Administration of vaccines
How to identify injection sites and use the correct techniques to administer vaccines for infants, children and adults
Preparing the vaccine
- 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 51
- you take the correct vaccine from the refrigerator
- the vaccine is within the expiry date
- any diluent container is not damaged or potentially contaminated
Gently shake 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
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 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, clean the bung with a single-use swab. Allow time for the bung to dry before drawing up the contents.4
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.
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.
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.
Use a separate new, sterile, disposable 22–25 gauge needle that is 25 mm long to give the vaccine in most cases.
Use only the diluent supplied with the vaccine. 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
Do not push small air bubbles through the needle for injection.
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
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 not routinely used in Australia. The exception is BCG (bacille Calmette–Guérin) vaccine (see Tuberculosis). All vaccines on the National Immunisation Program have single-use preparations.
Multidose vials have some advantages over single-dose vaccines for mass vaccination (such as during an influenza pandemic):
- They are more cost-effective.
- They may take less time to manufacture.
- They take up less storage room in a vaccine fridge.6
Infection risks for multidose vials
The primary risk with use of multidose vials is a breach in infection control through user error. For example, a person can:
- insert a non-sterile needle into the vial
- reuse a contaminated syringe
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.
When only multidose vials are available, mitigate the risk of transmission of infectious disease by following the Australian Guidelines for the Prevention and Control of Infection in Healthcare.2
Route of administration
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.
If an intramuscular vaccine is inadvertently given subcutaneously, see Vaccine injection techniques for advice on revaccinating.
Vaccines 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 healthcare workers negative for hepatitis B surface antigen who do not respond to a primary vaccination course and to later intramuscular doses (see Hepatitis B)
- 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)
- typhoid Vi polysaccharide vaccine
- MenB (meningococcal B) vaccine
- Hib-MenC (Hib-meningococcal C conjugate) vaccine
- MenACWY (quadrivalent meningococcal conjugate) vaccine
- PCECV (purified chick embryo cell vaccine) for rabies
If a subcutaneous vaccine is accidentally given intramuscularly, see Vaccine injection techniques for advice on revaccinating.
Vaccines administered by the subcutaneous route:
- IPV vaccine — IPV (IPOL) is given subcutaneously; combination vaccines containing IPV are given intramuscularly
- VV (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
- MMR (measles-mumps-rubella) vaccine (M-M-R II only)
- MMRV (measles-mumps-rubella-varicella) vaccine (ProQuad only)
- zoster vaccine
Intramuscular or subcutaneous injection
Vaccines that can be administered by either the intramuscular or subcutaneous routes:
- influenza vaccine — the intramuscular route is preferred to the subcutaneous route because it causes fewer local adverse events.7,8 However, if given subcutaneously, the vaccine does not need to be readministered
- MMR vaccine (Priorix only)
- MMRV vaccine (Priorix-tetra only)
- 23vPPV (23-valent pneumococcal polysaccharide vaccine) — the intramuscular route is preferred to the subcutaneous route because it causes fewer local adverse events.7,8 However, if given subcutaneously, the vaccine does not need to be readministered
- HDCV (human diploid cell vaccine) for rabies
- yellow fever vaccine
Only specially trained immunisation providers can give vaccines intradermally.
Vaccines administered by the intradermal route:
Vaccines administered by the oral route:
- rotavirus vaccine
- cholera vaccine
- oral typhoid vaccine
Preparing the person receiving the vaccine
If the skin is visibly clean, there is no need to wipe it with an antiseptic (such as an alcohol wipe).4,9
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, relaxation and other measures reduce distress and pain after vaccination in young children.11-15 Reducing children’s distress may encourage parents to attend for future vaccinations on time.
Distraction measures that may decrease discomfort after vaccination in children include:11-15
- swaddling and holding the infant securely (but not too tightly)
- 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)
- breastfeeding the infant when giving the vaccine
- giving the infant a sweet-tasting fluid immediately before the injection (with parental consent), such as 15–25% sucrose drops16
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.17
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
Paracetamol to reduce the risk of fever is not routinely recommended during or immediately after vaccination.
