Administer the Vaccine(s)
Each vaccine has a recommended administration route and site. This information is included in the manufacturer’s package insert for each vaccine. Deviation from the recommended route may reduce vaccine efficacy or increase local adverse reactions.
Health care personnel should always perform hand hygiene before administering vaccines by any route. Occupational Safety and Health Administration (OSHA) regulations typically do not 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. During 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.
Additional information on providing immunization services during a pandemic is available here: Routine and Influenza Immunization Services During the COVID-19 Pandemic: Interim Guidance | CDC
Vaccines available in the United States are administered by 4 routes:
- Oral Route (PO):
Oral vaccine is administered through drops to the mouth. Rotavirus vaccine (RV1 [Rotarix], RV5 [RotaTeq]) is the only routinely recommended vaccine administered orally. Rotavirus vaccine should never be injected. CDC videos demonstrating administering each vaccine:
Rotarix (RV1) – YouTube
RotaTeq (RV5) – YouTube
- Intranasal Route (NAS):
Intranasal vaccine is administered into each nostril using a manufacturer-filled nasal sprayer. Live, attenuated influenza (LAIV [FluMist]) vaccine is the only vaccine administered by the intranasal route. A video demonstrating administration of intranasal flu vaccine can be found here.
- Subcutaneous Route (Subcut):
Subcutaneous injections are administered into the fatty tissue found below the dermis and above muscle tissue. A video demonstrating administering a vaccine by subcutaneous injection can be found here.
- Intramuscular Route (IM):
Intramuscular injections are administered into the muscle through the skin and subcutaneous tissue. The recommended site is based on age. Use the correct needle length and gauge based on the age, weight, and gender of the recipient. A video demonstrating administering a vaccine by intramuscular injection can be found here.
When administering a vaccine by injection, choose the correct needle size based on the route, age, patient size, and injection technique. See chart below to identify the route for each injectable vaccine.
|DTaP, DT, HepA, HepB, Hib, HPV, IIV4, RIV4, ccIIV4, IPV*†, MenACWY, MenB, MMR‡ , PCV13, PPSV23*†, RZV, Td, Tdap, TT, VAR†||Intramuscular injection||Vastus Lateralis or Deltoid muscle|
|IPV*†, MMR‡, PPSV23*†, VAR†||Subcutaneous injection||Fatty tissue of thigh for infants younger or upper outer triceps area|
|DTaP-IPV, DTaP-IPV-HepB, DTaP-IPV/Hib, DTaP-IPV-HepB/Hib, HepA-HepB, MMRV†||Intramuscular injection||Vastus Lateralis or Deltoid muscle|
|MMRV†||Subcutaneous injection||Fatty tissue of thigh for infants younger or upper outer triceps area|
*Based on age. Detailed discussion can be found here: Pinkbook: Vaccine Administration | CDC
†Vaccine may administered by intramuscular or subcutaneous injection
‡MMR vaccine injection route varies by brand. PRIORIX is administered by subcutaneous route only. M-M-R II may be administered by the subcutaneous or intramuscular route.
Some vaccines are approved by the Food and Drug Administration (FDA) for administration by the Pharmajet Stratis needle-free injection system. This system administers vaccines by creating a narrow stream capable of penetrating the skin. For more information, see the manufacturer’s website.
Multiple Injections/Coadministration of Vaccines
Dosage, Route, and Site Guides:
- All Ages: Dose, Route, Site, and Needle Size
- Vaccine Administration: Intramuscular (IM) Injection Children 7 through 18 years of age
- Vaccine Administration: Intramuscular (IM) Injection Adults 19 years of age and older]
- Vaccine Administration: Needle Gauge and Length
Often, more than one vaccine is needed during the same doctor’s visit, requiring more than one shot. If multiple vaccines are administered at a single visit, administer each injection in a different injection site. For infants and younger children receiving more than two injections in a single 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. Best practices for multiple injections include:
- Prepare each injectable vaccine using a separate syringe.
- Label each syringe with the name and the dosage (amount) of the vaccine, lot number, the initials of the preparer, and the exact beyond-use time, if applicable.
- Use combination vaccines (e.g., DTaP-IPV-HepB or DTaP-IPV/Hib) to reduce the number of injections, when appropriate.
- Do NOT mix more than one vaccine in the same syringe in an effort to create a “combination vaccine.”
