General Best Practice Guidelines for Immunization: Vaccine Administration 90

6. Vaccine Administration

Infection Control and Sterile Technique

General Precautions

Persons administering vaccinations should follow appropriate precautions to minimize 

risk for disease exposure and spread. Hands should be cleansed with an alcohol-based 

waterless antiseptic hand rub or washed with soap and water before preparing vaccines for 

administration and between each patient contact (1). Occupational Safety and Health 

Administration (OSHA) regulations do not require gloves to be worn when administering 

vaccinations, unless persons administering vaccinations have open lesions on their hands 

or are likely to come into contact with a patient’s body fluids (2). If worn, gloves should be 

changed between patients.

Vaccine Administration: Preparation and Timely Disposal

Vaccines should be drawn up in a designated clean medication area that is not adjacent to 

areas where potentially contaminated items are placed. Multi-dose vials to be used for 

more than one patient should not be kept or accessed in the immediate patient treatment 

area. This is to prevent inadvertent contamination of the vial through direct or indirect 

contact with potentially contaminated surfaces or equipment that could then lead to 

infections in subsequent patients (3). Smallpox vaccine is accessed by dipping a 

bifurcated needle directly into the vaccine vial. The vaccine adheres to the sides of the 

bifurcated needle, and is administered via skin puncture. The vial must be accessed in the 

immediate patient area to reduce environmental contamination by vaccine virus. To 

prevent contamination of the vial, make sure the patient area is clean and free of 

potentially contaminated equipment.

Different single-components of combination vaccines should never be mixed in the same 

syringe by an end-user unless specifically licensed for such use (4). Single-dose vials and 

manufacturer-filled syringes are designed for single-dose administration and should be 

discarded if vaccine has been withdrawn or reconstituted and subsequently not used 

within the time frame specified by the manufacturer. Syringes that are prefilled by the 

manufacturer and activated (i.e., syringe cap removed or needle attached) but unused 

should be discarded at the end of the clinic day. For non-live vaccines, manufacturers 
General Best Practice Guidelines for Immunization: Vaccine Administration 91

typically recommend use within the same day that a vaccine is withdrawn or reconstituted. 

For live vaccines that require reconstitution, manufacturers typically recommend the 

vaccine be used as soon as possible after reconstitution and be discarded if not used within 

30 minutes after reconstitution. For example, varicella vaccine should be discarded if not 

used within 30 minutes after reconstitution, whereas MMR vaccine, once reconstituted, 

must be kept in a dark place at 36°F to 46°F (2°C to 8°C) and should be discarded within 8 

hours if not used. When in doubt about the appropriate handling of a vaccine, vaccination 

providers should contact that vaccine’s manufacturer.

ACIP discourages the routine practice of providers’ prefilling syringes for several reasons. 

Because the majority of vaccines have a similar appearance after being drawn into a 

syringe, prefilling might result in administration errors. Because unused prefilled syringes 

also typically must be discarded if not used within the same day that they are filled, 

vaccine wastage might occur. The FDA does not license administration syringes for 

vaccine storage.

In certain circumstances in which a single vaccine type is being used (e.g., in preparation 

for a community influenza vaccination campaign), filling a small number (10 or fewer) of 

syringes may be considered (5). The doses should be administered as soon as possible 

after filling, by the same person who filled the syringes. Unused syringes that are prefilled 

by the manufacturer and activated (i.e., syringe cap removed or needle attached) should be 

discarded at the end of the clinic day. Vaccine from two or more vials should never be 

combined to make one or more doses. This can lead to violation of expiration dates and 

product contamination (6,7).

