Practical and clinical guidance for vaccine administration

This page provides practical and clinical guidance for vaccine administration.

The information provided supports guidance in The Green Book - Immunisation against infectious disease. The Green Book provides policy guidance on vaccine administration, storage and disposal of vaccines, and reporting alongside information for all the vaccines given in the UK and how these should be administered. Immunisers must access the green book online as the resource is constantly updated to reflect the most up to date schedule and advice.

Please ensure if you are using a hard copy of any resources or documents that you are using the most recent version.

• The WHO Best Practices for Injections and Related Procedures Toolkit
• The RCN's Managing Childhood Immunisation Clinics - best practice guidelines (2018) provides a practical checklist to support general practice nurses in managing a childhood vaccine and immunisation clinics, it includes; prescribing and administration of prescription only medicines advice, the time needed for an immunisation appointment, what  resources and information should be available.

All immunisers must be familiar with the route of vaccine administration for each vaccine they are administering.

The majority of vaccines in the UK programme are administered by injection.

The Green Book Immunisation against infectious disease details the specifics for each vaccine as advised by the individual vaccine Summary of Product Characteristics (SmPC). Where there are differences to the manufacturer guidance and UK policy, it is the Green Book guidance that takes precedence, as detailed as a basic vaccination principle. See: Immunisation procedures: the Green Book, chapter 4.

While there  is other guidance which detail injection technique and procedures for other medicines and treatments, it is the Green book, Immunisation procedures: the Green Book, chapter 4 which should be followed for injection technique for vaccine administration.

The green book provides detail of the procedure but in principle for giving vaccines. The injection should be completed as quickly as possible to minimise pain and discomfort.
It is not necessary to aspirate the syringe after the needle is introduced into the muscle.

There is no requirement to hold the needle in place after giving the vaccine or to rub the area post vaccination. “Z tracking” is not recommended when injecting vaccines. 

Other useful resources:

WHO. Recommendations on reducing pain at the time of vaccination.

Nurses and all health professionals are an important and trusted source of advice on vaccination. The discussion with parents and the public is time well spent and people value having the opportunity to ask questions.

The 'Practical tips' below, are adapted from  Bedford H and Elliman D (2019) Fifteen-minute consultation: Vaccine-hesitant parents Arch Dis Child Educ Pract Ed:BMJ.

Practical tips

It is important that nurses are well informed in order to provide information for people’s questions. It is however, the approach you take during the conversation which is key:

• the aim of the conversation is to gain trust and support people to hopefully accept vaccination
• where it is identified that vaccines are due or missing; ask for permission to discuss this. Raising the subject gives the message that this is important and also gives people permission to ask questions
• ask questions to gain greater insight into the individual’s main concerns and listen to them
• be empathic, ‘I understand why you might be concerned’ it really is not surprising that parents and the wider public have questions and concerns
• avoid giving a fact-filled lecture, simply giving more and more information is not the solution and can be counterproductive
• Stick to the concerns raised and provide a limited number of main points in response, expressed simply
• focus on the risk of the diseases—the public, and some professionals, have little experience of diseases because of the success of the vaccination programme
• there is evidence that restating a myth serves to reinforce it— instead identify a myth as being false and focus on the facts: the benefits of vaccination while acknowledging the side effects of vaccines
• highlight the consensus among scientists/health professionals about the evidence in support of vaccination
• acknowledge that we all want the best for ourselves and our children
• do not belittle individuals' concerns
• if people decide not to vaccinate, be clear they can change their mind at any stage and leave the door open for further discussion
• if asked whether you have been vaccinated or your own children have, confirming that you have is an important exemplar. 

Additional information

It is good practice to support any advice you give with written information. Check that the information printed from websites is up to date, evidence based and from a credible source.

As a general guide when searching the web for information, ask yourself and encourage patients, parents and carers to ask the following questions:

• who or what is behind the information?
• is the information biased, or possibly selected to present one view point?
• does the author have a vested interest in the information they are presenting?
• is it dated? There may be more current advice available.
• is it referenced and are uncertainties acknowledged?

In addition look for websites providing reliable and trustworthy health information which have the Health on the net HONcode.

For RCN guidance in relation to the role of nursing associates (NA) and health care support workers (HCSW) and vaccine administration, see:

• The Role of Nursing Associates in Vaccination and Immunisation. Position statement (2019)
• Health Care Support Workers Administering Inactivated Influenza, Shingles and Pneumococcal Vaccines for Adults and Live Attenuated Influenza Vaccine (LAIV) for Children (2019)

All staff administering vaccines need to be appropriately trained and competent. See: Immunisation training section.

Vaccines are Prescription Only Medicine (POM) this means they require authorisation to supply and or administer from an appropriately registered practitioner. This would normally be by a Prescription or Patient Specific Direction (PSD).

