Immunisation services delivery

The UK immunisation and vaccination schedule is designed to protect the population from vaccine preventable disease. The UK policy and strategy are set out in Immunisation against infectious diseases, the Green Book. This provides policy guidance on; vaccine administration, storage and disposal of vaccines, and reporting alongside information about all the vaccines given in the UK and how these should be administered. All immunisers must be familiar with the guidance in this document for the vaccines they are administering and must access the Green Book online as the resource is frequently updated to reflect the most up to date schedule and advice.

Immunisation relies on a high and sustained uptake of vaccines to make sure the diseases they are designed to prevent do not circulate in the population. We know from experience that falls in immunisation rates lead to increases in cases of vaccine preventable diseases and deaths.

The routine immunisation schedule sets out the vaccines which should be made available to everyone in the population at the point at which they will most need or benefit from the protection. This needs to be used alongside the Vaccination of individuals with uncertain or incomplete immunisation status to identify what vaccines people need where they have missed some or all the vaccines they are eligible for.

This RCN guidance outlines the key principles for maintaining effective delivery of the national immunisation schedule, as well as large scale vaccine delivery. It provides information on how to make sure services are safe and meet the needs of the population. See the ‘Top Tips’ and further information section.

For further country specific information see:

England: UKHSA immunisation collection
Northern Ireland: HSC PHA Immunisation/vaccine preventable diseases
Scotland: Public Health Scotland Immunisation
Wales: Public Health Wales Immunisation and Vaccines

There are some key considerations for staff, as part of a risk assessment process, for delivering all vaccination services.

Services delivered in non-clinical settings will require particular consideration.

The information in this guidance is designed to make sure that services are reactive to the needs of the population while remaining safe and accessible to all.

It can be used to support the development of existing vaccination services and also for setting up large scale vaccination provision.

See also the RCGP ‘Delivering Mass Vaccinations During COVID-19 A Logistical Guide for General Practice’ 2020 via RCGP latest COVID guidance.

There are some key considerations to take into account when planning, commissioning and providing services to ensure that they are accessible to all and managed safely and effectively.

These are defined in the NICE guidance 'vaccine uptake in the general population':

• Having a named vaccination lead helps ensure on going patient and staff safety and governance and commitment to ensuring high uptake.
• Making vaccination services accessible and tailoring them to local and demographic needs.
• Building in a process for audit evaluation and feedback and to support a learning culture.
• Ensuring the staff have the appropriate education, skills and ongoing support.
• Making sure there is enough provision for appointments which are flexible and have enough time for adequate consultation and for making any reasonable adjustments, as necessary.

The RCN COVID-19 workplace risk assessment toolkit provides advice on managing workplace risks. These were written specifically for the COVID-19 pandemic but the principles would apply to any setting.

Vaccination in temporary open-air venues and structures can pose potential risks, such as difficulties in maintaining vaccine cold chain, waste management, hazards to staff and patients (weather and vehicles) or following infection prevention and control procedures.

Buildings with the capacity for large scale vaccination options such as sports and leisure centres, community centres and religious venues may offer the potential to facilitate a larger throughput of people. Providing certain logistics are thought through and a local risk assessment carried out they can be a valuable option.

Any risk assessment needs to be recorded, shared and regularly reviewed and updated especially if there has been a significant change or event.

Each venue will need a suitable and sufficient risk assessment to be carried out and consideration of making any reasonable adjustments as necessary:

• appropriate access and manoeuvrability for wheelchair, users, and for those with limited mobility
• whether the venue is appropriate for certain groups e.g. vulnerable adults such as those with learning disability and living with dementia
• is the venue suitable for responding to any potential behaviour needs that may affect the procedure
• what options are available for making any necessary reasonable adjustments available and whether carers can accompany people, especially those with vulnerabilities.

Local plans should be developed to meet the requirements of the local population. Consider the demographics and any specific needs of the community or any local groups; either in relation to beliefs about vaccines or how and when they can best access vaccine services at a time which is acceptable and convenient.

Develop plans alongside venue staff; if this is in schools, work with teaching and welfare staff to help and support. Other venues may have security and administrative staff who can help and support.

For mass vaccination sites consider the need for additional security on site to protect staff and patients.

There needs to be consideration to ensure safe, easy access to sharps and waste disposal (see under ‘Top tips for safe vaccine administration’).

Make sure staff are able to work safely and avoid the need for any continuous bending/stooping and the risk of back injuries. Consider staff rotation and rest periods for immunisers alongside welfare facilities and space for staff to take breaks and refresh.

