Vaccine Administration

69

6

This chapter summarizes best practices related to vaccine 

administration, a key factor in ensuring vaccination is as safe 

and effective as possible. Administration involves a series of 

actions: assessing patient vaccination status and determining 

needed vaccines, screening for contraindications and 

precautions, educating patients, preparing and administering 

vaccines properly, and documenting the vaccines administered. 

Professional standards for medication administration, 

manufacturer instructions, and organizational policies and 

procedures should always be followed when applicable. 

Staff Training and Education 

Policies should be in place to validate health care professionals’ 

knowledge of, and skills in, vaccine administration. All health 

care professionals should receive comprehensive, competencybased training before administering vaccines. Training, including 

an observation component, should be integrated into health 

care professionals’ education programs including orientation 

for new staff and annual continuing education requirements 

for all staff. In addition, health care professionals should 

receive educational updates as needed, such as when vaccine 

administration recommendations are updated or when new 

vaccines are added to the facility’s inventory. Training should 

also be offered to temporary staff who may be filling in on days 

when the facility is short-staffed or helping during peak periods 

of vaccine administration such as influenza season. Once initial 

training has been completed, accountability checks should be 

in place to ensure staff follow all vaccine administration policies 

and procedures. 

Before Administering Vaccine 

Health care professionals should be knowledgeable about 

appropriate techniques to prepare and care for patients when 

administering vaccines. 

Assess for Needed Vaccines

The patient’s immunization status should be reviewed at 

every health care visit. Using the patient’s immunization 

history, health care providers should assess for all routinely 

recommended vaccines as well as any vaccines that are 

indicated based on existing medical condition(s), occupation, 

or other risk factors. 

To obtain a patient’s immunization history, information from 

immunization information systems (IISs), current and historical 

medical records, and personal shot record cards may be used. 

In most cases, health care providers should only accept written, 

JoEllen Wolicki, BSN, RN and Elaine Miller, RN, BSN, MPH 

NOTES

https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html Aug 2021
70

Vaccine Administration

 6

dated records as evidence of vaccination; however, self-reported 

doses of influenza vaccine or pneumococcal polysaccharide 

vaccine (PPSV23) are acceptable. 

Missed opportunities to vaccinate should be avoided. If a 

documented immunization history is not available, 

administer the vaccines that are indicated based on the 

patient’s age, medical condition(s), and other risk factors, 

such as planned travel. 

Screen for Contraindications and Precautions

Before administering any vaccine, patients should be 

screened for contraindications and precautions, even if the 

patient has previously received that vaccine. The patient’s 

health condition or recommendations regarding contraindications and precautions for vaccination may change from 

one visit to the next. 

To assess patients correctly and consistently, health care 

providers should use a standardized, comprehensive 

screening tool. To save time, some facilities ask patients to 

answer screening questions before seeing the provider, either 

electronically via an online health care portal or on a paper 

form while in the waiting or exam room.

Educate Patients or Parents about Needed Vaccines 

Vaccines are one of the safest and most effective ways 

to prevent diseases. All health care personnel, including 

non-clinical staff, play an important role in promoting 

vaccination and creating a culture of immunization within 

a clinical practice. Inconsistent messages from health care 

personnel about the need for and safety of vaccines may cause 

confusion about the importance of vaccines. 

Talking with Parents about Vaccines for Infants

1

2

3

Assume parents

will vaccinate

Administer

recommended

vaccine doses

Give your strong

recommendation

Listen to and respond

to parent’s questions

Parents consent with 

no further questions?

Parents not ready

to vaccinate?

Parents have specific

questions or concerns?

Parents accept your

recommendation?

Parents respond positively

to your answers?

NOTES
Vaccine Administration

71

6

Studies show health care providers are the most trusted 

source of vaccine information. Research also shows when a 

strong recommendation is given by a health care provider, 

a patient is four to five times more likely to be vaccinated. 

When providers use presumptive language to initiate vaccine 

discussions, significantly more parents choose to vaccinate 

their children, especially at first-time visits. Instead of saying 

“What do you want to do about shots today,” an approach 

using presumptive language would be to say, “Your child 

needs three vaccines today.” 

Some patients and parents may have questions or concerns 

about vaccination. This does not necessarily mean they will 

not accept vaccines. Sometimes they simply want to hear their 

provider’s answers to their questions.

Health care professionals need to be prepared to answer 

questions. In addition, many state and local immunization 

programs and professional organizations, including the 

American Academy of Pediatrics, have resources. There are 

numerous strategies for effectively educating and talking to 

patients and parents about the need to vaccinate. 

Vaccine Information Statements (VISs)

Vaccine information statements (VISs) are documents that 

inform vaccine recipients or their parents about the benefits 

and risks of a vaccine. Federal law requires VISs be provided 

when routinely recommended childhood vaccines are 

administered. Everyone, including adults, should be given the 

appropriate VIS when receiving a vaccine covered under the 

law. The VIS must be given: • Before the vaccine is administered • Regardless of the age of the person being vaccinated 

(e.g., when influenza vaccine is given to an adult)

• Every time a dose of vaccine is administered, even if the 

patient has received the same vaccine and VIS in the past

CDC encourages the use of all VISs, whether the vaccine is 

covered by the law requiring VIS or not. VISs can be provided at 

the same time as a screening questionnaire, while the patient is 

waiting to be seen. They include information that may help the 

patient or parent respond to the screening questions and can 

be used by providers during conversations with patients. VISs 

are available as paper copies and in electronic formats that can 

be read on smart phones and other devices. 

After-Care Instructions

Patient and parent education should also include a discussion 

of comfort and care strategies after vaccination. After-care 

instructions should include information for dealing with 

common side effects such as injection site pain, fever, and 

NOTES
72

Vaccine Administration

 6

fussiness (especially in infants). Instructions should also provide 

information about when to seek medical attention and when 

to notify the health care provider about concerns that arise 

following vaccination. After-care information can be given to 

patients or parents before vaccines are administered, leaving 

the parent free to comfort the child immediately after the 

injection. Pain relievers can be used to treat fever and injectionsite pain that might occur after vaccination. In children and 

adolescents, a non-aspirin-containing pain reliever should be 

used. Aspirin is not recommended for children and adolescents. 