There are alternative authorisation processes identified by the legislation (Human Medicines Regulations 2012 HMR) relevant to vaccination which include:

• Patient Group Direction (PGD)  - these are an exemption under schedule 16 of HMR, for enabling the supply and/or administration of a POM. Limited to certain listed heath care professionals
• Written Instruction – (Schedule 17 of HMR) limited to Occupational Health Scheme and specific health care professionals operating under and instruction from a physician
• Emergency medicines - (Schedule 19 of HMR)  which means that adrenaline given in the case of anaphylaxis does not need a prescription. 

For information on medicines administration in occupational health settings and the use of written instructions, see: Specialist Pharmacy Service Written instruction for the administration of seasonal flu vaccination.

All staff involved in administering vaccines should be suitably trained and competent to fulfil the role and be able to answer questions with accuracy and confidence in line with nationally agreed standards.

It is recommended that immunisation training should be either through a face to face taught course or a blended approach of both e-learning and a face to face taught course.

New immunisers should also have a period of supervised practice and support with a registered healthcare practitioner who is experienced, up to date and competent in immunisation.

See:

• Public Health England (PHE). National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners. The aim of the national standards is to describe the training that should be given to all practitioners engaging in any aspect of immunisation so that they are able to confidently, competently and effectively promote and administer vaccinations. For health care support workers please see National minimum standards and core curriculum for immunisation training of health care support workers.
• The PHE immunisation training resources for health care professionals across the UK, includes many resources and Q&A documents for a range of vaccine programmes and a useful animation explaining how the immune system works for immunisers.
• PHE. Guidance from PHE on immunisation training and disruption to face to face training opportunities on immunisation
• RCN: competence assessment framework, Immunisation knowledge and skills competence assessment tool, is now also incorporated within the National minimum standards guidance. It is designed to be used in the workplace to support the training and the assessment of registered and non-registered health care workers who have a role in immunisations.
• Health Protection Scotland's Immunisation Education and Training has some additional resources for staff in Scotland. See ‘Promoting Effective Immunisation Practice’. For Wales see: Immunisation and vaccines and and Public Health Wales e-learning. 
• There is a specific PHE e-learning programme for flu vaccination, with open access to anyone involved in delivering the flu programme/vaccine.
• Information and resources on travel health, see: Jane Chiodini, Travel Health Specialist Nurse.

Immunisation e-learning resource 

Interactive e-learning programme to support the training of healthcare practitioners involved in advising on and/or delivering immunisation across the life course. The programme is free to access, just register to use the e-lfh portal. The course is designed around the updated National Minimum standards and the competency assessment tool.

View the Immunisation e-learning programme.

See the specific flu e-learning resource.

The immunisation programme in the UK is constantly evolving to best protect the public by controlling vaccine preventable diseases. Health professionals must keep up to date with these changes.

The vaccine supply newsletter, ‘Vaccine Update’ comes out approximately every four to six weeks and can be emailed directly to individuals upon request. Email: Vaccine.Supply@dh.gsi.gov.uk. This newsletter gives advice on current vaccine availability, any changes to the schedule and updates to the Green Book.

‘Vaccine Update’ is available to health care professionals across the UK. However, for country specific information, see:

• England: Public Health England immunisation pages.
• Northern Ireland: Public Health Agency: Immunisation / vaccine preventable diseases.
• Scotland: NHS Scotland Immunisation and vaccine preventable diseases pages. Health Protection Scotland produces a 'Scottish Vaccine Update' with similar information to the general version but it reflects the different vaccine supply arrangements. Contact NSS.HPS-SVU@nhs.net to subscribe to the mailing list.
• Wales: Public Health Wales - immunisation and vaccines.

The Green Book, chapter three provides information on the correct storage of vaccines. As biological substances, vaccines may lose their effectiveness quickly if they become too hot or too cold at any time, especially during transport and storage. Incorrect storage may result in the failure of the vaccine to protect, as well as resulting in vaccine wastage.

Vaccine wastage has significant cost implications.

Jane Chiodini reviews the best practice guidance to provide clinicians with knowledge to effectively enhance local storage and handling protocols.

The WHO guidance advises that gloves should not be worn for routine intradermal, subcutaneous or intramuscular injections providing the health worker’s skin is intact as gloves do not provide protection against needle stick injury. See: WHO Best Practices for Injections and related procedures Toolkit. Hand hygiene is essential in between each person vaccinated.

Further advice on glove use and dermatitis is provided in our publication Tools of the Trade. Guidance for health care staff on glove use and the prevention of work-related dermatitis. It is essential that staff look after their hands, the RCN resources on skin health provide information to help and on the use of regular hand cream along side hand hygiene.

There is a common misconception that individuals should wait 20 minutes after receiving a vaccine. The majority of reactions will occur within two minutes and some occur hours later. The advice from the RCN is that there is no need to keep patients waiting unless this is specifically indicated in the summary of product characteristics for a particular vaccine.

Patients should be given advice on adverse reactions and possible sides effects either from the patient information leaflet included with the vaccine or by giving appropriate leaflets such as Public Health England's leaflet What to Expect after Vaccinations.

The RCN supports practice nurses administering vaccines in a patient's home where it complies with their workload demands, workload priorities and when it is in the patient’s interests.

