Asplenia and hyposplenia

Background

The spleen plays an important role in preventing infection by removing bacteria (particularly encapsulated bacteria) from the blood stream. Individuals with anatomical asplenia (absent spleen) or functional asplenia/hyposplenia (no function or decreased function) are therefore at an increased risk of infections and are recommended to receive additional vaccines (outlined below).

The reason for asplenia or hyposplenia may be congenital or due to surgical removal (eg. in the case of trauma). Children with congenital asplenia, cancer related asplenia and those with sickle cell anaemia have a higher risk of infection than those who have had splenectomy for trauma.

Scheduling additional vaccines can be complicated by the cause of asplenia or hyposplenia. Where possible people having a planned splenectomy should ideally receive all additional vaccines at least 2 weeks prior to surgery. This is to ensure optimal protection prior to spleen removal. Those who undergo an unplanned or emergency splenectomy should defer vaccines for at least 7 days following surgery to allow time for recovery.

Individuals with asplenia/hyposplenia have a lifelong risk of infection. In addition to vaccination, patients are also recommended to receive prophylactic antibiotics.

Additional vaccine recommendations for children (<18 years)

  • Pneumococcal

  • Meningococcal

  • Haemophilus influenzae type B (HIB)

  • Influenza

  • COVID-19

Additional vaccine recommendations for adults (≥ 18 years)

  • Pneumococcal

  • Meningococcal

  • Haemophilus influenzae type B (HIB)

  • Influenza

  • COVID-19

Vaccine funding

Some of the recommendations in these guidelines are outside the scope of the National Immunisation Program (NIP). Different jurisdictions and individual hospitals have varying approaches to non-NIP vaccines, which should be clarified with the local health service.

Authors: Rachael McGuire (MVEC Education Nurse Coordinator) and Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator) and Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute)

Date: May 5, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Adverse events following COVID-19 immunisation

Background

  • anyone who experiences a significant reaction following immunisation should first seek medical attention from a health professional
  • while no vaccine is entirely free of potential side effects, the benefits of immunisation far outweigh the risks
  • severe side effects from vaccines are rare and common side effects are usually mild and short lasting.

Vaxzevria (AstraZeneca) side effects

Common side effects following vaccination with Vaxzevria (AstraZeneca) include swelling, redness, pain or itch at the injection site, joint pain and malaise (feeling unwell). Less common side effects include abdominal pain, dizziness, decreased appetite, pain in limb or enlarged lymph nodes. These side effects are experienced in up to two-thirds of people who receive this vaccine, and mostly resolve within 1-2 days. Symptomatic relief is recommended, eg. a cool compress at the injection site and simple analgesia such as paracetamol or ibuprofen.

Rare side effects include anaphylaxis and a rare clotting condition, thrombosis with thrombocytopenia (TTS). Symptoms of TTS may include a severe, persistent headache that does not settle with analgesia, abdominal pain, significant respiratory problems/distress, visual changes, vomiting, seizures, focal neurological deficits/changes, confusion/encephalopathy and usually occur 4-30 days after vaccination.

For more information please refer to COVID-19 vaccination: After your AstraZeneca vaccine.

Comirnaty (Pfizer) and Spikevax (Moderna) side effects

Common side effects following vaccination with mRNA vaccines Comirnaty and Spikevax include swelling or pain at the injection site, fatigue, headache, myalgia (body aches), fever, chills or joint pain.

Less common side effects include redness at the injection site, nausea, enlarged lymph nodes or malaise (feeling unwell). Itchiness at the injection site, pain in limb or insomnia can also occur following Comirnaty. These side-effects are usually mild, last 1-2 days and may require time off work. Systemic reactions are more common following the second dose of these vaccines. Symptomatic relief is recommended, eg. a cool compress at the injection site and simple analgesia such as paracetamol or ibuprofen.

Rare side effects following mRNA vaccines include anaphylaxismyocarditis and perdicarditis. Anaphylaxis following Spikevax has been shown to occur at a rate of 2.5 cases per million doses and, whilst extremely rare, at a slightly higher rate of 4.7 per million doses following Comirnaty.

