POST 00537E : ASPIRATION BEFORE INJECTION 4 January 2003
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Bernard Kaic (mailto:[log in to unmask]) from Croatia has submitted a
query that could be of interest to many of you. It is thus reproduced here
below with the reply provided by John Clements (mailto:[log in to unmask])
from WHO.
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I am a medical epidemiologist at the Croatian National Institute of Public
Health, and also the National EPI manager.
There is one thing I noticed reading WHO documents, which puzzles me.
Namely, neither of the documents dealing with vaccination, including
"Immunization in practice, Modules 1-11, (WHO/EPI/TRAM/98.01-11 REV.1)"
recommends aspiration prior to injection a vaccine during intramuscular
administration of vaccine.
During my medical education I was taught to pull the plunger, once the
needle is in the muscle, in order to check if the needle is inside a blood
vessel. No vaccine is allowed to be administered into the blood stream.
Since I always pull the plunger before injection, I found to be inside a
blood vessel with the needle on a few occasions. In such cases, the vaccine
has to be discarded and new vaccine administered at a different site.
Of course, intramuscular administration of vaccine at recommended sites
greatly reduces the risk of intravasal administration, but does not
eliminate it.
Could you please investigate the reason for omitting the recommendation to
pull the plunger before injecting the vaccine via the intramuscular route?
Thanks in advance for your response.
Best regards,
Bernard Kaic, MD, MSc
National EPI manager
Department of Infectious Disease Epidemiology
Croatian national institute of public health
Zagreb, Croatia
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Here is EPIs point of view:
It has been traditional in many health care settings to use a medicated
swab to prepare the skin before vaccination, and to aspirate the syringe
after insertion (1) in attempting to avoid injecting directly into a blood
vessel. Neither practice is endorsed by WHO.
If the intended vaccination site is visibly dirty, obvious dirt can be
removed using clean water, water for injection or saline and a clean
tissue, cloth, cotton wool, gauze or other such non-impregnated material.
Wipes that are impregnated with medicated chemical must not be used. Such
chemicals may interfere with the vaccines, especially live ones. A needle
should not be inserted through skin that is obviously infected - this would
introduce the infection into lower layers and possibly produce an abscess
or worse.
Another tradition has been to aspirate the syringe once it has been
inserted into the patient. By pulling back on the plunger, the negative
pressure produced will draw blood back into the barrel if the needle tip is
lying in a blood vessel. Thus, repositioning the tip would theoretically
avoid injecting the vaccine directly into the vessel. The theoretical
concern that the vaccine might be injected into a vessel is flawed. As well
as being virtually impossible to accomplish, large blood vessels are not
located around the recommended injection sites, minimizing the possibility
of placing the needle tip in a vessel.
The practice of aspirating is not "evidence-based" - there is no case
report of this occurring with a negative impact. In addition, the difficult
action of aspiration prolongs the time the needle is inserted into the
patient, and allows for the possibility of loss of control of the syringe
if both hands of the vaccinator are used instead of one hand holding the
patient. Trauma at the site of injection is likely to be increased during
attempts to aspirate. Most auto-disable syringes do not permit aspiration
to be performed prior to injection (2). None the less, there is also a lack
of evidence supporting not aspirating. As a result, WHO is neither able to
support nor offer alternative actions in relation to aspiration undertaken
during the administration of vaccines. Until such time as clear evidence
becomes available to indicate which method is preferable, vaccinators
should make locally appropriate choices.
References :
(1) General recommendations on immunization. Recommendations of the
Advisory Committee on Immunization Practices. Morbidity and Mortality
Weekly Report. 1994; 43: RR-1 page 6.
(2) Giving safe injections: introducing auto-disable syringes. PATH.
Seattle, WA U.S.A. 2000.
Dr C John Clements
Vaccines and Biologicals
World Health Organization
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