Immunisation of inpatients

  • Introduction

    • Immunisation is the safest and most effective way to protect infants and children from vaccine-preventable diseases.
    • It is important that healthcare professionals take every available opportunity to vaccinate infants and children 
    • 8-10% of Australian infants and older children are not up-to-date with their immunisations
    • Children who are due or overdue for their immunisations can usually be safely and effectively immunised during their inpatient stay, in consultation with the patient’s treating medical team
    • This guideline is intended for use by the nursing, medical and pharmacy staff at the Royal Children’s Hospital (RCH)
    • This guideline applies to infants, children and adolescents at the RCH, during their inpatient stay


    The aims of this guideline are;

    • To ensure that Registered Nurses at RCH are providing safe and effective immunisations. This applies specifically to nurses who are authorised to administer vaccines under the direction (e.g. drug order) of a medical practitioner
    • To ensure that all infants, children and adolescents are immunised in a safe environment according to the relevant legislation, best practice and the Australian Immunisation Handbook guidelines and recommendations at The Royal Children’s Hospital
    • To ensure that parents receive consistent, accurate and reliable information about the Immunisation procedure, including the potential risk and benefits, such as possible adverse events, how common they are and what they should do about them

    Definition of Terms

    Immunisation – The process of inducing immunity to an infectious agent by administering a vaccine 

    Immunity – the ability of the body to fight off certain infections; immunity can result from natural (wild) infection or from vaccination

    Vaccination – the administration of a vaccine; if vaccination is successful, it results in immunity

    Adverse event following immunisation (AEFI) – any untoward medical occurrence that follows immunisation and does not necessarily have a causal relationship with the usage of the vaccine.

    Cold chain – is the system of transporting and storing vaccines within the temperature range of +2ºC to +8 ºC from the place of manufacture to the point of administration.  Maintenance of cold chain is essential for maintaining vaccine potency and in turn, vaccine effectiveness.

    Contraindications - Only 2 absolute contraindications apply to all vaccines:

    • anaphylaxis following a previous dose of the relevant vaccine
    • anaphylaxis following any component of the relevant vaccine

    2 further contraindications apply to live vaccines (both parenteral and oral):

    • People who are significantly immunocompromised should not receive live vaccines. This is regardless of whether the immunocompromising condition is caused by disease or treatment.
    • Pregnant women should not receive live vaccines, in general. Women should be advised not to become pregnant within 28 days of receiving a live vaccine.

    Inactivated vaccines include: Prevenar 13®, Infanrix-Hexa®, Infanrix-IPV®, Nimenrix®. Boostrix®, Adacel®, Gardasil 9®, Act Hib®, Hiberix®, Infanrix®, Quadracel®, Tripacel®, COVID-19 vaccines, Vaxelis®, Pneumovax 23®, Bexsero®, Engerix®, IPOL®, Twinrix®, Vaqta®, Havrix®.

    Live vaccines include: Priorix®, Priorix Tetra®, Proquad®, MMRII®, Varilrix®, Varivax®, Rotarix®, BCG

    Valid consent – the voluntary agreement by an individual to a proposed procedure, given after sufficient, appropriate and reliable information about the procedure, including the potential risks and benefits, has been conveyed to that individual

    NIP – National Immunisation Program


    Every encounter with a health care professional is an opportunity to review immunisation status.  If you have identified that the patient requires immunisation, providers should;

    • Ensure which vaccine(s) are indicated, including any previously missed vaccine doses by referring to the NIP
    • If the patient does not have documented evidence of receipt of vaccines scheduled in the NIP appropriate for his/her age, then discuss this with the Immunisation service on 9345 6599 or discuss with the treating medical team
    • Consider whether additional vaccines should be given, due to any risk factors, i.e prematurity, underlying medical condition, immunosuppressive therapy
    • Check if there are any contraindications or precautions to the vaccines that are to be given
    • Check the correct time interval has passed since any previous vaccine(s) were given
    • Obtain a medication order from the medical team, which is required to be prescribed on the MARProvide the person to be vaccinated or the parent/carer with the Pre-vaccination Screening checklist and the vaccine side effects
    • If you identify the presence of a condition or circumstance indicated on the pre-vaccination screening checklist, refer to the Immunisation Service on 9345 6599 or discuss with the treating medical team
    • Consent should be obtained before each vaccination (verbal), once it has been established that there are no contraindications


