Vaccinations made friendly

October 2015

A child at a yellow fever vaccination campaign in Togo.
WHO/O. Asselin

Through tears, cries and with arms wrapped around their mothers or other caregivers, children brave routine life-saving vaccinations. While this is a common scene in health centres around the world, no caregiver or health professional wants to see children in pain. Instead, they want them to be as comfortable as possible.

“Studies are beginning to show that pain at the time of vaccination is a primary source of anxiety for caregivers of children,” says Dr Philippe Duclos, Senior Health Adviser for WHO’s Immunization, Vaccines and Biological Department. “Unaddressed, pain can potentially lead to caregivers delaying or avoiding future vaccinations.”

Combating vaccine hesitancy

For more than 30 years, Dr Noni MacDonald, a professor of paediatrics at Dalhousie University and IWK Health Centre in Nova Scotia, Canada, has seen the worry on mothers’ faces as their children are vaccinated.

“While mothers often do not tell you this in the exam room, studies show that almost half of them worry about pain at the time of immunization,” she says. “No mother wants to see her baby ‘hurt’.”

“It’s important to help countries find ways to close the immunization gap – and achieve the goals of the new Global Strategy to achieve the highest attainable standard of health for all women, children and adolescents,”

Dr Flavia Bustreo, WHO Assistant Director-General for Family, Women’s and Children’s Health

Fear of injection, due to pain, during the procedure is one of many factors leading people to delay or refuse vaccinations. Concerns over vaccine safety and mistrust in the health care system are also factors that may lead to vaccine hesitancy and lower vaccination rates.

Globally, 1 in 5 children still do not receive routine life-saving immunizations, and an estimated 1.5 million children still die each year of diseases that could be prevented by vaccines that already exist. Addressing vaccine hesitancy is essential to close the global immunization gap.

“Pain can cut across all of these reasons for resisting vaccinations,” says Dr MacDonald. “If families are already concerned about vaccine safety and have geographic barriers, pain will just be one more reason for them to forgo vaccines completely.”

“We need to do a better job of making vaccinations more comfortable for everyone,” she continues.

First WHO position paper

Recently, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) studied the feasibility of globally adapting Canada’s existing clinical practice guidelines for reducing pain and fear from vaccine injections. Based on SAGE’s thorough review of the evidence and issuance of recommendations, WHO published the first position paper, “Reducing pain at the time of vaccination,” which recommends the following measures be applied by national immunization programmes in all countries, across all age groups:

  • Health-care personnel carrying out vaccinations should be calm, collaborative and well informed and use neutral words when administering the vaccine such as “here I go” instead of “here comes the sting.”
  • Recipients of the vaccines should be positioned properly, according to age. Infants and young children should be held by their caregiver. Older populations should be sitting upright.
  • Aspiration or pulling back of the plunger of a syringe prior to intramuscular injections should not be performed as this may increase pain.
  • When multiple vaccines are scheduled to be injected in the same session, they should be given in order of painfulness – ending with the most painful.

For infants and young children, additional measures are recommended:

  • Caregivers should be present throughout and after the vaccination procedure.
  • Infants should be breastfed during or shortly before the vaccination session, if it is culturally acceptable.
  • Distractions such as toys, videos and music are recommended for children under 6 years of age.

The recommendations will be welcome news for caregivers, patients and health professionals, says Dr Duclos. “When caregivers are made aware of what they can do to comfort their child before and during vaccinations, hesitancy is reduced.”

Although topical anaesthetics can relieve pain during the time of vaccination, WHO does not recommend them due to the high cost, lack of availability in many countries and additional time required to apply them.

Good practice for global immunization programmes

While many immunization programmes have sustained high vaccine coverage levels without addressing pain during the procedure, reducing pain could be considered good practice for immunization programmes worldwide.

“It’s important to help countries find ways to close the immunization gap – and achieve the goals of the new Global Strategy to achieve the highest attainable standard of health for all women, children and adolescents,” said Dr Flavia Bustreo, WHO Assistant Director-General for Family, Women’s and Children’s Health. “Since pain is a factor contributing to vaccine hesitancy, implementing these measures will only help countries achieve and sustain high vaccine uptake rates, control diseases and improve child survival.”