Make No Mistake: Vaccine Administration, Storage, and Handling

CDC Expert Commentary

Andrew T. Kroger, MD, MPH

Vaccine Administration

Vaccine administration is a critical component of a successful immunization program. We label the 7 steps to successful immunization the "rights of medication administration." The word "right" implies "correct" -- the correct steps to ensuring successful administration.

1. Right #1 - the right patient. Make sure you are vaccinating the right person in the room, and also that screening has been performed to identify which vaccines are needed and which vaccines should be avoided because of medical conditions.
2. Right #2 - the right vaccine. Check your vials 3 times to make sure you have the correct vaccine in hand.
3. Right #3 - the right time. Make sure the patient is the appropriate age and is being vaccinated at an appropriate interval from other doses of the same or different vaccines. Vaccines and their diluents might expire as well, so check those dates.
4. Right #4 - the right dosage. Vaccine dosage is based on the age of the patient, not the weight. Vaccines differ from medications in this respect.
5. Right #5 - the right route. Whether oral, intranasal, subcutaneous, or intramuscular, this varies by the type of vaccine, and requires the appropriate administration technique. Correct needle length is also essential.
6. Right #6 - the right site. This is partially dependent on the correct route, and is also related to the age of the patient. Resources are available to assist in the determination of route, site, technique, and needle length. For instance, for vaccines administered by the intramuscular route, a table in the January 2011 General Recommendations on Immunization ^[1] (Table 10) guides administration by this route according to age, gender, site, and technique.
7. Right #7 - the right documentation. This is critical to ensure not only that your patient receives the correct number of doses to be adequately protected, but that excessive doses are not provided, which can cause mild local reactions and can waste valuable vaccine.

All staff (permanent and temporary) who administer vaccines should receive competency-based training and education on vaccine administration before administering vaccines to patients. Staff knowledge and skills should be validated with a skills checklist. Furthermore, all staff should receive continuing education when there are new schedules, vaccines, or recommendations.

Vaccine Storage and Handling

Each office should develop and maintain a detailed written storage and handling protocol; assign storage and handling responsibilities to a single person; designate a backup person; and provide training on vaccine storage and handling.
It is also important to prevent storage and handling errors. Maintaining vaccines at the correct temperature is critical to maintaining potency and protection. Vaccines must be stored properly from the time they are manufactured until they are administered to your patients. Vaccines stored at incorrect temperature can cost thousands of dollars in wasted vaccine and revaccination. The cold chain, which is a temperature-controlled supply chain, begins with the manufacturer and continues with the transfer of vaccine to the distributor; transfer from the distributor to the provider's office; and administration to the patient. Proper storage temperatures must be maintained at every link in the chain. These temperatures are defined in the package inserts for each product and in Table 11 of the General Recommendations on Immunization .

Vaccine storage units must be selected carefully and used properly. Refrigerators without freezers, and stand-alone freezers, are preferred because they are better than combination refrigerator-freezer units at maintaining the required temperatures. Any refrigerator or freezer used for vaccine storage must have its own exterior door and must be able to maintain the required temperature range throughout the year. It must be large enough to hold the year's largest vaccine inventory, and must be dedicated to the storage of biologics.
Proper temperature monitoring is vital to proper cold chain management. Check the storage temperatures twice a day -- once in the morning and once before you leave at the end of the workday -- and record the temperature readings twice daily. However, documentation is not enough. Equally important is taking immediate corrective action when the temperatures fall outside the recommended ranges. Remember, any mishandled or incorrectly stored vaccine should not be administered. It is especially important that inactivated vaccine that has been exposed to freezing temperature not be administered.

If you discover that your refrigerated vaccine has been exposed to freezing temperatures -- even if the vaccines do not appear to have been frozen -- you should remove and identify the exposed vaccine so it will not be used. Then contact the manufacturer or your state or local immunization program for advice. You should do the same thing if your freezer temperature rises above 5°F during other than the normal defrost cycle.