Support people with cognitive impairment who may be more comfortable receiving health care in familiar environments. Local systems should have options for making reasonable adjustments available where needed, including providing immunisation in the person’s place of residence, if this is the most appropriate option.

Assess the ease of access and transport routes to the venue, including consideration of traffic flow, parking and how adverse weather conditions (rain/ice/snow etc) will affect these.

Liaison with local authority and emergency services to ensure they are appropriately notified and have adequate access to the site.

For any open-air venues, consider how to manage potential issues due to the weather, for example, extremes of temperature or wet / windy weather.

Consideration needs to be given to the ability to maintain infection prevention and control with ready access to hot and cold running water and toileting facilities.

Consider generator back up in case of electrical failures for refrigerators and temperature data loggers to maintain vaccine storage.

Ensure there is a clear Standard operating procedure (SOP) for roving and mobile vaccination models and for the transportation and storage of the vaccines required. The Specialist Pharmacist Service (SPS) website includes a range of resources and guidance about this.

There needs to be clear lines of accountability and senior clinical leadership to ensure there is appropriate governance of the service and coordination with the existing systems and services.

Registered health care professionals must abide by their professional code of conduct (e.g. NMC Code of professional conduct), wherever they provide care, alongside local policies and procedures.

Any regulatory requirements must be met (e.g. Health and social care regulator such as the CQC see for example Regulation 15: premises and equipment) and the Health and Safety Sharp Instruments in Healthcare Regulations 2013.

Employers must ensure that the appropriate indemnity arrangements are in place for all staff wherever they are working (see RCN resources on Indemnity).

Make sure staff understand their role in relation to safeguarding for both adults and children, including those people within vulnerable groups.

Employers need to ensure staff are cleared to work and have the appropriate disclosure barring (DBS) or equivalent check in place.

Staff need to be up to date with safeguarding training and education requirements for the population group, see RCN Safeguarding resources.

Make sure staff have undergone mandatory training for giving the specific vaccine. (see section on education and training needs / who can vaccinate and keeping up to date).

While anaphylaxis following vaccination is rare, there needs to be a clear process for managing post vaccination anaphylaxis and any other adverse events (see info on safe vaccine administration and follow up in the top tips section).

There is generally no need for a specific observation period after vaccine administration. There may however be a requirement for this with new vaccines. The summary of product characteristics (SmPC) for the specific vaccine, Green Book, MHRA and JCVI advice regarding any required observation periods following vaccination must be followed.

Ensure the health and safety of staff and patients, so far as is practical, including mitigation of risk of needlestick injury, personal safety and readily available access to appropriate personal protective equipment.

Confirm all equipment on site will be kept secure.

Consider how to make sure equipment and supplies are transported to and from the venue. This includes the vaccine storage and transportation requirements (see further information under ‘vaccine storage’).

Make sure, as part of the risk assessment process that there is suitable and sufficient provision for the safe and appropriate disposal of clinical waste (e.g. used PPE, disposable hand towels). The HSE resources for management of waste publications and the NHS Health Technical memorandum on the safe management of healthcare waste (HTM 07-01) provide further guidance.

Ensure access to appropriate resources and information is available in easy read or other languages or formats where appropriate and attuned to specific population needs, to support; different age groups, people with disability or learning needs or where English is not a first language.

As people are often anxious when coming for a vaccine, aim to make the services welcoming and friendly.

Ensure there is access to each patient’s records as part of the pathway and provision for good documentation and record keeping. Where vaccines are given in other sites such as schools or other venues there must be a process to ensure the vaccination record is transferred to the patients’ primary care records.

Make sure there are processes in place to gain patient consent and ensure confidentiality alongside maintaining the individual’s right to privacy and dignity.

Data collection and monitoring overall uptake of vaccine is essential to ensure all eligible groups have access to the vaccines they need.

It is essential for services to have robust data reporting systems with the use of standard codes so data can be fed into local and national recording systems.

Record keeping is an essential part of clinical practice and it is a professional responsibility to make sure information on patient care and treatment is recorded as soon as possible and that it is clear and accurate, see NMC Code.

Ensure all data is recorded on the patient’s clinical record and personal held record where appropriate, i.e. the red book for children.

There may be times when vaccines are given and there is no immediate access to the patient’s clinical records. Where this happens, there should be a thorough risk assessment carried out. It is recommended that the details are recorded on a paper form or template at the time. This should include:

• patient details; name, DOB and or NHS number address and ethnicity
• the vaccine details; name and batch number
• date and the venue where the vaccine is given
• the injection site where the vaccine is given and the route of administration
• vaccine administered by; include name, signature and designation.

