Administration of vaccines

Ensure that:

• the vaccine refrigerator displays minimum/maximum temperatures within the +2°C to +8°C range before removing the vaccine from the refrigerator (see National Vaccine Storage Guidelines: Strive for 5)¹
• you take the correct vaccine from the refrigerator
• the vaccine is within the expiry date
• any diluent container is not damaged or potentially contaminated

Invert the vial, pre-filled syringe or reconstituted vaccine to ensure a homogeneous suspension. Check for particulate matter or colour change in the vaccine. If either is apparent, refer to the vaccine product information.

Wash your hands with soap and water or use an alcohol-based hand rub.^2,3

Prepare the appropriate injection equipment for the vaccine being given (see Equipment for vaccination in Preparing for vaccination).

If more than 1 person is being vaccinated at the same visit (such as family members), prepare vaccines for 1 person at a time to avoid potential error.

Injectable vaccines that do not need reconstitution

If the vaccine is in a vial, remove the cap carefully to maintain sterility of the rubber bung. There is generally no need to wipe the rubber bung of single-dose vials with an alcohol swab if it is visibly clean. If there is visible contamination or the rubber bung is inadvertently touched, clean the bung with a single-use swab. Allow time for the bung to dry before drawing up the contents. ⁴ For further guidance, please refer to state/territory or hospital infection prevention and control guidelines.

Use a new, sterile, disposable 19 or 21 gauge needle to draw up the recommended dose through the bung (or through the top of the ampoule), if required. Use a 45° entry angle and keep the bevel of the needle up as it passes through the bung, to reduce the risk of coring.

Change the needle after drawing up from a vial with a rubber bung or ampoule, before giving the injection. If using a safety needle system, draw up the vaccine, then draw back on the syringe to remove as much vaccine as possible from the tip of the needle. Then remove any air to the tip of the syringe without re-priming the needle.

Using the same needle for drawing up and administration may be more practicable in mass vaccination clinics.

Injectable vaccines that need reconstitution

Reconstitute the vaccine as needed immediately before administration.

Use a new, sterile, disposable 19 or 21 gauge needle for reconstitution, if required. Use a 45° entry angle and keep the bevel of the needle up as it passes through the bung, to reduce the risk of coring.

Use a separate new, sterile, disposable 22–25 gauge needle that is 25 mm long for most people (see Table. Recommended needle size, length and angle for administering vaccines).

Use only the diluent supplied with the vaccine or recommended in the product information. Do not use sterile water for injection instead of a supplied diluent. Completely mix the diluent and vaccine.⁵

Check reconstituted vaccines for signs of deterioration, such as a change in colour or clarity. If there are signs of deterioration, refer to the vaccine product information.

Give reconstituted vaccines as soon as practicable after reconstituting. This is because reconstituted vaccines may deteriorate rapidly. The vaccine’s product information states the maximum time between reconstitution and administration.

Never freeze a vaccine after it has been reconstituted.

All injectable vaccines

Prefilled syringes often come with an air lock bubble – this does not need to be expelled as it is in place to prevent vaccine leakage and allows all of the medication not to track back through subcutaneous tissue as the needle is withdrawn. In the rare case of a large air bubble in a pre-filled syringe:

• first draw back on the needle to ensure that no vaccine is expelled along with the air
• then expel the air through the needle, taking care not to prime the needle with any of the vaccine, because this can increase injection site reactions.

It is recommended that when drawing vaccine from a vial into a regular syringe, the air be expelled because the amount of air drawn into the syringe may be larger than the amount in a manufacturer-filled syringe.

Never mix multiple vaccines together in 1 syringe. The only exception is for Infanrix hexa, where the Hib (Haemophilus influenzae type b) component (a pellet) must be reconstituted with the DTPa-hepB-IPV (diphtheria-tetanus-acellular pertussis, hepatitis B, inactivated poliovirus) components (a liquid).⁵

Never mix a local anaesthetic with a vaccine.⁵

Vaccines in multidose vials

Multidose vials are used in Australia for the BCG (bacille Calmette–Guérin) vaccine (see Tuberculosis) and COVID-19 vaccines. If rabies vaccine is given by the intradermal route, the vial of vaccine may be used for multiple people and should be managed as a multidose vial.