Cases of myocarditis and pericarditis have been reported following mRNA vaccines, particularly in young males following dose two. Myocarditis is an inflammation of the heart muscle, whilst perdicarditis is an inflammation of the lining of the heart muscle. Symptoms of include pain with breathing, chest pain, pressure or discomfort, shortness or breath, palpitations or syncope (faint) and most commonly occur 4-5 days after vaccination. If these symptoms are experienced following vaccination with an mRNA vaccine a medical review by a GP or presentation to an emergency department is indicated.

For more information please refer to COVID-19 vaccination – after your Pfizer (COMIRNATY) or COVID-19 vaccination – after your Spikevax (Moderna).

Nuvaxovid (Novavax) side effects

Common side effects following vaccination with Nuvaxovid (Novavax) include pain or tenderness at the injection site, headache, myalgia, fatigue and malaise.

Less common side effects include fever, nausea, lymph node tenderness and redness or swelling at the injection site. These symptoms are usually mild and last 1-2 days. Symptomatic relief is recommended, eg. a cool compress at the injection site and simple analgesia such as paracetamol or ibuprofen.

Serious side effects are rare and can include anaphylaxis.

For more information please refer to After your Nuvaxovid (Novavax) COVID-19 vaccination.

Should all AEFIs (adverse events following immunisation) following COVID-19 vaccines be reported?

Reporting adverse events to SAEFVIC is not mandatory in Victoria, however doing so allows the rapid investigation of any potential vaccine or system problems by Victorian and national health authorities (Therapeutic Goods Administration). This helps to ensure a safe and effective immunisation program and it maintains community confidence in vaccines.

You do not need to routinely report:

  • common/expected reactions
  • these may include pain, redness, swelling and tenderness at the injection site, tiredness, headache, muscle pain, nausea, fever and chills, feeling unwell or joint pain.

You should report:

  • any event felt to be significant following COVID-19 immunisation, regardless of whether you think the side effect was related to the vaccine or not
  • any expected reactions that have not gone away after a few days
  • any reaction to a vaccine which requires assessment by a doctor or nurse
  • suspected shoulder injury related to vaccine administration (SIRVA)
  • any vaccine administration errors.

Can a patient be referred to a specialist immunisation clinic after experiencing an AEFI?

The Victorian Specialist Immunisation Services (VicSIS) will provide specialist vaccination services for people who have experienced an AEFI with a COVID-19 vaccine, or those who are identified as at risk of an AEFI. Most people are able to proceed with future vaccines following an AEFI. Clinical consults will be offered in which individual recommendations will be developed. VicSIS clinics also have the ability to vaccinate under extended observation.

More information on VicSIS, including how to refer patients, can be found via MVEC: Victorian Specialist Immunisation Services (VicSIS).

Resources

Authors: Francesca Machingaifa (MVEC Education Nurse Coordinator) and Georgina Lewis (SAEFVIC Clinical Manager, Murdoch Children’s Research Institute)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: January 31, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

 


AstraZeneca (Vaxzevria) COVID-19 vaccine

Name of vaccineVaxzevria (AZD1222 or ChAdOx1 nCoV-19)
Vaccine platformViral vector vaccine (chimpanzee adenovirus vector)
Developer of vaccineAstraZeneca
RegistrationProvisional registration granted by the TGA on 15 February 2021
For use≥ 18 years
Primary course in immunocompetent individuals2 doses, administered 12 weeks apart (noting a minimum interval of 4 weeks is acceptable)
Primary course in immunocompromised individual3 dose primary schedule, with the third dose 2-6 months post dose 2. *mRNA vaccines (Spikevax or Comirnaty) are preferred for the third dose of the primary schedule.
Booster dose recommendationsRegistered for use as a booster dose in individuals aged ≥ 18 years. *Vaxzevria is only recommended as a booster dose for those with a contraindication to mRNA vaccines.
ManufacturerCSL, Parkville, Australia
Storage requirementsCan be stored, transported and handled at standard refrigerator temperatures (2-8°C)
Preparation and injectionEach multi-dose vial contains either 8 or 10 0.5ml doses, to be administered via intramuscular (IM) injection. Reconstitution prior to administration is not required. Once opened and stored at room temperature (up to 30°C), vials must be discarded after 6 hours. If stored between 2-8°C, vials must be discarded 48 hours after opening.

