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QUESTION OF PRACTICE

[email protected] AJN ▼ June 2021 ▼ Vol. 121, No. 6 45

Preventing Shoulder Injury Related to Vaccine Administration

Proper injection technique is key.

Preventing the spread of COVID-19 has pre-sented a unique challenge for governments and public health authorities. As part of the strategy to combat the virus, the majority of the world’s population is targeted for vaccination. In the United States, large-scale vaccine distribution efforts are well underway—as of press time, an average of nearly 3 million doses had been admin- istered daily in the past seven days.1 A diverse coalition of vaccinators is facilitating these efforts, including retired health care providers, active-duty military members and the National Guard, emer- gency medical and fi re personnel, clinical students, physicians, nurses, physician assistants, and phar- macists.2 Government agencies such as the Indian Health Service, the Medical Reserve Corps, and the Army and Navy Medical Corps have also provided vaccinators.2

SHOULDER INJURY RELATED TO VACCINE ADMINISTRATION Vaccine administration is an art learned through practice, and awareness of proper technique should be at the forefront. Injectable vaccines may be admin- istered intradermally, subcutaneously, or intramuscu- larly, depending on the vaccine being administered.3

Many adult vaccines, including the current COVID- 19 vaccines, are given intramuscularly.4, 5

Shoulder injury related to vaccine administration (SIRVA) is a potential complication of improper needle placement during intramuscular (im) injec- tion. As first described in a review of 13 cases reported to the national Vaccine Injury Compensa- tion Program (VICP) database, SIRVA is similar to shoulder injuries related to overuse or trauma but is differentiated by rapid onset of shoulder pain and limited range of motion.6 The VICP defines SIRVA as an “adverse event following vaccination thought

to be related to the technique of intramuscular per- cutaneous injection,” thereby “resulting in trauma from the needle and/or the unintentional injection of a vaccine into tissues and structures lying under- neath the deltoid muscle.”7 Injecting “too high” in the shoulder has been reported as a common con- tributing factor.6, 8, 9

The underlying mechanism of SIRVA does not appear to be associated with a reaction to any par- ticular vaccine; rather, the condition is thought to be an inflammatory immune response to the injec- tion of the vaccine into the soft tissue structures of the shoulder synovial space instead of the deltoid muscle.6, 10

Symptoms and treatment. Unlike the transient symptoms of a typical immunization site reaction, the shoulder pain and limited range of motion associated with SIRVA are persistent.6, 11 Symp- toms typically occur within 48 hours of receiving a vaccine.6, 11 Pain from SIRVA can last months and, in some cases, may never fully resolve.8, 12 Treatment is similar to that for other types of shoulder dysfunction and may include nonsteroi- dal antiinflammatory drugs, steroid injections, physical therapy, and possible surgery to repair damaged joints.12, 13

Incidence. Because of SIRVA’s similarities to other shoulder injuries, its true incidence is not known, but it is considered to be a rare condi- tion.8-10, 13 In a study of VICP petitioner claims from 2010 to 2016, reports of SIRVA increased from two cases in 2011 to a total of 476 cases by 2016.8

Among these, 82.8% were women, median age was 51 years, and median body mass index was 25.1.8 The study was unable to identify individual SIRVA risk factors. Vaccinations were reported to have been given in a pharmacy or store (37.3%);

ABSTRACT: Shoulder injury related to vaccine administration (SIRVA) is a preventable complication caused by improper needle placement. It is associated with persistent shoulder pain and limited range of motion that occur within hours of vaccination and can last for months or longer. This article provides a brief overview of SIRVA and explains how vaccinators can prevent it by using proper injection technique.

Keywords: deltoid, injection, intramuscular injection, shoulder injury related to vaccine administration, SIRVA, vaccination

By Scarlett Shoemaker, MSN, RN

46 AJN ▼ June 2021 ▼ Vol. 121, No. 6 ajnonline.com

QUESTION OF PRACTICE

physician’s office (30.9%); workplace (15.1%); and hospital (6.5%); followed by ED/urgent care, health department, and nursing home/senior living facility (6.1%).8 Fewer than half of the vaccine reports included vaccinator credentials. Of those that did, 21.6% were nurses; 14.9% were pharmacists; 5.5% were medical assistants; 3% were physicians, physician assistants, or NPs; and 0.4% were phar- macy technicians.8

PREVENTION The best way to prevent SIRVA is to use proper injection technique. In adults, im injections should be administered at a 90 ° angle into the deltoid.14

The vaccinator should expose the patient’s entire arm so that appropriate landmarking techniques can be used to ensure proper needle placement.11

The deltoid is located approximately 2 inches, or 2 to 3 fingerbreadths, below the acromion process of the shoulder (see Figure 1).14

A 22-to-25-gauge needle should be used, and the needle should be long enough to penetrate the del- toid. Needle length can range from 5/8 in. to 1½ in. depending on the injection site and the patient’s age and body weight.14

Vaccinators should position themselves at the patient’s level to prevent inserting the needle “too high.”10, 12 For example, if a patient is in a wheel- chair or sitting in a chair, the vaccinator should also be seated.10, 12 Reminding the patient to relax can help to decrease the pain of the injection and might facilitate proper needle placement.15 Needle place- ment is critical, and improper location can affect absorption, skin reactions, comfort, and musculo- skeletal structures.

