INTRODUCTION

Measles is an extremely contagious viral illness caused by an enveloped RNA virus of the genus Morbillivirus and family Paramyxoviridae.^1,2 Once a routine childhood disease, the development and consistent administration of a measles vaccine effectually eliminated measles in the United States (U.S.). Recent falling vaccination rates have led to the reemergence of measles.³

 

Consider the following case: a man, Mike, and a toddler in a stroller, whose name is Bella, approach the pharmacy counter. He was shopping for nacho cheese flavored tortilla chips and saw the sign offering immunizations, which reminded him of his daughter’s recent well care visit. The pediatrician recommended routine vaccination with the measles, mumps and rubella vaccine, but Mike declined. He asks the pharmacist, someone he knows well and trusts, if the vaccine is necessary. Mike was under the impression there were no active measles cases in the U.S. Are there?

 

PREVALENCE

Prior to the availability of measles vaccine, almost everyone contracted measles during childhood. Approximately 90% of individuals obtained post-infection immunity by age 15.^3,4

 

The Vaccination Assistance Act provided federal funding to state and local agencies for childhood immunizations beginning in 1962.⁵ In 1963, two measles vaccines became available in the U.S.: a single dose of a live attenuated vaccine or three once-monthly doses of an inactivated vaccine.⁶ The inactivated vaccine was eventually discontinued in 1967 because it was less effective than the live vaccine.^6,7 By mid-1967, the reported number of measles cases had decreased from 1000 to 200 weekly.⁵

 

An increase in measles cases occurred from 1989 to 1991 due to decreased vaccination rates in young children and a rise in cases in individuals who had received only one dose of a measles vaccine. Increased vaccination awareness and rates in young children alongside the addition of a routine second dose of measles vaccine resulted in a major reduction in measles cases. The U.S. declared measles “eliminated” in 2000.¹

 

PAUSE AND PONDER: What factors influence vaccination rates?

 

Since then, vaccine hesitancy due to misinformation regarding adverse effects and an incorrect association with autism has fueled decreasing vaccination rates. Other causes of declining measles vaccinations include missed routine vaccines during the COVID-19 pandemic and community complacency with measles’ severity and its complications. The resulting unvaccinated children are susceptible to the infection and its spread, thus propelling its resurgence.^2,5

 

As of August 2025 in the U.S., 41 states had reported 1,356 confirmed cases of measles since January of that year. Most cases occurred in unvaccinated patients⁸:

• 92% were unvaccinated individuals or in people with unknown vaccination status
• 4% had received only one dose of MMR
• 4% had received two doses MMR.

Among these cases, 13% were hospitalized, and three cases resulted in death.⁸

 

A measles outbreak is defined as three or more related cases. From January to August 2025, the U.S. experienced 32 outbreaks, with 87% of confirmed cases related to these outbreaks. In 2024, 16 outbreaks were reported and 69% of measles cases were related to outbreaks.⁸

 

Reflecting on our case, the pharmacist explains to Mike that domestic cases are rising due to declining vaccination rates worldwide, and that vaccination offers the best protection available.

 

TRANSMISSION AND SYMPTOMS

Transmission of measles occurs by direct contact or airborne spread through respiratory droplets and aerosols, which can stay airborne for up to two hours in enclosed areas.^1,5,7 About 90% of non-immune people who are exposed to the measles virus will become infected.⁷

 

The physical manifestation of measles infection begins 11 to 12 days after exposure with a prodrome of malaise, cough, coryza (runny nose and nasal congestion), and conjunctivitis.³ Approximately 50% to 70% of patients also develop Koplik spots, which are small white or grey papules in the mouth, during the prodrome phase.⁵

 

After two to four days, a red, macropapular rash (a flat, red area on the skin that is covered with small bumps that may merge together) occurs, usually on the face or hairline.^3,9 The rash progresses to the trunk, and then to the lower extremities.³ Patients with uncomplicated measles usually improve by the third day after the rash began, and most cases resolve within seven to 10 days. Patients are contagious from four days before until four days after the onset of the rash.⁹

 

COMPLICATIONS

Complications of measles include diarrhea, dehydration, pneumonia, encephalitis, and death.³ For every thousand cases of measles, one case may lead to encephalitis and two to three cases may lead to death. Measles-related deaths are typically due to respiratory and neurologic complications.^1,3

 

Rare complications of measles include measles inclusion body encephalitis (MIBE) and subacute sclerosing panencephalitis (SSPE). MIBE usually occurs in immunocompromised patients within one year of infection and is characterized by neurologic dysfunction, such as altered level of consciousness, seizures, loss of speech, one-sided paralysis, and lack of coordinated movements. MIBE has a mortality rate of 75%.^1,10 SSPE is a degenerative central nervous system disease that results neurological decline and seizures. It usually develops seven to 11 years after infection, and it occurs most frequently in children infected with measles before age 2.¹

 

Patients at higher risk for measles infection are unvaccinated or incompletely vaccinated, have had exposure to measles, or have traveled to areas with active measles.⁸

 

Severe cases of measles may require hospitalization.³ Patients who are younger than 5 or older than 20, pregnant, or immunocompromised are at the greatest risk for severe measles infections or complications.⁸

 

Back to our case: Mike asks if there is medicine Bella can take to speed up her recovery if she catches measles, rather than prophylaxis with a vaccine.

 

POST-EXPOSURE MANAGEMENT

Confirmation of Diagnosis

The diagnosis of measles is confirmed through laboratory findings. Positive serology for measles IgM antibodies, significant increase in IgG antibody levels, and cell culture of the measles virus can be assessed through blood assays. Evidence of measles RNA by reverse transcription polymerase chain reaction can be assessed through nasal, throat, or nasopharyngeal swab or a urine sample.^5,11 Healthcare providers should obtain both a serum sample and a nasopharyngeal or throat swab or urine sample for all patients with clinical symptoms of measles.^1,11 Just looking at the patient’s rash is not sufficient for diagnosis. Laboratory evidence is crucial because clinicians may incorrectly diagnose or report other febrile illnesses with rash as measles.⁵

 

Reporting to Health Department

Because measles has a significant impact on public health, it is a nationally notifiable disease. The purpose of national notification is to assess the incidence and spread of measles, with the goal of controlling outbreaks. Healthcare providers, laboratories, and hospitals should report confirmed cases of measles to local health departments. Each state has its own guidelines and requirements for reporting. The states report suspected and confirmed measles cases to the Centers for Disease Control and Prevention (CDC) using the National Notifiable Diseases Surveillance System.^12,13

 

Post-Exposure Prophylaxis

Post-exposure prophylaxis (PEP) with measles, mumps and rubella vaccine (MMR) or immunoglobin in unvaccinated or partially vaccinated people may offer some protection against the disease, allowing for milder symptoms and a briefer course of illness.⁹ MMR should be administered within 72 hours of exposure.

