16.1 Immunization Practice: NACI Recommendations, Administration, Cold Chain & Adverse Events
Key Takeaways
Live vaccines are contraindicated in pregnancy and significant immunosuppression, and two live parenteral vaccines are given the same day or at least 4 weeks apart.
NACI recommends one dose of Pneu-C-20 or Pneu-C-21 at 65 and older, two doses of recombinant zoster vaccine from 50, Tdap in every pregnancy (ideally 27 to 32 weeks), and RSV vaccine for all adults 75 and older.
Infants receive IM vaccines in the anterolateral thigh, and adults in the deltoid, usually with a 1 inch needle and without aspiration.
Vaccines are stored at +2 to +8°C in a purpose-built refrigerator with twice-daily temperature logs; excursions are quarantined until public health or the manufacturer advises.
Egg allergy is not a contraindication to influenza vaccine, patients are observed for 15 minutes, and anaphylaxis is treated with IM epinephrine 0.01 mg/kg (maximum 0.5 mg).
Immunization Practice: NACI Recommendations, Administration, Cold Chain & Adverse Events
Pharmacists in every province now give vaccines. Influenza and COVID-19 vaccines are the most common, but many pharmacists also give a growing list of routine adult, travel and catch-up vaccines. National advice comes from the National Advisory Committee on Immunization (NACI) and is compiled in the Canadian Immunization Guide (CIG). Each province decides which vaccines are publicly funded and which ones pharmacists may give.
1. Vaccine Types and Spacing
- Live attenuated vaccines: measles-mumps-rubella (MMR), varicella, rotavirus, yellow fever, oral typhoid, BCG, and live attenuated influenza where available.
- Contraindicated in pregnancy and in significant immunosuppression (high-dose corticosteroids, chemotherapy, biologics).
- Spacing: two live parenteral vaccines are given on the same day or at least 4 weeks apart.
- Inactivated, subunit, toxoid, conjugate and mRNA vaccines can be given at any interval from other vaccines, and are generally safe in pregnancy when indicated.
- Interrupted series: do not restart. Continue where the schedule left off.
2. Key Adult Recommendations (NACI)
| Vaccine | Who | Schedule |
|---|---|---|
| Influenza | Everyone 6 months and older without contraindications | Every fall |
| Td / Tdap | All adults: one Tdap dose in adulthood; every pregnancy | Td booster every 10 years; in pregnancy Tdap ideally at 27 to 32 weeks (may be given from 13 weeks up to delivery) |
| Pneumococcal conjugate (Pneu-C-20 or Pneu-C-21) | Adults 65 and older, and adults under 65 at increased risk of invasive pneumococcal disease | One dose, regardless of earlier Pneu-C-13, Pneu-C-15 or Pneu-P-23 (usually at least 1 year after the last pneumococcal dose) |
| Recombinant zoster vaccine (RZV, Shingrix) | Adults 50 and older; may also be offered to immunocompromised adults 18 and older | 2 doses, 2 to 6 months apart, even after previous shingles or the older live zoster vaccine |
| RSV (older adults) | NACI, April 2026: all adults 75 and older; adults 65 to 74 at increased risk; adults 18 and older in long-term care, on home oxygen, on dialysis, or after lung or stem-cell transplant | A single dose (protection lasts at least 3 seasons) |
| HPV | NACI's current schedule: 1 dose for ages 9 to 20, 2 doses for ages 21 to 26, and 3 doses for immunocompromised people or those living with HIV | Per age group |
| Hepatitis B, hepatitis A, MMR, varicella | Non-immune adults at risk, health care workers, travellers; MMR for adults born in 1970 or later without documented immunity | Per product |
3. Administration Technique
- Intramuscular (IM) sites and needle length:
- Infants under 12 months: the anterolateral thigh (vastus lateralis), usually a 5/8 to 1 inch needle.
- Toddlers: the thigh or deltoid, depending on muscle mass.
- Children over 3 years and adults: the deltoid, usually a 1 inch (25 mm) needle, longer for larger adults. The 5/8 inch needle is generally for subcutaneous injection or very small deltoids.
- Gauge: 22 to 25.
- Subcutaneous injections use a 5/8 inch, 25 gauge needle at 45° into the upper outer triceps or the thigh.
- No aspiration before IM vaccine injection. It adds pain without benefit.
- Several vaccines at one visit: separate sites, at least 2.5 cm apart, and record each site.
- Pain reduction: for children, use breastfeeding, sweet solutions or topical anesthetic, distraction, an upright position, and give the most painful vaccine last.
- Documentation: product, lot, dose, site, route, date and the immunizer. Update the provincial registry, and give the patient a record.
4. Storage and the Cold Chain
- Refrigerated vaccines are kept at +2 to +8°C in a purpose-built (pharmaceutical-grade) refrigerator, not in the door or a bar fridge. Use continuous digital min/max temperature monitoring, checked and logged at least twice daily.
- Never freeze vaccines that should be refrigerated. Frozen aluminum-adjuvanted vaccines lose potency.
- After a temperature excursion: label the vaccines "Do not use", keep them refrigerated, record the times and temperatures, and contact public health or the manufacturer before using or discarding them.
5. Contraindications, Precautions and Adverse Events
- True contraindication: anaphylaxis to a previous dose or to a vaccine component.
- Precautions: moderate or severe acute illness (defer), and Guillain-Barré syndrome within 6 weeks of a previous influenza vaccine.
- Not reasons to delay: mild illness or low-grade fever, antibiotic use, or a family history of reactions.
- Egg allergy is not a contraindication to influenza vaccine, even with a history of anaphylaxis to eggs. The vaccine can be given in any usual setting with standard observation.
- Observation: observe for 15 minutes after vaccination (30 minutes if there is a specific concern). Seat adolescents, who are prone to fainting.
- Anaphylaxis: give epinephrine 1 mg/mL IM, 0.01 mg/kg (maximum 0.5 mg) in the anterolateral thigh, call 911, and repeat every 5 to 15 minutes if needed (section 2.2).
- Report adverse events following immunization (AEFI) to the local public health unit. Provinces forward these reports to PHAC's national surveillance system.
6. Addressing Vaccine Hesitancy
- Use a presumptive approach: "You're due for your flu and shingles vaccines today."
- Listen and respond with motivational interviewing: acknowledge concerns, ask permission before sharing information, and focus on what matters to the patient.
- Correct misinformation without repeating myths at length, and share personal recommendations.
- Document refusals and offer the vaccine again at later visits.
A 66-year-old man had shingles 3 years ago and received the live zoster vaccine (Zostavax) at age 61. He asks whether he needs another shingles vaccine. What is the best advice?
He should repeat the live zoster vaccine every 5 years.
He should receive 2 doses of recombinant zoster vaccine (Shingrix), 2 to 6 months apart.
He needs no further vaccination because he has already had both shingles and a zoster vaccine.
He should receive one dose of recombinant zoster vaccine only.
A 34-year-old with a history of hives and lip swelling after eating eggs asks if she can receive the influenza vaccine at the pharmacy. What is the most appropriate response?
Vaccinate in the pharmacy with usual observation; egg allergy is not a contraindication.
She should receive half the dose now and the other half in 30 minutes.
She must be referred to an allergist for skin testing with the influenza vaccine before any dose is given.
She cannot receive any influenza vaccine because of her egg allergy.
A pregnant patient at 29 weeks' gestation received Tdap during her previous pregnancy 2 years ago. What does NACI recommend?
Tdap should be postponed until after delivery to avoid fetal risk.
No Tdap is needed, because she was vaccinated with Tdap within the past 10 years.
Give Tdap now: it is recommended in every pregnancy, ideally at 27 to 32 weeks.
She should receive Td instead of Tdap during pregnancy.
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