Health Care Provider Exposure to Vaccine Components

Providers are sometimes concerned when they have the same contraindications or 

precautions as their patients from whom they withhold or defer vaccine. For 

administration of routinely recommended vaccines, there is no evidence of risk of 

exposure of vaccine components to the health care provider, so conditions in the provider 

labeled as contraindications and precautions to a vaccine components are not a reason to 

withdraw from this function of administering the vaccine to someone else. Historic 

concerns about exposure to vaccine components are limited to non-parenteral vaccines in 

which some degree of environmental exposure is unavoidable (5, 8), or situations in which 
General Best Practice Guidelines for Immunization: Vaccine Administration 92

self-inoculation is likely due to the nature of the vaccine microbe [e.g. reduced attenuation 

of smallpox vaccine virus (9)]. Persons administering ACAM 2000 smallpox vaccine to 

laboratory and health care personnel at risk for occupational exposure to orthopoxviruses 

can decrease the risk for inadvertent infection through recommended infection prevention 

measures. However, because of a theoretical risk for infection, vaccination with 

ACAM2000 can be offered to health care personnel administering this vaccine, provided 

individual persons have no specified contraindications to vaccination (10).

Safe Use of Needles and Syringes

Needles and syringes used for vaccine injections must be sterile and disposable. A separate 

needle and syringe should be used for each injection. Changing needles between drawing 

vaccine from a vial and injecting it into a recipient is not necessary unless the needle has 

been damaged or contaminated (11).

Bloodborne diseases (e.g., hepatitis B, hepatitis C, human immunodeficiency virus [HIV]) 

are occupational hazards for clinicians and other health-care providers. The Needlestick 

Safety and Prevention Act (2) was enacted in 2000 to reduce the incidence of needlestick 

injury and the consequent risk for bloodborne diseases acquired from patients. The act 

directed OSHA to strengthen its existing bloodborne pathogen standards. The revised 

standards became effective in 2001 (2). These federal regulations require the use of 

engineering and work practice controls to eliminate or minimize employee exposure to 

bloodborne pathogens. Engineering controls means controls (e.g., sharps disposal 

containers, self-sheathing needles, safer medical devices, such as sharps with engineered 

sharps injury protections and needleless systems) that isolate or remove the bloodborne 

pathogens hazard from the workplace). Needle-shielding or needle-free devices that might 

satisfy the occupational safety regulations for administering injectable vaccines are 

available in the United States (12-13). The regulations also require maintenance of records 

documenting injuries caused by needles and other medical sharp objects and that 

nonmanagerial employees be involved in the evaluation and selection of safety-engineered 

devices before they are procured. Additional information about implementation and 

enforcement of these regulations is available from OSHA.
General Best Practice Guidelines for Immunization: Vaccine Administration 93

To prevent inadvertent needlestick injury or reuse, safety mechanisms should be deployed 

after use and needles and syringes should be discarded immediately in labeled, punctureproof containers located in the same room where the vaccine is administered (5). Used 

needles should never be recapped. 

Route of Administration

Injectable Route

Routes of administration are recommended by the manufacturer for each immunobiologic 

(Table 6-1). With the exceptions of bacille Calmette-Guérin (BCG) vaccine and smallpox 

vaccine [ACAM2000] (both administered by the percutaneous route), injectable vaccines 

are administered by the intramuscular or subcutaneous route. The smallpox/monkeypox 

vaccine (Jynneos) is primarily administered by the subcutaneous route but in some 

circumstances is administered by the intradermal route. Deviation from the recommended 

route of administration might reduce vaccine efficacy (14-15) or increase the risk for local 

adverse reactions (16-18). 

The method of administration of injectable vaccines is determined, in part, by the 

inclusion of adjuvants in some vaccines. An adjuvant is a vaccine component distinct from 

the antigen that enhances the immune response to the antigen, but might also increase 

risk of adverse reactions. To decrease risk of local adverse events, non-live vaccines 

containing an adjuvant should be injected into a muscle. Administering a vaccine 

containing an adjuvant either subcutaneously or intradermally can cause local irritation, 

induration, skin discoloration, inflammation, and granuloma formation.

Intramuscular Injections

Needle Length

Injectable immunobiologics should be administered where local, neural, vascular, or tissue 

injury is unlikely. Use of longer needles has been associated with less redness or swelling 

than occurs with shorter needles because of injection into deeper muscle mass (16). 

Appropriate needle length depends on age and body mass. Injection technique is the most 

important parameter to ensure efficient intramuscular vaccine delivery.
General Best Practice Guidelines for Immunization: Vaccine Administration 94

For all intramuscular injections, the needle should be long enough to reach the muscle 

mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to 

involve underlying nerves, blood vessels, or bone (15,19-22). Vaccinators should be 

familiar with the anatomy of the area into which they are injecting vaccine. 

