Vaccine administration

Ancillary supplies and PPE 

Pharmacies are to continue to source their own ancillary supplies and protective personnel equipment (PPE) e.g., syringes, needles, alcohol swabs, band aids, sharps containers and medical masks etc. for both flu and COVID-19 vaccinations.

Infection prevention and control measures

Provincial Infection Control Network of BC (PICNet) guidance outlines the infection prevention and control measures required for the set-up and safe operation of immunizations in community settings (e.g., community pharmacies, community centers).

Further information can be found on BCCDC Infection Control webpage.

Vaccine preparation and administration techniques

Vaccine preparation and administration technique for intramuscular injections

Registrants are reminded to review proper injection techniques for influenza vaccines administered via the intramuscular (IM) route in order to ensure patient safety and avoid injury and harm. BCCDC Immunization Manual Appendix 2 – Administration of Biological Products provides detail guidance on proper product preparation and administration of vaccine.

Here are some important reminders for IM injection route for the influenza vaccine:

When drawing up vaccine from multi-dose vials, ensure the date (day/month/year) is recorded on the label of the vial. Partial doses from separate vials should not be combined to obtain a full dose. Immediately return multi-dose vials to the refrigerator. It is not necessary to change needles between drawing up the vaccine into the syringe and immunizing the client. Change the needle only if it is damaged or becomes contaminated. For detailed technique on drawing up vaccine from multi-dose vials, and using syringes pre-filled by the manufacturer, see Appendix 2 – Administration of Biological Products.

Reference: BCCDC Immunization Manual, Appendix 2 – Administration of Biological Products

 Resources:

• For influenza vaccine product dosages and schedule, see Part 4 – Biological Products.
• Immunizing Children – Suggested Best Practice Tips for BC Community Pharmacists
• BCCDC Immunization Clinical Resources

Landmarking reminder for deltoid IM injections

Based on information BCPhA has received on recent incidents in the field, we have been asked to remind injection-certified registrants to review landmarking techniques and adjust their respective practices as needed. Improper technique, especially for intramuscular injections, may lead to improperly administered vaccines, injury, and irreversible harm to the patient.

One of the most reported cause of injury stems from an injection that is administered too high up the patient’s upper arm and inadvertently, into the shoulder joint^1,2. Termed SIRVA or shoulder injury related to vaccine administration, this leads to inflammation and damage to the bursae, tendons, and ligaments in the area^1,2. Patients typically report symptoms such as persistent shoulder pain and limited range of motion within 48 hours of vaccine administration that are not alleviated by over-the-counter analgesics¹. If given too low, the vaccine can be accidentally injected into the radial nerve and if too far to the side, the axillary nerve¹. Both injection misplacements can lead to paralysis, neuropathy, and burning shooting pain during injection¹.

To avoid these injuries, below are some landmarking reminders for intramuscular injections^1,3:

1. Do not “eyeball” or approximate the injection site.

2. Define the injection site by forming an imaginary upside-down triangle on the patient’s arm by placing 2 to 3 fingers down from the acromion process. This forms the base of the triangle. The bottom point or the peak of the triangle is located at the level of the axilla.

Image adapted from BCCDC 

3. The injection site is the centre of this triangle and should be around 4 cm below the acromion for adults and 3 to 5 cm below the acromion for children aged 3 to 18 years old.

4. Assess the injection site and avoid injecting into lumps, bumps, nodules, bruising, wounds, and any new tattoos (newer than 3 months) 

Resources:

Centers for Disease Control and Prevention (IM Injection Sites) (starts at 2:24)

Appendix B: Administration of Biological Products

SIRVA Infographic

Administering multiple injections

When more than one vaccine is to be administered, it is preferable, but not necessary, to use different limbs. Use of different limbs assists in differentiation of local adverse events following immunization. 

When administering two or more vaccines in the same limb, separate the injections by as much distance as possible. A separation of 2.5 cm (1 inch) is preferable so that local reactions are unlikely to overlap. When selecting a site for multiple injections, consider available muscle mass to allow for adequate spacing between injections. 

Reference:

Communicable Disease Control Manual Chapter 2: Immunization Appendix B - Administration of Biological Products  pg4/5 Section 3. "Considerations for the Scheduling and Administration of Multiple Injections".

Immunizing children – suggested best practice tips 

Certified pharmacists in British Columbia may administer an injection to a child 5 years and older; and may administer a drug by intranasal route to a child 2 years old and older.

Improving the immunization experience for children has the potential to improve patient satisfaction and increase immunization rates. Negative experiences have the potential to delay or withhold further vaccinations.

There are many strategies that pharmacists and parents/guardians can use before and during the immunization appointment to:
- Reduce pain and anxiety for the patient.
- Prevent development of needle fears.
- Promote patient satisfaction.
- Promote trust in pharmacists.
- Ensure a positive experience for the child and family.
- Prevent vaccine hesitancy.
- Help increase immunization rates.

A comprehensive approach to each immunization encounter includes, at a minimum:
- Use of effective strategies to prevent and reduce pain and anxiety.
- A comfortable environment.
- Preparation of the child and/or parent/guardian before the procedure.
- Presence of calm adults who can coach children during the immunization.
- A positive attitude, focused on the child, and interactive with the child throughout.

For detailed information about each step in vaccinating a child, please refer to the BCPhA summary of Chapter 2 of the B.C. Centre for Disease Control's suggested best practices.

Resources for coping with needle phobia:

BCCDC – Improving the vaccination experience: A guide for health-care providers

Immunize BC – Immunization Communication Tool 2021

Canadian Institutes of Health Research – Dealing with needle pain and fear

Vaccine co-administration