Multidose vials have some advantages over single-dose vaccines for mass vaccination (such as during a pandemic):

• They are more cost-effective.
• They may take less time to manufacture.
• They take up less storage room in a vaccine fridge.

Infection risks for multidose vials

The primary risk with use of multidose vials is a breach in infection control through user error, e.g.:

• inserting a non-sterile needle into the vial
• reusing a contaminated syringe
• storing prepared syringes incorrectly and for longer than the manufacturer recommendation
• storing an opened multidose vial longer than the manufacturers recommendation

Bacteria and bloodborne viruses can be transmitted by inappropriate use of multidose vials. However, most reports of these events have been in high-risk settings such as haemodialysis units, or settings that used anaesthetics and did not involve immunisations.

For guidance on dose extraction from multidose vials see Table. Methods for dose extraction.

Most vaccines available in Australia are given intramuscularly. Only a few vaccines are given subcutaneously, orally or intradermally.

Rotavirus vaccines are only available for oral administration and must never be injected.

Immunisation providers need special training for intradermal administration. This is important for 2 vaccines: Q fever and tuberculosis.

Intramuscular injection

If an intramuscular vaccine is inadvertently given subcutaneously, see Inadvertent subcutaneous injection of intramuscular vaccines.

Vaccines and immunisation products administered by the intramuscular route:

• dT (diphtheria-tetanus) vaccine
• DTPa and dTpa (diphtheria-tetanus-acellular pertussis) vaccine
• DTPa and dTpa combination vaccines
• Hepatitis A vaccine and hepatitis A combination vaccines
• Hepatitis B vaccine and hepatitis B combination vaccines — hepatitis B vaccine can be given intradermally to people who are negative for hepatitis B surface antigen and who do not respond to a primary vaccination course and to later intramuscular doses (see Hepatitis B)
• Hiberix Hib vaccine
• HPV (human papillomavirus) vaccine
• IPV (inactivated poliovirus)–containing combination vaccines — combination vaccines containing IPV are given intramuscularly; IPV (IPOL) is given subcutaneously
• Japanese encephalitis vaccine (JEspect)
• 13vPCV (13-valent pneumococcal conjugate vaccine)
• 15vPCV (15-valent pneumococcal conjugate vaccine)
• 20vPCV (20-valent pneumococcal conjugate vaccine)
• typhoid Vi polysaccharide vaccine
• MenB (meningococcal B) vaccine
• MenACWY (quadrivalent meningococcal conjugate) vaccine
• PCECV (purified chick embryo cell vaccine) for rabies
• PVRV (purified Vero cell rabies vaccine) for rabies
• Recombinant zoster vaccine (Shingrix)
• RSV monoclonal antibodies (nirsevimab and palivizumab)
• RSV vaccines (Arexvy and Abrysvo)
• COVID-19 vaccines

Subcutaneous injection

Vaccines administered by the subcutaneous route:

• IPV vaccine — IPV (IPOL) is given subcutaneously; combination vaccines containing IPV are given intramuscularly
• Varilrix (varicella vaccine)
• Japanese encephalitis vaccine (Imojev)
• Q fever vaccine — the vaccine is given subcutaneously, but only specially trained immunisation providers can do intradermal Q fever skin testing
• Mpox vaccine (JYNNEOS)

If a vaccine that is registered for subcutaneous administration is inadvertently given intramuscularly, it is usually not necessary to repeat the dose. The immune response is unlikely to be affected.

Intramuscular or subcutaneous injection

Vaccines that can be administered by either the intramuscular or subcutaneous routes:

• Act-Hib Hib vaccine
• Influenza vaccine (inactivated) — the intramuscular route is preferred to the subcutaneous route because it causes fewer local adverse events.^6,7 However, if given subcutaneously, the vaccine does not need to be readministered
• MMR vaccine
• MMRV vaccine
• Varivax (varicella vaccine)
• 23vPPV (23-valent pneumococcal polysaccharide vaccine) — the intramuscular route is preferred to the subcutaneous route because it causes fewer local adverse events.^6,7 However, if given subcutaneously, the vaccine does not need to be readministered
• yellow fever vaccine

Intradermal

Only specially trained immunisation providers can give vaccines intradermally.