Vaccine Administration

Infection Control

Health care personnel should follow routine infection control 

procedures when administering vaccines. 

Hand Hygiene

Hand hygiene is critical to prevent the spread of illness and 

disease. Hand hygiene should be performed before vaccine 

preparation, between patients, and any time hands become 

soiled (e.g., when diapering). Hands should be cleansed 

with a waterless, alcohol-based hand rub or soap and water. 

When hands are visibly dirty or contaminated with blood or 

other body fluids, they should be washed thoroughly with 

soap and water. 

Gloves 

Occupational Safety and Health Administration (OSHA) 

regulations have not typically required gloves to be worn 

when administering vaccines unless the person administering 

the vaccine is likely to come in contact with potentially 

infectious body fluids or has open lesions on the hands. In the 

setting of the COVID-19 pandemic, gloves should be worn 

when administering intranasal or oral vaccines. If gloves are 

worn, they should be changed, and hand hygiene should be 

performed between patients.

Gloves will not prevent needlestick injuries. Any needlestick 

injury should be reported immediately to the site supervisor, 

with appropriate care and follow-up given as directed by state 

and local guidelines. 

Vaccine Preparation 

Preparing vaccine properly is critical to maintaining the integrity 

of the vaccine during transfer from the manufacturer’s vial to 

the syringe and, ultimately, to the patient. CDC recommends 

preparing and drawing up vaccines just before administration. 

During preparation: 

• Follow strict aseptic medication preparation practices.

NOTES
Vaccine Administration

73

6

• Perform hand hygiene before preparing vaccines.

• Use a designated, clean medication area that is not adjacent 

to areas where potentially contaminated items are placed. 

• Avoid distractions. Some facilities have a no-interruption 

zone, where health care professionals can prepare 

medications without interruptions.

• Prepare medications for one patient at a time. 

• Always follow the vaccine manufacturer’s directions, located 

in the package inserts.

Choose the Correct Vaccine 

Vaccines are available in different presentations, including 

single-dose vials (SDV), manufacturer-filled syringes (MFS), 

multidose vials (MDV), oral applicators, and a nasal sprayer. 

Always check the label on the vial or box to determine:

• It is the correct vaccine and diluent (if needed).

• The expiration date has not passed. Expired vaccine or 

diluent should never be used. 

Single-Dose Vials (SDV)

Most vaccines are available in SDVs. SDVs do not contain 

preservatives to help prevent microorganism growth. 

Therefore, vaccines packaged as SDVs are intended to be 

punctured once for use in one patient and for one injection. 

Even if the SDV appears to contain more vaccine than is needed 

for one patient, it should not be used for more than one patient. 

Once the appropriate dosage has been withdrawn, the vial and 

any leftover contents should be discarded appropriately. SDVs 

with any leftover vaccine should never be saved to combine 

leftover contents for later use. 

Manufacturer-Filled Syringes (MFS)

MFSs are prepared with a single dose of vaccine and sealed 

under sterile conditions by the manufacturer. Like SDVs, MFSs 

do not contain a preservative to help prevent the growth of 

microorganisms. MFSs are intended for one patient for one 

injection. Once the sterile seal has been broken, the vaccine 

should be used or discarded by the end of the workday. 

Multidose Vials (MDV)

A MDV contains more than one dose of vaccine. MDVs 

are labeled by the manufacturer and typically contain an 

antimicrobial preservative to help prevent the growth of 

microorganisms. Because MDVs contain a preservative, they 

can be punctured more than once. MDVs used for more 

than one patient should only be kept and accessed in a 

dedicated, clean medication preparation area, away from any 

NOTES
74

Vaccine Administration

 6

nearby patient treatment areas. This is to prevent inadvertent 

contamination of the vial through direct or indirect contact 

with potentially contaminated surfaces or equipment. Only 

the number of doses indicated in the manufacturer’s package 

insert should be withdrawn from the vial. Partial doses from 

two or more vials should never be combined to obtain a dose 

of vaccine. 

Oral Applicators and Nasal Sprayer

An oral applicator is for use with oral vaccines and contains 

only one dose of medication. Oral vaccines do not contain a 

preservative. Rotavirus vaccine is administered using an oral 

applicator. An intranasal sprayer is used for the live, attenuated 

influenza vaccine. 

Inspect the Vaccine

Each vaccine and diluent (if needed) should be carefully 

inspected for damage, particulate matter, or contamination 

before using. Verify the vaccine has been stored at proper 

temperatures.

Check the Expiration Date of the Vaccine or Diluent

Determining when a vaccine or diluent expires is an essential 

step in the vaccine preparation process. The expiration date 

printed on the vial or box should be checked before preparing 

the vaccine.

• When the expiration date has only a month and year, the 

product may be used up to and including the last day 

of that month unless the vaccine was contaminated or 

compromised in some way.

• If a day is included with the month and year, the product 

may only be used through the end of that day unless the 

vaccine was contaminated or compromised in some way.

Beyond-Use Date (BUD)

In some instances, vaccine must be used by a date earlier than 

the expiration date on the label. This time frame is referred to as 

the “beyond-use date” (BUD). The BUD supersedes but should 

never exceed the manufacturer’s expiration date. Vaccines 

should not be used after the BUD. The BUD should be noted 

on the label, along with the initials of the person making the 

calculation. Examples of vaccines with BUDs include:

• Reconstituted vaccines have a limited period for use once 

the vaccine is mixed with a diluent. This time period is 

discussed in the package insert.

NOTES
Vaccine Administration

75

6

• Some MDVs vials have a specified period for use once 

they have been punctured with a needle. For example, the 

package insert may state the vaccine must be discarded 28 

days after it is first punctured.

• Manufacturer-shortened expiration dates may apply when 

vaccine is exposed to inappropriate storage conditions. The 

manufacturer might determine the vaccine can still be used 

but will expire on an earlier date than the date on the label.