Immunogenicity

Pre-clinical (animal) trials were conducted in rhesus macaques, mice and ferrets. These trials showed that there were no adverse safety events or evidence of immune enhanced inflammatory disease and robust neutralising antibody and cellular immune responses were triggered. In animals, the vaccine appeared to reduce disease severity, but did not prevent infection or transmission (nasal shedding of the virus still occurred).

Phase 1/2 clinical trials showed antibody response against the SARS-CoV-2 spike protein peaked by day 28 (and remained elevated to day 56) in participants who only received 1 dose of vaccine. Responses following natural exposure to COVID-19 infection were compared with vaccine responses and were in similar ranges.

Phase 2/3 studies showed a clear impact on specific antibody response following a booster dose at day 56. This response was seen across all age groups. There was no increase in the anti-vector antibody responses.

Safety profile

Side effects were more common on the day following vaccination, and were mild to moderate in severity. Pain and tenderness at the injection site (83%), fatigue (68%) and headache (70%) were the most common symptoms in participants receiving Vaxzevria (AstraZeneca). Fever occurred in 18% of trial participants and flu-like symptoms of malaise (61%) and muscle ache (60%) were also common.

Reactions were less common in older adults (aged over 55 years) and following the second dose.

Vaccine Efficacy

Phase 3 US trials showed a vaccine efficacy of 79% at preventing symptomatic COVID-19 and 100% efficacy at preventing severe disease and hospitalisation. Efficacy in participants aged 65 years and over was 80%.

Pooled data from phase 2/3 studies in the UK and Brazil found an efficacy of 66.7% (57.4-74.0) for preventing symptomatic COVID-19 following 2 doses of Vaxzevria and 76% following one dose. Protection did not wane during the initial 3 month period following first vaccination with antibody levels maintained. There were no hospital admissions for COVID-19 in the vaccinated group from 21 days following first vaccination.

A longer prime boost interval (>12 weeks) produced higher efficacy (81.3%) than a short interval (55.1% at <6 weeks).

Post-licensure surveillance

Anaphylaxis

An independent expert review of 7 reported cases in Australia of suspected anaphylaxis following administration of the COVID-19 AstraZeneca vaccine has concluded that there is no increased risk of anaphylaxis associated with the vaccine above the expected rate for any other vaccine. Anaphylaxis is a very rare side effect that can occur with any vaccine.

Thrombosis with thrombocytopenia syndrome

Thrombosis with thrombocytopenia syndrome (TTS), is a rare and new syndrome which has been reported in people who have received an adenoviral vector COVID-19 vaccine (eg. Vaxzevria (AstraZeneca) and Johnson & Johnson/Janssen). The syndrome is distinct from other clotting conditions as it is characterised by thrombosis formation (blood clots) combined with thrombocytopenia (low platelet levels).  Symptoms occur 4-30 days following vaccination. Early recognition can lead to effective treatment.

Capillary leak syndrome

Cases of capillary leak syndrome have been reported following vaccination with Vaxzevria (AstraZeneca). The syndrome results in fluid leaking from capillaries (small blood vessels) into surrounding tissue and can lead to severe organ damage or death if left untreated. A causal link between capillary leak syndrome and the vaccine has not been established, however as a precautionary measure it is recommended that individuals with a history of capillary leak syndrome receive an alternate brand of COVID-19 vaccine.

Guillain-Barre Syndrome (GBS)

Following intensive post-licensure surveillance and investigations by the TGA and other international vaccine regulators, there is growing evidence of a possible link between GBS and Vaxzevria (AstraZeneca). In response to this GBS has been listed as a precaution for those receiving Vaxzevria.

Immune thrombocytopenia (ITP)

An association between Vaxzevria (AstraZeneca) and immune thrombocytopenia (ITP) has been reported. Rates of ITP following vaccination have been reported more frequently than the expected background rates of ITP. A link between COVID-19 vaccines and ITP is currently being investigated.