Vaccine injection techniques
Intramuscular injection technique18,19
- For intramuscular injection, use a 25 mm needle in most cases (see Table. Recommended needle size, length and angle for administering vaccines).
- Depending on the injection site, position the limb to relax the muscle that the vaccine is being injected into.
- Pierce the skin at a 90° angle, so the needle can be safely inserted to the hub.20 If the injection angle is >70°, the needle should reach the muscle layer.21
- If using a 25 gauge needle for an intramuscular vaccination, inject the vaccine slowly over a count of 5 seconds. This avoids injection pain and muscle trauma (see Table. Recommended needle size, length and angle for administering vaccines).
- It is not necessary to draw back on the syringe plunger before injecting a vaccine.14 However, if you have done this and a flash of blood appears in the needle hub, withdraw the needle and select a new site for injection.22
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.14,23-26
Inadvertent subcutaneous injection of intramuscular vaccines
If a vaccine that is registered for intramuscular administration is inadvertently given subcutaneously, check the vaccine product information and the relevant disease-specific chapters in this Handbook for more details.
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).
A clinical trial showed that, in infants, long (25 mm) needles (with the skin stretched flat and the needle inserted at 90°) were associated with significantly fewer local adverse events, and achieved comparable immunogenicity. Little difference in local adverse events or immune response was found between needles of the same length but with different gauges.20
Some intramuscular vaccines may still be immunogenic when given by the subcutaneous route. These vaccine doses do not need to be repeated.
Vaccines that should 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, including Australian bat lyssavirus.
Hepatitis B vaccines should usually be repeated if they are inadvertently given subcutaneously. However, some hepatitis B vaccines may be given subcutaneously in special circumstances. An example is in people with bleeding disorders (see Vaccination for people with bleeding disorders).
Age or size of person to be vaccinated
Angle of needle insertion
Infant, child or adult for intramuscular vaccines
22–25 gauge, 25 mm long
90° to skin plane
Preterm infant (<37 weeks gestation) up to 2 months of age, and/or very small infant
23–25 gauge, 16 mm long
90° to skin plane
Very large or obese person
22–25 gauge, 38 mm long
90° to skin plane
Subcutaneous injection in all people
25–27 gauge, 16 mm long
45° to skin plane
Sources: Kroger et al,14 Diggle and Deeks,18, Diggle et al,20 Poland et al,23 Cook et al27
Subcutaneous injection technique
Administer a subcutaneous injection at a 45° angle to the skin. 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
- Hepatitis B vaccine (in specific cases)
A 26 or 27 gauge, 10 mm needle is recommended.
Interruption to vaccination
If the process of administering a vaccine intramuscularly or subcutaneously is interrupted (such as by syringe–needle disconnection) and most of the dose has not been given, repeat the whole dose as soon as practicable.
Interruption to oral rotavirus vaccination
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.
Recommended injection sites
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)
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 ventrogluteal area is an alternative site for intramuscular vaccination of infants. See Figure. Anatomical markers used to identify the ventrogluteal injection site in Identifying the injection site. Immunisation providers who choose to use this site must be familiar with the landmarks used to identify it. The reactogenicity and immunogenicity of vaccines given in this site are comparable to those of vaccines given in the anterolateral thigh.28-30
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 ventrogluteal area is an alternative site for intramuscular vaccination of children ≥12 months of age. See Figure. Anatomical markers used to identify the ventrogluteal injection site. Immunisation providers should be familiar with the landmarks used to identify this 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).31
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.31
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.
Do not inject vaccines in the dorsogluteal site or upper outer quadrant of the buttock. These sites may induce a suboptimal immune response.32,33
Immunoglobulin can be given intramuscularly into the upper outer quadrant of the buttock. Do not use the other quadrants.
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.
The ventrogluteal area is an alternative injection site. See Figure. Anatomical markers used to identify the ventrogluteal injection site. Immunisation providers should be familiar with the landmarks used to identify this site.
People receiving treatment for breast cancer or people with lymphoedema
Avoid giving injections into a person’s arm that is affected by lymphoedema.34-36 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.34-36
More detail about vaccination in people receiving cancer treatment is in Vaccination for people who are immunocompromised.