Reconstitute Lyophilized Vaccine 

Reconstitution is the process of adding a diluent to a dry 

ingredient to make it a liquid. The lyophilized vaccine (powder 

or pellet form) and its diluent come together from the 

manufacturer. Vaccines should be reconstituted according to 

manufacturer guidelines using only the diluent supplied for 

a specific vaccine. Diluents vary in volume and composition, 

and are specifically designed to meet volume, pH balance, 

and the chemical requirements of their corresponding 

vaccines. A different diluent, a stock vial of sterile water, or 

normal saline should never be used to reconstitute vaccines. 

If the wrong diluent is used, the vaccine dose is not valid and 

must be repeated using the correct diluent. Vaccine should 

be reconstituted just before administering by following the 

instructions in the vaccine package insert.

Once reconstituted, the vaccine should be administered within 

the time frame specified for use in the manufacturer’s package 

insert; otherwise, the vaccine should be discarded. Changing 

the needle between preparing and administering the vaccine is 

not necessary unless the needle is contaminated or damaged.

Choose the Correct Supplies to Administer 

Vaccines by Injection 

OSHA requires that safety-engineered injection devices 

(e.g., needle-shielding syringes or needle-free injectors) be 

used for injectable vaccines in all clinical settings to reduce 

the risk of needlestick injury and disease transmission. General 

guidance when selecting supplies to administer a vaccine 

by injection includes:

• Inspect the packaging; never use supplies with torn or 

compromised packaging.

• Some syringes and needles are packaged with an expiration 

date. If present, check the expiration date. Never use 

expired supplies. 

• Use a separate syringe and needle for each injection. Never 

administer a vaccine from the same syringe to more than 

one patient, even if the needle is changed.

NOTES
76

Vaccine Administration

 6

Syringe Selection

An injectable vaccine may be administered in either a 1-mL or 

3-mL syringe.

Needle Selection

Vaccines must reach the desired tissue to provide an optimal 

immune response and reduce the likelihood of injection-site 

reactions. A supply of needles should be available in varying 

lengths appropriate for the facility’s patient population. Clinical 

judgment should be used when selecting needle length. 

Needle selection should be based on the: 

• Route of administration

• Patient age

• Gender and weight (for adults age 19 years or older)

• Injection site

• Injection technique

Needle Length and Gauge for Subcutaneous Injection

Age and Gender Needle Length and Gauge Injection Site

All ages and both genders 5/8-inch (16 mm): 23- to 25-gauge Thigh for infants younger than age 12 months*; upper outer 

triceps area for persons age 12 months and older

*May be administered into the upper outer triceps area if necessary

Needle Length and Gauge: Children and Adolescents (birth – 18 years) for Intramuscular Injection

Age and Gender Needle Length and Gauge Injection Site

Neonate, 28 days 

or younger

5/8-inch (16 mm)*: 22- to 25-gauge Vastus lateralis muscle of anterolateral thigh

Infants, 1–12 months 1-inch (25 mm): 22- to 25-gauge Vastus lateralis muscle of anterolateral thigh

Toddlers, 1–2 years 1- to 1.25-inch (25–32 mm): 

22- to 25-gauge

Vastus lateralis muscle of anterolateral thigh (preferred site)

5/8*- to 1-inch (16–25 mm): 

22- to 25-gauge

Deltoid muscle of arm

Children, 3–10 years 5/8*- to 1-inch (16–25 mm): 

22- to 25-gauge

Deltoid muscle of arm (preferred site)

1- to 1.25-inch (25–32 mm): 

22- to 25-gauge

Vastus lateralis muscle of anterolateral thigh 

Children, 11–18 years 5/8*- to 1-inch (16–25mm): 

22- to 25-gauge

Deltoid muscle of arm (preferred site)†

*If the skin is stretched tightly and subcutaneous tissues are not bunched.

†

The vastus lateralis muscle of the anterolateral thigh can also be used. Most adolescents and adults will require a 1- to 1.5-inch (25–38 mm) 

needle to ensure intramuscular administration.
Vaccine Administration

77

6

Needle Length and Gauge: Adults (age 19 years or older) for Intramuscular Injection

Age and Gender Needle Length and Gauge Injection Site

Less than 130 lbs (60 kg) 1-inch (25 mm)*: 22- to 25-gauge

Deltoid muscle of arm (preferred site)†

130–152 lbs (60–70 kg) 1-inch (25 mm): 22- to 25-gauge

Men, 153–260 lbs (70–118 kg) 1- to 1.5-inch (25–38 mm): 22- to 25-gauge

Women, 153–200 lbs (70–90 

kg)

1- to 1.5-inch (25–38 mm): 22- to 25-gauge

Men, greater than 260 lbs 

(118 kg) 

1.5-inch (38 mm): 22- to 25-gauge

Women, greater than 200 lbs 

(90 kg) 

1.5-inch (38 mm): 22- to 25-gauge

*Some experts recommend a 5/8-inch needle for men and women weighing less than 60 kg; if used, skin must be stretched tightly 

and subcutaneous tissues must not be bunched.

†

The vastus lateralis muscle of the anterolateral thigh can also be used. Most adolescents and adults will require a 1- to 1.5-inch (25–38 mm) 

needle to ensure intramuscular administration.

Filling Syringes

Standard medication preparation guidelines should be 

followed for drawing a dose of vaccine into a syringe. The cap 

on the top of an unopened vaccine vial functions as a dust 

cover. However, not all vaccine manufacturers guarantee the 

tops of unused vials are sterile, and the way the cover over the 

stopper is removed can potentially contaminate the stopper. 

Therefore, using friction and a sterile alcohol swab to wipe the 

stopper may help assure aseptic technique. Alcohol evaporates 

quickly and will dry while the needle is being prepared for 

insertion into the vial. 

Instilling air into a multidose vial prior to withdrawing a vaccine 

dose is not necessary. It could cause a “spritz” of vaccine to 

be lost the next time the vial is entered, which, over time, can 

decrease the amount of vaccine in the vial and lead to the loss 

of a dose (e.g., only nine full doses in a 10-dose vial).

Before withdrawing each dose, the vial should be agitated to 

mix the vaccine thoroughly and obtain a uniform suspension. 

The vaccine should be visually inspected for discoloration 

and precipitation or to see if it cannot be resuspended before 

administration. If problems are noted, the vaccine should not 

be administered. 