In contrast to im injections, subcutaneous injections should be administered at a 45°

angle into the fatty tissue of the triceps, with a 23-to-25-gauge needle that is 5/8 in. long (see Figure 2).14

VACCINE ADMINISTRATION RESOURCES Numerous resources provide instruction on vaccine administration. The Centers for Disease Control and Prevention (CDC; www.cdc.gov/vaccines/hcp/ admin/resource-library.html) and the Immunization Action Coalition (IAC; www.immunize.org) offer vaccination trainings, publications, and handouts at no cost. One such CDC training is Immuniza- tion: You Call the Shots (www2.cdc.gov/vaccines/ed/ vaxadmin/va/ce.asp), a thorough, self-paced online course for vaccinators. Two easy-to-read handouts from the IAC, “Administering Vaccines: Dose, Route, Site, and Needle Size” (www.immunize.org/ catg.d/p3085.pdf) and “How to Administer Intra- muscular and Subcutaneous Vaccine Injections to Adults” (www.immunize.org/catg.d/p2020A.pdf), provide straightforward overviews of needle size and administration sites. Additionally, the Ameri- can Nurses Association (www.nursingworld.org/ practice-policy/work-environment/health-safety/ immunize) and the Nursing Initiative Promoting Immunization Training (www.nip-it.org) provide information and resources on a wide range of immunization-related topics. ▼

Figure 1. Appropriate needle placement for intramuscular injection into the deltoid muscle. Images reproduced from www.immunize. org/catg.d/p2020a.pdf.

Figure 2. Appropriate needle placement for subcutaneous injec- tion into the fatty tissue of the triceps.

[email protected] AJN ▼ June 2021 ▼ Vol. 121, No. 6 47

Scarlett Shoemaker is a medical information associate at Eli Lilly and Company, Indianapolis, IN. Contact author: [email protected]. The author has disclosed no potential conflicts of interest, financial or otherwise. As an employee of Eli Lilly and Company, Shoemaker holds company stock. This article was written solely by Shoemaker based on her experience as an RN and immunization program manager, and is not associated with, nor does it reflect the opin- ions of, Eli Lilly and Company.

REFERENCES

1. Centers for Disease Control and Prevention. Trends in number of COVID-19 vaccinations in the US (updated daily). Atlanta; 2021 Apr 8. COVID data tracker; https://covid.cdc. gov/covid-data-tracker/#vaccination-trends.

2. The White House. National strategy for the COVID-19 response and pandemic preparedness. Washington, DC; 2021 Jan.

3. Immunization Action Coalition. Administering vaccines: dose, route, site, and needle size. St. Paul, MN; 2021 Mar. Item #P3085 (3/21). https://www.immunize.org/catg.d/p3085.pdf.

4. Centers for Disease Control and Prevention. U.S. COVID-19 vaccine product information. Atlanta; 2021 Mar 2. Vaccines and immunizations; https://www.cdc.gov/vaccines/covid-19/ info-by-product/index.html.

5. Immunization Action Coalition. Summary of recommen- dations for adult immunization (age 19 years and older). St. Paul, MN; 2020 Sep. Item P2011 (9/20). https://www. immunize.org/catg.d/p2011.pdf.

6. Atanasoff S, et al. Shoulder injury related to vaccine admin- istration (SIRVA). Vaccine 2010;28(51):8049-52.

7. U.S. Department of Health and Human Services, Health Resources and Services Administration. 42 CFR Part 100: National vaccine injury compensation program: revisions to the vaccine injury table. Washington, DC 2015; 45132-54.

8. Hesse EM, et al. Shoulder injury related to vaccine admin- istration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016. Vaccine 2020;38(5):1076-83.

9. Hibbs BF, et al. Reports of atypical shoulder pain and dys- function following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010-2017. Vaccine 2020;38(5):1137-43.

10. Bancsi A, et al. Getting it in the right spot: shoulder injury related to vaccine administration (SIRVA) and other injec- tion site events. Can Pharm J (Ott) 2018;151(5):295-9.

11. Bancsi A, et al. Shoulder injury related to vaccine adminis- tration and other injection site events. Can Fam Physician 2019;65(1):40-2.

12. Cross GB, et al. Don’t aim too high: avoiding shoulder injury related to vaccine administration. Aust Fam Physician 2016;45(5):303-6.

13. Szari S, et al. Shoulder injury related to vaccine administra- tion: a rare reaction. Fed Pract 2019;36(8):380-4.

14. Immunization Action Coalition. How to administer intra- muscular and subcutaneous vaccine injections to adults. St. Paul, MN; 2018 Jan. Item #P2020a (1/18). https://www. immunize.org/catg.d/p2020a.pdf.

15. Vaccines.gov. What to expect—for adults. Department of Health and Human Services, Office of Infectious Disease and HIV/AIDS Policy. 2020. https://www.vaccines.gov/get- vaccinated/for_adults.