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Outbreaks, Alerts and Hot Topics

June 2019

Avoid Injuries Related to Vaccine Administration, How to Recognize Risk for and Prevent SIRVA            

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Mary Anne Jackson, MD
 | Interim Dean - UMKC School of Medicine | Medical Editor, The Link Newsletter 

Local reactions associated with vaccine administration including pain, redness, induration and swelling at the injection site are well-recognized events and all self-resolve. Injuries related to injection of vaccine contents into the subdeltoid/subacromial bursa, or anterior branch of the axillary or radial nerve are less common, but associated with significant morbidity. First reported in 2007 by Bodor and Montalvo,1 reports have increased significantly over the last decade. Predominantly identified in adults, there is no specific vaccine association; however, the pathogenesis, diagnosis and preventative approach has been investigated and more recently better defined. 

The first reports of such events surfaced more than a decade ago with the identification of two patients with acute onset of shoulder pain following influenza and pneumococcal vaccine respectively. Using ultrasound measurements, the authors hypothesized that the vaccines were injected too high and into the upper third of the deltoid muscle, causing an inflammatory process in the subacromial bursa, bicipital tendon and capsule. Both patients improved after corticosteroid injection.             

Atansoff, et al., reported 13 patients with shoulder injuries related to vaccine administration (SIRVA), characterizing the presentation as the acute onset of pain in the shoulder of the arm where the immunization was given, associated with decreased range of motion.2 The authors noted that almost half of the patients thought their vaccine was given too high, and emphasized that numbness or tingling were not present. Notable in such injuries is the associated morbidity where pain persisted for months, and in some cases required surgical intervention.    

Using pharmacovigilance data, Arias et al., systematically reviewed all cases where vaccination-related bursitis and other shoulder injuries were reported.3 All occurred in adults, mainly in women, and were associated with vaccines given intramuscularly into the deltoid. Influenza and pneumococcal vaccines were most commonly associated, but such events also followed adult tetanus-containing vaccines, human papillomavirus and hepatitis A vaccine. The authors suggest these types of injuries are underreported, and suggest that a focused approach to improving injection technique, specifically related to site, angle and needle size, could prevent such injuries.     

In 2010, the national Vaccine Injury Compensation Program added shoulder injuries related to intramuscular vaccine administration to the Vaccine Injury Table and that all specified features must be present:  

• No antecedent history of pain, inflammation or dysfunction in the affected shoulder
• Pain onset within 48 hours of vaccine administration
• Pain and reduced range of motion limited to shoulder in which the vaccine was administered
• No alternative diagnosis

Bansci, et al., reported the potential for vaccine administration errors to cause injury if given too high (highest risk of shoulder injuries) associated with the risk of injection into the shoulder bursa or joint. In cases where the vaccine site is too far to the side, axillary nerve injury can occur, or if the site is too low, injury to the radial nerve can occur.4 Injection into the axillary or radial nerve causes immediate report of burning or shooting pain during injection. Rarely reported are errors where the needle length is too long and bone injury may occur.

Avoiding vaccine administration injuries starts with choosing the correct route, needle size and site based on the age and size of the patient.5 For adolescents and adults, providers should ensure that the vaccinee and vaccinator be seated; and for intramuscular upper-arm vaccination, that the shoulder be fully exposed. The Centers for Disease Control has an infographic outlining the appropriate site selection in adults for intramuscular vaccine injection to avoid shoulder injuries as 2-3 fingers down from the acromion and above the armpit in the middle of the upper arm.6

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An evidence-based protocol for prevention of upper arm injuries related to vaccine administration was published in 2011. Specified approaches to deltoid muscle vaccination based on location of the acromion were reviewed and noted to be varied and all subject to potential injury.7 He recruited 536 adult patients (253 women), to define anthropometric characteristics of the surface anatomical landmarks, and to map the position of structures that could be potentially injured by vaccine administration. Using the data, he outlined a vaccination protocol that defined the proper positioning and site selection to avoid injuries. The protocol identifies that the vaccinee should be positioned with their arm abducted 60º and hand on their ipsilateral hip to relax the deltoid muscle and optimize identification of the deltoid tuberosity. The vaccinator’s right-hand index finger is placed on the acromion and the thumb on the deltoid tuberosity. The midway site between the acromion and the deltoid tuberosity provides the safest site for vaccination.

There are a wide array of health care professionals who administer immunizations, including physicians, nurses, pharmacists and in some cases, students who are new to the field. Comprehensive vaccine administration training should be required for all who give vaccines before administering vaccines to patients. An increased awareness of the potential for SIRVA should allow practitioners to focus on education of their staff to ensure good practices.


1. Vaccine Related Shoulder Dysfunction. Bodor, et al. Vaccine 2007 25 (4): 585-587.       

2. Shoulder Injury Related to Vaccine Administration (SIRVA). Atanasoff, et al. Vaccine 2010: 28: 8049-8052.   

3. Risk of Bursitis and Other Injuries and Dysfunctions of the Shoulder Following Vaccinations. Arias, et al. Vaccine 2017; 35937): 4870-4876.    

4. Shoulder Injury Related to Vaccine Administration and Other Injection Site Events. Bancsi, et al. Can Fam Physician. 2019; 65(1): 40-42.                                                  

6. Optimal IM Needle Penetration Depth. Lippert, et al. Pediatrics 2008; 122 (30):355-563.   

7. An Evidence-Based Protocol for the Prevention of Upper Arm Injury Related to Vaccine Administration (UAIRVA). Cook IF. Human Vaccines. 2011; 7(8); 485-848.