When filling a syringe:

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

• Never mix different vaccine products in the same syringe.

• Never transfer vaccine from one syringe to another.

• Never combine partial doses from separate vials to obtain 

a full dose.
78

Vaccine Administration

 6

Once the syringe is filled, label it with the name of the vaccine in 

the syringe. Often more than one vaccine is administered at the 

same visit and, once drawn into a syringe, vaccines look similar. 

By labeling the syringe, health care providers will know the 

route to use to administer the vaccine correctly. 

Predrawing Vaccine

Vaccines should be drawn just before administration. However, 

while MFSs are recommended for large vaccination clinics, 

there may be rare instances when the only option is to predraw 

vaccine for off-site clinics. 

Procedural Pain Management

Vaccinations are the most common source of procedural 

pain for healthy children and can be a stressful experience 

for persons of any age. It has been estimated that up to 

25% of adults have a fear of needles, with most needle fears 

developing during childhood. If not addressed, these fears 

can have long-term effects such as preprocedural anxiety 

and avoidance of needed health care throughout a person’s 

lifetime. Fear of injections and needlestick pain are often cited 

as reasons why children and adults refuse vaccines. 

Pain is a subjective phenomenon influenced by multiple 

factors, including an individual’s age, anxiety level, previous 

health care experiences, and culture. Although pain from 

vaccination is to some extent unavoidable, there are some 

things that parents and health care providers can do to help. 

Evidence-based pharmacologic, physical, and psychological 

interventions exist to ease the pain associated with injections. 

Combining the interventions described below has been shown 

to improve pain relief.

Inject Vaccines Rapidly Without Aspiration

Aspiration is not recommended before administering a 

vaccine. Aspiration prior to injection and injecting medication 

slowly are practices that have not been evaluated scientifically. 

Aspiration was originally recommended for theoretical 

safety reasons and injecting medication slowly was thought 

to decrease pain from sudden distention of muscle tissue. 

Aspiration can increase pain because of the combined effects 

of a longer needle-dwelling time in the tissues and shearing 

action (wiggling) of the needle. There are no reports of any 

person being injured because of failure to aspirate. 

The veins and arteries within reach of a needle in the anatomic 

areas recommended for vaccination are too small to allow an 

intravenous push of vaccine without blowing out the vessel. 

A 2007 study from Canada compared infants’ pain response 

using slow injection, aspiration, and slow withdrawal with 

another group using rapid injection, no aspiration, and rapid 

withdrawal. Based on behavioral and visual pain scales, the 

NOTES
Vaccine Administration

79

6

group that received the vaccine rapidly without aspiration 

experienced less pain. No immediate adverse events were 

reported with either injection technique.

Inject Vaccines that Cause the Most Pain Last

Many persons receive two or more injections at the same 

clinical visit. Some vaccines cause more pain than others during 

the injection. Because pain can increase with each injection, 

the order in which vaccines are injected matters. Some vaccines 

cause a painful or stinging sensation when injected; examples 

include measles, mumps, and rubella; pneumococcal conjugate; 

and human papillomavirus vaccines. Injecting the most painful 

vaccine last when multiple injections are being administered 

can decrease the pain associated with the injections.

Breastfeed Children Age 2 Years or Younger During 

Vaccine Injections

Mothers who are breastfeeding should be encouraged to 

breastfeed children age 2 years or younger before, during, and 

after vaccination. Several aspects of breastfeeding are thought 

to decrease pain by multiple mechanisms: being held by the 

parent, feeling skin-to-skin contact, suckling, being distracted, 

and ingesting breast milk. Potential adverse events such as 

gagging or spitting up have not been reported. Alternatives 

to breastfeeding include bottle-feeding with expressed breast 

milk or formula throughout the procedure, which simulates 

aspects of breastfeeding.

Give a Sweet-Tasting Solution to Children Who 

Are Not Breastfed 

Children (age 2 years or younger) who are not breastfed during 

vaccination may be given a sweet-tasting solution such as 

sucrose or glucose one to two minutes before the injection. 

The analgesic effect can last for up to 10 minutes following 

administration and can mitigate vaccine injection pain. Parents 

should be counseled that sweet-tasting liquids should only be 

used for the management of pain associated with a procedure 

such as an injection and not as a comfort measure at home. 

Pain Relievers 

Topical anesthetics block transmission of pain signals from 

the skin. They decrease the pain as the needle penetrates the 

skin and reduce the underlying muscle spasm, particularly 

when more than one injection is administered. These 

products should be used only for the ages recommended 

and as directed by the manufacturer. Because using topical 

anesthetics may require additional time, some planning by 

the healthcare provider and parent may be needed. Topical 

anesthetics can be applied during the usual clinic waiting 

times, or before the patient arrives at the clinic provided 

parents and patients have been shown how to use them 

NOTES
80

Vaccine Administration

 6

appropriately. There is no evidence that topical anesthetics 

have an adverse effect on the vaccine immune response. 

The prophylactic use of antipyretics (e.g., acetaminophen 

and ibuprofen) before or at the time of vaccination is not 

recommended. There is no evidence these will decrease the 

pain associated with an injection. In addition, some studies 

have suggested these medications might suppress the 

immune response to some vaccine antigens.

Follow Age-Appropriate Positioning Best Practices

For both children and adults, the best position and type of 

comforting technique should be determined by considering the 

patient’s age, activity level, safety, comfort, and administration 

route and site. Parents play an important role when infants and 

children receive vaccines. Parent participation has been shown 

to increase a child’s comfort and reduce the child’s perception of 

pain. Holding infants during vaccination reduces acute distress. 

Skin-to-skin contact for infants up to age 1 month has been 

demonstrated to reduce acute distress during the procedure. 

A parent’s embrace during vaccination offers several benefits. 

A comforting hold: 

• Avoids frightening children by embracing them rather than 

overpowering them

• Allows the health care professional steady control of the 

limb and the injection site

• Prevents children from moving their arms and legs 

during injections

• Encourages parents to nurture and comfort their child

A combination of interventions, holding during the 

injection along with patting or rocking after the injection, is 

recommended for children up to age 3 years. Parents should 

understand proper positioning and holding for infants and 

young children. Parents should hold the child in a comfortable 

position, so that one or more limbs are exposed for injections. 