Resources

Authors: MVEC Education Team

Reviewed by: Rachael McGuire, (MVEC Education Nurse Coordinator) and Francesca Machingaifa (MVEC Education Nurse Coordinator)

Date: May 30, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


AEFI-CAN: Adverse Events Following Immunisation - Clinical Assessment Network

AEFI-CAN (Adverse Events Following Immunisation – Clinical Assessment Network) is a formal collaboration between Australian state and territory-based vaccine safety clinics and their adult and paediatric immunisation/infectious diseases/allergy specialists. It also includes representatives from the Therapeutic Goods Administration (TGA), most state/territory health departments and the immunisation branch of the Australian Government Department of Health (DoH).

As a national network, AEFI-CAN works collaboratively to clinically assess and manage individual patients following serious or unexpected adverse events after immunisation. The network is also involved in:

  • developing a consistent robust national approach to serious and/or severe AEFI with the creation of standardised protocols
  • standardising AEFI and clinical follow up reporting
  • enhancing community and health/vaccine provider knowledge and practice about AEFI
  • providing expert advice to health professionals as required.

AEFI-CAN bridges the important link between surveillance and clinical assessment and management. As such, AEFI-CAN assists in determining patient outcomes and supports investigation of possible safety signals in a real-time integrated way.

Authors: Adele Harris (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Annette Alafaci (SAEFVIC Research Assistant, Murdoch Children’s Research Institute)

Reviewed by: Annette Alafaci (SAEFVIC Research Assistant, Murdoch Children’s Research Institute)

Date: December 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Australian Immunisation Register

In 2016, the previously known Australian Childhood Immunisation Register (ACIR) expanded to an all of life register and became known as the Australian Immunisation Register (AIR). It is a national register recording the immunisations of all Australians of all ages.

Why should vaccines be recorded?

The AIR records any vaccine doses administered, the date of administration and the specific brands given.  It also identifies any vaccines that are due or overdue according to the National Immunisation Program (NIP). Immunisation history statements (IHS) can also be generated from AIR.

For families accessing Family Tax Benefit Part A payments or childcare subsidies, a child’s AIR record needs to show that immunisations are up to date to ensure that payments are not reduced.

In order to confirm enrolment into early childhood education and care services (including childcare and kindergarten), an up to date IHS from AIR must be produced.

A comprehensive reporting of all vaccinations administered, helps to increase vaccination coverage rates and the effectiveness of the NIP.

Who can record immunisations?

Any recognised immunisation provider can record vaccines onto AIR.

What vaccines should be recorded?

All vaccines administered since January 1 1996 can be recorded onto AIR. This includes all vaccines on the NIP, influenza and travel vaccines, as well as any additional vaccines given to an individual (eg. tetanus vaccines given for tetanus prone wounds, Boostrix® in pregnancy, meningococcal B vaccines etc). Any vaccines given overseas can and should also be recorded.

In 2021, a legislation change came into effect mandating the reporting of all NIP, influenza and COVID-19 vaccines to AIR.

Immunisation exemptions and catch up plans

All approved immunisation exemptions and recognised catch up plans are documented onto AIR to ensure that immunisation records are accurate.

Do patients need to be eligible for medicare in order to have an AIR record?

No. Everyone can have an AIR record. If a person does not have medicare, immunisations can still be recorded based on name, date of birth and address.

Immunisation history statements

An IHS can be used to keep track of vaccines that have been given, that are due or that are overdue. All medical exemptions are noted on an IHS. IHS is the only acceptable form of documentation when enroling into early childhood education and care services.

How do I access my own AIR record?

Statements can be accessed using a Medicare online account through myGov. Alternatively, copies may be obtained from any immunisation provider or the AIR enquiries line.

Resources

Author: Rachael McGuire (MVEC, Education Nurse Coordinator)

Reviewed by: Rachael McGuire (MVEC, Education Nurse Coordinator)

Date: February 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Aboriginal and Torres Strait Islander peoples immunisation recommendations

Background

It is widely recognised that Aboriginal and Torres Strait Islander peoples have higher rates of some vaccine preventable diseases (VPD) than non-Indigenous persons. This is not necessarily due to being of Aboriginal and/or Torres Strait Islander background, but rather due to the higher rates of underlying chronic health conditions and social circumstances that can lead to an increase in disease burden. For this reason, additional vaccines are recommended, some of which are available through the National Immunisation Program (NIP).