Vaccines administered by the intradermal route:

• BCG (bacille Calmette–Guérin) vaccine
• Rabies vaccine
• Q fever skin testing
• Mpox vaccine (JYNNEOS) - may be used intradermally as a dose-sparing strategy in the context of vaccine shortage

Intranasal

Vaccines administered by the Intranasal route:

• Influenza vaccine (live-attenuated)

Oral

Vaccines administered by the oral route:

• rotavirus vaccine
• cholera vaccine
• oral typhoid vaccine

Skin cleaning

If the skin is visibly clean, there is no need to wipe it with an antiseptic (such as an alcohol wipe).^4,8,9

Alcohol wipes may increase injection site reactions as alcohol may track in with the vaccine.

If you use alcohol or other disinfecting agents to clean skin that is visibly dirty, the skin must be allowed to dry before injecting the vaccine. This prevents inactivation of live vaccines and reduces the likelihood of irritation at the injection site.¹⁰

Distraction techniques

Distraction, relaxation and other measures reduce distress and pain after vaccination in young children.^11-15 Reducing children’s distress may encourage parents to present for future vaccinations on time.

Distraction measures that may decrease discomfort during vaccination in children include:^11-17

• swaddling and holding the infant securely (but not too tightly)
• allowing the infant to breastfeed when giving the vaccine
• giving the infant a sweet-tasting fluid immediately before the injection (with parental consent), such as 15–25% sucrose drops¹⁸
• having the calmer parent or grandparent present with the child
• shaking a noisy toy (for infants and very young children)
• playing music
• encouraging older children to pretend to blow away the pain using a windmill toy or bubbles
• using a BUZZY® bee (a bee-shaped distraction device with cooling pads)
• using a NeedleCalm device
• using a Virtual Reality headset (e.g. Smileyscope)

Anaesthetics and vapocoolant sprays

Topical anaesthetics, such as EMLA, are not recommended for routine use. They could be considered in a child with excessive fear or dislike of needles. These products need to be applied 30–60 minutes before an injection.¹⁹

Coolsense is a topical anaesthetic device that numbs the skin within 10 seconds of application. It can be used before injection.

Vapocoolant sprays are applied 15 seconds before vaccination. These sprays are more effective in adults than children. This is because children can perceive coldness as painful, and applying the spray may also focus the child on the procedure.

Topical lignocaine/prilocaine is not recommended for children <12 months of age because of the risk of methaemoglobinaemia.¹⁴

Analgesics

Analgesics, such as paracetamol or ibuprofen to reduce the risk of fever are not routinely recommended during or immediately after vaccination. 

The exception is a specific recommendation to give paracetamol prior to meningococcal B vaccine in infants <2 years of age. See Adverse events following immunisation in After vaccination.

Vaccination under sedation

Sedation should not be used as a first line option to facilitate vaccination and may not be available in all jurisdictions or settings.

Many individuals with anxiety or behavioural disorders can be safely vaccinated in the community using non-pharmacological techniques, such as a low-sensory stimulation environment, presence of comfort person/object, distraction with music, video or toys, relaxation techniques and cognitive behaviour therapy (for anxiety/needle-phobia). Possible indications for sedation include people with severe anxiety or needle-phobia and developmental or behavioural disorders, where non-pharmacological measures to facilitate vaccination have been exhausted.

Informed consent must be obtained prior to each dose from the patient themselves, or, where the patient does not have capacity to give consent, from the parent, guardian or substitute decision-maker. Sedation must never be used as a measure to enforce compliance with vaccination requirements.

Sedation involves the administration of medication(s) to depress awareness and reduce responsiveness to external stimulation to varying degrees:

• anxiolysis involves administering a medication to reduce anxiety alone, where the patient is still able to respond verbally
• conscious sedation involves depression of consciousness, during which patients can still respond purposely to verbal commands or tactile stimulation and do not require any breathing support
• deeper sedation involves loss of consciousness, during which patients require breathing support.

Refer to operational policies and guidelines of your local health service or facility regarding sedation procedures. The choice of sedative agent(s) and degree of sedation (light versus deep) should be determined by the treating clinician, taking into account the patient’s medical history, available resources such as a disability liaison service if available, and local procedural sedation guidelines.

All patients who undergo sedation for vaccination require careful observation in the post-vaccination period, ensuring recovery from the sedative agents used and to detect any potential immediate adverse events relating to the vaccine (minimum 15 minutes observation). The period of observation varies depending on choice of sedative(s) and local procedural sedation guidelines.