Research shows that children age 3 years or older are less 

fearful and experience less pain when receiving an injection 

if they are sitting up rather than lying down. The exact 

mechanism behind this phenomenon is unknown. It may be 

that the child’s anxiety level is reduced, which, in turn, reduces 

the child’s perception of pain.

NOTES
Vaccine Administration

81

6

Tactile Stimulation

Moderate tactile stimulation (rubbing or stroking the skin) near 

the injection site before and during the injection process may 

decrease pain in children age 4 years or older and in adults. 

The mechanism for this is thought to be that the sensation of 

touch competes with the feeling of pain from the injection 

and, thereby, results in less pain. 

Route and Site for Vaccination

The recommended route and site for each vaccine are 

based on clinical trials, practical experience, and theoretical 

considerations. There are five routes used to administer 

vaccines. Deviation from the recommended route may reduce 

vaccine efficacy or increase local adverse reactions. Some 

vaccine doses are not valid if administered using the wrong 

route, and revaccination is recommended. 

Oral Route (PO)

Oral vaccines should generally be administered before 

injectable vaccines. Rotavirus vaccines (RV1 [Rotarix], RV5 

[RotaTeq]) are administered orally. Because the two brands of 

rotavirus vaccine are prepared differently and have different 

types of oral applicators, health care professionals should be 

familiar with how to prepare and administer the brand stocked 

in their facility. Rotavirus vaccine should never be injected. 

To administer rotavirus vaccine:

• Perform proper hand hygiene. In the setting of the 

COVID-19 pandemic, gloves should be worn.

• Administer the liquid vaccine slowly against the inside of 

the infant’s cheek (between the cheek and gum) toward the 

back of the infant’s mouth. Never administer the vaccine 

directly into the throat. This can increase the chance that 

the infant will cough or gag and spit out the vaccine rather 

than swallowing it.

• Allow the infant time to swallow.

• Care should be taken to avoid triggering the gag reflex.

An infant can eat or drink immediately before or after 

administration of either product. The dose does not need to 

be repeated if an infant regurgitates, spits out the vaccine, 

or vomits during or after administration. No data exist on 

the benefits or risks associated with readministering a dose 

of rotavirus vaccine. The infant should receive the remaining 

recommended doses of rotavirus vaccine following the 

routine schedule. 

NOTES
82

Vaccine Administration

 6

Intranasal Route (NAS)

Live, attenuated influenza (LAIV [FluMist]) vaccine is 

administered by the intranasal route. LAIV is administered 

into each nostril using a manufacturer-filled nasal sprayer. A 

dose-divider clip, located on the plunger, separates the total 

vaccine dose of 0.2 mL into two equal parts of 0.1 mL each. 

LAIV should never be injected. The patient should be seated 

in an upright position and instructed to breathe normally. The 

provider should gently place a hand behind the patient’s head 

to prevent inadvertent movement. 

To administer the vaccine:

• Perform proper hand hygiene. In the setting of the 

COVID-19 pandemic, gloves should be worn.

• Remove the rubber tip of the nasal sprayer and place the tip 

of the applicator just inside the patient’s nostril. 

• Push the plunger rapidly in a single motion until the dosedivider clip is reached.

• Pinch and remove the dose-divider clip.

• Place the tip of the applicator just inside the other nostril 

and repeat the process to administer the remaining vaccine.

The dose does not need to be repeated if the patient coughs, 

sneezes, or expels the dose in any other way. 

Subcutaneous Route (Subcut)

Routinely recommended vaccines administered by 

subcutaneous injection include MMR (MMR-II), VAR (Varivax), 

IPV (IPOL), MMRV (ProQuad), and PPSV23 (Pneumovax 23). 

IPOL and Pneumovax 23 can be administered by intramuscular 

(IM) or subcutaneous injection.

Subcutaneous injections are administered into the fatty tissue 

found below the dermis and above muscle tissue. For infants 

younger than age 12 months, a subcutaneous injection 

NOTES
Vaccine Administration

83

6

is usually administered into the fatty tissue of the thigh, 

although the upper outer triceps area of the arm may be used 

if necessary. For persons age 1 year or older, subcutaneous 

injections are given in the fatty tissue above the upper outer 

triceps of the arm.

Sites for Subcutaneous Injection

When administering a vaccine subcutaneously:

• Perform proper hand hygiene.

• Cleanse the skin with a sterile alcohol swab and 

allow it to dry.

• Pinch up the skin and underlying fatty tissue.

• Insert the needle at a 45-degree angle into the 

subcutaneous tissue and inject the vaccine. Avoid 

reaching the muscle.

• Withdraw the needle.

• Apply an adhesive bandage to the injection site if 

there is any bleeding.

Subcutaneous Administration Technique

Source: California Department of Public Health

Source: California Department of Public Health

Intradermal Injection 

No routinely recommend U.S. vaccines are administered by the 

intradermal route of injection.

NOTES
84

Vaccine Administration

 6

Intramuscular Route 

Routinely recommended vaccines administered by IM 

injection include:

• DT

• DTaP (Daptacel, Infanrix)

• DTaP-IPV-HepB (Pediarix)

• DTaP-IPV/Hib (Pentacel)

• DTaP-IPV (Kinrix, Quadracel)

• Hib (PedvaxHIB, ActHIB, Hiberix)

• HepA (Havrix, Vaqta)

• HepB (Engerix B, Recombivax HB)

• HepB-CpG (Heplisav-B)

• HepA-HepB (Twinrix)

• HPV (Gardasil 9)

• IIV (multiple brands)

• IPV (IPOL)

• MenACWY (Menactra, MenQuadfi, Menveo)

• MenB (Bexsero, Trumenba)

• PCV13 (Prevnar 13)

• PPSV23 (Pneumovax 23)

• RZV (Shingrix)

• Td (Tenivac, Tdvax)

• Tdap (Adacel, Boostrix)

IPOL and Pneumovax 23 can be administered by IM 

or subcut injection

NOTES

IM injections are administered into the muscle through the skin 

and subcutaneous tissue. There are only two recommended 

sites for administering vaccines by IM injection:

• Vastus lateralis muscle in the anterolateral thigh

• Deltoid muscle in the upper arm
Vaccine Administration

85

6

Sites for Intramuscular Injection

Source: Lynne Larson, www.biovisuals.com

Injection at these sites reduces the chance of involving neural or 

vascular structures. The preferred site depends on the patient’s 

age, weight, gender, and the degree of muscle development.