The recommendations and funding for additional vaccines for Aboriginal and Torres Strait Islander peoples vary from state to state, based on local disease burden. In addition, individual immunisation providers may have varying approaches to non-NIP vaccines, and this should be clarified with the local health service.

Accessing immunisations

Routine and additional immunisations can be administered via GP services, councils, hospitals, local Aboriginal Health Services and some pharmacies.

Additional funded vaccines for Aboriginal and Torres Strait Islander people living in Victoria

Hepatitis B

Rates of hepatitis B infection in Aboriginal and Torres Strait Islander peoples population are up to 3 times higher than the non-Indigenous with notification rates increasing with age.

Hepatitis B vaccination is funded on the NIP with routine doses given at birth, 6-weeks, 4-months and 6-months of age. A booster dose is also given at 12-months of age for those who were born at < 32-weeks gestation and/or < 2000g birth weight.

In addition to this, hepatitis B vaccination is also funded in Victoria for all non-immune Aboriginal and Torres Strait Islander peoples of any age.

Pneumococcal

The risk of invasive pneumococcal disease (IPD) is greatest in young children and older adults. Rates of IPD are 6–7 times higher in Aboriginal and Torres Strait Islander people.

Aboriginal and Torres Strait Islander children living in Australian Capital Territory (ACT), New South Wales (NSW), Tasmania (Tas) or Victoria (Vic) are funded for 1 dose of Prevenar 13® (13vPCV) at ages 6 weeks, 4-months and 12-months (3 doses in total). For those with a risk condition/< 28-weeks gestation an extra dose of 13vPCV is given at 6-months of age (4 doses in total) as well as a dose of Pneumovax 23® (23vPPV) at 4-years of age.

Aboriginal and Torres Strait Islander children in Northern Territory (NT), Queensland (Qld), South Australia (SA) and Western Australia (WA) are funded to receive an extra dose of pneumococcal vaccine at age 6 months followed by two further doses of 23vPPV at age 4-years and at least 5 years later.

All Aboriginal and Torres Strait Islander individuals aged > 12 months with risk conditions are recommended to receive 1 additional dose of 13vPCV unless they have previously received a total of 4 doses of 13vPCV (according to the routine schedule for Aboriginal and Torres Strait Islander infants in NT, Qld, SA and WA) followed by two doses of 23vPPV. These doses are funded for some but not all risk conditions.

All Aboriginal and Torres Strait Islander adults ≥ 50 years of age are eligible for 1 dose of 13vPCV and two doses of 23vPPV.

The maximum number of doses of 23vPPV received in a lifetime is two.

For more information please refer to MVEC: Pneumococcal.

Influenza

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous people to be admitted to hospital for influenza and pneumonia.

Annual influenza vaccination is funded on the NIP for all Aboriginal and Torres Strait Islander peoples from 6 months of age.

Meningococcal B and ACWY

In 2019, Aboriginal and Torres Strait Islander people had a 10-fold increased incidence of meningococcal disease than non-Indigenous people across some age groups. The most common strains causing infection were types B and W. The recommendation for all Aboriginal and Torres Strait Islander peoples is immunisation against meningococcal disease from 6 weeks of age.

Nimenrix® (meningococcal ACWY) is currently funded on the NIP as a single dose at 12-months of age and an adolescent dose at 14-15 years of age (Year 10 equivalent).

Meningococcal B vaccine (Bexsero®) is free and recommended under the NIP for Aboriginal and Torres Strait Islander infants at 2, 4, and 12 months of age.  An additional dose at 6 months of age is required for Aboriginal and Torres Strait Islander infants with certain medical risk conditions.

Meningococcal B and meningococcal ACWY vaccines are also funded under the NIP for people of all ages with specified medical risk conditions that increase their risk of IMD.

For more information refer to MVEC: Meningococcal.