Identifying the injection site
The choice of injection site depends on the age of the person to be vaccinated. See Recommended injection sites.
Anterolateral thigh (vastus lateralis)
- Undo the infant’s nappy to completely expose the injection site and allow the anatomical markers to be easily identified by sight and palpation.
- 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).
- Identify the following anatomical markers:
- The upper marker is the midpoint between the anterior superior iliac spine and the pubic tubercle.
- The lower marker is the upper part of the patella
- 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.
Figure showing the anatomical markers used to identify the vastus lateralis injection site on the anterolateral thigh. The injection site is halfway down the vastus lateralis, which is the muscle on the outside of the thigh. Markers include the greater trochanter, and the lateral femoral condyle – the injections site is about halfway between these two levels.
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.37,38 Subcutaneous tissue over the injection site is consistently thin.38,39
- Undo the child’s nappy to completely expose the injection site and allow the anatomical markers to be easily identified by sight and palpation.
- 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).
- 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.
- 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
- Place your palm over the greater trochanter (the uppermost bony prominence of the thigh bone), with the thumb pointing towards the umbilicus.
- 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.
Photograph of an infant showing the ventrogluteal injection site. The infant is laying down over a carer’s lap, so the legs are down at about a 45-degree angle. The person restraining the child is holding the infant’s feet together with the right hand, and the left hand is positioned on the infant’s bottom, with their hand placed to indicate the injection site. The tip of the middle finger is on the iliac crest. The tip of the index finger is on the anterior superior iliac spine. The tip of the thumb is held against the index finger and placed on the greater trochanter. The injection site is in the middle of the triangle formed by the index and middle fingers spread apart.
- 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.
- Locate the shoulder tip (acromion) and the muscle insertion at the middle of the humerus (deltoid tuberosity).
- 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.
Figure showing the anatomical markers used to identify the deltoid injection site. The deltoid is a large rounded triangular shape on the outside of the upper arm, on top of the humerus, the clavicle and the scapula. The brachial artery and the radial nerve sit behind the deltoid and come down from the muscle. The injection site is a smaller triangle-shaped area, in the middle of the deltoid, above the deltoid tuberosity.
Subcutaneous injection sites
Give subcutaneous injections either:
- over the deltoid muscle, or
- over the anterolateral thigh
Figure. Subcutaneous injection into the deltoid area shows the recommended technique for any subcutaneous injection.
An adult is having a subcutaneous injection in the deltoid. The person giving the injection is holding the person’s shoulder with their left hand, and inserting the needle upwards into the deltoid, at a 45 degree angle to the arm.
Positioning for vaccination
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.
A photo of an infant held on their carer’s lap in the cuddle position. The infant is seated on the carer’s left thigh, and slightly reclined. The carer’s right arm is around the infant, and restraining the infant’s outside arm. The infant’s inside arm is tucked against the carer’s chest. The carer’s other (left) hand is holding the infant’s outside (right) foot against their own thigh. The injection site is the vastus lateralis on the anterolateral thigh.
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.17 The mechanism for this is unclear.
Prone position across the lap for ventrogluteal vaccination
For ventrogluteal injection, position the child face down across the parent’s/carer’s lap (see Figure. Anatomical markers used to identify the ventrogluteal injection site). This allows the hips to be flexed and provides access to the ventrogluteal area.
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
A photo of a child in the cuddle position. A child of about 2–3 years old is sitting sideways on their carer’s lap, on the left side. Both their legs are in between the carer’s thighs. The carer’s outside (left) arm is wrapped around the back of the child and holding the child’s left arm snuggly against the child’s side. The carer is holding the child’s left hand snuggly against the child’s stomach with their right hand. The child’s inside (right) arm is tucked under the carer’s left armpit. This reveals the injection side in the child’s left deltoid muscle.
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.
A photo of a child in the straddle position. A child of about 4–5 years old is straddling the carer, so that the carer is hugging the child against their chest. The child is straddling both of the carer’s legs. The carer is holding the child tightly with their left arm. The child’s right arm is tucked under the carer’s left armpit. The carer is holding the child’s left arm at the elbow against the child’s body, using their right hand. The deltoid muscle injection side on the child’s left arm is exposed.
