Routes for Vaccine Administration: Intramuscular, Subcutaneous,

Intradermal and Intranasal

Ruth Carrico PhD RN FSHEA CICAssociate Professor

Division of Infectious DiseasesUniversity of Louisville

Objectives

• Describe basic infection prevention and control relevant to administration of medication including vaccines

• Review administration of vaccines via intramuscular, subcutaneous, intradermal, and intranasal routes

• Apply knowledge of administration techniques in simulated setting

Infection Prevention Practice Competencies

Safe Injection Practices– Role of microorganisms in disease– Transmission– Precautions– Problem solving– Preparedness

Injection Safety

• Measures taken to perform injections in a safe manner for patients and providers

• Part of Standard Precautions– Infection prevention practices that apply to all patients,

regardless of suspected or confirmed infection status, in any healthcare setting

• Healthcare should not provide any opportunity for transmission of bloodborne viruses– Patient protections in the context of IV injections should be

on par with transfusion safety and healthcare worker safety (OSHA BBP Standard)

Transmission of Bloodborne Pathogens Via Unsafe Injection Practices

SOURCEInfectious person,e.g. chronic, acute

CASESusceptible,

non-immune person

CONTAMINATED INJECTABLE EQUIPMENT OR PARENTERAL

MEDICATION

Limit or eliminate reuse

Standard Precautions• Assume that anyone might be infected with a bloodborne

pathogen • Basic infection control principles that apply every where

and every time healthcare is delivered• Safe Injection Practices– Never administer medications from the same syringe to

more than one patient– Do not enter a vial with a used syringe or needle– Minimize the use of shared medications– Maintain aseptic technique at all times

What are some of the incorrect practices that have resulted in transmission of pathogens?

• Direct (i.e., “overt”) syringe reuse– Using the same syringe from patient to patient (even if needle changed)

• Indirect syringe reuse– Accessing shared medication vials with a used syringe

• Reuse of single dose vials• Contamination of multidose vials• Using a common bag of saline or other IV fluid for more than

one patient– Leaving IV set in place for dispensing fluid– Accessing IV bag with syringe that has already been used to flush a

catheter• Sharing of blood contaminated glucose monitoring equipment• Preparing medications in area contaminated with used syringes

Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded

FACT: injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections

Ref: Samandari et al. ICHE 2005; 26: 745-750

Photo: Don Weiss / NYCDOHMH

Indirect Syringe ReuseNevada endoscopy center HCV outbreak

investigation, 2008

• Syringes were reused to withdraw multiple doses for individual patients

• Remaining volume in single dose propofol vials was used for subsequent patients

• The vial became the vehicle for HCV spread

Misperceptions

• I changed the needle so I can reuse the syringe• The vial says single dose but it has enough

medication for more than one patient, so I can use it

• This is an emergency situation so I can push aside strict adherence with good technique

Examples of some “BIG IFs”• IF I’m going to be throwing away this vial after this

case, I can reuse this syringe to draw more meds• IF we always use a new needle and syringe to draw

meds, it’s OK to reuse vials• IF I’m very careful, I can safely predraw multiple

syringes from this saline bag or vial• IF I keep things straight, I can predraw meds for

the next person while I am preparing for the present person

Injection Safety – Standard Precautions• Use aseptic technique during the preparation and

administration of injected medications • Do not use medication drawn into a single syringe for

multiple patients, even if the needle is changed• Consider a syringe or needle contaminated after it has

been used to enter or connect to a patients’ intravenous infusion bag or administration set

• Do not enter a vial with a used syringe or needle• Single dose vials have no preservative so the vial must be

discarded after that single dose

Adapted from: CDC. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

Minimizing the use of shared medications affords an extra layer of protection to reduce

patient risk• Use single-dose medication vials whenever possible• Single-dose vials should not be used for more than one

patient• Multi-dose vials have preservatives but still require

aseptic technique when entered

Adapted from: CDC. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

Basics of assessment and triage prior to pharmaceutical agent administration

• Be aware of purpose of the pharmaceutical intervention

• Know the agent (action, the 5 Rs, contraindications, other safety issues)

• Know the type of vaccine (live or killed)• Know the targeted patient population• Special needs necessitate special interventions

Intramuscular Injection Sites

• Children (3-18 years)– Deltoid– 22 to 25 gauge 5/8 to 1 inch needle depending upon body

mass– May use gluteal muscle but know the landmarks

• Adults (19 years and older)– Deltoid using 1 inch to 1 ½ inch needle

• 130-152 lbs use 1 inch• 152-200 lbs 1 to 1 ½ inch• >200 lbs use 1 ½ inch

– Can use anterolateral thigh if deltoid not an option

Intramuscular Injection Sites

• Infants <12 months– Anterolateral aspect of the thigh (vastus lateralis muscle) is

preferred site– 22-25 gauge needle– 5/8 inch needle for neonates (first 28 days of life) and

preterm infants– 1 inch for others

• Toddlers (12 months-2 years)– Anterolateral thigh using 1 inch needle– Can use deltoid if muscle mass is adequate. May use 5/8

inch needle for deltoid.

Steps in administration of intramuscular, intradermal, intranasal, subcutaneous and

oral vaccines/agents

• Know administration site• Be aware of any special handling required of

the vaccine or agent• Be familiar with the steps involved in

administration• Be familiar with equipment and supplies• Identify critical steps in the process• Practice, when possible

Needle Selection for Intramuscular Injection

• Injection technique is critical• Use of a longer needle has been associated with less

redness or swelling than with a shorter needle• Needle must be long enough to reach the muscle

mass and prevent seeping into subcutaneous tissue. • Vaccinators must be familiar with the anatomy of

the area in which the vaccine is to be injected• Needles are inserted at 90° angle for intramuscular

injection in children and adults

Subcutaneous

• Involves injection of the agent into the tissue beneath the skin but above the muscle

• Generally requires a needle of approximately 5/8 of an inch

• Area of administration is generally in the upper third of the upper arm away from larger muscles, in the abdomen or thigh.

Intradermal

• Intradermal administration utilizes a smaller needle length and administers a smaller dose volume.

• Administration of intradermal vaccine differs from other intradermal medication administration such as the TB skin test

• At present, the intradermal flu vaccine comes in its own prefilled syringe.

• Verify the age requirements for this, and all other vaccines• Let the vaccine recipient know what to expect following

immunization

Intranasal

• Know equipment• Position patient• Provide tissue• Prepare the patient for administration• Administer the dose• Provide post-immunization education• Dispose of supplies and equipment• Hand hygiene

Patient Positioning

• Dependent upon age, ability to participate, setting for administration, type of pharmaceutical agent

• Children may need secure, comforting position that prevents movement

• Injection position influenced by setting (e.g., sitting, drive-thru, standing)

• Intranasal may be given sitting, standing, drive-thru

• Oral agent administration v. dispensing

Handling and Disposal of Medical Waste

• Regulated– Blood/potentially infectious body fluids, some

pharmaceutical wastes– Federal and state regulations– Impacts disposal as well as transporting waste– Designated receptacles

• Non-regulated– General trash– Items not considered to be soaked, saturated with blood,

body fluids, or other potentially infectious material; non-regulated biologic/pharmaceutical waste