Where electronic data is entered into the patient’s clinical record post clinic, the data inputting process can be undertaken by administrator support. This record should include the date the data entry was made, and the administrator named, to enable audit and any look-back.

Where a patient decides not to have all their vaccinations, ensure this is recorded and that the patient has received all the information including the continued risk of disease but ensure they know they can come back at any time to discuss further.

Governance process requires a scanned copy of the paper form is saved on to the patients general practice system in case of need to cross check or retrospectively access.

Consider conducting regular audit of records to be assured data is inputted correctly and that all reasonable steps have been taken to ensure all eligible people are vaccinated.

National vaccine data and coverage statistics are available:

England: Vaccine uptake guidance and the latest coverage data
Northern Ireland: Vaccination coverage | HSC Public Health Agency
Scotland: PHS overview of immunisations
Wales: National immunisation uptake data

All staff involved in administering vaccines should be suitably trained and competent to fulfil their role and be able to answer questions with accuracy and confidence, in line with nationally agreed standards.

New immunisers should also have a period of supervised practice and support with a registered healthcare practitioner who is experienced, up to date and competent in immunisation.

The National Minimum Standards (NMS) for immunisation training are applicable for any healthcare practitioner involved in delivering vaccines and they set out the education and competency requirements for all vaccinators:

• UKHSA (formally PHE). National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners
• UKHSA (formally PHE). National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers.

Further resources to support education and learning for vaccinators:

• UKHSA animation how the immune system works for immunisers
• RCN: competence assessment framework, Immunisation knowledge and skills competence assessment tool
• Resuscitation Council UK. Emergency treatment of anaphylactic reactions: Guidelines for health care providers
• RCGP eLearning. Community CPR in the COVID-19 world
• Interactive e-learning programme to support the training of healthcare practitioners involved in advising on and/or delivering immunisation across the life course. Available from Health Education England (HEE) e-lfh portal:
  Immunisation e-learning programme for the routine programme and specific e-learning resources for influenza and COVID-19 vaccines
• Oxford Vaccine Group (OVG): Vaccine Knowledge Project - this site is aimed at informing parents about vaccine preventable diseases and has useful films on decision making.

The UKHSA immunisation collection includes further information and links to education and training resources UKHSA training.

The general principals and resources from the UKHSA and RCN for immunisation are supported across the UK. For country specific education information see:

Northern Ireland. Public Health Agency. Health professional resources
Scotland. e-learning resources NHS Education for Scotland TURAS
Wales. Public Health Wales e-learning

All registered health care staff must also adhere to their regulator Code for example the NMC Code.

For some vaccination services, unregistered staff can be involved. The RCN have developed guidance on vaccination provision by health care support staff, e.g. nursing support workers (Healthcare Support Workers HCSW), working under the delegation of a registered health care professionals. This provides advice on the legal medicines management requirements and need for professional and personal accountability and delegation in the processes, see NMC Accountability - The Nursing and Midwifery Council and Delegation - The Nursing and Midwifery Council and also RCN resources on accountability and delegation.

This guidance applies in England and Wales: Health Care Support Workers Administering Inactivated Influenza, Shingles and Pneumococcal Vaccines for Adults and Live Attenuated Influenza Vaccine (LAIV) for Children.

For Scotland, see the Scotland National Framework for Vaccine Administration by Healthcare Support Workers in Scotland.

Unregistered staff do not ordinarily give vaccines in Northern Ireland. For the COVID-19 vaccine and influenza vaccine campaigns, administration under the National Protocol (see section on medicines management) has allowed nursing/medical/allied health professional (AHP) students to vaccinate under supervision.

There is separate RCN guidance on the role for nursing associates in England: The Role of Nursing Associates in Vaccination and Immunisation. Position statement.

The immunisation programme in the UK is constantly evolving to best protect the public by controlling vaccine preventable diseases. Health professionals must keep up to date with these changes.

The ‘Vaccine Update’ newsletter comes out approximately every four to six weeks and can be emailed directly to individuals across the UK upon request. Email: Vaccine.Supply@dh.gsi.gov.uk to be added to the mailing list. This newsletter gives advice on current vaccine availability, any changes to the schedule and updates to the Green Book.