Intramuscular injections are administered at a 90-degree angle to the skin, preferably into 

the anterolateral aspect of the thigh or the deltoid muscle of the upper arm, depending on 

the age of the patient (Table 6-2).

The needle gauge for intramuscular injection is 22-25 gauge. A decision on needle length 

and site of injection must be made for each person on the basis of the size of the muscle, 

the thickness of adipose tissue at the injection site, the volume of the material to be 

administered, injection technique, and the depth below the muscle surface into which the 

material is to be injected (Figure 1). Some experts allow intramuscular injection with a 5⁄8-

inch needle but ONLY if the skin is stretched flat (21). If the subcutaneous and muscle 

tissue are bunched to minimize the chance of striking bone (19), a 1-inch needle or larger 

is required to ensure intramuscular administration. Aspiration before injection of vaccines 

or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before 

injection) is not necessary because no large blood vessels are present at the recommended 

injection sites, and a process that includes aspiration might be more painful for infants 

(22).

Infants (Aged <12 Months)

For the majority of infants, the anterolateral aspect of the thigh is the recommended site 

for injection because it provides comparatively larger muscle mass than the deltoid 

(Figure 2) (23). In certain circumstances (e.g., physical obstruction to other sites and no 

reasonable indication to defer doses), the gluteal muscle can be used. If the gluteal muscle 

must be used, care should be taken to define the anatomic landmarks.(a) For the majority of 

infants, a 1-inch needle is sufficient to penetrate the thigh muscle.

Toddlers (Aged 12 Months-2 Years)

For toddlers, the anterolateral thigh muscle is preferred, and when this site is used, the 

needle should be at least 1 inch long. The deltoid muscle can be used if the muscle mass is 

adequate. If 2 vaccines are to be administered in a single limb, they should be spaced an 

inch apart (4, 24).
General Best Practice Guidelines for Immunization: Vaccine Administration 95

Children (Aged 3-10 Years)

The deltoid muscle is preferred for children aged 3-10 years (25); the needle length for 

deltoid site injections can range from 5⁄8 to 1 inch on the basis of technique. The 

anterolateral thigh can also be used (25). In this case the needle length should be 1 inch to 

1.25 inches. Knowledge of body mass can be useful for estimating the appropriate needle 

length (26).

Young Adolescents (Aged 11-18 years)

The deltoid muscle is preferred for adolescents 11-18 years of age. The anterolateral thigh 

can also be used. For injection into the anterolateral thigh, most adolescents will require a 

1-1.5-inch needle to ensure intramuscular administration (27).

Adults (Aged ≥19 Years)

For adults, the deltoid muscle is recommended for routine intramuscular vaccinations 

(23) (Figure 3). The anterolateral thigh also can be used. When injecting into the deltoid 

muscle, for adults a measurement of body mass/weight is allowable prior to vaccination, 

understanding that resources to measure body mass/weight are not available in all clinical 

settings. For men and women who weigh <130 lbs (<60 kg), a 5⁄8-inch needle is sufficient 

to ensure intramuscular injection in the deltoid muscle if the injection is made at a 90-

degree angle and the tissue is not bunched. For men and women who weigh 130-152 lbs 

(60-70 kg), a 1-inch needle is sufficient. For women who weigh 152-200 lbs (70-90 kg) and 

men who weigh 152-260 lbs (70-118 kg), a 1- to 1.5-inch needle is recommended. For 

women who weigh >200 lbs (>90 kg) or men who weigh >260 lbs (>118 kg), a 1.5-inch 

needle is recommended (table 6-2) (20). For injection into the anterolateral thigh muscle, 

a 1.5-inch needle should be used, although a 1-inch needle may be used if the skin is 

stretched tightly and subcutaneous tissues are not bunched.

Subcutaneous Injections

Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for 

infants aged <12 months and in the upper-outer triceps area of persons aged ≥12 months. 

Subcutaneous injections may be administered into the upper-outer triceps area of an 

infant if necessary. A 5⁄8-inch, 23- to 25-gauge needle should be inserted into the 

subcutaneous tissue (Figures 4 and 5) (4).
General Best Practice Guidelines for Immunization: Vaccine Administration 96

Oral Route

Rotavirus, adenovirus, cholera vaccine, and oral typhoid vaccines are the only vaccines 

administered orally in the United States. Oral typhoid capsules should be administered as 

directed by the manufacturer. The capsules should not be opened or mixed with any other 

substance. Rotavirus vaccines are licensed for infants. There are 2 brands of rotavirus 

vaccine, and they have different types of applicators. Providers should consult package 

inserts for details.

Intranasal Route

Live attenuated influenza vaccine is approved for healthy nonpregnant persons aged 2-49 

years and is the only vaccine administered by the intranasal route. The administration 

device is a nasal sprayer with a dose-divider clip that allows introduction of one 0.1-mL 

spray into each naris. The tip should be inserted slightly into the naris before 

administration. Even if the person coughs or sneezes immediately after administration or 

the dose is expelled any other way, the vaccine dose need not be repeated (5).

Severely immunosuppressed persons (i.e., those who require care in a protected 

environment, e.g., bone marrow transplant recipients, individuals with severe combined 

immunodeficiency diseases) should not administer LAIV. It would be uncommon for 

persons with these conditions to be in a role administering vaccines. Other persons at 

increased risk for influenza complications can administer LAIV. These include persons 

with underlying medical conditions placing them at higher risk or who are likely to be at 

risk, including pregnant women, persons with asthma, and persons aged ≥50 years (2).

Multiple Injections

If multiple vaccines are administered at a single visit, administer each preparation at a 

different anatomic site (28). The location of all injection sites with the corresponding 

vaccine injected should be documented in each patient’s medical record. Health-care 

practices should consider using a vaccination site map so that all persons administering 

vaccines routinely use a particular anatomic site for each particular vaccine.

For infants and younger children, if more than 2 vaccines are injected in a single limb, the 

thigh is the preferred site because of the greater muscle mass; the injections should be 

sufficiently separated (separate anatomic sites [i.e. ≥1 inch] if possible) so that any local 
General Best Practice Guidelines for Immunization: Vaccine Administration 97

reactions can be differentiated (13,29). For older children and adults, the deltoid muscle 

can be used for more than one intramuscular injection.

If a vaccine and an immune globulin preparation are administered simultaneously (e.g., 

Td/Tdap and tetanus immune globulin [TIG], hepatitis B and hepatitis B immunoglobulin 

[HBIG]), separate limbs should be used for each injection (29-30).

Jet Injections

Jet injectors are needle-free devices that pressurize liquid medication, forcing it through a 

nozzle orifice into a narrow stream capable of penetrating skin to deliver a drug or vaccine 

into intradermal, subcutaneous, or intramuscular tissues (32-33). Immune responses 

generated by jet injectors against both attenuated and non-live viral and bacterial antigens 

are usually equivalent to, and occasionally greater than, immune responses induced by 

needle injection. However, local reactions or injuries (e.g., skin laceration, transient 

neuropathy, hematoma) are sometimes more frequent on delivery of vaccine by jet 

injectors compared with needle injection, depending on the inherent irritability of the 

vaccine and operator technique (33).

Multiple use jet injectors using the same nozzle for consecutive injections without 

intervening sterilization were used in mass vaccination campaigns from the 1950s through 

the 1990s (33); however, these were found to be unsafe because of the possibility of 

bloodborne pathogen transmission (34-37) and should not be used. A new generation of 

jet injectors with disposable cartridges and syringes has been developed since the 1990s. 