 

Patients who are ineligible for MMR (age less than 6 months, severely immunocompromised, or pregnant) and patients ages 6 to 11 months who did not receive MMR within the initial 72 hours can receive immunoglobulin within 6 days of exposure. Patients younger than 12 months of age can receive intramuscular immunoglobulin 0.5 mL/kg of body weight, with a maximum dose of 15 mL. Patients who are severely immunocompromised, pregnant, or weigh more than 30 kg can receive intravenous immunoglobulin 400 mg/kg.¹

 

Patients should not receive both immunoglobulin and MMR because the immunoglobulin will decrease the vaccine’s efficacy.¹⁴ Patients without immunity who receive immunoglobulin should be given MMR or MMRV (MMR with a varicella component) at least 6 months after intramuscular immunoglobulin and 8 months after intravenous immunoglobulin.

 

Patients with documented immunity do not need PEP.¹

 

Treatment of Measles

Treatment of measles is mainly limited to supportive care. Caregivers can give acetaminophen, ibuprofen, or intravenous fluids if needed for symptom control.¹⁵ Additionally, patients should isolate for four days after the rash appears to minimize the transmission of measles.¹⁶

 

No antivirals are currently approved by the Food and Drug Administration for the treatment of measles. Although the measles virus displays in vitro susceptibility to riboviran, this has not been studied in clinical trials and is not indicated for the treatment of measles.¹

 

Treatment with vitamin A is an option for pediatric patients with measles. Vitamin A deficiency during measles infection has been linked with increased disease severity, additional complications, and prolonged recovery.¹⁵ Administration of vitamin A in children with measles in low- and middle-income countries has been connected to decreased morbidity and mortality.¹ Although vitamin A deficiency is not as prevalent in higher income countries, infection with measles can reduce vitamin A stores.¹⁵ Given the benefit of vitamin A supplementation, the World Health Organization (WHO) recommends treatment with vitamin A for all children (not adults) with severe measles that requires hospitalization.^1,15

 

Vitamin A is given once daily for two days, as described in Table 1. Additionally, a third dose of vitamin A should be given two to six weeks after the initial dose for children with signs and symptoms of vitamin A deficiency.¹

 

Table 1. Vitamin A Dosing1,15,17
Age of child	Dose: International Units (IU)	Dose: retinol activity equivalent (RAE)*
12 months or older	200,000	60,000
6 to 11 months	100,000	30,000
Under 6 months	50,000	15,000
*Research at the turn of the Century found that provitamin-A carotenoid absorption is only half as much as previously believed. Consequently, the U.S. Institute of Medicine recommended a new unit, the retinol activity equivalent (RAE) in 2001. Each mcg RAE corresponds to 1 mcg retinol, 2 mcg of β-carotene in oil, 12 mcg of "dietary" β-carotene, or 24 mcg of the three other dietary provitamin-A carotenoids.

 

Revisiting our case: the pharmacist explains to Mike that although treatment with vitamin A is an option that may ease severity and promote recovery, it will not treat the infection. Mike now shares that Bella received a single dose of MMR five months ago (at age 10 months) before a trip to Europe for his sister’s wedding. He is wondering why she would need to be vaccinated again. Doesn’t that dose offer protection?

 

VACCINE RECOMMENDATIONS

To be considered immune to measles, patients must have documented administration of an age-appropriate live measles containing vaccine, laboratory confirmation of either immunity or disease, or birth prior to 1957.³ Individuals born before 1957 are assumed to be immune to measles due to childhood exposure, as most people developed immunity through infection with the virus before the availability of the vaccine.⁵

 

Vaccination is key to measles prevention and control. Both the CDC and the American Academy of Pediatrics recommend routine vaccination with either MMR or MMRV.^1,3 Table 2 provides additional information regarding current vaccines options.

 

Table 2. Measles Vaccines Available in the United States1,18-20
Brand name	Manufacturer	Active ingredients	Age of administration	Administration
M-M-R II	Merck	measles, mumps, and rubella vaccine, live (MMR)	12 months and older*	0.5 ml subcutaneously or intramuscularly
Priorix	GlaxoSmithKline	measles, mumps, and rubella vaccine, live (MMR)	12 months and older*	0.5 ml subcutaneously
ProQuad	Merck	measles, mumps, rubella, and varicella vaccine, live (MMRV)	12 months to 12 years	0.5 ml subcutaneously or intramuscularly
*May be administered at ages 6 to 11 months for international travel, community outbreak, or post-exposure prophylaxis

 

The first dose is usually given between 12 and 15 months of age, and the second dose is usually given between ages 4 and 6 years. The second dose may be given earlier, at least 28 days after the first dose for MMR and 90 days for MMRV, during a community outbreak of measles, before international travel, or to individuals who did not receive the vaccine during the recommended ages for administration. The MMRV vaccine should not be given to children younger than 1 year.^1,21

 

The CDC recommends that MMR and varicella vaccines are given separately when administered as the first dose for children aged 12 to 47 months, unless the parent or caregiver prefers MMRV. Clinicians usually prefer MMRV as the second dose in children age 15 months to 12 years and for both doses in unvaccinated children age 48 months and older. The SIDEBAR explains this further.

 

At the time of this writing, the CDC Advisory Committee on Immunization Practices (ACIP) recommends that MMR and varicella vaccine be administrated separately until age 4. This is a change from the current recommendation to administer MMRV for the second dose in children 15 months and older. The ACIP recommendation is still pending approval from the CDC acting director and is not yet official.²²

 

SIDEBAR: How to choose MMR vs. MMRV²³

Piper, age 4, and her brother Oliver, age 12 months, are both due for measles and varicella vaccines. Piper received separate MMR and varicella vaccines when she was 1 year old. Their mom, Barbara, would like to minimize injections for each child. She asks if they can each receive MMRV to limit their shots today.

 

Although MMRV is indicated for children ages 12 months to 12 years, it has been associated with an increased risk of fever and febrile seizure when given as the first dose to children ages 12 to 47 months of age. Experts encourage healthcare providers to counsel parents and caregivers of children in this age group regarding the risks and benefits of MMRV vaccination. MMRV may be administered if the parent or caregiver prefers; however, the CDC recommends that MMR and varicella vaccines are given separately for the first dose in this age range.

 

Approximately 15% of children aged 12 to 47 months who receive MMR and varicella vaccines separately will experience post-vaccination fever (102°F or higher up to 42 days after vaccination), compared with 22% who receive MMRV. Administering the vaccines separately in this age group also decreases the febrile seizure risk by half: four of 10,000 children experience febrile seizure five to 12 days after vaccination with MMR and varicella separately, as compared to eight of 10,000 with MMRV.

 

For children aged 48 months and older, the risk of fever or febrile seizure with the first dose of MMRV declines and is similar to the risk when MMR and varicella vaccine are administered separately. The risk also decreases in all age groups when MMRV is administered as the second dose. Clinicians usually prefer MMRV for both doses in children aged 48 months and older and for the second dose in children ages 15 months to 12 years.

 

MMR and varicella vaccine should be administered separately for children with a personal or family history of seizures because they are at increased risk of febrile seizure after MMRV vaccination.

