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Groups Revise General Vaccination Recommendations

Kate Traynor

The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP) recently revised ACIP’s "General Recommendations on Immunization" to reflect issues raised since the document was last updated in 1994.1

Among the changes to the recommendations is the expansion of the section on i.m. vaccination of people who have a bleeding disorder to include patients receiving anticoagulant therapy. ACIP and AAFP recommend that i.m. vaccines be administered as indicated if a physician who is familiar with the patient’s bleeding risk deems that vaccination can be done "with reasonable safety."

The guidelines state that, compared with the general population, people with bleeding disorders have a greater risk for hepatitis B infection and a normal risk for contracting other vaccine-preventable diseases. This underscores the need to administer vaccines to a population that normally might not receive i.m. injections.

To minimize the risk of bleeding complications in high-risk patients, ACIP and AAFP suggest that i.m. vaccines be delivered with a 23-gauge or finer needle. Bruising can be reduced by applying firm pressure to the vaccination site for at least two minutes after the shot is given. When possible, i.m. vaccination of patients who receive antihemophelia therapy should be scheduled soon after an antihemophilia agent is administered.

The revised guidelines also contain an expanded section describing recommended routes of injection, needle size, and angle of needle placement. In contrast to the 1994 document, the revision does not name the deltoid muscle as an acceptable vaccination site for infants. The recommended needle sizes for vaccinations were changed to the following:

  • A minimum length of 7/8 inch for deltoid-muscle vaccination of toddlers and adolescents,
  • A 1-inch needle for the anterolateral-thigh-muscle vaccination of toddlers and adolescents,
  • A needle no larger than 20 gauge for i.m. vaccination of adults, and
  • A 5/8-inch needle for s.c. vaccination of all patients.

Another notable change to the guidelines is the discussion of ways to make vaccination less traumatic for children. The document briefly mentions "comfort measures," such as playing music and pretending to "blow away" a child’s pain. Also discussed is the use of lidocaine–prilocaine topical anesthetics, which can reduce pain and do not seem to interfere with the effectiveness of at least one product—the measles, mumps, and rubella virus vaccine.

According to the guidelines, nonaspirin analgesics, such as ibuprofen, and "vapocoolant" sprays can alleviate the pain of vaccination. But acetaminophen, which alleviates vaccination-associated pain and fever, may cause methemoglobin to form, thereby decreasing the effectiveness of concurrently used lidocaine–prilocaine products.

A revised section in the guidelines discusses the use of "nonstandard vaccination practices." ACIP and AAFP strongly discourage vaccine providers from using vaccination sites and injection routes that do not conform to standard practice. The two groups also advise vaccine providers not to split vaccine doses or administer less than the recommended amount of any vaccine.

The revised guidelines make no mention of coping with vaccine shortages, although a single paragraph in the document addresses lapsed vaccination schedules. ACIP and AAFP encourage vaccination providers to adhere as closely as possible to the recommended vaccination intervals. If any dose in a vaccine series is missed, the guidelines advise against restarting the series from the beginning or supplementing with extra doses.

  1. Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices and the American Academy of Family Physicians. MMWR. 2002; 51(RR-2):1-36.