With a new, sterile dose chamber and nozzle for each patient and correct use, these 

devices do not have the same safety concerns as multiple-use nozzle jet injectors. Several 

of the newer devices have been approved by FDA for use with specific vaccines (33). Jet 

injectors prevent needlestick injuries to health-care providers (2) and can overcome 

improper, unsterile reuse and other drawbacks of needles and syringes in developing 

countries (9, 38-39).
General Best Practice Guidelines for Immunization: Vaccine Administration 98

Methods for Alleviating Discomfort and Pain Associated 

with Vaccination

Comfort measures, such as distraction (e.g., playing music or pretending to blow away the 

pain), cooling of the injection site(s), topical analgesia, ingestion of sweet liquids, 

breastfeeding, swaddling, and slow, lateral swaying can help infants or children cope with 

the discomfort associated with vaccination (40-42). Pretreatment (30-60 minutes before 

injection) with a 5% topical lidocaine-prilocaine emulsion might decrease the pain of 

vaccination by causing superficial anesthesia (43-44). Evidence indicates that this cream 

does not interfere with the immune response to MMR (45). There is no evidence the cream 

interferes with other vaccines (46-49). 

Topical lidocaine-prilocaine emulsion should not be used on infants aged <12 months who 

are receiving treatment with methemoglobin-inducing agents (e.g., acetaminophen, amyl 

nitrate, nitroprusside, dapsone) because of the possible development of 

methemoglobinemia (50). Use of a topical refrigerant (vapocoolant) spray immediately 

before vaccination can reduce the short-term pain associated with injections and can be as 

effective as lidocaine-prilocaine cream (51). 

Evidence does not support use of antipyretics before or at the time of vaccination; 

however, they can be used for the treatment of fever and local discomfort that might occur 

following vaccination. Studies of children with previous febrile seizures have not 

demonstrated antipyretics to be effective in the prevention of febrile seizures (48).

Clinical Implications of Nonstandard Vaccination 

Practices

Best practice guidance for route, site, and dosage of immunobiologics is derived from data 

from clinical trials, practical experience, normal intervals of health care visits, and 

theoretical considerations. ACIP discourages variations from the recommended route, site, 

volume, or number of doses of any vaccine.

Variation from the recommended route and site can result in inadequate protection. In 

adults (but not in infants) (52), the immunogenicity of hepatitis B is substantially lower 

when the gluteal rather than the deltoid site is used for administration (8). Hepatitis B 

administered intradermally might result in a lower seroconversion rate and final titer of 
General Best Practice Guidelines for Immunization: Vaccine Administration 99

hepatitis B surface antibody than when administered by the deltoid intramuscular route 

(53-54). Hepatitis B administered by any route other than intramuscular, or in adults at 

any site other than the deltoid or anterolateral thigh, should not be counted as valid and 

should be repeated (9). Similarly, doses of rabies vaccine administered in the gluteal site 

should not be counted as valid doses and should be repeated (54). Hepatitis A vaccine and 

meningococcal conjugate vaccine do not need to be repeated if administered by the 

subcutaneous route (55-56). However, for DTaP, Hib, and PCV13, there is no evidence 

related to immunogenicity of these 3 vaccines given subcutaneously. Providers should 

address circumstances in which dose(s) of these vaccines have been administered 

subcutaneously on a case-by-case basis. 

Inactivated influenza vaccine is immunogenic when administered in a lower-thanstandard dose by the intradermal route to healthy adult volunteers. Intradermal injection 

produced antibody responses similar to intramuscular injection in vaccinees aged 18-60 

years (57). However, the immunogenicity for persons aged ≥65 years is inadequate, and 

varying the recommended route and dose either with the intradermal product licensed 

through 64 years of age or with other influenza vaccines is not recommended (24).

Live, attenuated injectable vaccines (e.g., MMR, varicella, yellow fever) and certain nonlive vaccines (e.g., meningococcal polysaccharide) are recommended by the manufacturers 

to be administered by subcutaneous injection. PPSV23and IPV are recommended by the 

manufacturer to be administered by the subcutaneous or intramuscular route. Response 

to vaccines recommended by the subcutaneous route is unlikely to be affected if the 

vaccines are administered by the intramuscular rather than subcutaneous route. 

Repeating doses of vaccine administered by the intramuscular route when recommended 

to be by the subcutaneous route is not necessary (10).

Administering volumes smaller than recommended (e.g., inappropriately divided doses) 

might result in inadequate protection. Using reduced doses administered at multiple 

vaccination visits that equal a full dose or using smaller divided doses is not recommended 

(4). Any vaccination using less than the standard dose should not be counted, and the 

person should be revaccinated according to age unless serologic testing indicates that an 

adequate response has developed. However, if 2 half-volume formulations of vaccine have 

already been administered on the same clinic day to a patient recommended for the full 

volume formulation, these 2 doses can count as one full dose. If less than a full 
General Best Practice Guidelines for Immunization: Vaccine Administration 100

recommended dose of a vaccine is administered because of syringe, applicator, or needle 

leakage, the dose should be repeated (5). Using larger-than-recommended dosages can be 

hazardous because of excessive local or systemic concentrations of antigens or other 

vaccine constituents.

(a) If the gluteal muscle is chosen, injection should be administered lateral and superior to a line between the posterior superior iliac 

spine and the greater trochanter or in the ventrogluteal site, the center of a triangle bounded by the anterior superior iliac spine, the 

tubercle of the iliac crest, and the upper border of the greater trochanter.
General Best Practice Guidelines for Immunization: Vaccine Administration 101

TABLE 6-1. Dose and route of administration for selected vaccines

Vaccine Dose Route

DEN4CYD 0.5 mL Subcut

DTaP, DT, Td, Tdap 0.5 mL IM

DTaP-HepB-IPV 0.5 mL IM

DTaP/Hib 0.5 mL IM

DTaP-IPV/Hib 0.5 mL IM

DTaP-IPV 0.5 mL IM

Hib 0.5 mL IM

Hib-MenCY 0.5 mL IM

HepA ≤18 years: 0.5 mL

≥19 years: 1.0 mL

IM 

HepB ≤19 years: 0.5 mL(a)

≥20 years: 1.0 mL

IM 

HepA-HepB ≥18 years: 1.0 mL IM

LAIV 0.2 mL divided dose between 

nares

Intranasal spray

IIV 6-35 months: 0.25 mL or 0.5 mL

≥3 years: 0.5 mL(b)

IM 

MenB 0.5 mL IM

MMR 0.5 mL Subcut

MMRV 0.5 mL Subcut

MenACWY 0.5 mL IM

MPSV4 0.5 mL Subcut

PCV13 0.5 mL IM

PCV15 0.5 mL IM

PCV20 0.5 mL IM

PPSV23 0.5 mL IM or Subcut

HPV 0.5 mL IM

IPV 0.5 mL IM or Subcut

Rotavirus (RV1 or RV5) (1.0 mL or 2.0 mL) Oral

Varicella 0.5 mL Subcut

RZV 0.5 mL(c) IM

Abbreviations: DEN4CYD = dengue vaccine; DT = diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus 

toxoids and acellular pertussis; HepA = hepatitis A; HepB = hepatitis B; Hib = Haemophilus influenzae type b; HPV = 

human papillomavirus; IIV = inactivated influenza vaccine; IM = intramuscular; IPV = inactivated poliovirus; LAIV = 
General Best Practice Guidelines for Immunization: Vaccine Administration 102

TABLE 6-1. Dose and route of administration for selected vaccines

Vaccine Dose Route

live, attenuated influenza vaccine; MenACWY = quadrivalent meningococcal conjugate vaccine; MenCY = bivalent 

meningococcal conjugate vaccine component; MMR = measles, mumps, and rubella; MMRV = measles, mumps, 

rubella, and varicella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV13 = pneumococcal 

conjugate vaccine; PPSV23= pneumococcal polysaccharide vaccine; RV1 = live, attenuated monovalent rotavirus 

vaccine; RV5 = live, reassortment pentavalent rotavirus vaccine; RZV = recombinant adjuvanted zoster vaccine; 

Subcut = subcutaneous; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and 

acellular pertussis.

Source: Adapted from Immunization Action Coalition: http://www.immunize.org.

(a) Persons aged 11-15 years may be administered Recombivax HB (Merck), 1.0 mL (adult formulation) on a 2-dose schedule.

(b) Note that prefilled syringes of High-Dose Fluzone have a volume of 0.7 cc and the recommended volume of administration is 

0.7 ccs.

