ALLEVIATION OF PAIN ASSOCIATED WITH INJECTIONS

Comfort measures, such as distraction (e.g. playing music or pretending to blow away the pain), ingestion of sweet liquids, breastfeeding, cooling of the injection site, and topical or oral analgesia, can help infants or children cope with the discomfort associated with vaccination. Pretreatment (30–60 minutes before injection) with 5% topical lidocaine-prilocaine emulsion can decrease the pain of vaccination by causing superficial anesthesia. Topical lidocaine-prilocaine emulsion should not be used on infants aged <12 months who are receiving treatment with methemoglobin-inducing agents because of the possible development of methemoglobinemia.Use of a topical refrigerant (vapocoolant) spray immediately before vaccination can reduce the short-term pain associated with injections and can be as effective as lidocaine prilocaine cream. Acetaminophen may be used immediately following DTP vaccination at the rate of 15 mg/kg/dose to reduce the discomfort and fever.

INJECTION ROUTE, SITE, METHOD, AND NEEDLE LENGTH

With the exception of BCG and sometimes rabies and IPV,all parenteral vaccines are given by either intramuscular (IM) or subcutaneous (SC) route. The SC route is recommended for measles, MMR, varicella, meningococcal polysaccharide, Japanese encephalitis (JE), and Yellow fever vaccines; either SC or IM route may be used for pneumococcal polysaccharide vaccines, such as IPV; the rest of the vaccines should be given intramuscularly. Generally speaking, there is no harm done if SC vaccines are given IM. However, vaccines designated to be given IM should not be given SC due to risk of side effects (as seen with aluminum adjuvanted vaccines) or reduced efficacy (due to reduced blood supply in SC tissue and hence reduced immunogenicity). The gluteal region should never be used for administration of IM injections due to risk of sciatic nerve injury and reduced efficacy (rabies and hepatitis B vaccines). When used at the recommended sites where no large blood vessels exist, pulling back of the syringe to check for blood is not recommended. The needle should be withdrawn a few seconds after finishing administration of the vaccine (to prevent backflow of vaccine into the needle track) following which the injection site should be pressed firmly for a few seconds with dry cotton. The injection site should not be rubbed following injection.

If multiple vaccines are administered at a single visit, administration of each preparation at a different anatomic site is desirable. For infants and younger children, if more than two vaccines must be injected in a single limb, the thigh is the preferred site because of the greater muscle mass; the injections should be sufficiently separated (i.e. 1 inch or more if possible) so that any local reactions can be differentiated. For older children and adults, the deltoid muscle can be used for more than one IM injection (Table 1). If a vaccine and an immune globulin preparation are administered simultaneously [e.g. Td/ Tdap and tetanus immune globulin (TIg), hepatitis B and hepatitis B immunoglobulin (HBIg)], separate anatomic sites should be used for each injection. The location of each injection should be documented in the patients’ medical record (Figs. 1 to 4).


General instructions and guidelines for vaccines- myth busters

  • Vaccination at birth means as early as possible within 24–72 hours after birth or at least not later than 1 week after birth.
  • Whenever multiple vaccinations are to be given simultaneously, they should be given within 24 hours if simultaneous administration is not feasible due to some reasons.
  • The recommended age in weeks/months/years mean completed weeks/ months/years.
  • Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible.
  • The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines.
  • When two or more live parenteral/intranasal vaccines are not administered on the same day, they should be given at least 28 days (4 weeks) apart; this rule does not apply to live oral vaccines.
  • If given <4 weeks apart, the vaccine given second should be repeated.
  • The minimum interval between 2 doses of inactivated vaccines is usually 4 weeks (exception rabies)
  • Vaccine doses administered up to 4 days before the minimum interval or
    age can be counted as valid (exception rabies). If the vaccine is administered
    >5 days before minimum period, it is counted as invalid dose
  • Any number of antigens can be given on the same day
  • Changing needles between drawing vaccine into the syringe and injecting it
    into the child is not necessary
  • Different vaccines should not be mixed in the same syringe unless specifically
    licensed and labeled for such use
  • Patients should be observed for an allergic reaction (anaphylaxis) for 15–20
    minutes after receiving immunization(s)
  • When necessary, two vaccines can be given in the same limb (1–2 inches
    apart) at a single visit
  • The anterolateral aspect of the thigh is the preferred site for two simultaneous
    intramuscular (IM) injections because of its greater muscle mass
  • The distance separating the two injections is arbitrary but should be at least
    1 inch so that local reactions are unlikely to overlap
  • Although most experts recommend “aspiration” by gently pulling back on
    the syringe before the injection is given, there are no data to document the necessity for this procedure. If blood appears after negative pressure, the needle should be withdrawn and another site should be selected using a new needle
  • A previous immunization with a dose that was less than the standard dose or one administered by a nonstandard route should not be counted, and the person should be re-immunized as appropriate for age

  • Vaccine doses administered up to 4 days before the minimum interval or
    age can be counted as valid (exception rabies). If the vaccine is administered
    >5 days before minimum period, it is counted as invalid dose
  • Any number of antigens can be given on the same day
  • Changing needles between drawing vaccine into the syringe and injecting it
    into the child is not necessary
  • Different vaccines should not be mixed in the same syringe unless specifically
    licensed and labeled for such use
  • Patients should be observed for an allergic reaction (anaphylaxis) for 15–20
    minutes after receiving immunization(s)
  • When necessary, two vaccines can be given in the same limb (1–2 inches
    apart) at a single visit
  • The anterolateral aspect of the thigh is the preferred site for two simultaneous
    intramuscular (IM) injections because of its greater muscle mass
  • The distance separating the two injections is arbitrary but should be at least
    1 inch so that local reactions are unlikely to overlap
  • Although most experts recommend “aspiration” by gently pulling back on
    the syringe before the injection is given, there are no data to document the necessity for this procedure. If blood appears after negative pressure, the needle should be withdrawn and another site should be selected using a new needle
  • A previous immunization with a dose that was less than the standard dose or one administered by a nonstandard route should not be counted, and the person should be re-immunized as appropriate for age

Source : IAP guidebook on Immunisation 2018-19 by ACVIP

What is the correct INJECTION PROCEDURE?