COVID-19 vaccines

A primary course of COVID-19 vaccines are recommended for all Aboriginal and Torres Strait Islander person > 5 years of age. Additional booster doses are also recommended for certain age groups. Aboriginal and Torres Strait Islander people are prioritised for immunisation as there is an increased risk of severe COVID-19 disease and death due to a number of factors. This includes a higher prevalence of underlying medical conditions, as well as a greater likelihood of living in communities where other preventative measures (social distancing, mask wearing and hand hygiene) cannot be maintained.

Please refer to COVID-19 vaccination – ATAGI clinical guidance on COVID-19 Vaccine in Australia in 2021 and COVID-19 vaccination information for Aboriginal and Torres Strait Islander people.

Additional funded vaccines for Aboriginal and Torres Strait Islander people living in other states

Vaccine Age group State
BCG (tuberculosis) Children < 5 years QLD
Prevenar 13® (13-valent pneumococcal conjugate vaccine) 6 months NT, QLD, SA, WA
Vaqta® Paediatric (hepatitis A – 2 dose course) 18 months and 4 years NT, QLD, SA, WA

SA Health- Aboriginal and Torres Strait Islander people immunisation recommendations QLD Health- Aboriginal and Torres Strait Islander people immunisation recommendations WA Department of Health – Immunisation schedule ATAGI clinical advice on hepatitis A vaccine

Resources

Aboriginal health services

Other resources

Authors: Rachael McGuire (MVEC Education Nurse Coordinator), Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute) and Rebecca Feore (Immunisation Nurse, The Royal Children’s Hospital)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: May 30, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Administration of injected vaccines - correct technique

Most vaccines on the National Immunisation Program (NIP) are administered via intramuscular or subcutaneous route. Correct injection technique is of paramount importance when administering vaccines to ensure optimal immune response, minimise side effects and to reduce the risk of injury to the patient.

Preparing the site for injection

The skin at the injection site should be visibly clean prior to administering a vaccine. The swabbing of clean skin before giving an injection is not necessary. If the skin is visibly dirty, clean the site with alcohol wash/single use alcohol swab and allow the site to dry completely before administering the injection. If active/infected eczema is present at the recommended site, consider an alternate site to minimise the risk of injection site abscess. If there is no alternate site suitable, consider cleaning the site with an alcohol based wash/single use alcohol swab and allowing the site to dry completely before injecting.

Recommended injection sites by age

Infants < 12 months

The recommended injection site is the middle third of the vastus lateralis (anterolateral thigh).

To locate the correct anatomical site for injection:

  • ensure the infant’s leg is completely exposed
  • locate the upper and lower anatomical landmarks- greater trochanter of femur and patella
  • draw an imaginary line between the 2 landmarks down the front of the thigh
  • then imagine the thigh is divided into thirds
  • the correct injection site is located in the middle third and on the outer aspect of the imaginary line (see images below).

Where only two vaccines are scheduled it is recommended to give one vaccine into each thigh. If more than two vaccines are recommended at the one visit, two vaccines may be given into each thigh ensuring they are separated by 2.5 cm.

Do not inject into the anterior aspect of the thigh as underlying structures may be damaged.

In some circumstances (eg; congenital limb malformations, active eczema or hip brace placement) alternate sites should be considered. In these scenarios, alternate sites include the deltoid or opposite anterolateral thigh (ensuring that each vaccine has a 2.5cm spacing).

Children ≥ 12 months of age, adolescents and adults

The recommended injection site is the deltoid (upper arm).

To locate the correct anatomical site for injection:

  • expose the arm completely from the top of the shoulder to the elbow; remove shirt or clothing if needed
  • locate the upper and lower anatomical landmarks- acromion (shoulder tip) and the muscle insertion of the deltoid (deltoid tuberosity)
  • draw an imaginary inverted triangle below the shoulder tip, using the identified landmarks (see images below)
  • the site for injection is halfway between the acromion and the deltoid tuberosity, in the middle of the deltoid muscle (triangle).

More than one vaccine can be given into the deltoid muscle ensuring each vaccine is separated by 2.5cm.

For children at 12 and 18 months of age the anterolateral aspect of the thigh may be used as an alternate site when giving more than 2 vaccines [see resources].