Opportunistic vaccination during an unrelated elective procedure undertaken under sedation or anaesthesia may be appropriate for some patients and should be considered when possible as it could avoid the need for a separate episode of sedation. Opportunistic vaccination should only be considered during elective procedures where the patient is not acutely unwell.

When administering vaccines under sedation for an unrelated procedure, providers should be aware that:

• attribution of adverse events may be more challenging following vaccination during an unrelated procedure,
• overlapping adverse effects may increase discomfort for the patient (e.g. fever, muscle aches, joint pain after vaccination)
• the inflammatory responses and fever elicited by vaccines may interfere with the postoperative course.

Although surgery and anaesthesia are associated with transient (approximately 48 hours) immunomodulatory effects, these are not anticipated to interfere with an effective immune response to vaccination.²⁰

Most vaccines are suitable to administer under sedation in well patients, however clinicians must use their judgement on a case-by-case basis. Follow existing guidance on co-administration in disease chapters. For additional advice contact your jurisdictional Specialist Immunisation Service.

The choice of injection site mainly depends on the person’s age.

The 2 anatomical sites recommended as routine injection sites are: 

• anterolateral thigh (see Figure. Anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh and Figure. Vastus lateralis injection site on the anterolateral thigh in Identifying the injection site)
• deltoid muscle (see Figure. Anatomical markers used to identify the deltoid injection site in Identifying the injection site)

In addition to the use of the deltoid for intradermal injection, other alternative sites are the inner aspect of the forearm and the upper back below the scapula.

Immunisation providers should be familiar with the landmarks used to identify anatomical sites used for vaccination. The images in this section are not a substitute for training. 

See also Identifying the injection site.

Infants aged <12 months

The vastus lateralis muscle in the anterolateral thigh is the recommended site for intramuscular vaccination in infants <12 months of age. This is because it is a large muscle and is free of neurovascular structures that could be harmed by vaccine administration. See Figure. Anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh and Figure. Vastus lateralis injection site on the anterolateral thigh.

The deltoid muscle is not recommended for intramuscular vaccination of infants <12 months of age.

Children aged ≥12 months

The deltoid muscle is the recommended site for intramuscular vaccination in children ≥12 months of age. See Figure. Anatomical markers used to identify the deltoid injection site.

The vastus lateralis in the anterolateral thigh may also be used in children ≥12 months of age. See Figure. Anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh and Figure. Vastus lateralis injection site on the anterolateral thigh. Only use this site for vaccines that are less locally reactogenic, such as MMR.

Children with congenital limb malformation

Children with congenital limb malformation(s) should receive their vaccines in an unaffected limb if possible. They can also receive vaccines in the ventrogluteal area (see Figure. Anatomical markers used to identify the ventrogluteal injection site).²¹

Children in spica casts

Children in spica casts can be vaccinated when the cast is being changed.

Inform parents about the importance of looking for any signs of swelling that may compromise circulation. If swelling occurs, they should seek advice from their physiotherapist or doctor as soon as possible.²¹

The deltoid muscle can be an alternative vaccination route for children in spica casts. If using this site, it is important to avoid the radial nerve. This is located superficially near the deltoid in children <12 months of age.

Adolescents and adults

The deltoid muscle is the recommended site for intramuscular vaccination in adolescents and adults. See Figure. Anatomical markers used to identify the deltoid injection site.

Older children and adults can also receive vaccines in the anterolateral thigh. See Figure. Anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh. However, they should only receive the least reactogenic vaccine in this muscle to decrease the likelihood of injection site reactions.

People receiving treatment for breast cancer or people with lymphoedema

Avoid giving injections into a person’s arm that is affected by lymphoedema.^24-26 Arm swelling after vaccination may to lead to, or exacerbate, lymphoedema. However, there is limited evidence to support this.

If possible, use a different site, such as the other arm or thigh.^24-26 

More detail about vaccination in people receiving cancer treatment is in Vaccination for people who are immunocompromised.

The choice of injection site depends on the age of the person to be vaccinated. See Recommended injection sites. These illustrations are an approximation only and immunisation providers should refer to approved training modules for proper vaccine administration technique.