    Administration of Vaccines

    1. Occupational health and safety issues 

    Standard occupational health and safety guidelines should always be followed during vaccination

    2. Equipment for vaccination

    The equipment chosen will vary depending on whether the vaccine is a reconstituted vaccine or a vaccine in a pre-filled syringe.  Equipment may include;

    • Sharps container
    • Vaccine, plus diluent if reconstitution is required
    • 3mL syringe (unless vaccine is in pre-filled syringe)
    • 19 gauge drawing up needle (to draw up through rubber bung once vaccine reconstituted)
    • 23 gauge 25mm injecting needle (intramuscular)
    • 25 gauge 16mm injecting needle (subcutaneous)
    • Clean cotton wool and micropore tape to apply to injection site after vaccination

    3. Preparing the vaccine

    • Ensure that the correct vaccine is taken from the refrigerator and that it is within the expiry date and cold chain has been maintained
    • Wash hands with soap and water or use an alcohol-based hand rub
    • Prepare the appropriate injection equipment for the vaccine to be administered
    • Injectable medications, should be checked and counter signed by appropriately endorsed Registered Nurses – see Medication Management Procedure.
    Injectable vaccines that do not require reconstitution
    • These vaccines include Prevenar 13®, Infanrix-IPV®, Boostrix®, Gardasil 9®, Infanrix®, Quadracel®, Tripacel®, Vaxelis®, Pneumovax 23®, Bexsero®, Engerix®, IPOL®, Twinrix®, Vaqta®, Havrix®.
    • If the vaccine is in a vial, remove the cap carefully to maintain sterility of the rubber bung.  Wipe the outer surface of the rubber stopper of injection vials with an alcohol swab.  Allow rubber stopper to dry before inserting any device into the vial. 
    • Use the 19 gauge needle to draw up the recommended dose through the bung
    • Change the needle after drawing up from a vial before giving the injection
    Injectable vaccines that require reconstitution
    • These vaccines include Nimenrix®, Priorix®, Infanrix Hexa®, Priorix Tetra®, Proquad®, MMRII®, Varilrix®, Varivax®
    • Reconstitute the vaccine as needed immediately before administration
    • Use a sterile 19 gauge needle for reconstitution and a separate 23 gauge needle, 25mm in length for administration of the vaccine.  If the patient is pre-term ( <37 weeks gestation) up to 2 months of age, a 16 mm needle in length can be used.  If the patient is obese, a 38 mm needle length can be used.
    • Use only the diluent supplied with the vaccine; do not use sterile water for injection instead of supplied diluent.  Ensure that the diluents and vaccine are completely mixed.
    • Administer reconstituted vaccines as soon as practicable after they have been reconstituted, as they may deteriorate rapidly.
    For all injectable vaccines
    • In the instance of a large air bubble in a pre-filled syringe, expel the air through the needle, taking care not to prime the needle with any of the vaccine.  This prevents the potential for partial loss of vaccine dose.
    • Never mix a local anaesthetic with a vaccine

    4. Administering the vaccine

    • Most vaccines are given intramuscularly. 
    • Priorix®, MMRII®, Priorix Tetra® and Varilrix® and Varivax® are given subcutaneously.
    • Rotavirus vaccines are only available for oral administration
    • Provided the skin is visibly clean, there is no need to wipe it with an alcohol wipe
    Intramuscular injection technique

    Refer to the intramuscular injection guideline to facilitate the administration of IM injections

    Subcutaneous injection technique
    • For subcutaneous (SC) injection, administer the injection at a 45° angle to the skin.
    • The standard needle for administering vaccines by SC injection is a 25 or 26 gauge needle, 16mm in length.
    Oral Rotavirus vaccine technique
    • The liquid formulation is presented as a clear liquid contained in a squeezable plastic, latex-free dosing tube with a twist-off cap.  Keep the cap – you need this to pierce the tube (see product information)
    • The current 1.5 ml dose of vaccine should be administered orally from the oral applicator onto the inside of the infant’s cheek in small aliquots.
    • If most of an oral rotavirus vaccine dose has been spat out or vomited within minutes of administration, a single repeat dose can be administered during the same visit.
    • If an infant regurgitates or vomits only a small part of a vaccine dose, it is not necessary to repeat the dose.
    • The Rotavirus vaccine can be administered via a Nasogastric tube – see relevant procedure.

    5. Positioning for vaccination

    It is important that movement of infants and children is minimised during injection of vaccines.  The following positions may be used for vaccinating.

    Infants less than 12 months of age
    • Position the infant in a semi-recumbent position on the lap of the parent/carer.  It can also be used for young children.
    • Alternatively, lay the infant on their back in the cot, with the infant’s feet towards you. Keep the infants hip and knee flexed by cupping their patella in your non-injecting hand.
    Children aged 12 months or older
    • Position the child sideways on the lap of the parent/carer, with the arm to be injected held close to the child’s body, while the other arm is tucked under the armpit and behind the back of the parent/carer.                          
    Adolescents and adults
    • Adults should sit in a chair, feet resting flat on the floor, with arms relaxed at the sides
    • Encourage the shoulders to relax, by asking the person to take a deep breath in, and dropping the shoulders whilst breathing out
    • The deltoid is the area for vaccination and needs to be completely exposed and visualised by the immunisation provider.  The patient may be required to take their arm completely out of their sleeve or remove the shirt if needed.  Ensure patient privacy is maintained.
    • Locate the shoulder tip (acromion) and the muscle at the middle of the humerus.  The deltoid site is halfway between these two landmarks.

    6. Distraction techniques and analgesia

    Immunisations can result in distress and anxiety for infants, children and their parents.  It is important that effective pain management strategies are used during immunisation.  Some strategiesthat are recommended during administration of the vaccine include;

    • Oral sucrose(infants, 0-18 months) used alongside dummy if appropriate
    • Breastfeeding
    • Shaking a noisy toy (infants and children)
    • Active techniques - blowing bubbles, windmill or party blower
    • Passive techniques, such as watching TV, looking at a book
    • Buzzy® Device
    • Exocool® (see procedure)
    • Smileyscope® VR goggles

    Topical anaesthetic agents, such as AnGel® cream or EMLA® can also be used. Routine use of paracetamol at the time of, or immediately after, vaccination is not recommended, unless Bexsero ® is being administered (see MVEC).

    For more information please see:

    Post - Vaccination

    Immediate after care

    • Dispose of clinical and sharps waste, including vaccine vials
    • The live oral Rotavirus vaccine squeezable plastic container should also be discarded in clinical waste or sharps container
    • Cover the injection site quickly with cotton wool and tape as needed
    • Gently apply pressure for 1-2 minutes (do not rub the injection site, as may lead to local irritation)
    • Inform patient to remain under observation by the health care professional for a minimum of 15 minutes after the vaccination (to observe for any immediate adverse event, such as anaphylaxis)

    Documentation requirements

    • All vaccines administered to infants and children should be documented in the MAR on EPIC as well as in the parent held Child Health record book
    • Details which should be recorded include;
      • Vaccine given, including brand name, batch number, dose number
      • Date and time of vaccination
      • Site of administration
      • Name of the person providing the vaccination

    Special Considerations

    Vaccine side effects

    • The most common adverse events following immunisation are; local reactions (such as pain, redness or swelling at the injection site), fever, irritability and injection site nodules.  These responses are usually mild and self-limiting and generally, do not require specific treatment.
    • Routine use of paracetamol at the time of, or immediately after, vaccination is not recommended, unless Bexsero® is being administered (see MVEC).

    Adverse Events Following Immunisation (AEFI)

    • An adverse event following immunisation (AEFI) is any untoward medical occurrence that follows immunisation and does not necessarily have a causal relationship with the usage of the vaccine.
    • The most serious AEFI following immunisation is anaphylaxis.  Nursing staff must be aware of anaphylaxis management
    • Fainting is relatively common after vaccination of adults and adolescents.  If this occurs, lie the patient in a supine ‘head-down and feet-up’ position
    • Any AEFI should be reported to SAEFVIC(Surveillance of Adverse Events Following Vaccination In the Community).  SAEFVIC is based at the RCH/MCRI and can be contacted on 1300 882 924 (Option 1)

    Immunisation and Anaesthesia

    • Patients can receive vaccination whilst under general anaesthesia, see the linkfor more information.  


