Reducing Pain at the Time of Vaccination: WHO Position Paper

"Not addressing pain at the time of vaccination may be one of many factors which have a negative impact on health attitudes and behaviours and may lead to delay or avoidance of future vaccinations. Hesitancy towards vaccination can result in lower vaccination coverage rates, putting the individual and the public at risk of vaccine-preventable disease."

Recognising that studies have shown that pain at the time of vaccination is a primary source of anxiety for caregivers of children, the World Health Organization (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 review of the evidence and issuance of recommendations, WHO published this position paper, which is the first policy paper in a series that integrates information pertaining to the reduction of pain, distress, and fear. A systematic review which examined 55 interventions (including for injections unrelated to vaccination) applicable to infants, children, adolescents, and adults was used as the basis of the review by SAGE. Interventions were selected for potential global implementation, taking into consideration the following criteria: benefits and harms; patients' values and preferences; resource utilisation; cost of interventions; impact on equity; acceptability; and feasibility from a global perspective. Assessment of the global feasibility of interventions requires consideration of their relevance and cultural acceptability within different geographic regions and cultural settings - in particular, in low- and middle-income countries. Recommendations on reducing pain and anxiety at the time of vaccination were discussed by SAGE in April 2015; evidence presented at the meeting can be accessed here.

The report recommends that national immunisation programmes in all countries consider the importance of communication across all age groups, such as that health-care personnel carrying out vaccinations should be calm, collaborative, and well informed - using neutral words when administering the vaccine such as "here I go" instead of "here comes the sting". For infants and young children, additional measures are recommended - e.g., caregivers should be present throughout and after the vaccination procedure, and distractions such as toys, videos, and music might be helpful for children under 6 years of age.

It is also suggested that education of health-care workers on pain mitigation strategies be implemented such as through inclusion of this topic in training curricula. "Additionally, it should be ensured that caregivers and, if appropriate, vaccine recipients, are educated on vaccination pain mitigation strategies. Information could be provided during prenatal visits, breastfeeding education, or at time of vaccination. Context-specific educational methods to be utilized should include teaching of individuals or groups, or provision of written information." Other specific tips are provided; for example: "When rotavirus vaccination is part of the schedule, the vaccine may be given first as the formulation of the currently licensed liquid rotavirus vaccine has shown to have a pain mitigating effect through its sucrose content, followed by oral polio vaccine. Injectable vaccines should be administered after oral vaccination. In the absence of specified grading of painfulness, health-care professionals are encouraged to use their practical experience on the painfulness of specific vaccines to determine accordingly the best sequencing of the injections".