Anterolateral thigh (vastus lateralis)

1. Undo the infant’s nappy to completely expose the injection site and allow the anatomical markers to be easily identified by sight and palpation.
2. Position the leg so that the hip and knee are flexed and the vastus lateralis is relaxed (see Figure. Vastus lateralis injection site on the anterolateral thigh).
3. Identify the following anatomical markers: 
   • The upper marker is the midpoint between the anterior superior iliac spine and the pubic tubercle (at the level of the greater trochanter).
   • The lower marker is the upper part of the patella (at the level of the lateral femoral condyle).
4. Draw an imaginary line between the 2 markers down the front of the thigh. The correct site for intramuscular vaccination is lateral to the midpoint of this line, in the outer (anterolateral) aspect (see Figure. Anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh and Figure. Vastus lateralis injection site on the anterolateral thigh). Do not inject into the anterior aspect of the thigh where neurovascular structures can be damaged.

Deltoid area

1. Expose the person’s arm completely, from the top of the shoulder to the elbow. Roll up the person’s sleeve or remove their shirt, if needed.
2. Locate the shoulder tip (acromion) and the muscle insertion at the middle of the humerus (deltoid tuberosity).
3. Draw an imaginary inverted triangle below the shoulder tip, using the identified anatomical markers (see Figure. Anatomical markers used to identify the deltoid injection site). The deltoid site for injection is halfway between the acromion and the deltoid tuberosity, in the middle of the muscle.

Also see Avoiding shoulder injury related to vaccine administration.

Ventrogluteal area

Do not confuse this area with the dorsogluteal area (buttock).

The ventrogluteal area is an alternative site for giving vaccines to children (as well as adolescents and adults, adapting the guidance in this section). It is especially useful when a person needs multiple injections at the same visit.

The ventrogluteal area is relatively free of major nerves and blood vessels, and has the greatest thickness of gluteal muscle.^27,28 Subcutaneous tissue over the injection site is consistently thin.^28,29

1. Undo the child’s nappy to completely expose the injection site and allow the anatomical markers to be easily identified by sight and palpation.
2. Place the child in a prone position (face down) on the parent’s/carer’s lap or on the clinic table/bed, with the child’s arms tucked against their chest. Allow the child’s legs to dangle towards the floor (see Figure. Anatomical markers used to identify the ventrogluteal injection site).
3. Use the injection site that is closest to you. Ensure that the knee and hip are turned inwards to relax the muscle at the injection site.
4. Identify the following anatomical markers (see Figure. Anatomical markers used to identify the ventrogluteal injection site):
   • anterior superior iliac spine
   • greater trochanter of the femur
   • iliac crest
5. Place your palm over the greater trochanter (the uppermost bony prominence of the thigh bone), with the thumb pointing towards the umbilicus.
6. Point your index finger towards the anterior superior iliac spine, and spread your middle finger so it aims at the iliac crest. This creates a ‘V’ outlining the ventrogluteal triangular area. The injection site is at the centre of this area (see Figure. Anatomical markers used to identify the ventrogluteal injection site). 

In small children and infants, the placement of the hand in relation to these anatomical markers may vary, as shown in Figure. Anatomical markers used to identify the ventrogluteal injection site.

Subcutaneous injection sites

Give subcutaneous injections either: 

• over the deltoid muscle, or
• over the anterolateral thigh

There is no difference in efficacy between a ‘subcutaneous injection’ and a ‘deep subcutaneous injection’. 

Figure. Subcutaneous injection into the deltoid area shows the recommended technique for any subcutaneous injection.

It is important that infants and children do not move during vaccine injection. However, too much restraint can increase fear and muscle tension. This section describes positions that may be used for vaccinating different age groups.

Infants aged <12 months

Cuddle position for infants

Position the infant in a semi-recumbent cuddle position on the parent’s/carer’s lap (see Figure. Positioning a child <12 months of age in the cuddle position). The parent/carer should: 

• tuck the infant’s inside arm against the parent’s/carer’s chest
• securely hold the infant’s outside arm and outside leg
• flex the infant’s outside knee to relax the vastus lateralis for intramuscular injections

This position can also be used for young children.

Positioning an infant on an examination table

Lay the infant on their back on an examination table, with the infant’s feet towards you. The parent/carer can stand beside you to immobilise and distract the baby.

Keep the infant’s hip and knee flexed by cupping their patella in your non-injecting hand.