 

The pharmacist discusses the risks and benefits with Barbara, explaining that Piper received MMR and varicella vaccines separately at age 1 to reduce the risk of fever and febrile seizure. Because Piper is 4, she is an excellent candidate for MMRV. Barbara confirms that neither Oliver nor anyone in his family has a history of seizures. The pharmacist discusses the risks of MMRV at Oliver’s age (increased risk of fever and febrile seizures) and benefits (one injection rather than two). Barbara weighs the information presented to her and decides to follow the CDC recommendation of vaccinating Oliver with separate vaccines today, but will plan for MMRV for his second dose at age 4.

 

Before Barbara leaves, she pauses at the pharmacy counter. She asks about her niece, Lucy, who is 4 and unvaccinated. She wonders if Lucy is eligible for MMRV vaccination, and if consolidating shots might encourage Lucy’s mom to consider vaccination.

 

The pharmacist confirms that MMRV is appropriate for Lucy based on her age and vaccination status. Children aged 4 and older have not demonstrated an increased incidence of fever and febrile seizure when MMRV is administered as either the first or second dose. A decreased risk of adverse events and administration of a single injection rather than two with each dose may be preferable to Lucy and her parent. The pharmacist offers to contact Lucy’s mom and discuss vaccination options with her, explaining that Lucy could receive the first dose of MMRV now and the second dose in 90 days.

 

The MMR vaccine may be given to children ages 6 to 11 months if a community outbreak occurs or if the child is traveling internationally. For optimal efficacy, clinicians should give the vaccine at least two weeks before travel. It is important to note that a dose given before age 1 does not count towards completing the immunization series; a total of two doses are required to be administered after age 1, and doses given at ages 12 to 15 months and 4 to 6 years are still recommended.¹

 

Reflecting back on our case: the pharmacist explains to Mike that Bella needs two doses after age 1 to ensure immunity to measles. Although Bella received a dose prior to international travel, she was younger than 12 months old, and it does not count towards completing the series.

 

PAUSE AND PONDER: Who else would benefit from measles vaccinations?

 

Although the guidelines are age based for routine administration, some patients may fall outside these parameters. Adults and older children, such as those in high school or college, who received a single dose after 12 months of age should receive a second dose, regardless of their current age.¹

 

Other populations that should receive two doses of MMR, at least 28 days apart, include

• Students without immunity at educational institutions after high school, such as college or university
• International travelers without immunity
• Healthcare workers without immunity
• Healthcare workers born prior to 1957 without laboratory confirmation of immunity
• Close contacts of immunocompromised individuals who do not have documented immunity
• Individuals older than 12 months of age with human immunodeficiency virus (HIV) infection without immunosuppression and without immunity

 

An additional one to two doses of MMR may be required for ²¹

• Recipients of the inactivated measles vaccine between 1963 and 1967
• Individuals at risk during an outbreak as determined by a health department

 

People who should not receive MMR or MMRV are individuals with^18-20

• Hypersensitivity to any component of a measles-containing vaccine
• Immunodeficiency or immunosuppression due to disease or medical therapy
• Pregnancy or those who plan to become pregnant within a month
• Active febrile illness with fever greater than 101.3°F (38.5°C) (M-M-R II and ProQuad)
• Active tuberculosis in those who are not receiving treatment (M-M-R II and ProQuad)

 

Patients who may be at greater risk for a experiencing a serious adverse reaction or having a less robust immune response after vaccination are those with²¹

• Acute illness, with or without fever
• Use of blood product containing antibodies within the past 11 months
• Thrombocytopenia or thrombocytopenic purpura
• Indication for tuberculin skin testing or interferon gamma release assay testing
• Seizures, either personal or family history

 

Back to the dad in our case: he’s still hesitant. He feels that his daughter has had so many vaccines already. And he’s read online that vaccines aren’t always safe. He wonders aloud if it is it really worth the risk?

 

VACCINE HESITANCY

Vaccine hesitancy (VH) is complicated and multifactorial. It is formed by social, cultural, political, and personal elements.^24,25 The WHO defines VH as a “delay in acceptance or refusal of vaccines despite availability of vaccination services.”²⁶ Examples include delaying vaccines, limiting the number of vaccines administered at the same time, avoiding specific vaccines, and omitting all vaccines completely.²⁷ Some VH individuals believe that natural immunity (immunity resulting from infection) is more beneficial to the immune system than vaccine-induced immunity. While both routes provide immunity, the risks of vaccination are usually lower than the potential complications or consequences of acquiring the infection.^25,28 VH is not clear cut; VH is a spectrum that encompasses a range of beliefs, attitudes, and actions.

 

PAUSE AND PONDER: How can pharmacy teams effectively address VH?

 

The 3 C model describes vaccine hesitancy as a result of decreased confidence, increased complacency, and decreased convenience. Table 3 describes the components of the 3 C Model of vaccine hesitancy.²⁹

 

Table 3. The 3 C Model of Vaccine Hesitancy29,30
Confidence	Patient trust regarding •   The safety and effectiveness of vaccines •   The healthcare system providing vaccines •   The motivation of policymakers who determine vaccine guidelines
Complacency	•   The risks of vaccine preventable diseases are believed to be low •   May occur when the disease being prevented is no longer prevalent
Convenience	Ease in obtaining vaccination, influenced by •   Availability •   Affordability •   Accessibility •   Literacy •   Immunization services •   Comfort

 

 

Healthcare providers might assume VH is a fairly new development, resulting from and driven by the Internet and social media. While it is true that social media often propagates vaccine misinformation, VH was first recognized more than 200 years ago with the administration of smallpox inoculation. VH evolved further in the late 1800s when smallpox vaccination requirements led to the adoption of personal belief exemption. Personal belief exemption, which is the practice of omitting a vaccination based on individual convictions, continued to gain popularity as more vaccines became available.²⁴

 

Sources for vaccine information abound, including healthcare providers, the Internet, social media, word of mouth, and traditional media.²⁷ Pharmacists are strong resources to answer vaccine questions and concerns because people view pharmacists as trusted and accessible. This position of responsibiliy allows pharmacists to help patients navigate the abundance of information—and misinformation—available.³¹

 

Traditionally, healthcare providers tackled individual VH through fact-based education to correct misinformation. However, a well-rounded approach focusing on individual beliefs in addition to evidence-based facts may be more effective in encouraging vaccine adoption.³¹

 

An option for addressing VH is the ASPIRE framework. This method helps pharmacists interact with patients regarding vaccination beyond basic education. It encourages pharmacists to actively engage with patients to establish trust and address their specific concerns.³¹

 

The ASPIRE framework consists of the following actions³¹:

• Assume that people want to be vaccinated and be prepared for questions
• Share key facts and information sources to counter misinformation
• Present strong recommendations to vaccinate and stories about vaccination experiences
• Initiate discussion or address questions about adverse effects proactively and share credible information sources
• Respond to questions and listen actively
• Empathize and understand concerns

 

In our case, the pharmacist recognizes Mike’s concern but assures him that misinformation is rampant. The pharmacist explains with empathy that measles vaccine is both safe and effective, and that exposure to the disease often carries severe complications. The pharmacist offers to vaccinate today. Mike decides to think it over while he shops for snacks. The pharmacist will continue to offer the vaccination every time Mike and Bella visit the pharmacy.

 

CONCLUSION

Measles is no longer a disease of the past. The recent uptick in cases is directly related to declining vaccination rates. Unvaccinated individuals are at risk for infection and complications, which may be severe. People without immunity may also transmit the disease to other unvaccinated individuals, perpetuating the cycle. Healthcare providers, laboratories, and hospitals should confirm suspected cases of measles with laboratory findings and report to the appropriate local health department. While supportive care may offer symptom control, prevention is key to measles control; both the MMR and MMRV vaccine are safe, effective, and available. Active and empathetic counseling techniques can help pharmacists build vaccine confidence and adoption.

 

 

Download CE Activity

INTRODUCTION

As the healthcare community mobilizes and begins vaccinating to prevent the spread of coronavirus-SARS-19, pharmacists and in many places pharmacy technicians will be called to assist. In an effort to engage Americans in the program and encourage vaccination, the media is full of stories and videos of people receiving vaccinations. We at the University of Connecticut School of Pharmacy have watched with great interest, reading national newspapers and watching television clips about vaccination. One comment posted in response to an article in the New York Times caught our attention. Someone who dubbed herself “Retired Nurse” wrote the following comments¹:

“As for sore arms, I am not surprised. The wide variation in injection techniques displayed on television have been horrendous: Slow, tentative needle insertions, not stabilizing the site, too high up in the shoulder, exceptionally large needle lengths in tiny arms, etc. make me cringe. Hilariously, they showed doctors ceremoniously giving some of them on television but let's be honest, most physicians do not routinely administer shots. That task is delegated to a nurse or even a medical assistant in doctors' offices in many states. A vaccination can be a lot less painful, if not virtually painless, with good injection training.”

We could not agree more, and as we prepare to train people from a number of professions in our state, we decided to create this short continuing education homestudy to help you review injection technique and stay abreast of the most recent developments.

Intramuscular Injections

Vaccines administered in pharmacies are generally given by one of two routes: (1) intramuscularly, or (2) subcutaneously. Most (but not all) immunizations are given intramuscularly. Most inactivated vaccines are administered intramuscularly in the deltoid, whereas all live-attenuated injectable vaccines are administered subcutaneously in the anterior arm (midway between the elbow and armpit).² An exception of a common inactivated vaccine given subcutaneously would be meningococcal vaccine. To date, the available COVID-19 vaccines are all given intramuscularly. Intramuscular (IM) injections are exactly what the name implies – they are injections given into a muscle using a syringe.

Let’s review the parts of the syringe very quickly. A syringe has three primary parts. The needle, the barrel, and the plunger (see Figure 1). The needle is also called the “sharp,” and for vaccines, it’s a very fine needle. This is the distal part of the syringe that penetrates the skin. The barrel is the tube that holds the vaccine, and it has markings similar to that on a ruler. In most cases, the barrel measures milliliters (mL). The plunger is the plastic device used to pull the vaccine into and push the vaccine out of the syringe.

An important area of the syringe is called the hub or the hilt. This is the place where the needle meets the barrel. When penetrating the skin, you will push the needle all the way to the hub or the hilt. Before you inject, the entire needle will be in the skin and the muscle – you won’t be able to see any of the metal needle. Many people worry that they will hit the patient’s bone. It’s a comfort to know that if you hit the bone, you will feel it. The patient will not. This is a word-for-word explanation that our peer reviewer and authors like³:

"Needle length should be chosen based on the body habitus and weight of the patient. A needle that is too long can penetrate the deltoid muscle, hitting the bone. Although patients will not feel their bones being hit, the vaccine might not fully absorb into the muscle, leading to a reduced immune response. Furthermore, if the needle is too short the vaccine might be administered subcutaneously, which might result in decreased immune response and the development of nodules or cellulitus."

Good Technique

Good technique starts with preparation. Before you start administering vaccines, it’s essential that you prepare and anticipate how many patients you’ll see and what their needs will be. A cornerstone of good technique is knowing exactly how you will document. Especially with the COVID-19 vaccine, knowing how to document will be essential. Our understanding is that a new Vaccine Administration Management System has been developed to capture that data. When you arrive at your site, and eventually when the vaccine is available in your pharmacy, someone should train you on how to use the Vaccine Administration Management System. As with all vaccines, you’ll need to document the patient’s name, the vaccine’s lot number and expiration date, and where you gave the vaccine (left deltoid, right deltoid, etc.).⁴ And here is a quick aside: Many pharmacies don’t do a good job of documenting vaccines they give in their medication systems. Be certain to know what documentation is necessary, either in addition to or instead of Vaccine Administration Management System. For instance, health systems will require documentation in their electronic medical records or pharmacy system.

Before you start, survey your area and ensure that the station at which you vaccinate has a sufficient amount of supplies. Table 1 lists items that you need at your station at all times and items you have to have ready for each patient. One thing we wish to emphasize is a technique that one of our students taught us. When you have gloves on, it’s very difficult to open a Band-Aid and apply it. In anticipation of needing it, if you peel back the outer wrapper before you start, it will be much easier to use the Band-Aid should you need it after vaccination.  Some people even place the small opened section of the bandage on the patient’s skin right next to where they will inject, so it’s easy access. And note that often, if you have good technique, the patient will not bleed. But use a Band-aid in case they “spring a leak” later.

Table 1. Necessary Supplies for Immunization^4,5

Always at Your Station	Have Ready for Each Patient
•        A sharps container •        A handy trash can •        Band-Aids •        Cleaning solution •        Your personal protective equipment (mask, face shield, gloves) •        A box of tissues	•        One alcohol wipe •        One sterile 2 x 2 gauze pad •        A new needle and syringe that are the correct size •        A clean pair of disposable gloves (for you to wear) for each patient •        A Band-Aid, partially open

Next, commit to cleaning as you go. Have you ever noticed that when you go to any fast food restaurant, it is always clean and organized? That’s because they teach their staff to clean as they go. This lesson, when employed in our homes and in our workplaces, is extremely useful. It’s especially useful when you are immunizing many people. You don’t accumulate trash that has to be picked up later. This process has three key points when it comes to immunization^4,5:

• Throw paper and miscellaneous trash away immediately. What this means is if you take the cap off the needle, throw it in the trash immediately. You won’t be using the cap because we don’t recap needles any longer. Throwing it in the trash ensures you won’t be tempted to recap the needle. Similarly, any paper trash generated from anything that you open should go into the trash can immediately.
• After you inject and withdraw the needle from the muscle, activate the safety device on the needle using a hands-free method immediately.
• Place used needles or sharps in the sharps container as soon as you finish with them. Do not place the used syringe on your work area even for a moment. Put it in the sharps container. (Yes, we are stressing this point!)