When administering an IM injection:

• Perform proper hand hygiene.

• Identify the appropriate landmarks for the site.

• Cleanse the skin with a sterile alcohol swab and allow 

it to dry.

• Spread the skin tight to isolate the muscle. Another 

acceptable technique for pediatric and geriatric patients 

is to grasp the tissue and “bunch up” the muscle.

• Insert the needle at a 90-degree angle and inject 

the vaccine.

• Withdraw the needle.

• Apply an adhesive bandage to the injection site if there 

is any bleeding.

NOTES
86

Vaccine Administration

 6

Intramuscular Administration Technique

Source: California Department of Public Health

Site Recommendations for Intramuscular Vaccination

For both sites, an IM injection ideally should be administered 

into the middle of the muscle where the muscle tissue 

is thickest.

Infants (12 Months or Younger)

For most infants, the vastus lateralis muscle in the anterolateral 

thigh is the recommended site for injection because it provides 

a large muscle mass. The muscles of the buttock are not used 

for administration of vaccines in infants and children because 

of concern about potential injury to the sciatic nerve, which 

has been well-documented after injection of antimicrobial 

agents into the buttock. If the gluteal muscle must be used 

(e.g., because of reduced anatomic site availability), care should 

be taken to define the anatomic landmarks. A gluteal muscle 

injection should be administered laterally 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 

bound by the anterior superior iliac spine, the tubercle of the 

iliac crest, and the upper border of the greater trochanter.

Toddlers (1 Year through 2 Years)

For toddlers, the vastus lateralis muscle in the anterolateral 

thigh is preferred. The deltoid muscle can be used if the muscle 

mass is adequate. 

Children/Adolescents (3 Years through 18 Years)

The deltoid muscle is preferred for children age 3 through 

18 years. The vastus lateralis muscle in the anterolateral thigh 

is an alternative site if the deltoid sites cannot be used. 

Adults (19 Years or Older)

For adults, the deltoid muscle is recommended. IM injections 

are administered at a 90-degree angle to the skin and, for 

most adult patients, the skin is spread and the tissues are not 

NOTES
Vaccine Administration

87

6

bunched. It is acceptable in geriatric patients to grasp the tissue 

and “bunch up” the muscle. As with children and adolescents, 

the vastus lateralis muscle in the anterolateral thigh is an 

alternative site if the deltoid sites cannot be used.

Multiple Vaccinations

Children and adults often need more than one vaccine at the 

same time. Giving more than one vaccine at the same clinical 

visit is preferred because it helps keep patients up-to-date. Use 

of combination vaccines can reduce the number of injections. 

Considerations when administering multiple injections include:

• Administer each vaccine in a different injection site. 

Recommended sites (i.e., vastus lateralis and deltoid 

muscles) have multiple injection sites. Separate injection 

sites by 1 inch or more, if possible, so that any local 

reactions can be differentiated. 

• For infants and younger children, if more than two vaccines 

are being injected into the same limb, the thigh is the 

preferred site because of the greater muscle mass. For older 

children and adults, the deltoid muscle can be used for 

more than one intramuscular injection. 

• Vaccines that are the most reactive and more likely to cause 

an enhanced injection site reaction (e.g., DTaP, PCV13) 

should be administered in different limbs, if possible.

• Vaccines that are known to be painful when injected (e.g., 

HPV, MMR) should be administered after other vaccines. 

• If both a vaccine and an immune globulin (Ig) preparation 

are needed (e.g., Td/Tdap and tetanus immune globulin 

[TIG] or hepatitis B vaccine and hepatitis B immune globulin 

[HBIG]), administer the vaccine in a separate limb from the 

immune globulin.

Vaccine and Supply Disposal

Immediately after use, all syringe/needle devices should be 

placed in biohazard containers that are closable, punctureresistant, leakproof on sides and bottom, and labeled or 

color-coded. This practice helps prevent accidental needlestick 

injury and reuse. Used needles should not be recapped or cut or 

detached from the syringes before disposal.

Empty or expired vaccine vials are considered medical waste 

and should be disposed of according to state regulations.

Medical waste disposal requirements are set by state 

environmental agencies. Contact the state or local 

immunization program or state environmental agency 

for guidance.

NOTES
88

Vaccine Administration

 6

Patient Care after Vaccine Administration

Health care providers should be knowledgeable about the 

policies and procedures for identifying and reporting adverse 

events after vaccination. A vaccine adverse event refers to any 

medical event that occurs after vaccination which may or may 

not be related to vaccination. Further assessment is needed to 

determine if an adverse event is caused by a vaccine. An adverse 

vaccine reaction is an untoward effect caused by a vaccine.

Managing Acute Reactions after Vaccination

Health care providers should be familiar with strategies to 

prevent and identify adverse reactions after vaccination. 

Potential life-threatening adverse reactions that can occur 

immediately after vaccination are severe allergic reactions and 

syncope (fainting). 

Severe Allergic Reactions 

Severe, life-threatening anaphylactic reactions following 

vaccination are rare. Thorough screening for contraindications 

and precautions prior to vaccination can often prevent 

reactions. Health care providers should be familiar with 

identifying immediate-type allergic reactions. Symptoms 

of immediate-type allergic reactions can include local 

or generalized urticaria (hives), angioedema, respiratory 

compromise due to wheezing or swelling of the throat, 

hypotension, and shock. Health care providers should be 

competent in treating these events at the time of vaccine 

administration. All vaccine providers should be certified 

in cardiopulmonary resuscitation (CPR) and be skilled in 

administering epinephrine. Equipment needed for maintaining 

an airway should be available for immediate use and the 

provider should be skilled in using the equipment. Providers 

should also have a plan in place to contact emergency medical 

services immediately if there is an anaphylactic reaction to 

vaccination, and staff members should know their individual 

roles in the event of an emergency. 

