chapter 3.17, Q fever).

Table 1.4.2: Recommended needle size, length and angle for administering vaccines^{5,10,12,14,19}

Age or size of child/adult	Needle type	Angle of needle insertion
Infant, child or adult for IM vaccines	23 or 25 gauge,* 25 mm in length†	90° to skin plane
Preterm babies (<37 weeks’ gestation) up to age 2 months; very small infants	23 or 25 gauge,* 16 mm in length	90° to skin plane
Very large or obese patient	23 gauge, 38 mm in length	90° to skin plane
Subcutaneous injection in all individuals	25 or 26 gauge, 16 mm in length	45° to skin plane

* If using a narrow 25 gauge needle for an IM vaccination, ensure vaccine is injected slowly over a count of 5 seconds to avoid injection pain and muscle trauma.

† The use of short needles for administering IM vaccines may lead to inadvertent subcutaneous (SC) injection and increase the risk of significant local adverse events, particularly with aluminium-adjuvan

References

5. Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). [erratum appears in MMWR Morb Mortal Wkly Rep. 2006 Dec 8;55(48):1303]. MMWR - Morbidity & Mortality Weekly Report 2006;55(RR-15):1-48.

10. Diggle L, Deeks J. Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial. BMJ 2000;321:931-3.

11. Groswasser J, Kahn A, Bouche B, et al. Needle length and injection technique for efficient intramuscular vaccine delivery in infants and children evaluated through an ultrasonographic determination of subcutaneous and muscle layer thickness. Pediatrics 1997; 100:400-3.

12. Diggle L, Deeks JJ, Pollard AJ. Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomised controlled trial. BMJ 2006;333:571.

13. Katsma DL, Katsma R. The myth of the 90º-angle intramuscular injection. Nurse Educator 2000;25:34-7

14. Poland GA, Borrud A, Jacobson RM, et al. Determination of deltoid fat pad thickness. Implications for needle length in adult immunization. JAMA 1997;277:1709-11.

15. Ipp MM, Gold R, Goldbach M, et al. Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length. Pediatrics 1989;83:679-82.

16. Mark A, Carlsson RM, Granström M. Subcutaneous versus intramuscular injection for booster DT vaccination of adolescents. Vaccine 1999;17:2067-72.

17. Ruben FL, Froeschle JE, Meschievitz C, et al. Choosing a route of administration for quadrivalent meningococcal polysaccharide vaccine: intramuscular versus subcutaneous. Clinical Infectious Diseases 2001;32:170-2.

18. Program for Appropriate Technology in Health (PATH). Using auto-disable syringes. In: Giving safe injections: using auto-disable syringes for immunization. Seattle: PATH, 2001.

19. Cook IF, Williamson M, Pond D. Definition of needle length required for intramuscular deltoid injection in elderly adults: an ultrasonographic study. Vaccine 2006;24:937-40.