Positioning for vaccination

Infants and younger children

It is important that children remain still during a vaccination to ensure that the vaccine can be administered into the correct anatomical site, as well as reduce the risk of any unintended injury (eg. needle stick injury). It is important to involve both the child and parent/guardian in discussions when deciding if a child can sit independently or requires support. When positioning a child for vaccination it is important to ensure that they are comfortable and the mobile joints of the limb receiving the vaccine are stable. The immunisation provider must be able to adequately visualise the anatomical landmarks and correct site for injection (deltoid or anterolateral thigh).

Infants can be held in the cuddle position or on their parents lap facing the provider, with the parent/guardian holding their arms securely and their thighs completely exposed. Younger children can be held in the cuddle or straddle positions with their upper arm completely exposed as demonstrated in the clip below.

Older children, adolescents and adults

It is recommended that older children, adolescents and adults sit in a straight-backed chair with their feet on the floor for vaccine administration. Providers should encourage the vaccine recipient to relax their forearms and rest their hands on their upper thighs, keeping their arms flexed at the elbow to assist in relaxing the deltoid muscle.

Vaccine recipients who are prone to vasovagal responses (fainting) should be vaccinated lying down to prevent unintended injury due to a fall.

Recommended needle size, length and angle for administering vaccines

Age or size of the patient Needle type Angle of needle insertion
Infant, child or adult for IM injection 22 – 25 gauge, 25mm in length
Preterm infant or very small infant for IM injection 23 – 25 gauge, 16mm in length
Very large/obese patient for IM injection 22 – 25 gauge, 38mm in length
Subcutaneous injection in all patients 25 – 27 gauge, 16mm in length

* Table adapted from the Australian Immunisation Handbook

Implications of incorrect injection technique

Injection site reactions are more likely following inadvertent administration into subcutaneous tissue as opposed to the intended muscular tissue.

Shoulder injury related to vaccine administration (SIRVA) is a rare complication of incorrect vaccine administration causing an immune-mediated inflammatory reaction within the shoulder joint. When a vaccine is given into the shoulder joint (too high) it can cause a sudden onset of pain and limited range of movement which can persist for variable lengths of time and require medical investigations and treatment.

Impaired immune response can follow administration of vaccines utilising an incorrect injection technique. Depositing vaccines into the subcutaneous tissue (when muscular tissue was intended) or into the joint can lead to a decreased immune response to the vaccine.

Authors: Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator)

Date: May 30, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Allergy and immunisation

Hypersensitivity/allergic reactions following immunisation can be classified as:

  • urticarial- a red, itchy skin rash often referred to as hives, which characteristically has a central raised white wheal surrounded by an area of redness
  • non-urticarial rash- skin changes that don’t involve hives
  • angioedema- swelling in the deeper layers of the skin
  • generalised allergic reaction- involving symptoms like vomiting and diarrhoea
  • anaphylaxis- a sudden onset and rapid progression of symptoms involving the skin, respiratory and/or cardiovascular systems.

Suspected hypersensitivity reactions, particularly non-urticarial skin rashes following immunisation, are common, however true vaccine allergy, where a person is contraindicated from being immunised with the same vaccine in the future, is rare (less than 1 case per million doses).

A true vaccine allergy can only be diagnosed after specialist consultation with a vaccine allergy specialist, often after specific testing is carried out.

For future vaccine advice in the setting of immunisation hypersensitivity/allergic reactions, referrals should be made to SAEFVIC. SAEFVIC staff may direct the referral to an immunisation specialist or alternatively to a vaccine allergy specialist.

Influenza vaccine and egg allergy

Based on prospective and retrospective studies of influenza vaccination in those with and without egg allergy (including egg anaphylaxis), the presence of egg allergy does not increase the risk of allergic reactions to the influenza vaccine.

The influenza vaccine can be administered in community vaccination clinics (which may or may not have direct medical practitioner supervision), General Practitioner surgeries or Immunisation clinics, as a single dose followed by the recommended 15 minute observation period.

MMR vaccine and egg allergy

Although measles and mumps vaccine viruses are cultivated in eggs, these vaccines (MMR or MMR-Varicella vaccines) contain negligible amounts of egg protein/allergen. Therefore individuals with allergy/anaphylaxis to egg can be safely immunised in the community setting without any need for extra monitoring or additional observation.