Use the thumb and index finger of your non-injecting hand to stabilise the hub of the needle once the needle has been inserted.

Placing a child in the supine position may result in more pain than if the child is held in an upright position.¹⁹ The mechanism for this is unclear.

Children aged ≥12 months 

Cuddle position for an older child

Sit the child sideways on the parent’s/carer’s lap. The parent/carer should:

• hold the arm to be injected close to the child’s body and secure it at the elbow
• tuck the child’s other arm under the parent’s/carer’s armpit and behind the parent’s/carer’s back
• hold the child’s legs between the parent’s/carer’s legs

See Figure. Positioning an older child in the cuddle position.

Straddle position

An older child may face the parent/carer with their legs straddled over the parent’s/carer’s lap. The child’s arms should be folded in front, and the parent/carer should hug the child’s body to their chest. 

Alternatively, the child can ‘hug’ the parent/carer, with the parent’s/carer’s arms holding the child’s arms in a reciprocal hug (see Figure. Positioning a child in the straddle position). This position allows access to both deltoids and both anterolateral thighs.

Older children, adolescents and adults

Solo sitting position for deltoid injections

Most vaccines can be administered into the deltoid area. Older children, adolescents and adults should: 

• sit in a straight-backed chair
• rest their feet flat on the floor
• relax their forearms and hands on their upper thighs
• keep their arms flexed at the elbow to encourage the deltoid muscle to relax

Encourage the person to drop their shoulders and use distraction to keep muscles relaxed during the procedure. For example, have an interesting poster or similar for the person to concentrate on during the procedure and ask them to describe what they can see.

The vastus lateralis is an alternative site, if needed. Adapt the guidance in Recommended injection sites and Identifying the injection site.

If a person is receiving multiple vaccines, give the most painful vaccine last, if known (such as pneumococcal conjugate vaccine and tetanus-toxoid vaccines). This may decrease the overall pain response.

Record the location of each separate injection, so the vaccine can be identified if the child has a local adverse event.

Infants aged <12 months

Where only two vaccines are scheduled it is recommended to give one vaccine into each thigh. If more than two vaccines are recommended at the one visit, two vaccines may be given into each thigh ensuring they are separated by 2.5 cm.

Children aged ≥12 months, adolescents and adults

Where only two vaccines are scheduled it is recommended to give one vaccine into each deltoid. If more than two vaccines are recommended at the one visit, the options will depend on the deltoid muscle mass.

If the deltoid mass is large enough, give up to 2 injections into each deltoid muscle (separated by 2.5 cm).

If the deltoid muscle mass is small give further injections into either anterolateral thigh (2.5 cm apart if 2 vaccines are given in the same thigh).

For younger children, the cuddle or straddle positions (see Figure. Positioning an older child in the cuddle position and Figure. Positioning a child in the straddle position) can provide access to multiple limbs during a single vaccination encounter.

Simultaneous injections by 2 immunisation providers 

There is insufficient evidence for or against having 2 immunisation providers give vaccines at the same time, rather than 1 vaccine after the other.^30,31

2 studies did not detect a difference in pain response in the child between simultaneous administration and sequential administration.^30,31

2 immunisation providers can give vaccines at the same time if:

• multiple immunisation providers are available
• the technique has been explained to the parent 
• the parent gives consent 
• different injection sites can be safely accessed

Intramuscular injection technique^32,33

1. For intramuscular injection, use a 25 mm needle in most cases (see Table. Recommended needle size, length and angle for administering vaccines).
2. Depending on the injection site, position the limb to relax the muscle that the vaccine is being injected into.
3. Pierce the skin at a 90° angle, so the needle can be safely inserted deep into the muscle layer.³⁴ If the injection angle is >70°, the needle should reach the muscle layer.³⁵
4. It is not necessary to draw back on the syringe plunger before injecting a vaccine.¹⁴ Aspiration can increase pain because of the combined effects of a longer needle-dwelling time in the tissues and wiggling action of the needle.

Ensure that the vaccine is deposited into the muscle and not into the subcutaneous layer. For most vaccines, this minimises local adverse events and improves immunogenicity.^14,36-39

Subcutaneous injection technique

Administer a subcutaneous injection at a 45° angle to the skin into fatty tissue. The standard needle for administering vaccines subcutaneously is a 25–27 gauge needle, 16 mm long. See Table. Recommended needle size, length and angle for administering vaccines.

If a vaccine that is registered for subcutaneous administration is inadvertently given intramuscularly, it is usually not necessary to repeat the dose. The immune response is unlikely to be affected. 

Intradermal injection technique

Intradermal injection is needed for:

• BCG vaccine
• Q fever skin test
• Rabies vaccine
• Mpox vaccine (JYNNEOS); JYNNEOS can also be administered subcutaneously
• Hepatitis B vaccine (in specific cases)

A 26 or 27 gauge, 10 mm needle is recommended.

The intradermal injection technique requires special training. Only trained providers can use this technique.

1. Use a short (10 mm) 26–27 gauge needle with a short bevel. (See Table. Recommended needle size, length and angle for administering vaccines.) The risk of spillage can be minimised by using an insulin syringe that already has a needle attached.
2. Inject vaccine into the skin over the region where the deltoid muscle inserts into the humerus. This is just above the midpoint of the upper arm. This site is recommended to minimise the risk of keloid formation.
3. Stretch the skin between a finger and thumb. Insert the bevel into the dermis, bevel uppermost, to a distance of about 2 mm. The bevel should be visible through the transparent epidermis.
4. You should feel considerable resistance as you give the injection. If there is no resistance, the needle may be in the subcutaneous tissues. A correct intradermal injection should raise a blanched bleb of about 7 mm diameter that looks like orange peel.
5. If the injection is not intradermal, withdraw the needle and repeat at a new site.

Intranasal administration technique

For live-attenuated influenza vaccine (LAIV):

1. Check expiration date (expiry usually different from inactivated influenza vaccines). Product must not be used after date on applicator label.
2. Remove rubber tip protector. Do not remove dose-divider clip at the other end of the applicator.
3. With the patient in an upright position, place the tip just inside the nostril to ensure the vaccine is delivered into the nose.
4. With a single motion, depress plunger as rapidly as possible until the dose-divider clip prevents you from going further.
5. Pinch and remove the dose-divider clip from plunger.
6. Place the tip just inside the other nostril and with a single motion, depress plunger as rapidly as possible to deliver remaining vaccine.

Video demonstrations are available online.

Vaccine administration errors

Guiding principles on vaccine administration errors are presented below. A risk/benefit discussion may be required with the individual to determine if a replacement dose is needed.

For all vaccine administration errors:

• inform the recipient/caregiver of the administration error, following the principles of open disclosure
• provide advice on monitoring for local and systemic adverse events, and when to seek medical attention
• review how the error occurred and consider implementing measures that could prevent it happening again
• report the error as an adverse event, even if no adverse event has occurred, either through your state or territory health department, or directly to the TGA
• if a dose is deemed to be invalid but has already been entered into the Australian Immunisation Register (AIR), you may need to advise the AIR. The best way to do this is by calling 1800 653 809.

Inadvertent subcutaneous injection of intramuscular vaccines

If a vaccine that is only registered for intramuscular administration is inadvertently given subcutaneously, this may not be recognised as an immunogenic route; consider repeating the dose.

Using short needles to give intramuscular vaccines may lead to inadvertent subcutaneous injection. This can increase the risk of significant local adverse events, particularly with aluminium-adjuvanted vaccines (such as hepatitis B, DTPa, DTPa combination or dT vaccines).

Vaccines that should always be repeated if given subcutaneously

Rabipur Inactivated Rabies Virus Vaccine (PCECV) is invalid if given subcutaneously and must be repeated. See Rabies and other lyssaviruses.

Incorrect dose quantity

If the process of administering a vaccine intramuscularly or subcutaneously is interrupted (such as by syringe–needle disconnection, or the correct antigen but incorrect age formulation is given, resulting in less than half of the intended vaccine dose (estimated) being administered, give a replacement dose as soon as feasible.

If an infant spits out or vomits most of an oral rotavirus vaccine dose within minutes of administration, they can receive a single repeat dose during the same visit.

If an infant spits out or vomits only a small part of an oral rotavirus vaccine dose, there is no need to repeat the dose. The regurgitated (and incomplete volume) dose is still considered as the valid dose.

See Rotavirus.

If higher than the approved dose has been administered, the error should be reported and the recipient informed about the potential for local or systemic adverse events. The dose does not need to be repeated.

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