Vaccine Update: Vaccinate with Confidence: A Guide to Safe Immunization Practice

Column Author: Christine A. Symes, MSN, APRN, CPNP
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Column Editor: Angela L. Myers, MD, MPH | Chief Wellbeing Officer, Center for Wellbeing, Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Vaccination is a common procedure in pediatric health care. Safe vaccine storage, preparation and administration are important to protect patients and ensure they develop adequate immunity to vaccine-preventable diseases. This article will provide an overview of safe vaccination practices.

Vaccine safety starts with proper handling and storage. Vaccines should be stored in a proper storage unit with manufacturer labels intact to ensure accurate identification. Vaccines have specific requirements for storage temperatures. Most should be stored in a refrigerator at temperatures of 2° C to 8° C or 36° F to 46° F. A few vaccines (Moderna COVID-19, varicella, MMR/varicella, and Mpox) vaccines require storage in a freezer at -50° C to -15° C or -58° F to 5° F. Pfizer-BioNTech COVID-19 vaccine requires ultra-cold freezer temperatures if it is to be stored for longer than 10 weeks. A quick-information sheet with storage temperature requirements can be found here.¹      

The next step is safe preparation for administration. Vaccines should be prepared in a clean, designated area away from anything that could cause potential contamination. Personnel should perform proper hand hygiene prior to preparing vaccines. A separate needle and syringe should be used for each injection. Vaccines should be prepared just prior to administration, and as best practice, the person who prepares the vaccine should be the one who administers it. Expiration dates of vaccines and diluent, as well as syringes and needles, should be checked, and expired products or equipment should not be used.

There are seven rights of vaccine administration.² They are:

1. The right patient — all patients should be screened for contraindications and precautions with a screening questionnaire every time a vaccine is administered.
2. The right time — ensure the patient is receiving the vaccine at the right time for their age as well as at the right interval.
3. The right vaccine and diluent — ensure the correct vaccine formulation is being given, and if the vaccine requires reconstitution, use only the diluent provided by the vaccine manufacturer.
4. The right dosage — this is especially important if a vaccine is being drawn up from a multi-dose vial.
5. The right route — intramuscular, subcutaneous, oral, or intra-nasal.
6. The right needle, technique, and site — needle length is based on age, needle angle and depth are dependent on intramuscular versus subcutaneous administration, and site is dependent on size, with children <3 years of age receiving vaccines only in the anterolateral thigh. A summary of these requirements can be found here.³
7. The right documentation — manufacturer, lot number, date of administration, date vaccine information statement(s) (VIS) provided (this is required by the Centers for Disease Control and Prevention), site, route, expiration date of vaccine, and name and business address of the professional administering the vaccine should all be documented in the patient’s medical record.

Other important things to remember are to use a separate anatomic site for each vaccine, label vaccines if more than one is drawn up at the same time, perform hand hygiene and wear gloves when administering vaccines, and use safety syringes to reduce the risk of needle-stick injuries. Also, children <3 years of age require caution when using a bandage at the vaccine site, as this could be a potential choking hazard.

Providers should be prepared to manage any adverse reactions following vaccination. Syncope is an immediate reaction that can occur following vaccine administration and typically occurs within the first 15 minutes. Adolescents and young adults are especially at risk, making up 76% of all reported cases of syncope following vaccine administration. This reaction requires special attention due to the risk for serious secondary injuries, including skull fracture and cerebral hemorrhage. Vaccine Adverse Event Reporting System (VAERS) reports reveal that 9% of those who experienced syncope experienced a secondary injury.⁴ Providers should take appropriate measures to prevent injuries if a patient becomes weak or dizzy or loses consciousness. Adolescents and young adults should be seated or lying down during vaccination. Consider observing patients for 15 minutes following vaccination to decrease the risk for injury. If syncope develops, patients should be observed until the symptoms resolve.

Allergic reactions are another immediate reaction that can occur following vaccine administration. Anaphylaxis following vaccines is rare, occurring at a rate of approximately one incidence per million doses of vaccines given.⁴ Epinephrine and equipment for managing an airway should be available for immediate use. Identifying individuals at increased risk by obtaining a history of any allergy to previous vaccinations or vaccine components can help to prevent allergic reactions.

Monitoring the safety of vaccines is an ongoing process. Clinically significant adverse events following immunization should be reported to VAERS, which aids in monitoring vaccine safety and identifying rare adverse events.

Vaccine administration is performed by multiple members of the health care team. Before providing vaccines to patients, all personnel should receive clearly defined education and competency-based training on administering vaccines. Ongoing monitoring of vaccine practices and refresher training should be part of pediatric practice, especially as new vaccines become available and recommendations evolve over time.

References:

1. Centers for Disease Control and Prevention. Handle with care: protect your vaccine, protect your patients. Accessed April 10, 2025. https://www.cdc.gov/vaccines/hcp/admin/storage/downloads/vaccine-storage-temperatures.pdf
2. American Academy of Pediatrics. 7 rights of vaccine administration. Accessed April 10, 2025. https://www.aap.org/en/patient-care/immunizations/implementing-immunization-administration-in-your-practice/vaccine-administration/?srsltid=AfmBOop1UcG3_Z_ds-7wDvwcNU1jMTuKxMyiByFh6_4wQ8iMFSkM0SuS
3. org. Administering vaccines: dose, route, site, and needle size. Accessed April 10, 2025. https://www.immunize.org/wp-content/uploads/catg.d/p3085.pdf.
4. Centers for Disease Control and Prevention. Preventing and managing adverse reactions. Accessed April 10, 2025. https://www.cdc.gov/vaccines/hcp/imz-best-practices/preventing-managing-adverse-reactions.html