‘Vaccine Update’ is available to health care professionals across the UK. However, for country specific information, see:

England: UKHSA Vaccine Update
Northern Ireland: Public Health Agency: Immunisation / vaccine preventable diseases
Scotland: NHS Inform Immunisation in Scotland and e-learning resources NHS Education for Scotland TURAS
Wales: Public Health Wales - immunisation and vaccines

See the RCN indemnity pages.

The Clinical Negligence Scheme for General Practice (CNSGP) in England, the General Medical Practice Indemnity (GMPI) in Wales and local arrangements in Northern Ireland and Scotland, provide clinical negligence indemnity cover for all general practice staff, including General Practice Nurses (GPNs), undertaking NHS primary medical services functions under a contract.

The indemnity cover extends to the provision of such primary medical services functions, regardless of the location from where a service / function might be provided or administered to a patient.

This could include the provision of a flu vaccination ‘clinic’ for its registered patients at a neutral location off site from the GP practice, for example in a church or school hall.

The regulation of medicines is defined under the Human Medicines Regulations HMR 2012. Vaccines are classified as Prescription Only Medicines (POM) which means they need to have the appropriate authorisation from a prescriber in order to be supplied and or administered to a patient.

Prescription only medicines (POM) are medicines which cannot usually be supplied and/or administered unless there is a valid prescription or a patient specific direction (PSD). This includes all vaccines.

The prescription or Patient Specific Direction (PSD) needs to be from an appropriate practitioner; a registered medical practitioner, dentist or an independent non-medical prescriber, referred to as the ‘prescriber’.

The prescriber is responsible for the clinical assessment for suitability of the patient to receive the vaccine.

There are various exemptions under the regulations for authorisation of medicines applicable to vaccination: patient group directions, written instructions, national protocols and specific exceptions for medicines used in an emergency, these are described in detail in alternative authorisation.

The RCN medicines management provide additional resources and information on the legal authorisation processes needed for safe medicines administration.

There are some specific exemptions within the legislation which are relevant to providing vaccines and allow for alternative authorisation processes for the supply and or administration of a POM in certain situations or circumstances. These include:

Patient Group Direction (PGD):

• Allow for the supply and/or administration of a POM by some registered health care professionals, as defined under schedule 16 of HMR 2012 legislation
• Registered nursing associates (NA) in England and other nursing support workers are not listed in the legislation and cannot supply and/or administer medicines under a PGD
• PGDs need to describe the exact group of people for whom vaccination is appropriate and list the exceptions. For immunisation there are nationally agreed templates for PGDs which need to be adopted and signed-off for use by local or regional organisations and health boards. The UKHSA have Immunisation patient group direction (PGD) templates. In Scotland, PHS template PGDs are available for adoption by Health Boards
• A PGD describes the complete process and practitioners cannot delegate aspects of the care under a PGD, or deviate from the specified requirements
• PGDS can be developed for use across multiple organisations Patient Group Direction (PGD) use in a service provided by multiple organisations.

Written instruction:

• Allows for POMs to be supplied and/or administered by a registered nurse in the course of an occupational health scheme (OHS). The written instruction is developed and signed by a doctor. The details are explicit under schedule 17 of HMR 2012 legislation
• The HMR amendments allow for other registered professionals to use written instructions within NHS or local authority provided OHS. (This includes registered nursing associates in England)
• The Specialist Pharmacy Service (SPS) have a standard template for Written Instruction for the administration of seasonal ‘flu vaccination and advice for PGDs and Occupational Health Services.

National protocol:

• Emergency legislative changes to the Human Medicines Regulations (HMR) allow for COVID-19 and influenza vaccine delivery under a protocol
• The aim of the protocol is for the safe administration of a vaccine to those eligible in the population
• It allows for delegation and administration of COVID-19 and influenza vaccines under a different mechanism to those in a PSD or PGD
• The protocol is overseen by a clinical supervisor who is responsible the overall delivery of the service and making sure all staff are appropriately trained and have supervision
• It allows for different, appropriately trained people to carry out different functions of the process such as: clinical assessment and gaining patient consent, both of which must be done by a registered health care professional and vaccine preparation, vaccine administration and administrative support, which can be undertaken by other staff providing they are supervised and have the necessary skills and competence
• The national protocols need to be approved by the Secretary of State, the Scottish Ministers, the Welsh Ministers or the Minister of Health in Northern Ireland, as appropriate.

Emergency medicines:

• Certain medicines can be administered in an emergency without the directions of a prescriber. This includes adrenaline 1 in 1000 which can be administered in an emergency for the purpose of saving life and this is defined under schedule 19 of HMR 2012 legislation.