Do not withdraw more than 0.5 mL from the reconstituted product, even if some product is left in the vial.
General Best Practice Guidelines for Immunization: Vaccine Administration 103

TABLE 6-2. Needle length and injection site of IM injections for children 

aged ≤18 years (by age) and adults aged ≥19 years (by sex and weight)

Age group Needle length Injection site

Children (birth-18 years)

Neonates(a) 5/8 inch (16 mm)(b) Anterolateral thigh

Infants, 1-12 months 1 inch (25 mm) Anterolateral thigh

Toddlers, 1-2 years 1-1.25 inch (25-32

mm)

Anterolateral thigh(c)

5/8(b)-1 inch (16-25 

mm)

Deltoid muscle of arm

Children, 3-10 years 5/8(b)-1 inch (16-25 

mm)

Deltoid muscle of arm(c)

1-1.25 inches (25-32 

mm)

Anterolateral thigh

Children, 11-18 years

5/8(b)-1 inch (16-25 

mm)

Deltoid muscle of arm(c)

1-1.5 inches (25-38 

mm)

Anterolateral thigh

Adults (≥19 years)

Men and women, <60 kg (130 lbs) 1 inch (25 mm) (d) Deltoid muscle of arm

Men and women, 60-70 kg (130-

152 lbs)

1 inch (25 mm)

Men, 70-118 kg (152-260 lbs) 1-1.5 inches (25-38 

mm)

Women, 70-90 kg (152-200 lbs)

Men, >118 kg (260 lbs) 1.5 inches (38 mm)

Women, >90 kg (200 lbs)

Men and women, any weight 1.5 inches (38 mm)(e) Anterolateral thigh
General Best Practice Guidelines for Immunization: Vaccine Administration 104

Abbreviation: IM = intramuscular.

Source: (14).

(a) First 28 days of life.

(b) If skin is stretched tightly and subcutaneous tissues are not bunched.

(c) Preferred site.

(d) Some experts recommend a 5/8-inch needle for men and women who weigh <60 kg, if used, skin must be 

stretched tightly (do not bunch subcutaneous tissue).

(e) Some experts recommend a 1-inch needle if the skin is stretched tightly and subcutaneous tissues are not 

bunched.
General Best Practice Guidelines for Immunization: Vaccine Administration 105

Figure 1. Intramuscular needle insertion

Source: Adapted from California Immunization Branch.

Alternate Text: This drawing shows intramuscular needle insertion into a crosssection of skin. The needle is inserted at a 90-degree angle and penetrates the dermis, 

fatty tissue (subcutaneous), and muscle tissue.
General Best Practice Guidelines for Immunization: Vaccine Administration 106

Figure 2. Intramuscular/subcutaneous site of administration: anterolateral 

thigh

Source: Adapted from Minnesota Department of Health.

Alternate Text: This drawing shows a mother holding an infant. The anterolateral 

aspect of the infant’s thigh is shaded, showing the proper site for 

intramuscular/subcutaneous vaccine administration.
General Best Practice Guidelines for Immunization: Vaccine Administration 107

Figure 3. Intramuscular site of administration: deltoid

Source: Adapted from Minnesota Department of Health and Immunize.org.

Alternate Text: This line drawing is a side view of an adult. The deltoid muscle of the 

arm is shaded, showing the proper site for intramuscular vaccine administration.
General Best Practice Guidelines for Immunization: Vaccine Administration 108

Figure 4. Subcutaneous site of administration: triceps

Source: Adapted from the Minnesota Department of Health.

Alternate Text: This line drawing is a rear/dorsal view of an adult. The triceps muscle 

of the arm is shaded, showing the proper site for subcutaneous vaccine administration.
General Best Practice Guidelines for Immunization: Vaccine Administration 109

Figure 5. Subcutaneous needle insertion

Source: Adapted from California Immunization Branch.

Alternate Text: This drawing shows subcutaneous needle insertion into a crosssection of skin. The needle is inserted at a 45-degree angle and penetrates the dermis 

and fatty tissue (subcutaneous) but not the muscle tissue.
General Best Practice Guidelines for Immunization: Vaccine Administration 110

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