Yellow fever vaccine and egg allergy

Currently, many guidelines advise that egg anaphylaxis is a contraindication to receiving a yellow fever vaccine (YFV), with the Australian Immunisation Handbook recommending people requiring the vaccine discuss this with an immunologist or allergist due to the YFV containing egg ovalbumin.

Due to the serious nature of the disease, some countries requiring proof of immunisation as an entry requirement and the widely varying guidelines pertaining to YFV in egg-allergic people; researchers from the National Centre for Immunisation Research and Surveillance (NCIRS), and the Royal Children’s Hospital in Melbourne, have published a case series proposing that skin testing may not be required for patients with mild egg allergy, and that a 2-step graded challenge under medical supervision is a safe alternative.

COVID-19 vaccines and allergy

Additional precautions are recommended for individuals with possible allergic reactions to a previous dose of a COVID-19 vaccine; allergic reactions to ingredients in the COVID-19 vaccine to be administered (including Polysorbate 80 in Vaxzevria (AstraZeneca) and Nuvaxovid (Novavax), and PEG in Comirnaty (Pfizer) and Spikevax (Moderna)); prior anaphylactic reactions to other vaccines or medications where PEG or Polysorbate 80 may have been the cause; or a known systemic mast cell activation disorder with raised mast cell tryptase that has required treatment.

In these instances a specialist review by an immunology/allergy/vaccination specialist to undertake a risk/benefit assessment to assess suitability for vaccination should be undertaken.

For all other allergies, including those with a history of anaphylaxis to food, drugs, venom or latex, it is recommended a routine observation period of 15 minutes following COVID-19 vaccination is observed.

Author: Kirsten Perrett (Clinician Scientist Fellow, Murdoch Children’s Research Institute)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: May 31, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Adverse event reporting Australia

Vaccines are medications and like any medication, there are possible side effects or adverse events. Serious adverse events from immunisation are extremely rare. If you or your child has experienced an adverse event it should be reported to your local government health authority for follow up and management.

Please see the list below for the appropriate body to report to, according to your state or territory.

It is important to note that these services do not provide emergency care and are reporting services only.

If you require medical assistance please see your GP, local emergency department or dial 000 if immediate support is required.

Author: Rachael McGuire (MVEC Education Nurse Coordinator)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator)

Date: February 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


ATAGI (Australian Technical Advisory Group on Immunisation)

The Australian Technical Advisory Group on Immunisation (ATAGI) provides independent advice to the Minister for Health on the Immunise Australia Program and other related issues.

In addition to technical experts, ATAGI’s membership includes a consumer representative and general practitioners.

The Terms of Reference of the Australian Technical Advisory Group on Immunisation are to:

  • provide technical advice to the Minister for Health on the medical administration of vaccines available in Australia, including those on the National Immunisation Program (NIP)
  • through the department, provide advice to research funding bodies regarding the status of current immunisation research and areas where additional research is required
  • advise the Pharmaceutical Benefits Advisory Committee (PBAC) on matters relating to the ongoing strength of evidence pertaining to existing, new and emerging vaccines in relation to their effectiveness and use in Australian populations
  • consult with relevant organisations to produce the Australian Immunisation Handbook 
  • consult with the National Immunisation Committee (NIC) on the content and format of the Australian Immunisation Handbook and associated implementation strategies
  • consult with the Communicable Diseases Network Australia (CDNA) and the Advisory Committee on Vaccines (ACV) on matters relating to the implementation of immunisation policies, procedures and vaccine safety
  • provide advice on COVID-19 immunisation programs and policies, to improve confidence in COVID-19 vaccines and to ensure equitable access to COVID-19 vaccines as they become available in Australia.

ATAGI meet regularly and provide bulletins detailing the important outcomes from meetings. These bulletins, COVID-19 vaccination statements and weekly updates are available via the ATAGI website.

The vaccine PBAC outcomes are also publicly available.

Resources

Author: Nigel Crawford (Director, SAEFVIC, Murdoch Children’s Research Institute)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator, Murdoch Children’s Research Institute)

Date: August 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.