    Remember to read the disclaimer

    The development of this nursing guideline was coordinated by Sonja Elia, NP, Immunisation Service, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2023.  

    Evidence Table 


    Source of evidence

    Key findings and considerations 

    Hull B P, Hendry A, Dey A, Brotherton J, Macartney and Beard F. (2021).  Annual Immunisation Coverage Report 2021.  

    Expert opinion Data provided in this report reflect continuing successful delivery of the NIP in Australia, while identifying impacts of the COVID-19 pandemic particularly on adolescent coverage.  

    National Health and Medical Research Council (NHMRC).  The Australian Immunisation Handbook,    Expert opinion

    Clinical guidelines for health professionals on the safest and most effective use of vaccines in their practice.  Recommendations developed by the Australian Technical Advisory Group on Immunisation (ATAGI) and approved by the National Health and Medical Research Council (NHMRC). 

    Grayson ML, Russo P, Ryan K, Havers S and Heard K. (2013) Hand Hygiene Australia - 5 moments for hand hygiene. Australian Commission on Safety and Quality in Healthcare, 2013.  
    Expert opinion

    Provides a practical step-by-step guide to implementing and sustaining the Hand Hygiene culture change in hospitals and how to participate in the National Hand Hygiene Initiative.

     Hutin Y, Hauri A, Chiarello L, Catlin M, Stilwell B, Ghebrehiwet T and Garner J (2003). Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health Organization, 81:491-500  Single descriptive study

    When intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles. 

    Diggle L, Deeks JJ, Pollard AJ (2006). Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomised controlled trial, British Medical Journal;333:571.  Randomised controlled trial Local reactions to vaccinations decreased significantly with wide, long needles compared with narrow, short needles. Non-inferiority of the immune response was shown using a wide, long needle rather than a narrow, short needle. Little difference was found between needles of the same length but different gauges in local reaction or immune response.   

    Harrison D, Elia S, Manias E and Royle J (2014). Sucrose and lollypops to reduce immunisation pain in toddlers and young children: Two pilot randomised controlled trials. Neonatal, Paediatric & Child Health Nursing, 17(1): 19-26  Randomised controlled trial

    Interventions, standard care and all aspects of the study were acceptable to children, parents and immunisation nurses. There were no significant differences in crying time or pain scores between intervention and control groups in either pilot RCT.  The study interventions were acceptable to children and parents.

     Jenkins, N Orsini F, Elia S & Perrett K (2020).  Minimising immunisation pain of childhood vaccines: the MIP pilot study.  Journal of Paediatrics and Child Health  Randomised controlled trial

    This RCT paper assesses the feasibility and acceptability of two novel devices; Coolsense (cold) and Buzzy (vibration +/- cold pads) versus standard care to minimise pain during immunisation.  The study achieved its aim of demonstrating feasibility. 

    Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Pillai Riddell R, Rieder M, Scott J and Shah V (2010). Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ Canadian Medical Association Journal;182:E843-55  Systematic review of descriptive studies  

    This paper looks at the evidence of practice recommendations to reduce pain.  The practice recommendations were breastfeeding, sweet tasting solutions, brand of vaccine, position of child, intramuscular injection technique, order of injections, tactile stimulation, distraction and coaching, topical anesthetics, clinician led distraction, child led distraction, breathing techniques, combined psychological interventions, simple suggestions that “it won’t hurt”, skin cooling techniques, multiple injections , routes of administration and oral analgesics.  

    World Health Organization (WHO). WHO best practices for injections and related procedures toolkit- external site. Geneva: WHO; 2010.  Expert opinion

    The document describes best injection practices and assessment and management of occupational risks and injuries.  It promotes the implementation of safe practices associated with intradermal, subcutaneous and intramuscular needle injections.