Have a Seat, Please

It’s critical for patients to be seated when you give injections. Ideally, you should be seated also and we will discuss why below. Ask patients to relax their arms. They can place their palms on their legs or dangle their arms at the sides. Completely expose the upper arm and find your upside-down triangle target area of the deltoid muscle. If administering more than one vaccine in the same arm, separate the injection sites by one inch so that any local reactions can be differentiated.⁶

As we implied above, for most adults, we administer the COVID-19 and most other IM vaccines in the upper arm. This is the location of the deltoid muscle. You will give the injection in the center of an upside-down triangle. To give the vaccine, completely expose the patient’s upper arm, and feel for the bone that goes across the top of the upper arm. This is the acromion process. The bottom of the acromion process is the flat edge of the inverted triangle (see Figures 2 and 3).⁵ The triangle points down. It ends at about the level of the armpit. You will inject into the lower two thirds of the deltoid. Note that giving injections in the upper third of the deltoid can damage the muscle and cause inordinate pain.^7-9

 

Shoulder injury related to vaccine administration (SIRVA) is an emerging concern. ^3,7-9 This occurs when immunizers inject vaccines into the subdeltoid bursa or within the joint space. SIRVA causes shoulder pain and limited range of motion within 48 hours after IM vaccine administration.^10,11 Experts advise immunizers to avoid administering vaccines in the top one-third of the deltoid. Studies show that immunizers who sit and administer vaccines to seated patients, using needles of the appropriate length, reduce the risk of SIRVA.^7,8,12

Let’s get more specific. The correct area to give an injection is in the center of the triangle. You would inject one to two inches or two to three finger widths below the lower edge of the acromion process.^5,14 Gently stretch the skin around the injection site with your non-dominant hand. This displaces the subcutaneous tissue, aids needle entry and reduces pain. Insert the needle at a 90 degree angle, all the way to the hub. Depress the plunger at a rate of 1 second for every 0.1 ml of fluid.¹³ Again, avoid injecting too close to the top of the arm. Don’t use this site if a person is very thin or the muscle is very small. In these cases, it’s better to inject into the anterolateral thigh.⁴ The SIDEBAR describes considerations when selecting needles size and length.

A final word before we go to the actual injection process. Please don’t say, “This will not hurt a bit!” People have very different thresholds for pain and it’s impossible to predict whether it will hurt. Develop some language that you are comfortable with, and use it. A good response of people who ask if it will hurt is to say, “It may hurt or sting a little but just for a minute or two.”

Prepare yourself before you give an injection by using personal protective equipment, and using it correctly.⁴ During the pandemic, we advise covering your nose and your eyes, keeping your hands away from your face, and washing your hands often. Practice good hygiene before and after immunizing each patient. Do not wear the same set of gloves for more than one patient. Change gloves between patients and wash your hands and sanitize (and let dry) before putting on a new pair of gloves.^4,5

SIDEBAR: Choosing the Right Needle^4,5,14-17

Immunizers will administer current COVID-19 vaccine from Pfizer and Moderna using needles that fall in the ranges of 22-25 gauge and 1-1.5 inches in length. Remember, the higher the gauge, the finer the needle! The Pfizer COVID vaccine is currently approved for ages 16 and older while the Moderna vaccination has approval for ages 18 and older. CDC vaccination recommendations on needle gauge and length are consistent with current Pfizer and Moderna recommendations. The table below summarizes CDC recommendations on general needle gauges and lengths for IM injections based on age.

Although we may be injecting 1 to 1.5-inch needles into patients' deltoids now, our near future will consist of younger and frail patients. This may require use of shorter needles (i.e., 5/8 inch) and a different injection site - that being the vastus lateralis (a muscle on the outer thigh).

Ready, Set, Go

Let’s go through the process twice and review first the general procedure, then some specifics.

Here are the steps^4,14:

• First, open the alcohol wipe. Wipe the area where you plan to give the injection.
• Prepare the needle.
• Hold (stretch) the skin around where you will give the injection.
• Insert the needle into the muscle at a 90° angle, all the way to the hub.
• Inject the vaccine at a rate of 0.1 ml per second.
• Remove the needle at the same 90 degree angle.

Now let’s review some nuances.^4,5,14

• First, open the alcohol wipe. Wipe the area where you plan to give the injection. Wiping in a circular motion from the center out sometimes increases circulation and desensitizes the area. However, there’s no need to scrub. Just wipe firmly and dispose of the used alcohol wipe and its wrapper. Let the area dry (approximately 30 seconds) and do not blow on or touch the area until you give the injection.
• Prepare the needle. Hold the syringe with your dominant hand and pull the cover off with your other hand. Throw the cover in the trashcan immediately so you are not tempted to recap. Place the syringe between your thumb and first finger (like a dart). Let the barrel of the syringe rest on your finger.
• Hold the skin around where you will give the injection. With your free hand, which is also your non-dominant hand, gently press on the skin and pull it so that it’s slightly tight. Experts recommend two different ways of doing this. One is to make a “C” with your nondominant hand and stretch the skin between your first finger in your thumb. The second is to use the outer edge of you hand below the pinkie finger and pull the patient’s skin taut by pushing toward the outer edge of the arm (toward your non-dominant hand).
• Insert the needle into the muscle. Hold the syringe barrel tightly and inject the needle through the skin and into the muscle at a 90° angle.
• Inject the vaccine. Push down on the plunger and inject the medicine using your index finger. Push firmly and steadily at a rate of about 0.1 mL per second. Note that the Pfizer COVID-19 vaccine is only 0.3 mL, so you can inject it in about three seconds. The Moderna COVID-19 vaccine is a 0.5 mL volume, so it will take five seconds to inject.
• Remove the needle. Once you have injected the vaccine, remove the needle at exactly the same angle as you used for it to go in – that is, 90°. Activate the safety device and dispose of the entire syringe in your sharps container. You can place gauze over the area where you give the injection or cover the injection site with a Band-Aid (do not massage the area).

SIDEBAR: Needle Safety^4,18

Now let's quickly discuss how we can keep ourselves safe while immunizing. The CDC estimates that 590,194 needlestick injuries occur annually in all healthcare settings. Immunizing exposes pharmacists to an increased risk of needlestick injury and transmission of bloodborne disease, with the most dangerous being hepatitis B, hepatitis C, and HIV. Therefore, if we are to know the perfect technique to immunize we must also know the perfect technique to keep ourselves safe.

Prevention is key to avoiding needlestick injury. Prevention includes:

• NEVER recapping needles by hand (if you absolutely must recap a syringe by hand, use a one-handed method and scoop the cap onto the needle. That is, place cap on a flat surface, remove your hand from the cap, insert the syringe needle tip deep into the cap, and press the tip of the cap against an inanimate object to secure it in place)
• Disposing of used needles in sharps containers
• Use needles with safety features, called "engineered injury protection"
• NEVER handing a syringe with an uncapped needle to someone else

If a needlestick injury should occur, you must be equipped with the knowledge of what to do next.