These have been adapted from Bedford H and Elliman D (2019) Fifteen-minute consultation: Vaccine-hesitant parents Arch Dis Child Educ Pract Ed:BMJ.

It is important that nurses and nursing staff are well informed in order to respond to and provide information for people’s questions. It is however, the approach you take during the conversation which is key:

• the aim of the conversation is to gain trust and support people to hopefully accept vaccination
• where it is identified that vaccines are due or missing, ask for permission to discuss this. Raising the subject gives the message that this is important and also gives people permission to ask questions
• ask questions to gain greater insight into the individual’s main concerns and listen to them
• be empathic, using phrases such as ‘I understand why you might be concerned’ it really is not surprising that parents and the wider public have questions and concerns
• avoid giving a fact-filled lecture. Simply giving more and more information is not the solution and can be counterproductive
• stick to the concerns raised and provide a limited number of main points in response, expressed simply
• focus on the risk of the diseases—the public, and some professionals, have little experience of the diseases we vaccinate against because of the success of the vaccination programme
• there is evidence that restating a myth serves to reinforce it— instead identify a myth as being false and focus on the facts: the benefits of vaccination while acknowledging the side effects of vaccines
• highlight the consensus among scientists/health professionals about the evidence in support of vaccination
• acknowledge that we all want the best for ourselves and our children
• do not belittle individuals' concerns
• if people decide not to vaccinate, be clear about the continued risk of a vaccine preventable disease and ask them to choose which vaccine not to give. Emphasise that they can change their mind at any stage and leave the door open for further discussion
• if asked whether you have been vaccinated or your own children have, confirming that you have is an important exemplar.

It is good practice to support any advice you give with written information. Check that the information printed from websites is relevant, up to date, evidence based and from a credible source.

As a general guide when searching the web for information, ask yourself and encourage patients, parents and carers to ask the following questions:

• who or what is behind the information?
• is the information biased, or possibly selected to present one view point?
• does the author have a vested interest in the information they are presenting?
• is it dated? There may be more current advice available
• is it referenced and are uncertainties acknowledged?.

The RCN immunisation page includes a number of useful web sites.

Also see:

Oxford Vaccine Group (OVG): Vaccine Knowledge Project - this site is aimed at informing parents about VPDs and has useful films on decision making
The COVID-19 Vaccine Communication Handbook: A practical guide for improving vaccine communication and fighting misinformation

Contact the individuals due for the vaccination by text, letter or phone call. Have information in different languages and use translation services If necessary.

Arrange a call to explain the process and consider in advance any reasonable adjustments that may need to be made. Where appropriate, ensure the vaccination details and appointment is shared with the person’s representative and / or powers of attorney / carers, or in the patient passport, for example for people with learning disability or those with a long term condition.

Reassure individuals all reasonable steps will be in place to reduce the risk of exposure to infection while attending a clinic for vaccination. Health care staff will take necessary precautions including; hand washing, environmental cleanliness and use of PPE when and if necessary.

It is easy to forget and lose initial reminder letters. Recall individuals who do not respond and make sure they are given opportunities to have alternative appointments and opportunities to discuss any issues or concerns.

Sending out information in advance and electronically may be an option. For example in school based services, parents can be sent information and request for consent via email or text.

Make sure records of contact details are up to date for example mobile phone records to send timely reminders by text.

Use data audits to recall those who have missed appointments and no record of vaccination or refusal.

Recognise that people may have some anxiety when attending clinics and clinics and health centres.

Have clear relevant and appropriate signage in the clinic or venue to support people.

People may have questions about vaccines in general and feel unsure how best to address these so allow time in appointments for discussion so that they feel that they can have their questions and concerns addressed.

Make sure the environment is welcoming and for children’s vaccines child friendly, so that individuals will want to attend.

It is important to reiterate the importance of vaccination. Having a call and contact will help as a reminder for the vaccination appointment.

Reinforce the message that if they decide to not have some or all of the vaccines offered, it is ultimately their decision. It is important that they understand the risks and that the individual will remain vulnerable to those vaccine preventable diseases.

Ensure open access by making sure that they know they can contact you at any time to discuss vaccination or arrange further appointments.

Consider the potential for domiciliary vaccination for patients with particular care needs or for example in residential care or nursing home settings.

Ensure all members of the team are aware of the importance of vaccination so that when people ask, they are directed to the correct information and/or to other appropriate support.

Provide reception staff and other members of the team with relevant and appropriate leaflets and reputable web sites they can direct people to including easy read and information in other languages. Awareness training for reception and other support staff is useful so they can appropriately signpost people to good and reliable information.