- Separate injection sites by 1 inch or more, if possible.
- Administer vaccines that are known to be painful when injected (e.g., MMR, HPV) last. Because pain can increase with each injection, the order in which vaccines are injected matters. Injecting the most painful vaccine last when multiple injections are needed can decrease the pain associated with the injections.
- Administer vaccines that may be more likely to cause a local reaction (e.g., tetanus-toxoid-containing and PCV13) in different limbs, if possible.
Additional information on coadministration of vaccines can be found at: Pinkbook: Vaccine Administration | CDC
COVID-19 vaccine and coadministration with other vaccines
CDC and the Advisory Committee on Immunization Practices (ACIP) guidance states COVID-19 vaccines can be given during the same visit with other vaccines, including flu vaccine, if the recipient is eligible for the vaccines.
Considerations for Coadministration of COVID-19 Vaccines and Other Vaccines
While there is limited data on giving COVID-19 vaccines with other vaccines, including flu vaccines, experience with giving other vaccines together has shown the way our bodies develop protection and possible side effects are generally similar when vaccines are given alone or with other vaccines.
- Whether the patient is behind or at risk of becoming behind on recommended vaccines.
- Their risk of vaccine-preventable disease (e.g., during an outbreak or occupational exposures).
- The reactogenicity profile of the vaccines (It is unknown whether reactogenicity of COVID-19 vaccine is increased with coadministration, including with other vaccines known to be more reactogenic, such as adjuvanted vaccines or live vaccines).
COVID-19 vaccine has been associated with enhanced local/injection site reactions l (e.g., pain, swelling, redness). If possible, administer COVID-19 vaccine and other reactogenic vaccines (e.g., MenB, Tdap) in different limbs. Clinical information and materials on COVID-19 vaccine products can be found here.
Procedural Pain Management
Vaccine injections are often cited as a common source of procedural pain in children. The pain associated with injections is a source of distress for children and their parents and/or guardians. Although pain from injections is, to some extent, unavoidable, there are some things that parents and health care providers can do to help prevent distress and decrease fear. Evidence-based strategies to reduce procedural pain include:
- Giving sweet-tasting liquids (orally)
- Injecting vaccines rapidly without aspiration
- Injecting the most painful vaccine last
- Using tactile stimulation (rubbing/stroking near the injection site before and during injection)
- Distracting the patient (done by either the parent or clinician)
- Having the patient seated rather than lying down
- Using topical anesthetics
Fear of injections is often a reason why adults, including health care personnel, decline vaccines. Some of the evidence-based strategies for reducing procedural pain in children can also be used to help prevent distress and alleviate fear in adults.
A detailed discussion of strategies to reduce procedural pain can be found here.
Managing Acute Vaccine Reactions
Severe, life-threatening reactions following vaccinations are rare. However, all vaccination providers should be familiar with the office emergency plan and currently certified in cardiopulmonary resuscitation.
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.
- Be aware of symptoms that precede fainting (e.g., weakness, dizziness, pallor).
- Provide supportive care and take appropriate measures to prevent injuries if such symptoms occur.
- Observe recipients after vaccination to decrease the risk for injury should they faint. For most vaccines a 15-minute observation period is recommended. Some persons should be observed longer–30 minutes–after receiving COVID-19 vaccine. Detailed guidance can be found here.
- Medical Management of Vaccine Reactions in Children and Teens
- Medical Management of Vaccine Reactions in Adults
- General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)
- Hand Hygiene in Healthcare Settings
- Injection Safety
- Sharps Safety for Healthcare Settings
- Vaccine Administration chapter, Epidemiology and Prevention of Vaccine-Preventable Diseases (the Pink Book)
- Taddio A, Appleton M, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline.Can Med Assoc J 2010;182(18):E843-55.
- Rotarix (RV1) [4:57 minutes]
- RotaTeq (RV5) [4:04 minutes]
- Subcutaneous (SC or Subcut) Injection: Sites [3:26 minutes]
- Subcutaneous (SC or Subcut) Injection: Administration [6:27 minutes]
- Intramuscular Injection: Sites [5:07 minutes]
- Live, Attenuated Influenza Vaccine (LAIV) [4:09 minutes]
- Comfort and Restraint Techniques for Children [4:46 minutes]
- It Doesn’t Have to Hurt