• Needlestick/cut: wash with soap and water
• Splashed on skin or in nose or mouth: flush with water (soap if possible)
• Splashed in eyes: irrigate with clean water, saline, or sterile irrigants

Be sure to report the incident to your supervisor and seek medical treatment to discuss possible risk of exposure or need for post-exposure treatment. Keeping ourselves safe is just as important as keeping our patients safe.

Refining Technique

So now we’ve reviewed the step-by-step process for giving an IM vaccine. Let’s talk about a few points that will refine your technique and make you a real pro.

As we prepare to vaccinate an entire nation, pharmacists will be working side-by-side with people from many different healthcare disciplines. In fact, we may be working with people who are not healthcare providers but have simply been trained to administer immunizations. From our experience, we have learned that conflict sometimes arises because healthcare practitioners trained in different disciplines have different ways of doing things. Our intent is to follow the most recent expert advice and use best practices. For that reason, we want to point out a few things that are either so new that others may not be aware of them or different from what you may see or hear at immunization sites.

First, some helpful observers may tell you that you need to aspirate before you inject. For many years, many healthcare professionals were trained to aspirate – meaning after the needle is in the muscle, the immunizer will pull back on the plunger and see if they draw up any blood. This is an outdated practice.¹⁴ The Centers for Disease Control and Prevention indicates that aspiration is unnecessary and unwarranted when administering vaccines. They indicate, “Aspiration before injection of vaccines or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary because no large blood vessels are present at the recommended injection sites, and a process that includes aspiration might be more painful for infants.”^4,19  Should another provider approach you and criticize your technique, telling you that you need to aspirate, feel free to educate them about the proper way to give a vaccine!

Second, while you are going through the immunization steps, you can help patients relax and build some confidence if you talk to the patient. A little chitchat will help patients feel comfortable. We probably don’t need to say this but we will: Stick with safe topics. Some good questions are things like, “Do you have a pet?” or “It’s really cold today, isn’t it?” Remember that it’s best to use open-ended questions once you get the conversation started, with open-ended questions being those that cannot be answered with a yes or a no. For example, if the patient responds affirmatively to your question about pets, keep the ball rolling by saying “What kind of pet do you have?” If you’re talking about the weather, you can ask the patient what his or her favorite season is, or what they like about rainy days. Asking, “What’s for dinner tonight?” is also of great conversation starter. It will also give you some ideas for your own supper!

Next, let’s talk about skin that is not clear or is discolored. Ideally, we would want to inject into an area of the skin that is clear. You should never inject into broken skin, moles, or rashy areas. While you can inject into tattooed skin, we advise against it. The reason for this is the same as the reason that we inject into the clear areas of the skin: we want to be able to see a local reaction if it develops.⁴

Finishing Up

Finally, we are ready to finish the process. Once you’ve administer the vaccine, you’ll need to direct patients about their next steps and what they need to do. With the current COVID-19 vaccines at the current time, patients need to stay at the immunization site for 15 minutes for observation or as directed by your site’s specific policy.²⁰ This may change as we administer significantly larger numbers of vaccinations. Older pharmacists were trained to provide a vaccine fact sheet to every patient they immunize. That practice seems to be site-specific at this point, so if your site requires a vaccine fact sheet be given to patients, do that.

Review your documentation, and make sure that you have completed it entirely. This is critical for the COVID-19 vaccines because at some point, patients may need to prove that they were vaccinated to engage in certain activities. Take a few minutes to ensure that you have completed the documentation and submitted it appropriately.²⁰

A last PRO TIP is to take a minute to look at your station. Ensure that you have enough supplies to continue immunizing patients. Do not overfill your sharps containers. Know where the “FULL” line is. When they are close to full ask for or retrieve an empty container as a backup. Sanitize the area as directed by your site in preparation for the next patient.

CONCLUSION

Even the most proficient immunizer sometimes faces dilemmas in the immunization clinic. A final PRO TIP is indispensable: If at any time you encounter a problem and you are unsure or uncomfortable, find a more experienced immunizer and ask for help. We see all kinds of issues when we immunize—people who experience vasovagal syndrome (faint at the sight or thought of needles), people who are very thin or obese, people who have latex allergies and need to know if the vial’s stopper contains latex (neither the Pfizer or Moderna vaccine vials do). Finding someone with more expertise or simply collaborating with others to plan an approach is smart. It important to do your best to ensure the patient receives the vaccine; if you turn a patient away, he or she may not return.

 

 

 

 

 

 

Download CE Activity

INTRODUCTION

 

Download CE Activity

INTRODUCTION

Malaria cases in 2020 totaled an estimated 241 million, leading to more than 600,000 deaths, mostly in Africa.¹ Direct costs of malaria prevention and treatment in the United States (U.S.) total about $12 billion annually, excluding the toll it takes on affected individuals and their families.¹ The World Health Organization (WHO) reports that between 100 to 400 million people are infected with dengue fever each year.² About 80% of cases are mild and asymptomatic, but dengue fever can progress to “severe dengue,” which is classified as a medical emergency requiring immediate medical care.^2,3

 

Mosquitos, Malaria, and Dengue – Oh My!

Plasmodium parasites—common to tropical areas (e.g., Africa, South America, the Caribbean Islands, South Asia)—cause malaria.¹ Most commonly, malaria is transmitted through the bite of infected mosquitoes, specifically the Anopheles species, during local outbreaks. There is also a term coined “airport malaria,” describing disease that is transported from an infected country to a non-infected country.⁴ Congenital malaria occurs when mothers infected with the disease transmit parasites to the child during pregnancy or birth.⁴ Although rare, prompt diagnosis is crucial to ensure infected neonates and infants survive. Transfusion-transmitted malaria is also possible where blood recipients can be infected with malaria accidently. There are no approved tests to screen blood donations for malaria, only questioning of prospective donors.⁴ Although rare in the U.S., complications are severe and organizations should take action to prevent potentially-infected individuals from donating.

 

Patients with malaria generally present with fever, chills/sweating, headache, and weakness within 10 to 15 days of infection.⁵ Diarrhea, abdominal pain, and cough are also possible. As malaria progresses, patients develop a classic paroxysm (i.e., symptoms that come and go) comprising three stages⁶:

1. 15-to-60-minute cold stage (shivering and feeling cold)
2. 2-to-6-hour hot stage (fevers up to nearly 106°F; flushed, dry skin; and often headache, nausea, and vomiting)
3. 2-to-4-hour sweating stage (rapid drop in fever and sweating)

 

Missed or delayed malaria diagnosis can lead to potentially fatal complicated disease manifesting as severe anemia, renal failure, altered consciousness, and multisystem organ failure.⁶ Clinicians diagnose malaria via a blood smear test. Although rapid and polymerase chain reaction (PCR) tests are available, medical professionals confirm diagnosis through microscopic blood smear examination.⁷

 

Dengue fever is a viral disease caused by mosquitos—mainly females from the Aedes aegypti and Ae. albopictus species—carrying dengue virus (also known as DENV).² Four DENV serotypes exist, so it is possible to contract the disease four times. The virus can be transmitted through mosquito bite, from pregnant mother to child, and via infected blood products/organ donations and infusions. Transovarial transmission within mosquitoes (from parent to offspring) has also been noted.²

 

Most dengue cases are asymptomatic or mild and fatalities are rare, but increasing severity can be life-threatening.^2,3 Providers should suspect dengue when a high fever (104°F or greater) is accompanied by any two of the following symptoms^2,3:

• severe headache
• pain behind the eyes
• muscle/joint/bone pain
• nausea/vomiting
• swollen glands
• rash

 

This febrile phase lasts about 2 to 7 days, and most people recover after about a week.^2,3 Severe dengue is a potentially fatal complication due to plasma leakage, fluid accumulation, respiratory distress, severe bleeding, or organ impairment.² Patients are at risk of severe dengue symptoms about 3 to 7 days after initial symptoms appear.² As fever drops to below 100°F, patients enter a “critical phase” for 24 to 48 hours. Warning signs to watch for during the critical phase include²

• severe abdominal pain
• rapid breathing
• blood in vomit, stool, gums, or nose
• persistent vomiting
• restlessness/fatigue

 

Clinicians use commercially available PCR or rapid diagnostic tests to confirm dengue diagnosis.² Enzyme-linked immunosorbent assays are also available to confirm active or previous infections.

 

Global Implications  

Beyond clinical symptoms, malaria and dengue fever inflict social and financial loss for diagnosed individuals and the countries tasked with treating affected populations. Some examples of the indirect burden of these mosquito-borne diseases include¹

• expenses for traveling and receiving treatment
• absences from work/school
• burial expenses in cases of death
• purchases of medication and supplies
• public health interventions (e.g., insecticide spraying, bed nets)
• opportunity loss for tourism

 

Populations at increased risk of contracting malaria include infants, children younger than 5 years, pregnant women, immunosuppressed patients, and migrant workers or traveling populations.⁵ There is also concern that certain mosquitoes are resistant to insecticide, and by migrating throughout the world they can spread malaria to urban populations.⁸ Researchers have identified Anopheles gambiae mosquitoes, originally found in India and Iran, as insecticide-resistant. These are projected to put nearly 126 million people in African cities at risk for contracting malaria.⁸

 

Populations most vulnerable to contracting dengue fever include pregnant women and children.³ Many asymptomatic or mild dengue cases go unreported. WHO reports most of the dengue burden occurs in Asia, and the number of cases has steadily increased to just over 5 million in 2019.²

 

PREVENTION AND TREATMENT

Following prevention and treatment guidelines are crucial to lower transmission rates of dengue fever and malaria.

 

Dengue Fever

WHO states that countries should be aware of community mosquito presence and develop active mosquito and virus surveillance to prevent further disease spread.² They should also remain knowledgeable about the number of infected individuals.

 

The dengue vaccine (Dengvaxia) has been licensed in other countries since 2015, but the U.S. Food and Drug Administration (FDA) approved the vaccine in 2019.² WHO recommends people aged 9 to 45 years be vaccinated, but Dengvaxia is only FDA approved for patients 9 to 16 years old with a history of previous infection who live in high-risk areas. As a live-attenuated vaccine, it is contraindicated in individuals with severe immunodeficiency.² Children receiving Dengvaxia need a 3-dose series administered subcutaneously with doses separated by 6 months.⁹ Providers should store the vaccine in the refrigerator.¹⁰ After reconstitution, it should be administered immediately or stored in the refrigerator and used within thirty minutes.

 

WHO and the FDA only recommend Dengvaxia for patients with a history of dengue virus infection.^10,11 This is based on clinical trial evidence that the vaccine is efficacious and safe in patients with a history of previous DENV infection because a subsequent infection is more serious and life-threatening than the first.¹¹ They also advise countries using the vaccine to control viral spread to implement pre-vaccination screening to confirm previous infection.

 

As no dengue-specific treatment is available, providers should treat infected patients symptomatically with acetaminophen, rest, and fluids.² Patients with dengue fever should avoid non-steroidal anti-inflammatory drugs (e.g., ibuprofen, aspirin) because they thin the blood. Given the risk of hemorrhage in this disease, blood thinners may exacerbate the problem.²

 

Malaria

WHO recommends that countries engage in vector control and surveillance for the spread of malarial disease.⁵ Malaria vaccines have been in development for decades, but no malaria vaccine is available in the U.S.¹² In 2021, however, WHO recommended a new malaria vaccine (Mosquirix) for children aged older than 5 months who live in areas with moderate to high transmission of P. falciparum.¹³ The vaccine is only recommended for children as malaria is one of the main killers of children younger than 5 years in countries with moderate or high rates of malaria.¹⁴ WHO also recommends giving the vaccine seasonally in countries where malaria transmission is high during certain seasons.¹³

 

Initial Mosquirix pilot studies are ongoing, and more widespread vaccine rollout is expected in 2023. For now, people in the U.S. traveling to malaria-endemic countries continue to use oral medications as chemoprophylaxis (i.e., to prevent the disease), including atovaquone/proguanil, chloroquine, doxycycline, mefloquine, primaquine, and tafenoquine.¹⁵

 

Clinicians administer Mosquirix as a 4-dose schedule.¹⁶ The vaccine’s adverse effects are pain and swelling at the injection site and fever.¹⁷ Providers should store the vaccine in the refrigerator. After reconstitution it should be administered immediately or stored in the refrigerator and used within 6 hours.¹⁶

 

Malaria treatment involves the use of antimalarial drugs based on four main factors¹⁵:

• Infection severity: Malaria infection is either considered uncomplicated (effectively treated with oral antimalarials) or severe (requiring aggressive intravenous antimalarial therapy).
• Infecting Plasmodium species: P. falciparum and P. knowlesi infections can cause rapidly progressive severe illness or death, necessitating urgent therapy initiation, while other species are less likely to cause severe disease. P. vivax and P. ovale infections also require treatment for hypnozoites (parasites that lay dormant in the liver and then re-awaken to become active infectants).
• Drug susceptibility: In addition to disease severity differences, Plasmodium species also have different drug susceptibilities, so providers select an antimalarial therapy based on the species of the infecting parasite. If the species cannot be determined, patients must initiate antimalarial treatment against chloroquine-resistant P. falciparum as soon as possible.
• Previous antimalarial use: Patients using antimalarial medication as chemoprophylaxis, should not receive that same drug or drug combination to treat malaria infection unless no other options are available.

 

CONCLUSION

Pharmacists and pharmacy technicians should be familiar with the signs and symptoms of malaria and dengue fever to inform patients when these conditions are suspected and about their appropriate treatment. Pharmacy teams who suspect a case of malaria or dengue fever should refer patients for medical attention and contact their local or state health department.