Syncope 

All health care professionals who administer vaccines to older 

children, adolescents, and adults should be aware of the 

potential for syncope after vaccination and the related risk of 

injury caused by falls. Appropriate measures should be taken 

to prevent injuries if a patient becomes weak or dizzy or loses 

consciousness, including: • Have the patient seated or lying down for vaccination. • Be aware of symptoms that precede fainting (e.g., weakness, 

dizziness, pallor).

NOTES
Vaccine Administration

89

6

• Provide supportive care and take appropriate measures to 

prevent injuries if such symptoms occur. 

• Strongly consider observing patients (seated or lying down) 

for 15 minutes after vaccination to decrease the risk for 

injury should they faint.

Reporting an Adverse Event 

Health care providers are required by law to report certain 

adverse events, and encouraged to report other events, 

following vaccination to the Vaccine Adverse Event Reporting 

System (VAERS). Details on reporting adverse events after 

vaccination can be found at https://vaers.hhs.gov. 

Documenting Vaccinations

Accurate and timely documentation can help prevent 

administration errors and curtail the number and cost of 

excess vaccine doses. In addition, preventing excess doses 

of vaccines may decrease the number of adverse reactions. 

All vaccines administered should be fully documented in the 

patient’s permanent medical record. Health care providers 

who administer vaccines covered by the National Vaccine 

Injury Compensation Program (which include all vaccines 

listed on the Advisory Committee on Immunization Practices 

recommended child and adolescent immunization schedule) 

are required by law to ensure the permanent medical record of 

the recipient indicates:

• Date of administration

• Vaccine manufacturer

• Vaccine lot number

• Name and title of the person who administered the vaccine 

and the address of the facility where the permanent record 

will reside

• The edition date of the VIS distributed and the date it was 

provided to the patient

Vaccine administration best practices also include 

documenting the route, dosage, and site. Providers should 

update a patient’s permanent medical record to reflect any 

documented episodes of adverse events after vaccination 

and any serologic test results related to vaccine-preventable 

diseases (e.g., those for rubella screening or antibody to 

hepatitis B surface antigen). The patient or parent should be 

provided with a personal immunization record that includes 

the vaccination(s) and date administered.

Although there is no national law, it is also important to 

document when parents or adult patients refuse vaccines 

despite the vaccine provider’s recommendation. Professional 

NOTES
90

Vaccine Administration

 6

organizations such as the American Academy of Pediatrics and 

others have developed forms to document when vaccines are 

refused (https://www.aap.org/en-us/documents/immunization_

refusaltovaccinate.pdf).

By age 2 years, more than 20% of the children in the United 

States typically have seen more than one health care 

provider, resulting in scattered paper medical records. IISs are 

confidential, population-based, computerized information 

systems that collect and consolidate vaccination data from 

multiple health care providers. Vaccine providers are strongly 

encouraged to participate in an IIS, and some states mandate 

documenting vaccinations in an IIS. Laws regarding using an IIS 

vary by state or region. 

Some states’ IISs use bar-coding technology. Implementation 

of a 2D bar code on vaccine vials and VISs allows for rapid, 

accurate, and automatic capture of certain data, including 

the vaccine product identifier, lot number, expiration date, 

and VIS edition date using a handheld imaging device or 

scanner that could populate these fields in an IIS and/or an 

electronic health record. 

Vaccine Administration Errors

The National Coordinating Council for Medication Error 

Reporting and Prevention defines a medication error as “any 

preventable event that may cause or lead to inappropriate 

medication use or patient harm while the medication is in the 

control of the health care professional, patient, or consumer.” 

A preventable event is one that is due to an error that could 

be avoided. For example, if a patient receives the wrong drug 

because of look-alike labels between different products, 

that is considered a preventable event. Vaccines, like other 

medications, can be involved in errors. Vaccine administration 

errors can have many consequences, including inadequate 

immunological protection, possible injury to the patient, cost, 

inconvenience, and reduced confidence in the health care 

delivery system. 

Common vaccine administration errors include: 

• Doses administered too early (e.g., before the minimum 

age or interval)

• Wrong vaccine (e.g., Tdap instead of DTaP)

• Wrong dosage (e.g., pediatric formulation of hepatitis B 

vaccine administered to an adult)

• Wrong route (e.g., MMR given by IM injection)

• Vaccine administered outside the approved age range

• Expired vaccine or diluent administered

• Improperly stored vaccine administered

NOTES
Vaccine Administration

91

6

• Vaccine administered to a patient with a contraindication

• Wrong diluent used to reconstitute the vaccine or only the 

diluent was administered

Traditionally, medication errors are thought to be caused by 

mistakes. This “blame-seeking” approach fails to address the root 

cause, potentially causing the error to recur. An environment 

that values the reporting and investigation of errors (and “near 

misses”) as part of risk management and quality improvement 

should be established. Health care personnel should be 

encouraged to report errors and trust that the situation and 

those involved will be treated fairly without fear of punishment 

and ridicule. Error reporting provides opportunities to discover 

how the errors occur and to share ideas to prevent or reduce 

those errors in the future. When a vaccine administration 

error occurs, health care providers should determine how it 

happened and put strategies in place to prevent it in the future. 

Guidance for handling some common vaccine administration 

errors is included in ACIP’s General Best Practice Guidelines for 

Immunization. Some vaccine administration errors require 

revaccination, but others do not. 

Vaccine administration errors requiring revaccination include:

• Hepatitis B vaccine administered by any route other than IM 

injection, or in adults at any site other than the deltoid or 

anterolateral thigh

• HPV vaccine that is administered by any route other than IM 

injection

• Influenza vaccine administered subcutaneously

• Any vaccination using less than the appropriate dose (e.g., 

pediatric formulation hepatitis A vaccine given to an adult) 

does not count and the dose should be repeated according 

to age unless serologic testing indicates an adequate 

response has developed (however, if two half-volume 

formulations of vaccine are administered on the same 

clinic day, these 2 doses can count as 1 valid dose)

• If a partial dose of an injectable vaccine is administered 

because the syringe or needle leaks or the patient 

jerks away 

Vaccine administration errors not requiring revaccination include: 

• Any vaccination using more than the appropriate dose (e.g., 

DTaP administered to an adult) should be counted if the 

minimum age and minimum interval have been met. 