Encourage a positive and welcoming attitude to vaccination in all the staff people will encounter during the vaccination process.

The UK public health agencies provide leaflets and resources:

England: UKHSA immunisation collection
Northern Ireland: HSC PHA Immunisation/vaccine preventable diseases
Scotland: Public Health Scotland Immunisation
Wales: Public Health Wales Immunisation and Vaccines

The RCN Immunisation clinical page also includes a list of useful and reputable web sites.

The length of time required for vaccination appointments will vary considerably depending on the type and number of vaccines being offered.

Children and those with complex care needs and / or cognitive impairment will generally need more time allocated.

It is important to ensure that individuals, parents and carers have time for questions. See The RCN's Managing Childhood Immunisation Clinics - best practice guidelines (2021).

Consider telephone consultation for pre-vaccination discussion if this is needed and have post-immunisation advice available on web sites and in leaflets. Ensure any reasonable adjustments are planned in advance as relevant (e.g.- Interpreters/language line).

Consider sending out relevant information by text or email or direct individuals to your web site.

Consider how to manage time most effectively, for example:

• reception administration staff able to welcome people
• manage flow of patients and waiting room space so that people may potentially be able to read though information and start potentially for completing pre-vaccination checks
• set out the clinical area for the vaccination procedure in an effective and logical way. Ensure the area is safe so people can move freely and keep sharps bins out of reach
• provide written post vaccination and any follow up advice.

Managing infection and prevention control requirements and ensuring that patients, as well as the staff, are safe.

Remind patients and carers not to attend if they, or the vaccine recipient, is unwell.

Minimise risk of infection transmission, see the RCN resources on infection prevention and control.

Use appropriate and proportionate PPE following the relevant guidance.

Effective hand hygiene between each person vaccinated is paramount See: RCN poster. Gloves and aprons are not necessary unless there is a risk to the healthcare worker, for example, when there is (anticipated) exposure to blood/body fluids or non-intact skin. See: RCN's Tools of the trade and RCN Why you don’t always need gloves when giving vaccines.

The WHO guidance advises that gloves should not be worn for routine intradermal, subcutaneous or intramuscular injections providing the health worker’s skin is intact as gloves do not provide protection against needle stick injury. See: WHO best practices for injections and related procedures toolkit.

Further advice on glove use and dermatitis is provided in the publication Tools of the Trade. Guidance for health care staff on glove use and the prevention of work-related dermatitis. It is essential that staff look after their hands. The RCN resources on skin health provide information to help care for skin and on the use of regular hand cream along side hand hygiene.

Following storage recommendations for vaccines is essential to maintain their potency and effectiveness. These are detailed in the individual vaccine summary of product characteristics (SmPC) and generally in Chapter 3 of the Green Book.

The Summary of Product Characteristics (SmPC) for each vaccine, which can be found on the electronic medicines compendium website, includes information about the storage and preparation requirements for that vaccine prior to administration.

Most vaccines used in the UK are recommended to be stored within the range of +2°C to +8°C - this is referred to as the ‘Cold Chain’. There are some very specific storage requirements for some COVID-19 vaccines which may differ from this. These are detailed in the specific product information or Summary of Product Characteristics (SmPC).

Vaccine services need to have validated vaccine refrigerators. When vaccines are taken off site validated cool boxes must be available for use, to ensure vaccines are kept within the cold chain during transportation and at the destination.

Staff should record and then reset the vaccine fridge temperature at least daily. If vaccines are taken out of the fridge for community sessions, the temperature inside the cool box should be monitored during the session. Having a functioning data logger to record ongoing fridge temperature, independent of the general mains electricity supply can also be useful, see: Chapter 3 of the Green Book.

Where vaccines are taken off site for domiciliary or off site vaccine clinics there need to be policies in place for transport of vaccines.

Ensure there are processes in place to monitor the cold chain process and report any vaccine storage errors. See Chapter 3 of the Green Book and the PHE vaccine incident guidance and responding to vaccine errors.

This is covered in detail in the Green Book Chapter 4 – Immunisation procedures and Chapter 8 – Vaccine safety and adverse events following immunisation.

All immunisers must be familiar with the route of vaccine administration for each vaccine they are administering. The details the specifics for each vaccine as advised by the individual vaccine Summary of Product Characteristics (SmPC).

Where there are differences between the manufacturer guidance and UK policy, the Green Book guidance takes precedence and should be followed. See: Immunisation procedures: the Green Book, Chapter 4.

While there is other guidance which detail injection technique and procedures for other medicines and treatments, it is the Green Book, Immunisation procedures: the Green Book, Chapter 4 which should be followed for injection technique for vaccine administration.

The Green Book provides detail of the procedure but in principle, for giving vaccines, the injection, whether Intramuscular (IM) or subcutaneous (SC), should be completed as quickly as possible to minimise pain and discomfort.

It is not necessary to aspirate the syringe after the needle is introduced into the muscle.

There is no requirement to hold the needle in place after giving the vaccine or to rub the area post vaccination. “Z tracking” is not recommended when injecting vaccines.

See also: WHO. Recommendations on reducing pain at the time of vaccination.

Consider the environment particularly for those who are anxious about the process or having an injection e-lfh have some useful resources for supporting people who are needle phobic or anxious. Also see from School And Public Health Nurses Association SAPHNA Guidance: children, young people and needle phobia and guidance from the British Psychological Society on supporting children and young people with anxiety about needles.

See: Green Book, Chapter 8.

The Resuscitation Council UK (RCUK) have ‘guidance on managing anaphylaxis’. This includes Emergency treatment of anaphylactic reactions, guidelines for healthcare providers and guidance specifically to support managing anaphylaxis in vaccination setting. The RCUK also have the quality standards for primary care on resuscitation and basic life support. See also the updated position statement: RCUK statement on COVID-19 Guidance August 2021.

All staff in primary care organisations, including non-clinical staff, should undergo regular training in resuscitation of both adults and children to the level appropriate to their role. Staff should undergo such training at induction and at appropriately regular intervals thereafter to maintain knowledge and skills. Clinical staff should have annual updates.

There is no definitive requirement on the frequency of updates for anaphylaxis training, it would generally be determined by the employer depending on the role of the practitioner. Best practice for staff administering vaccines, or any medications, would generally require annual updates on the management of anaphylaxis. If management of anaphylaxis is identified in your role, there should be update training at the local level and this could form part of annual resuscitation training.

E-lfh have an online anaphylaxis training programme.

There must be easy access to emergency drugs and equipment easily accessible to all vaccinators; NB Adrenaline is listed as an exemptions under the Human Medicines Regulations 2012 and can be administered by anyone in an emergency for the purpose of saving life. This means there is no requirement for a prescription or PGD in order to administer them. Link to the medicines management.

Emergency drugs must be checked regularly to ensure they remain in date and are replaced before expiry.

Details of the Yellow Card system for reporting adverse events following vaccine administration are available on the Medicines and Healthcare products Regulatory Agency (MHRA) section of the gov.uk website. The yellow card scheme is the key source of data for real-time safety surveillance. Vaccinators have a responsibility to make sure that any adverse events are reported through this process. This is important to strengthen vaccine safety through effective pharmacovigilance.

See: Green Book, Chapters 3 and 4.

A sharps risk assessment should be carried out to safely manage the risks from sharps injuries, including the provision of safer sharps.

Ensure sharps boxes are provided close to where medical sharps are being used accessible but kept safely out of reach of children, don’t store boxes on the floor.

For advice on the prevention and management of sharps injuries, members should refer to their local policies. Injuries from a source patient known to have a blood borne virus or those which result in a blood borne infection must be reported at the earliest opportunity to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

The Health and Safety Executive (HSE) has information on the prevention of sharps injuries, including risk assessment, safe disposal and compliance with the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 and on RIDDOR in health and social care.

The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance: Criterion Ten, is available on the Department of Health website.

There is generally no evidence to support the practice of keeping patients under observation after having a vaccine. See: Green Book Chapter 4.

Recipients of any vaccine should be observed for immediate Adverse Drug Reactions.

The majority of anaphylactic reactions will occur within a few minutes of vaccination although can occur hours later. In general. there is no need to keep patients under specific observation following vaccination unless this is specifically indicated in the Green Book or the MHRA for a particular vaccine.

For the COVID-19 vaccines; there may be a requirement in some situations to keep patients under observation for 15-30 minutes post vaccination (for example, those who have had a previous allergic or anaphylactic reaction). This is described in the Green Book COVID-19 Chapter.

Where people are driving immediately, advise people not to drive for 15 mins post vaccination.

Patients should be given verbal and written advice on adverse reactions and possible sides effects and what to do if they occur. They should be provided with the patient information leaflet included with the vaccine and could also be given one of the UKHSA “What to expect after vaccination” leaflets (see UKHSA resources).

Links to post vaccination care information could also be sent via email or text links.

