Practical Aspects of Immunisation
Introduction to Immunisation Study Day
Vaccine Advice for CliniCians Service
Contents
• Cold Chain
• Administration of vaccines
• Documentation
Cold Chain
What is the cold chain?
Why is it important?
Cold Chain
Manufacturer
Transport
Surgery/pharmacy/clinic
Vaccine session/appt
Patient
Vaccine storage
Fridge
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Dedicate vaccine fridge, no specimens, milk etc
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Temp between +2 and +8 °C’
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Min, Actual & Max temp recorded daily
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Two min/max thermometers
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Has good air flow around vaccines
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Appropriate size for quantity of vaccines
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Locked or kept in a locked room
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Power supply secured
Ordering/delivery/storage
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Order 2-4 weeks at a time
Check delivery for leaks/damages
Store promptly (in original vaccine boxes)
Rotate stock
Maintain a stock information system to track orders, expiry dates
and keep a running total of vaccines.
At least two named, trained people need to be responsible for ordering,
receipt and care of vaccines (one from the nursing team and one from
management). All members of the primary care team should be aware of
the importance of good vaccine management.
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Risks of excess stock
Over-Packed
Fridge
Poor Storage
Rotation
Poor Air
Flow
Increased Risk
of using out of
date Stock
Freezing
Sub-Optimal
Vaccines
Increased
Waste
Increased Cost
To Clinic
Administration
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Site
Correct positioning of the patient
Needle length
Injection method
Audit
• Every week – fridge contents
• Every month – vaccine stock
• Every three months – audit stock and temp records
• Annually – Vaccine Storage Audit Tool
(www.ovg.ox.ac.uk/Vaccsline.htm)
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4 R’s
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Read
Record
Reset
React
Cold chain incidents
What is a cold chain incident?
What action would you take?
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Actions
• Quarantine/ label vaccines
• Restore to correct temperature
• Gather information
– How long & at what temperature?
– Has anyone been vaccinated?
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Contact manufactures for stability data
Identify why occurred – could it be avoided?
Contact PCT
Complete a ‘Stock Incident capture form’ on immForm
http://immunisation.dh.gov.uk/
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Maintenance of the cold chain is
vital to the delivery of successful
immunisation programmes
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Administration of vaccines
Preparation
• Change needle between drawing up and injecting – UK
recommended practice1
• Cleansing of injection site – no need to use alcohol
wipes 2
• Is aspiration necessary?
•
1.Department of Health. Immunisation procedure chapter. www.dh.gov.uk
2. Dann T, (1969)Routine skin preparation before injection, an unnecessary procedure. Lancet 2:96-98.
Site
Site
Why not use the buttock?
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Infants: sciatic nerve not fixed
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Adults: thicker layer of S/C fat –
would need a 1½ inch needle
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Evidence of reduced
immunogenicity of Hep B¹ &
Rabies²
1. MMWR (1985)
2. Shill et al (1987)
What is the preferred route for
vaccines?
Injection technique
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Most vaccines IM
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Optimises immunological benefit
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Minimises local side effects
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Poor drainage channels in fat,
retains injected material for longer
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SC tissue more susceptible to
adverse effects of injection
Needle size in infants
L Diggle et al (2006) BMJ 333.571
• Infants immunised at 2, 3 & 4 months of age
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23G 25mm (standard blue)
25G 16mm (standard orange)
25G 25 mm
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Longer needle (25mm) =
less local reaction because ensures vaccine given IM
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Gauge (23G or 25G) – no difference for local reactions
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Evidence favours the blue long, 23G, 25 mm (1 inch) needle
achieving comparable, if not superior immunogenicity
Best Practice
Adults, children and
infants
25 mm, 23G (blue)
Or
25mm, 25G (long orange)
Larger adults
Consider 38mm, 21G (green)
Pre-term infants
Consider 16mm,25G (orange)
Some common (ish) problems
• Vaccine loss/spillage
• Administering the wrong vaccine/expired vaccine
Documentation
• Effective documentation
– Vaccine name, product name, batch number & expiry date
– Dose administered
– Site used, and clear description of where they were given i.e.
upper/lower if 2 in same limb
– Date
– Name & signature of vaccinator
• Information recorded in;
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Patient held record or Red Book(PCHR)
GP / Clinic system
Child Health Information System
Unscheduled forms, if apporpriate