Sterile Technique and Injection Safety

Hands should be washed with soap and water for 2 minutes using WHO’s 6-step technique. Alternately, alcohol-based waterless antiseptic hand rub can be used. Gloves need not be worn when administering vaccinations, unless the person administering the vaccine has open lesions on hands or is likely to come in contact with potentially infectious body fluids. Needles used for injections must be sterile and preferably disposable. Autodisable (AD) syringes are single use, self-locking syringes designed in such a way that these are rendered unusable after single use. Thus, they prevent immediate/ downstream reuse and their use is being promoted in the national immunization program. A separate needle and syringe should be used for each injection. Changing needles between drawing a vaccine from a vial and injecting it into a recipient is not necessary.

If multidose vials are used, the septum should be swabbed with alcohol prior to each withdrawal and the needle should not be left in the stopper in between uses. Different vaccines should never be mixed in the same syringe unless specifically licensed for such use, and no attempt should be made to transfer between syringes. Prefilling of syringes should not be done because of the potential for administration errors as the majority of vaccines have a similar appearance after being drawn into a syringe. Thus, vaccine doses should not be drawn into a syringe until immediately before administration. To prevent inadvertent needle-stick injury or reuse, needles and syringes should be discarded immediately after use in labeled, puncture-proof containers located in the same room where the vaccine is administered. Needles should not be recapped before being discarded.

Source : IAP guidebook on Immunisation 2018-19 by ACVIP

General Aspects of Vaccination- Why Vaccinate?

COMMUNICATING WITH PARENTS/CAREGIVERS

With several newer vaccines available in the open market, it is an arduous task for pediatricians to offer ideal advice to parents regarding pros and cons of each vaccine. Most of these vaccines are included in the Indian Academy of Pediatrics (IAP) recommendations necessitating one- to-one discussion. Thus, pediatricians are required to communicate properly with clarity and appropriate information that should help parents to make their own decision in favor or against each of these vaccines. Ideally, we need to offer a balanced scientific view without appearing to suggest one way or another. Unfortunately, most of the educated parents would leave the choice to their pediatricians and it is quite unfair to take responsibility for making a choice for parents.

Prerequisite of one-to-one discussion is commitment on the part of pediatricians to inform relevant facts about disease and vaccines. It takes very little time if one uses structured format covering important aspects in simple language. Following points need to be discussed regarding each vaccine.

  • Risk of developing disease: It is not possible to evaluate risk of
    disease in an individual child, but figures from literature may be quoted, e.g. the risk of invasive pneumococcal disease (IPD) in a healthy child aged less than 1 year is roughly 200 per 100,000 (as per Western data). Some general statements are also helpful. Water or food-borne infections are preventable to some extent but not airborne droplet infections. Risk of complications of disease is higher in infants and younger children and in undernourished populations. Age prevalence of disease decides appropriate age of vaccination as per the standard recommendations.
  • Efficacy of vaccine: No vaccine provides 100% protection though most of the vaccines do offer a high degree of protection. Vaccines significantly decrease chance of disease and even partial protection is useful to prevent complications. Occasional failure of vaccine protection is no reason to consider against its use.
  • Safety of vaccine: Vaccines are very safe and serious adverse reactions are extremely rare. Media outbursts of fatal reactions to vaccines are mostly due to human error of administration and not due to the vaccine itself. Thus, benefits of vaccines outweigh the risk of side effects caused by vaccines.
  • Cost of vaccine: Decision of affordability should be left to parents. It is important to reiterate facts that all vaccines are equally efficacious even though they may differ in their cost. For example, DTwP (diphtheria, tetanus, and whole-cell pertussis) and DTaP (diphtheria, tetanus, and acellular pertussis) are equally efficacious though differ in reactogenicity. Similarly, vaccines from different manufacturers are equally effective and indigenously manufactured vaccines are usually as good as imported ones. Finally, it is important to emphasize that the above discussion is based on the current understanding of vaccines and its present place in prevention of disease. With increasing experience over time, there can be a change in the recommendations of individual vaccines and it is necessary to adapt to such changes. For example, a second dose of MMR is now recommended.
  • Many new vaccines are likely to be introduced over the next few years. It would be a challenge for pediatricians to develop communication skills to discuss pros and cons of all these vaccines. But far more relevant is the need to keep updated on issues related to vaccines and disease prevention. It is only then that “one-to-one discussion” will become more meaningful.
  • Source : IAP guidebook on Immunisation 2018-19 by ACVIP

Source : IAP guidebook on Immunisation 2018-19 by ACVIPSource : IAP guidebook on Immunisation 2018-19 by ACVIP Cost of vaccine: Decision of affordability should be left to parents. It is important to reiterate facts that all vaccines are equally efficacious even though they may differ in their cost. For example, DTwP (diphtheria, tetanus, and whole-cell pertussis) and DTaP (diphtheria, tetanus, and acellular pertussis) are equally efficacious though differ in reactogenicity. Similarly, vaccines from different manufacturers are equally effective and indigenously manufactured vaccines are usually as goodSource : IAP guidebook on Immunisation 2018-19 by ACVIP