Vaccine administration and placement: Reply from Vancouver Coastal Health

Issue: BCMJ, vol. 58, No. 3, April 2016, Page 124 Letters
By: Meenakshi Dawar, MD

Thank you for inviting us to comment on Dr Cimolai’s letter. Vaccine safety, including injection safety, is important to the public, immunizers, and public health. In this regard, we produce immunization updates regularly[1] with administration advice based on provincial guidance.[2] This advice is consistent with national and US recommendations.[3,4]

While vaccines are very safe, an injection given in the wrong place can cause a nerve or joint injury. An intramuscular injection given too high in the deltoid can injure the shoulder joint/bursa; those given too low can injure a branch of the axillary nerve. These complications are preventable if the correct landmarking technique is followed. 

Radial nerve injury following subcutaneous and intramuscular injection in the outer triceps area, or radial nerve injury following intramuscular injection in the deltoid, is highly unusual. We receive approximately 150 reports of adverse events following immunization annually, but we do not recall a single report of radial nerve injury. A correctly landmarked intramuscular injection of the deltoid should not result in injury to the radial nerve (a graphic showing the course of the radial nerve is available at www.medicineplexus.com/index.php/articles/86-radial-nerve [5]). The radial nerve courses on the posterior axillary wall, and then runs through the spiral groove between lateral and medial heads of the triceps; thus, it does not have exposure in the deltoid area. In addition, the outer triceps area is reserved for subcutaneous procedures only. A vaccine given outside the recommended area of the deltoid or given incorrectly (intramuscular instead of subcutaneous) in the outer triceps area could result in a radial nerve injury. The remedy here is not to change injection site recommendations but rather to correct the injection technique.

We recommend all physicians follow local health authority/provincial guidance in immunizing patients and invite physicians to report adverse events to local public health centres.[6] Vaccine safety surveillance is an important partnership between primary care providers and public health. We appreciate the opportunity to promote this dialogue.
—Meena Dawar, MD, FRCPC
Medical Health Officer

References

1.    Vancouver Coastal Health. Physicians’ update. Accessed 9 March 2016. www.vch.ca/your-health/health-topics/communicable-diseases/for-health-pr....
2.    BC Centre for Disease Control. Communicable disease control manual: Immunization. Section IV: Administration of biological products. Accessed 9 March 2016. www.bccdc.ca/health-professionals/clinical-resources/communicable-diseas...
3.    Public Health Agency of Canada. Canadian immunization guide. Route, site, and technique for vaccine administration. Accessed 9 March 2016. www.phac-aspc.gc.ca/publicat/cig-gci/p01-07-eng.php#rout.
4.    Kroger AT, Sumaya CV, Pickering LK, et al. General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60:1-60.
5.    Medicine Plexus. Article: Radial nerve. Accessed 10 March 2016. www.medicineplexus.com/index.php/articles/86-radial-nerve. 
6.    BC Centre for Disease Control. Surveillance forms: Adverse events following immunization. Accessed 9 March 2016. www.bccdc.ca/health-professionals/professional-resources/surveillance-forms.

Meenakshi Dawar, MD. Vaccine administration and placement: Reply from Vancouver Coastal Health. BCMJ, Vol. 58, No. 3, April, 2016, Page(s) 124 - Letters.


Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.


For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply