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Ask the Experts: Proper anatomical location for administering herpes zoster vaccine

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In what region of the arm should this subcutaneous injection be administered?

Question. What is the proper anatomical location to administer the herpes zoster vaccine?

Answer. The Zostavax (Merck & Co., Inc.) prescribing information states that this vaccine is to be administered “as a single 0.65-mL dose subcutaneously in the deltoid region of the upper arm.“1 Several pharmacists have contacted Merck and were told that in the Shingles Prevention Study, the vaccine was administered in the deltoid region of the upper arm. Merck Vaccines recommends that if a patient is unable to receive the vaccine in the deltoid region, then subcutaneous administration of Zostavax in another region of the body will probably not affect the response to the vaccine (D. Gallagher, personal communication, March 2012). Merck is required to recommend administering the vaccine in the deltoid region because FDA approved it for that location.

Most other vaccines suggest administering in the outer aspect of the upper arm in adolescents or adults or in the “deltoid area” (e.g., MMR [measles–mumps–rubella], varicella, MMRV [measles–mumps–rubella, varicella], MPSV4 [quadrivalent meningococcal polysaccharide vaccine]) or do not provide a suggested administration location.2–5 Other vaccines that can be administered intramuscularly or subcutaneously include PPSV (pneumococcal polysaccharide vaccine) and IPV (inactivated polio vaccine).

This is consistent with the Advisory Committee on Immunization Practices (ACIP) General Recommendations,6 in which the following appears:

  • “Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants aged <12 months and in the upper-outer triceps area of persons aged ≥12 months. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. A 5/8-inch, 23- to 25-gauge needle should be inserted into the subcutaneous tissue.”

APhA teaches subcutaneous administration in the same location as ACIP. Because administration in the triceps area contains looser skin, it is less likely to be inadvertently administered intramuscularly. I recommend continued administration of the vaccine in the triceps area, as taught and practiced in the APhA Pharmacy-Based Immunization Delivery certificate training program. If contacting representatives at Merck Vaccines, you can expect them to say that the herpes zoster vaccine should be administered in the deltoid region because they are required to follow the FDA-approved package insert.

Stephan L. Foster, PharmD, FAPhA
Professor and Vice Chair
College of Pharmacy
University of Tennessee Health Sciences Center
Memphis
APhA Liaison Representative to the Advisory Committee on Immunization Practices (ACIP)
CAPT (Ret) U.S. Public Health Service

References

  1. Merck & Co., Inc. Zostavax prescribing information. Accessed at www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdf, March 16, 2012.
  2. Merck & Co., Inc. MMRII Prescribing information. Accessed at www.merck.com/product/usa/pi_circulars/m/mmr_ii/mmr_ii_pi.pdf, March 16, 2012.
  3. Merck & Co., Inc. Varivax prescribing information. Accessed at www.merck.com/product/usa/pi_circulars/v/varivax/varivax_pi.pdf, March 16, 2012.
  4. Sanofi-pasteur. Poliovirus vaccine inactivated (IPOL) prescribing information. Accessed at www.vaccineshoppe.com/image.cfm?doc_id=5984&image_type=product_pdf, March 16, 2012.
  5. Merck & Co., Inc. Pneumovax 23 prescribing information. Accessed at www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdf, March 16, 2012.
  6. National Center for Immunization and Respiratory Diseases. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1–64.

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