 

 

 

 

Download CE Activity

INTRODUCTION

Major developments to vaccines and vaccine administration in recent years have demanded a great deal from pharmacists. The coronavirus disease-19 pandemic asked us to fight misinformation and vaccine hesitancy to educate the public about a new virus and new vaccine technology. We’ve been challenged to keep up with booster recommendations and the increased workflow that comes with vaccine administration. Many of us also taught our pharmacy technicians how to immunize.

 

Now, with the emergence of monkeypox comes yet another new vaccine with an unfamiliar method of administration (see our FREE monkeypox activity for a more in-depth discussion about this virus). In August 2022, the United States (U.S.) declared monkeypox a public health emergency and ramped up efforts to vaccinate at-risk individuals subcutaneously (a method with which pharmacists are generally familiar).¹ Shortly thereafter, the U.S. Food and Drug Administration (FDA) recognized that the country’s supply of monkeypox vaccine was unable to meet the current demand given the rapid spread of the virus.² Administering the vaccine intradermally only requires one-fifth of the subcutaneous dose, so the FDA issued an emergency use authorization (EUA) allowing healthcare providers to use this method of administration. This effectively increased the total number of available doses by up to five-fold.²

 

In September 2022, the U.S. Department of Health and Human Services authorized pharmacists, pharmacy interns, and pharmacy technicians, as appropriate, to administer monkeypox vaccines and therapeutics, under certain conditions.³ Pharmacists should be prepared to offer intradermal vaccination to eligible individuals to increase vaccination rates, slow viral spread, and improve outcomes both for this virus and any future viruses for which this applies.

 

THE ROLE OF INTRADERMAL ADMINISTRATION

Researchers have studied intradermal vaccination for a range of viral diseases, but only a few things are administered intradermally including^4,5

• tuberculosis skin testing
• BCG (tuberculosis) vaccine
• rabies vaccine
• allergy skin testing

 

Intradermal administration occurs in the dermis just below the epidermis (see Figure 1).⁴ The epidermis—the thinnest layer—is made up mostly of epithelial cells, but also contains melanocytes (pigment-producing cells), Merkel cells (for light-touch stimuli), and Langerhans cells (tissue-resident macrophages).⁵ The dermis is a thicker layer containing cells of the adaptive and innate immune systems including macrophages, mast cells, Langerhans cells, and dermal dendritic cells. Cells of the dermis are essential in processing incoming antigens to decide if they are harmful and activate the immune system accordingly.⁵

 

 

Figure 1. Methods of Vaccine Administration

 

High levels of antigen-presenting cells in the dermis induce a more potent immune response, making this an attractive (and potentially superior) vaccination site.^5,6 This significant reactivity in the dermis also prompts a strong immune response to a smaller quantity of vaccine antigen—as little as one-fifth to one-tenth the dose—compared to intramuscular or subcutaneous administration.^5,7 For this reason, intradermal administration is dose-sparing and potentially cost saving.⁵ Intradermal administration also avoids the rare risk of nerve, blood vessel, or joint space injury.⁷

 

Clinical studies are evaluating intradermal delivery of other vaccines, but none are currently available in the U.S. aside from monkeypox under the recent EUA.⁵ In years past, an intradermal influenza vaccine was available, but the manufacturer stopped production after the 2017-2018 flu season for unknown reasons.⁸ Of all parenteral routes, intradermal injections have the longest absorption time due to the lack of blood vessels and muscle tissue in this area. This is attractive for sensitivity testing, as reactions are easier to visualize and assess for severity.⁴

 

While intradermal administration is more efficient and cost-effective, it requires more skill and practice compared to subcutaneous or intramuscular administration.⁹ If incorrectly administered, the vaccine may enter the subcutaneous tissue instead and be ineffective because the dose is too small.

 

INTRADERMAL ADMINISTRATION TECHNIQUE

The most common intradermal injection sites are the volar aspect (inner surface) of the forearm and the upper back below the scapula (shoulder blade).⁴ Intradermal injection is not the best choice for every patient. Skin should be free of lesions, rashes, moles, or scars that could alter visual inspection of the injection site (or interpretation of test results, when applicable).⁴ In the case of the monkeypox vaccine, intradermal administration is only authorized for patients 18 years or older without a history of keloids (thick, raised scars).¹⁰

 

Researchers have developed various devices for intradermal drug delivery, but in the absence of specialized devices, individuals can employ the Mantoux technique using a hypodermic needle.⁵ The Mantoux technique is named for French physician Charles Mantoux who used this method for tuberculosis testing in the early 1900s.¹¹ The optimum needle size for this method is 26 to 27 gauge and ¼ to ½ inch long.⁴

 

The Mantoux technique is new to pharmacists (we know because we could only find information about administration technique in nursing resources), so listen up, take notes, and remember that practice makes perfect^4,10:

• Inspect the injection site and select an area that is free from lesions, rashes, moles, or scars. Avoid vaccination in an area where there is a recent tattoo (less than one month old). If tattoos cover both arms, select an area without pigment (ink) if possible. If the tattoo is unavoidable, administer through it.
• Clean the site with an alcohol or antiseptic swab using a firm, circular motion. Allow the site to dry completely to prevent alcohol from entering the tissue, which can cause stinging and irritation.
• Using the nondominant hand, spread the skin taut at the injection site. Taut skin provides easy entrance for the needle. This is especially important in older individuals with less elastic skin.
• Hold the syringe in the dominant hand between the thumb and forefinger at a 5- to 15-degree angle at the selected injection site with the bevel of the needle facing up.
• Place the needle almost flat against the patient’s skin and insert the needle into the skin no more than 1/8-inch (about 3 mm) to cover the bevel. Keeping the bevel side up allows the needle to smoothly pierce the skin and deliver the medication to the dermis.
• Once the needle is in place, use the thumb of the nondominant hand to slowly push the plunger to inject the medication.
• Inspect the injection site for a bleb (small blister) which should appear under the skin. The presence of a bleb indicates that the medication is correctly placed in the dermis. The bleb is desired but not required, so if it doesn't appear, don't panic. Simply adjust your technique for next time.
• Withdraw the needle at the same angle it was placed so as not to disturb the bleb and to minimize patient discomfort and tissue damage. Safely discard the syringe in a sharps container.

 

For more visual learners, the Centers for Disease Control and Prevention provides a video demonstrating how to administer a vaccine intradermally at https://www.cdc.gov/wcms/video/low-res/poxvirus/2022/53345334Monkeypox-Vaccine-Administration.mp4.

 

CONCLUSION

Vaccines work, that much we know. However, this is only true if they’re accessible, trusted, and used appropriately. Pharmacists can help promote access, education, and vaccine uptake if they have the knowledge and skills to do so. New vaccines and administration recommendations are challenging, but don’t let it get under your skin. We hope this quick-and-dirty overview of intradermal vaccines boosted your confidence and made it easier for you to give it a shot.

 

 

 

Download CE Activity