Practical and clinical guidance for vaccine administration

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.

The RCN position 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 (April 2019)
• Health Care Support Workers Administering Inactivated Influenza, Shingles and Pneumococcal Vaccines for Adults and Live Attenuated Influenza Vaccine (LAIV) for Children

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

RCN guidance on medicines administration: For more information on the administration of vaccines in relation to Patient Specific Directions (PSD) and Patient Group Directions (PGD) please visit the RCN medicines management resource.

For information on medicines administration in occupational health settings and the use of written instructions see the Specialist Pharmacy services guidance and useful Q&A.  The Specialist Pharmacy Service have developed guidance on written instruction for the administration of seasonal flu vaccination, with a  template written instruction for the seasonal flu vaccine.

All staff administering vaccines need to be appropriately trained and competent.

Vaccine conversation

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.

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.

Storage and Cold Chain

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.

Wearing gloves

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 the WHO Best Practices for Injections and related procedures Toolkit.

Further advice on glove use and dermatitis is provided in our publication Tools of the Trade.

Observation times after administering a vaccine

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 the DH leaflet “What to Expect after Vaccinations”.

Practice nurses administering vaccines in patients' homes

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.

Administering vaccines in a General Practice setting

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.

6-8 week developmental assessment and baby immunisations

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 the Newborn and infant physical examination: programme handbook.

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.

For guidance on reporting adverse incidents, please see the MHRA website.

Disposal of equipment and management of sharps injuries

Green Book, chapters three and four.

For advice on the management of and prevention 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).

Health and Safety Executive (HSE) information on sharps and '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, available on the Department of Health website.  

Employers and occupational health vaccination

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)