Deborah L. Wexler, MD, Executive Director, Immunization Action Coalition
To determine the proper needle length for your patients’ vaccinations, the first things you need to consider are the route of injection — whether it is intramuscular (IM) or subcutaneous (SC) — and the anatomic site of the injection. For infants and children, the patient's age must be considered, and for adults, the patient's weight may need to be taken into account.
Below is a summary of the guidance on choosing the proper needle length for IM and SC injections based on CDC’s General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (pages 13–16).
The deltoid muscle is most often used as the site for IM injections in adults: Needle length is usually 1–1½", 22–25 gauge, but a longer or shorter needle may be needed depending on the patient's weight.
According to CDC’s General Recommendations on Immunization (page 16), you should choose needle length based on the weight of your adult patients as follows:
An alternate site for IM injection in adults is the anterolateral thigh muscle (use 1–1 ½” needle, 22–25 gauge).
Fatty tissue overlying the triceps muscle: ⅝" needle, 23–25 gauge
For more detailed information on IM and SC injections, including proper injection technique, please see the following resources:
$8,079 — That’s the total private sector cost for 10 doses of each of the 13 vaccines recommended by the Centers for Disease Control and Prevention (CDC) for routine use in children from birth through 17 years of age.*
Since most vaccines are available in 10-dose packages, this means that even small medical practices are storing approximately $8,000 of vaccine at any one time. Of course, the total value of vaccines available in a practice is usually much greater than that, and very large practices may be storing more than 10 times that value in inventory. How can you ensure that your sizeable vaccine investment is appropriately protected from potential loss (and subsequent replacement costs) and that your patients receive viable vaccines?
To assist with your efforts to properly store and protect your vaccine supply, CDC recently released a wide range of new tools, including:
The Immunization Action Coalition (IAC) also maintains a wide variety of helpful tools in its Clinic Resources: Storage & Handling Web section, such as temperature logs for refrigerators and freezers and the following two recently updated pieces:
All of these tools provide great information to assist your medical practice with appropriate vaccine storage and handling. Take a minute to have your staff review the tools, and institute recommended policies and systems in your healthcare setting. You will be rewarded with dollars saved from reduced vaccine wastage. But more importantly, you’ll have the satisfaction of knowing that your efforts have helped ensure that your patients receive effective protection against vaccine preventable diseases — and nothing is more valuable than that!
*Private sector cost1 (rounded to nearest dollar) for 10 doses each of DTaP ($235), influenza ($148), IPV ($274), Hepatitis A ($296), Hepatitis B ($223), Hib ($245), HPV ($1,351), meningococcal conjugate ($1,152), MMR ($561), pneumococcal conjugate ($1,351), rotavirus ($909), Tdap ($393), and varicella ($941) vaccines. (Note: When more than one brand of a vaccine type was available, the average cost was used. Due to the wide variety of formulations/costs, combination vaccines were not included in this assessment.)
1Cost per CDC Pediatric/VFC Vaccine Price List (accessed July 7, 2014)
Question of the Week: For the purpose of vaccine spacing, what constitutes a month: 28 days (4 weeks), 30 days, or 31 days? (Find the answer at end of this article.*)
Looking for answers to difficult, real-life immunization questions like the one above? The Immunization Action Coalition's (IAC's) free weekly electronic immunization newsletter, IAC Express, recently launched “Question of the Week,” a new feature that highlights a topical or important-to-reiterate question that is answered by experts from the Centers for Disease Control and Prevention (CDC).
This new feature is a cooperative venture between IAC and CDC. IAC's associate director for immunization education, William L. Atkinson, MD, MPH, selects a new Q&A every week based on common or especially intriguing questions forwarded to IAC by CDC experts.
In addition to being featured in IAC Express, the “Question of the Week” is posted online in the following places:
We hope you enjoy this new feature in IAC Express and find it helpful when dealing with real-life scenarios that arise in your vaccination practice. To receive these weekly questions, be sure to subscribe to IAC Express and please encourage your healthcare professional colleagues to sign up as well, so they too will benefit from this practical and invaluable resource.
And if you have a question for CDC’s immunization experts, you may email them directly at firstname.lastname@example.org. There is no charge for this service.
*Answer to Question of the Week: For intervals of three months or less, you should use 28 days (4 weeks) as a "month." For intervals of four months or longer, you should consider a month to be a "calendar month": the interval from one calendar date to the next a month later. This is a convention that was introduced on the childhood schedule in 2002 and discussed in the paper "Evaluation of Invalid Vaccine Doses" (Stokely S, Maurice E, Smith PJ, et al. Am J. Prev Med. 2004 Jan; 26(1):34–40).
Unfortunately, vaccine administration errors happen all too often. To avoid this situation, it is essential that all clinic staff members be well trained in proper vaccine administration technique. Avoiding vaccine administration errors will save your clinic time and money, as well as potential embarrassment. Most importantly, it can prevent your practice from having unprotected patients who must be recalled to have doses repeated.
The Immunization Action Coalition (IAC) receives frequent inquiries from healthcare professionals regarding vaccine administration errors and what to do about them. Some of the most common errors are:
To prevent these errors from happening, make sure that everyone who administers vaccines is properly trained and that you use standardized protocols for vaccine administration. The following resources can help with training for new staff, as well as for providing periodic refreshers for all staff members.
Immunization Techniques: Best Practices with Infants, Children and Adults. This 25-minute DVD was developed by the Immunization Branch, California Department of Public Health, and is available for a nominal charge from the Immunization Action Coalition (IAC). It provides excellent training for new staff members and is a first-rate refresher for experienced staff.
Several free print materials are available for downloading from IAC’s Administering Vaccines Web section. Some of the most utilized materials are:
Do you have a question about vaccine administration errors? Check out IAC's "Ask the Experts" archive for Q&As answered by CDC experts. If you are unable to find answers to your specific vaccine administration questions, e-mail CDC at email@example.com or IAC at firstname.lastname@example.org for answers.
Protecting the health of your patients depends on following the recommendations of the U.S. Centers for Disease Control and Prevention (CDC) for preparing and administering vaccines to patients. Are you and your staff fully versed in the technical aspects of administering vaccines? Can the staff who provide vaccines in your setting answer “yes” to the following questions?
Do you know how to:
The Immunization Action Coalition (IAC) is here to help with a multitude of both practical and technical vaccination resources for healthcare professionals, including free print materials covering important topics in vaccine administration. Also available for a nominal charge is an excellent training DVD, Immunization Techniques: Best Practices with Infants, Children and Adults.
IAC’s immunize.org website features helpful print materials on vaccine administration in its Handouts for Patients and Staff web section. Its Administering Vaccines Web section includes the following up-to-date tools and forms for clinic staff:
Developed by the Immunization Branch of the California Department of Public Health, in collaboration with a team of national experts, the 35-minute DVD "Immunization Techniques: Best Practices with Infants, Children, and Adults" focuses on the skills and techniques needed for vaccine administration. Every organization that administers vaccines should have a copy of this comprehensive educational program, which includes “how to” information about providing vaccinations in a clinic or non-traditional setting. It is appropriate for training and orientation, as well as a refresher for more experienced staff. To purchase this great DVD, visit www.immunize.org/dvd.
Finally, please remember that it’s a federal requirement to provide a copy of the relevant Vaccine Information Statement (VIS) to your patient or their legal guardian before administering almost all vaccines to infants, children and adults. Check the IAC website to find a wealth of VIS information, including translations of the forms into a wide variety of languages.
Missed opportunities to vaccinate contribute to lower immunization rates in medical practices and healthcare systems across the nation. Here are some simple tips to help your practice facilitate vaccination during all patient visits.
Tip #1: Remember that vaccines can be given at any clinic visit — not just during well-child or adult physical exam visits.
All medical visits (including acute care and follow-up visits) offer the opportunity to assess your patients’ immunization status and provide them with needed vaccinations. In particular, patients with chronic illnesses, many of whom visit a provider only during an acute episode, may be the individuals who are most at risk for complications from vaccine-preventable illnesses. Don’t miss any opportunity to provide protection for your patients. Consider facilitating patient access to vaccines by establishing systems that allow them to walk in during regular office hours or to call ahead for a “nurse only” visit.
Tip #2: You don't need to routinely check temperatures on all patients before vaccinating them.
Routinely measuring temperatures is not a prerequisite for vaccinating patients who appear to be healthy. As part of your routine pre-vaccination screening for contraindications and precautions, simply ask the parent or patient about the patient's current state of health. Here are two handy checklists to help you screen:
Mild acute illness (e.g., diarrhea or mild upper-respiratory tract infection) with or without fever is not a reason to postpone vaccination. If an illness is reported that is moderate or severe, vaccination is considered to be a precaution, not a contraindication; but, in general, it probably should be postponed.
Tip #3: You don't need to routinely test for pregnancy in girls and women of childbearing age before administering a live virus vaccine.