Prone position across the lap for ventrogluteal vaccination
For ventrogluteal injection, position the child face down across the parent’s/carer’s lap (see Figure. Anatomical markers used to identify the ventrogluteal injection site).
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 by asking them to raise their shoulders up while taking a deep breath in and to drop them while breathing out forcefully. 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 ventrogluteal and vastus lateralis are alternative sites, if needed. Adapt the guidance in Recommended injection sites and Identifying the injection site).
Giving multiple vaccine injections at the same visit
If a child is receiving multiple vaccines, give the most painful vaccine last (such as pneumococcal conjugate vaccine). 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
Infants should receive vaccines in the anterolateral thigh (preferred) and the ventrogluteal area.
For the routine schedule when only 2 vaccines are needed, give 1 vaccine in each thigh.
If a child needs 3 or 4 injectable vaccines at the same visit, the options are:
- 2 injections in the same anterolateral thigh, separated by at least 2.5 cm (see Figure. Recommended technique for giving multiple vaccine injections into the anterolateral thigh in an infant <12 months of age, injection numbers 1 and 2); more intramuscular vaccines can be given in this way in the other thigh (injection number 3), or
- 1 injection into each anterolateral thigh and 1 injection into each ventrogluteal area (only give 1 injection into each ventrogluteal area)
An infant is being held in the cuddle position for children <12 months old for an anterolateral thigh injection. Two injection sites are in the same thigh, at least 2.5 cm apart. The third injection should go into the other thigh.
Children aged ≥12 months, adolescents and adults
A single injection can be given into each deltoid muscle in children, adolescents and adults.
If a child needs 3 or 4 intramuscular vaccines at the same visit, the options will depend on the child’s 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), or
- give 1 injection into each ventrogluteal area
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.40,41
2 studies did not detect a difference in pain response in the child between simultaneous administration and sequential administration.40,41
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
- National vaccine storage guidelines: Strive for 5. 2nd ed. Canberra: Australian Government Department of Health and Ageing; 2013.
- National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC; 2010.
- Ryan K, Havers S, Olsen K, Grayson ML, eds. 5 moments for hand hygiene. Melbourne: Hand Hygiene Australia; 2017.
- Hutin Y, Hauri A, Chiarello L, et al. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health Organization 2003;81:491-500.
- Vidor E. The nature and consequences of intra- and inter-vaccine interference. Journal of Comparative Pathology 2007;137 Suppl 1:S62-6.
- Australian Technical Advisory Group on Immunisation. ATAGI statement: Use of multi-dose vials in vaccination programs. 24 September 2009. (Accessed Apr 2018).
- Ruben FL, Jackson GG. A new subunit influenza vaccine: acceptability compared with standard vaccines and effect of dose on antigenicity. Journal of Infectious Diseases 1972;125:656-64.
- Cook IF, Pond D, Hartel G. Comparative reactogenicity and immunogenicity of 23 valent pneumococcal vaccine administered by intramuscular or subcutaneous injection in elderly adults. Vaccine 2007;25:4767-74.
- Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl alcohol swabbing before injection really necessary? Medical Journal of Australia 2001;174:306.
- Cocoman A, Murray J. Intramuscular injections: to swab or not to swab. World of Irish Nursing 2007;15:26-7.
- Felt BT, Mollen E, Diaz S, et al. Behavioral interventions reduce infant distress at immunization. Archives of Pediatrics and Adolescent Medicine 2000;154:719-24.
- Halperin SA, McGrath P, Smith B, Houston T. Lidocaine-prilocaine patch decreases the pain associated with the subcutaneous administration of measles-mumps-rubella vaccine but does not adversely affect the antibody response. Journal of Pediatrics 2000;136:789-94.
- Reis EC, Roth EK, Syphan JL, Tarbell SE, Holubkov R. Effective pain reduction for multiple immunization injections in young infants. Archives of Pediatrics and Adolescent Medicine 2003;157:1115-20.
- Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Atlanta, GA: Centers for Disease Control and Prevention; 2017.
- World Health Organization (WHO). Reducing pain at the time of vaccination: WHO position paper – September 2015. Weekly Epidemiological Record 2015;90:505-10.
- Kassab M, Sheehy A, King M, Fowler C, Foureur M. A double-blind randomised controlled trial of 25% oral glucose for pain relief in 2-month old infants undergoing immunisation. International Journal of Nursing Studies 2012;49:249-56.
- Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ Canadian Medical Association Journal 2010;182:E843-55.
- 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.
- 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.
- 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.
- Katsma DL, Katsma R. The myth of the 90°-angle intramuscular injection. Nurse Educator 2000;25:34-7.
- Program for Appropriate Technology in Health (PATH). Giving safe injections: using auto-disable syringes for immunisation. Seattle, WA: PATH; 2001.
- 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.
- 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.
- Mark A, Carlsson RM, Granström M. Subcutaneous versus intramuscular injection for booster DT vaccination of adolescents. Vaccine 1999;17:2067-72.
- 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.
- 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.
- Cook IF, Murtagh J. Comparative immunogenicity of hepatitis B vaccine administered into the ventrogluteal area and anterolateral thigh in infants. Journal of Paediatrics and Child Health 2002;38:393-6.
- Cook IF, Murtagh J. Comparative reactogenicity and parental acceptability of pertussis vaccines administered into the ventrogluteal area and anterolateral thigh in children aged 2, 4, 6 and 18 months. Vaccine 2003;21:3330-4.
- Cook IF, Murtagh J. Ventrogluteal area – a suitable site for intramuscular vaccination of infants and toddlers. Vaccine 2006;24:2403-8.
- Clarke S, McKay M. An audit of spica cast guidelines for parents and professionals caring for children with developmental dysplasia of the hip. Journal of Orthopaedic Nursing 2006;10:128-37.
- de Lalla F, Rinaldi E, Santoro D, Pravettoni G. Immune response to hepatitis B vaccine given at different injection sites and by different routes: a controlled randomized study. European Journal of Epidemiology 1988;4:256-8.
- Shaw FE, Jr., Guess HA, Roets JM, et al. Effect of anatomic injection site, age and smoking on the immune response to hepatitis B vaccination. Vaccine 1989;7:425-30.
- National Breast and Ovarian Cancer Centre (NBOCC). Review of research evidence on secondary lymphoedema: incidence, prevention, risk factors and treatment. Surry Hills: NBOCC; 2008.
- Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. Journal of the National Cancer Institute 2001;93:96-111.
- Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA: A Cancer Journal for Clinicians 2000;50:292-307.
- Zelman S. Notes on techniques of intramuscular injection: the avoidance of needless pain and morbidity. American Journal of the Medical Sciences 1961;241:563-74.
- Greenway K. Using the ventrologluteal site for intramuscular injection. Nursing Standard 2004;18:39-42.
- Michaels L, Poole RW. Injection granuloma of the buttock. Canadian Medical Association Journal 1970;102:626-8.
- Horn MI, McCarthy AM. Children's responses to sequential versus simultaneous immunization injections. Journal of Pediatric Health Care 1999;13:18-23.
- Schechter NL, Zempsky WT, Cohen LL, et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics 2007;119:e1184-98.
- diphtheria-tetanus-acellular pertussis vaccine
- inactivated poliomyelitis vaccine
- bacille Calmette-Guérin
- diphtheria-tetanus vaccine for use in adults
- diphtheria-tetanus-acellular pertussis vaccine, reduced antigen content formulation
- 13-valent pneumococcal conjugate vaccine
- purified chick embryo cell vaccine (rabies)
- 23-valent pneumococcal polysaccharide vaccine
- National Health and Medical Research Council
- World Health Organization
- Western Australia
- diphtheria-tetanus vaccine
- Japanese encephalitis
This document was printed on: 15/11/2018. Printed content may be out of date. For up to date information, always refer to the digital version: https://immunisationhandbook.health.gov.au/vaccination-procedures/administration-of-vaccines.