NOTES
92

Vaccine Administration

 6

• Hepatitis A vaccine and meningococcal conjugate vaccine 

administered by the subcutaneous route if the minimum 

age and minimal interval have been met

• Administering a dose 4 or fewer days earlier than the 

minimum interval or age is unlikely to have a substantially 

negative effect on the immune response to that dose. 

Vaccine doses administered in this 4-day grace period 

before the minimum interval or age, with a few exceptions, 

are considered valid. However, state or local mandates 

might supersede this guideline. 

• MMR, varicella, and MMRV administered by IM injection if 

the minimum age and minimum interval have been met 

NOTES
Vaccine Administration

93

6

Acknowledgements

The editors would like to acknowledge Beth Hibbs and Andrew 

Kroger for their contributions to this chapter.

Selected References

Australian Technical Advisory Group on Immunization 

(ATAGI). Australian Immunization Handbook, Australian 

Government Department of Health. Canberra; 2018. 

https://immunisationhandbook.health.gov.au/. Accessed 

October 11, 2020.

Canadian Government. Public Health Agency of Canada. 

Canadian Immunization Guide. www.canada.ca/en/publichealth/services/canadian-immunization-guide.html. Accessed 

October 11, 2020.

CDC. General Best Practice Guidelines for Immunization: Best 

Practices Guidance of the Advisory Committee on Immunization 

Practices (ACIP). www.cdc.gov/vaccines/hcp/acip-recs/generalrecs/index.html. Accessed October 11, 2020.

CDC. Injection Safety. www.cdc.gov/injectionsafety/index.html. 

Accessed October 11, 2020.

Cohen M. Medication Errors. 2nd ed. Washington, D.C.: American 

Pharmacists Association;2007.

Committee on Identifying and Preventing Medication Errors. 

Board of Health Care Services: Aspden P, Wolcott J, Bootman J et 

al., eds. Preventing Medication Errors. Washington D.C.: National 

Academies of Sciences;2007.

Harrington J, Logan S, Harwell C, et al. Effective analgesia using 

physical interventions for infant immunizations. Pediatrics

2012;129(5):815–22.

Hibbs B, Miller E, Shi J, et al. Safety of vaccines that have been 

kept outside of recommended temperatures: Reports to the 

Vaccine Adverse Event Reporting System (VAERS), 2008-2012. 

Vaccine 2018;36(4):553–8.

Hibbs B, Miller E, Shimabukuro T. Centers for Disease Control 

and Prevention (CDC). Notes from the field: rotavirus vaccine 

administration errors--United States, 2006-2013. MMWR

2014;63(4):81.

Ipp M, Taddio A, Sam J, et al. Vaccine-related pain: randomized 

controlled trial of two injection techniques. Arch Dis Child 

2007;92(12):1105–8.

NOTES
94

Vaccine Administration

 6

Jacobson R, St Sauver J, Griffin J, et al. How health care 

providers should address vaccine hesitancy in the clinical 

setting: Evidence for presumptive language in making a strong 

recommendation. Hum Vaccin Immunother 2020;16(9):2131–5.

Lynn, P. Clinical Nursing Skills: A Nursing Process Approach. 5th ed. 

Philadelphia PA: Wolters Kluwer;2019.

Moro P, Arana J, Marquez P, et al. Is there any harm in 

administering extra-doses of vaccine to a person? Excess doses 

of vaccine reported to the Vaccine Adverse Event Reporting 

System (VAERS), 2007-2017. Vaccine 2019;37(28):3730–4.

Occupational Health and Safety Administration. Occupational 

exposure to bloodborne pathogens: needlesticks and other 

sharps injuries: Final Rule (29 CFR Part 1910). Fed Regist 

2001;66(12):5317–25.

Opel D, Robinson J, Spielvogle H, et al. Presumptively Initiating 

Vaccines and Optimizing Talk with Motivational Interviewing’ 

(PIVOT with MI) trial: a protocol for a cluster randomised 

controlled trial of a clinician vaccine communication 

intervention. BMJ Open 2020;10(8):e039299.

Shimabukuro T, Miller E, Strikas R, et al. Notes from the Field: 

Vaccine Administration Errors Involving Recombinant Zoster 

Vaccine - United States, 2017-2018. MMWR 2018;67(20):585–6.

Smith S, Duell D, Martin, B. Clinical Nursing Skills: Basic to 

Advanced Skills. 8th ed. Saddle River, NJ: Pearson Education, 

Inc.;2011.

Su J, Miller E, Duffy J, et al. Notes from the Field: Administration 

Error Involving a Meningococcal Conjugate Vaccine--

United States, March 1, 2010-September 22, 2015. MMWR

2016;65(6):161–2.

Suragh T, Hibbs B, Marquez P, et al. Age inappropriate influenza 

vaccination in infants less than 6 months old, 2010-2018. 

Vaccine 2020;38(21):3747–51.

Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain 

of childhood vaccination: an evidence-based clinical practice 

guideline. Can Med Assc Journal 2010;182:1989–95.

Taddio A, Ilersich A, Ipp M, et al. Physical interventions and 

injection techniques for reducing injection pain during routine 

childhood immunizations systematic review of randomized 

controlled trials and quasi-randomized controlled trials. Clinical 

Therapeutics 2009;31(Suppl 2):S48–S76.

NOTES
Vaccine Administration

95

6

Taddio A, McMurtry C, Shah V, et al. Reducing pain during 

vaccine injections: clinical practice guideline. CMAI 

2015;187(13):975–82.

Taylor L, Greeley R, Dinitz-Sklar I, et al. Notes from the Field: 

Injection Safety and Vaccine Administration Errors at an 

Employee Influenza Vaccination Clinic—New Jersey, 2015. 

MMWR 2015;64(49):1363–4.

NOTES
96

Vaccine Administration

 6