Routine pregnancy testing of girls and women of childbearing age before administering a live virus vaccine is not recommended, according to CDC's General Recommendations on Immunization (see page 27). However, females of childbearing age should be asked about the possibility of their being pregnant or their intention to become pregnant during the next four weeks prior to being given any vaccine for which pregnancy is a contraindication or precaution. (See CDC’s Guidelines for Vaccinating Pregnant Women, page 8). The patient's answer should be documented in the medical record. If the patient is uncertain if she is pregnant, a pregnancy test should be performed before administering live virus vaccines.
Tip #4: Implementing standing orders for vaccination allows appropriate medical personnel to administer vaccines even if a physician is not on site.
Vaccines can be administered only with an order from a physician or a healthcare provider who is authorized by the state to prescribe them. However, a physician may not necessarily need to be present to administer vaccines if standing orders are used. Several studies have shown that the use of standing orders can improve vaccination rates, and the Task Force on Community Preventive Services strongly recommends the use of standing orders programs among children, adolescent and adult vaccination programs (see Table 15 on page 50). A comprehensive set of Sample Standing Orders for Child and Teen Vaccination and Adult Vaccination is available from IAC. These sample orders may be modified to suit your work setting.
At the beginning of each year, the Centers for Disease Control and Prevention (CDC), in collaboration with professional societies, releases updated versions of the recommended U.S. immunization schedules for children and teens as well as for adults. These updated schedules reflect changes that were made in vaccination recommendations during the previous year.
Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, U.S., 2014. This six-page schedule, which was published on the CDC website on January 31, 2014 includes the age-based routine vaccination schedule for children and teens and the approved catch-up immunization schedule for people age 4 months through 18 years who start vaccination late or who are more than one month behind. The schedule also includes three pages of essential explanatory footnotes. An article in the February 7 MMWR provides a summary of these changes.
Recommended Immunization Schedule for Adults Aged 19 Years and Older, U.S., 2014. Released by CDC on February 3, this five-page schedule for adult vaccination provides recommendations by age group as well as by medical condition, two pages of essential footnotes, and a final page summarizing the contraindications and precautions for adult vaccine use. An article in the February 7 MMWR summarizes the changes to the adult guidance.
Several additional formats of the schedules, including patient-friendly versions, are available on the CDC website.
To make your job easier, the Immunization Action Coalition (IAC) has designed two user-friendly documents that summarize the guidance contained in the current CDC/ACIP recommendations.
These summaries distill the ACIP recommendations for child, teen and adult immunization into two easy-to-use documents. Each summary includes the routine schedule, spacing between doses, schedules for catch-up vaccination, routes of administration, and contraindications and precautions for all routinely recommended vaccines in the United States.
These summaries of the recommendations have long proved their value — for almost two decades, they have been top downloads from IAC's website for busy healthcare professionals. They have been reprinted in textbooks and state health department newsletters and distributed at countless medical, nursing and public health conferences. Print the summaries on card stock and place them in every exam room for easy reference — you'll be glad you did!
In addition, IAC has developed the following specialized recommendation summaries for situations that providers often find confusing:
You can access these and more than 250 other ready-to-copy IAC materials
for healthcare professionals and patients on the IAC website.
Let’s start with the good news. Since human papillomavirus (HPV) vaccine was licensed for use in the U.S. in 2006, vaccine-type HPV prevalence has declined 56 percent among females 14 through 19 years of age.
Now for the bad news. According to the United States Centers for Disease Control and Prevention’s (CDC) most recent National Immunization Survey for teens, HPV vaccination rates did not increase at all from 2011 to 2012 in 13- to 17-year-old girls. Only half of these teens received the first dose of this anticancer vaccine, and only one-third received the full three-dose series.
Tdap and meningococcal vaccines were added to the vaccination schedule for preteens at about the same time, yet their coverage rates are much higher, 85 percent and 74 percent, respectively.
These survey results demonstrate that we are missing opportunities to vaccinate preteens against HPV. We need to do better.
Research consistently shows that a provider’s recommendation to vaccinate is the single most influential factor in convincing parents to vaccinate their children. Here are some important points to remember and statements you can make to parents when recommending HPV vaccine:
Your approach to discussing HPV vaccination with a parent strongly influences whether they have their child vaccinated. When you only ask parents if they’d like to vaccinate their child, rather than recommending it, vaccine acceptance drops significantly. Your strong recommendation is what is needed to protect our nation’s children from HPV.
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