Advise that a raise in temperature is a normal reaction after vaccination and provide information as to how to manage this. See what to expect after vaccination. Inform the patient/parent/carer that if fever is still present 48 hours after vaccines or if they are concerned, they should seek advice from their GP or NHS 111.

The Office for National Statistics report increasing overseas travel. Travel health medicine is a fast growing specialist area of practice.

See the RCN Travel Health guidance for more information.

RCN 'Competencies: travel health nursing: career and competence development' (RCN, 2018) provide further information on current guidelines and standards and defines the standards of care expected for a competent registered nurse, experienced/proficient nurse and a senior practitioner/expert nurse working in travel health nursing.

The National Travel Health Network and Centre (NaTHNaC) provides advice on travel health, including travel vaccination.

TRAVAX (login required) and fitfortravel from Health Protection Scotland (HPS) provides similar information to NaTHNaC.

NHS Wales has an organisational subscription to TRAVAX which is therefore freely available to NHS Wales users (via Health of Wales Information Service HOWIS).

Travel health consultations often provide a good opportunity to bring people up to date with the routine vaccines recommended in the UK.

There are some vaccines which are not available free of charge.

Travel health is part of the GP contract and the essential services general practice deliver.

There are a number of vaccines which people should be able to get via the NHS as part of the routine schedule and it’s often a good opportunity to catch people up where they have missed doses of vaccines also required for travel such as the dT/IPV-containing vaccines. There are some vaccines which may not be available through the NHS- see the advice from the British Medical Association BMA travel vaccination advice.

It is important to remember travel health involves more than vaccination and travellers should be given information about other travel health risks.

Migrants and asylum seekers in the UK will also need specific advice regarding vaccines.

The Office for Health improvement and Disparities OHID Migrant Health Guide, provides an online resource for healthcare professionals to help them support their migrant patients. The guide includes guidance on health topics, entitlements to an interpreter, information on data sharing and clarifies migrants’ entitlements to NHS services, among other resources. There is a section specifically on immunisation.

The UKHSA Vaccination of individuals with uncertain or incomplete immunisation status is a useful tool to support bringing people up to date with the UK schedule.

NHS England and improvement resources on reducing health inequalities in vaccine uptake.

See also: RCN Migrant Health resources.

The RCN maintains that any organisation which provides health care is responsible for ensuring that their staff and patients are safe.

Appropriate vaccination is in the interest of staff, employers and patients/clients. This is underpinned by extensive legislation:

• Health and Safety at Work Act (1974)
• Control of Substances Hazardous to Health Regulations (COSHH) (2002)
• Management of Health, Safety and Welfare Regulations (1999).

The Green Book Chapter 12 provides details of the vaccinations recommended.

Unless the vaccines are recommended as part of the UK national schedule, occupational health vaccines are not generally provided in primary care, see the British Medical Association (BMA) Hepatitis B immunisations – Guidance for GPs.

See also: RCN Occupational Health resources.

It is sometimes appropriate for nurses to administer vaccines in a patient's home where it complies with their workload demands, workload priorities and when it is in the patient’s interests.

It is not necessary for registered health care professionals to have another person with them when vaccinating. Unregistered staff however, should not vaccinate alone and would need to have a registered health care professional with them.

Good record keeping is important for domiciliary vaccination to ensure the vaccines given are recorded in the patients record.

There is no reason for a medical practitioner to be on site when vaccines are being administered. Nurses should only administer vaccines if they are trained and competent and this includes being up to date with anaphylaxis management.

In all cases of anaphylaxis, an ambulance should be called. It is good practice to have another person available who can assist in an emergency situation.

It is not necessary to defer routine childhood immunisations in babies who have not yet had their 6 to 8 week checks.

The 6 to 8 week check forms part of the newborn and infant physical examination screening programme (NIPE). The newborn element aims to identify and refer all children born with congenital abnormalities of the eyes, heart, hips, and testes, within 72 hours of birth. The second examination is designed to identify abnormalities that may become detectable in older infants –i.e at 6-8 weeks of age.

As none of the conditions screened for would constitute a contra-indication to immunisation, there is no requirement for the examination to be undertaken before the first set of primary vaccines are given. Babies will need the normal assessment of suitability for vaccines as outlined in the relevant documents e.g. vaccine PGDs.

It is often helpful for parents to time the 6-8 week check alongside the first vaccinations but is not a requirement for vaccination.

If a baby presents for vaccination at eight weeks having not had the 6 to 8 week check, it is an opportunity to do the check at the same visit.

See: Newborn and infant physical examination: programme handbook.