Practice nurses should also check that the patient is not being visited by the district nurses. It is inefficient for both district nurses and practice nurses to visit the same household.

There is no reason for a medical practitioner to be on site when vaccines are being administered. Nurses should only administer immunisation and vaccines if they are trained and competent and this includes being up to date with anaphylaxis management.

In all cases of anaphylaxis, an ambulance should be called. It is good practice to have another person available who is also trained in managing anaphylaxis.

There were 72.8 million visits overseas by UK residents in 2017, an increase of 3% on 2016 and the highest recorded (Office for National Statistics 2018). Travel health medicine is a fast growing specialist area of practice. The RCN guidance, 'Competencies: travel health nursing: career and competence development' (RCN, 2018) provides information on current guidelines and standards and defines the standards of care expected for a competent registered nurse, experienced/proficient nurse and a senior practitioner/expert nurse working in travel health nursing.

The National Travel Health Network and Centre (NaTHNaC) provides advice on travel health, including travel vaccination.

TRAVAX (LOGIN REQUIRED) and fitfortravel from Health Protection Scotland (HPS) provides similar information to NaTHNaC.

NHS Wales has an organisational subscription to TRAVAX which is therefore freely available to NHS Wales users (via HOWIS (Health of Wales Information Service)).

The British Medical Association (BMA) publication, Focus on Travel Immunisation offers clarity around the immunisation issues within the General Medical Services (GMS) contract and how travel immunisations may be funded.

More people in the world are migrating today than at any other point in human history and the Health Protection Agency (now part of Public Health England) has produced a Migrant Health Guide, which supports practitioners making decisions around best protecting the health of migrants. An accompanying video looks at how to catch up immunisations for migrants to the UK.

People often wonder whether it is necessary to defer routine childhood immunisations in babies who have not yet had their 6 to 8 week checks.

The 6 to 8 week check forms part of the newborn and infant physical examination screening programme (NIPE). The newborn element aims to identify and refer all children born with congenital abnormalities of the eyes, heart, hips, and testes, within 72 hours of birth. The second examination is designed to identify abnormalities that may become detectable in older infants – that is at 6-8 weeks of age.

As none of the conditions screened for would constitute a contra-indication to immunisation, there is no requirement for the examination to be undertaken before the first vaccines are given. Babies will need the normal assessment of suitability for vaccines as outlined in the relevant documents e.g. vaccine PGDs. If a baby presents for vaccination at eight weeks having not had the 6 to 8 week check, then this is an opportunity to do the check at the same visit.

See: Newborn and infant physical examination: programme handbook.

See: Green Book, chapter eight.

Guidance on managing anaphylaxis is also available from the Resuscitation Council UK with quality standards for primary care on resuscitation and basic life support.

All staff in primary care organisations, including non-clinical staff, should undergo regular training in resuscitation of both adults and children to the level appropriate to their role. Staff should undergo such training at induction and at appropriately regular intervals thereafter to maintain knowledge and skills, clinical staff should have annual updates.

There is no definitive requirement on the frequency of updates for anaphylaxis training and would be a risk assessment per practitioner. However, if management of anaphylaxis is identified in your role, there should be update training at the local level and this could form part of resuscitation training.

The Anaphylaxis Campaign have an e-learning course accredited by the RCN - there is a fee for this course.

NB Adrenaline and Hydrocortisone are listed exemptions under the Human Medicines regulations 2012 and can be administered by anyone in an emergency for the purpose of saving life. This means there is no requirement for prescription or PGD in order to administer them. See the RCN guidance on medicines optimisation.

Details of the Yellow Card system for reporting adverse events following vaccine administration are available on the Medicines and Healthcare products Regulatory Agency (MHRA) section of the gov.uk website. The yellow card scheme is the key source of data for real-time safety surveillance, nurses have a responsibility to make sure that any adverse events are reported through this process. This is important to strengthen vaccine safety through effective pharmacovigilance.

See: Green Book, chapters three and four.

For advice on the prevention and management of sharps injuries, members should refer to their local policies. Injuries from a source patient known to have a blood borne virus or those which result in a blood borne infection need to be reported to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

The Health and Safety Executive (HSE) has information on the prevention of sharps injuries, including risk assessment, safe disposal and compliance with the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 and on RIDDOR in health and social care.

The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance: Criterion Ten, is available on the Department of Health website.  

The RCN maintains that any organisation which provides health care is responsible for ensuring that their staff and patients are safe. Appropriate vaccination is in the interest of staff, employers and patients/clients. This is underpinned by extensive legislation:

• Health and Safety at Work Act (1974)
• Control of Substances Hazardous to Health Regulations (COSHH) (2002)
• Management of Health, Safety and Welfare Regulations (1999).

The British Medical Association (BMA) has produced guidance for GPs on which vaccines they should provide:

• Focus on vaccines and immunisations - Guidance for GPs (June 2014)
• Focus on hepatitis B immunisations – Guidance for GPs (August 2012)
• Focus on travel immunisations – Guidance for GPs (November 2012)