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November 08, 2014

Shoulder injury from Flu shots and other vaccinations

Recently a member of our blog crew received a flu shot and subsequently experienced symptoms very similar to the ones described in the article below.  It is based on the work done by Cheryl Simmons, a registered nurse from Wilmington, Del. We also used other sources to compile this posting.
The main idea was to go for any vaccine shot prepared not to scare or stop our readers of receiving flu or other shots.If you are looking for pros and cons of the flue shots check following posting out:
Flu shot may be good for  your heart or Is it the flu or norovirus? How to tell the difference
We want you to go prepared for the shot administered in your arm to avoid rare but some time long term complications from something considered to be a routine injection. 
Influenza vaccination administration is performed millions of times each year by nurses, an unintended consequence can occur, namely shoulder injury related to vaccination administration, or SIRVA.
Recipients of the influenza vaccination should be informed about the possibility of this injury.
Nurse education regarding SIRVA centers on teaching the proper technique required to prevent improper penetration to the bursa when performing an injection to the mid-deltoid region.

Vaccination Technique
Vaccination TechniqueCurrent administration suggestions include that both the person who administers the vaccine and the recipient be seated.2 Varying methods to denote the specific proper injection site have been researched. Palpating the acromion process then placing the needle three to four fingers below helps ensure the injection is administered into the thickest and most central region of the muscle.3
Cook (2011) recommends abduction of the arm to 60% with the recipient's hand on their hip to allow for proper landmark site selection midway between the acromion and deltoid tuberosity4 Knowledge about anatomy is imperative to prevent injecting too high, thus predisposing to SIRVA.4 Appropriate needle size is also a consideration, according to the CDC.5
Cases of SIRVA could be prevented, however, by updating CDC injection guidelines, including a recommendation for seated positioning.6,7

Data Analysis
Attention to shoulder injury from vaccination was reported by Bodor and Montalvo (2007). They noted an inflammatory immune response in patients reporting injection location in a high area of the deltoid muscle with results including subacromial bursitis.8

Physicians reviewing the database of claims submitted to the Vaccine Injury Compensation Program (VICP) identified and researched reports of shoulder injury.9 Included in the research are reports that the "vaccine hit something hard".7 They termed this phenomenon SIRVA and reiterated the need for appropriate injection technique.
Injury symptoms include pain beginning at the time of injection (or within 24 hours) and impairment of range of motion.9 MRI results included collection of fluid, bursitis, tendonitis, and rotator cuff tears.9 Treatment includes steroid injection and possible [arthroscopic shoulder] surgery.9
The landmark investigation by Atanasoff, et. al. created legitimacy of the SIRVA diagnosis. It is now is a compensable injury from the National Vaccine Injury Compensation Program administered by the Health Resources and Services Administration, Healthcare Systems Bureau, of the U.S. Department of Health and Human Services, when proof can be made that the condition was caused by the vaccine; such as by medical records or testimony based on expert opinion.10

Currently, SIRVA is not listed on the Vaccine Injury Table despite a 2011 proposal by Ryan (2011), a co-researcher with Atanosoff. Ryan's Report Generated Proposals for Updates to the Vaccine Injury Table (VIT) included the information that "the IOM reviewed the scientific and medical literature finding that the evidence convincingly supported a causal relationship between vaccine administration and deltoid bursitis" and that "Atanasoff et al. published a [sic] case series reporting the experience of the National Vaccine Injury Compensation Program with regard to shoulder injuries following vaccination. The IOM reviewed this article and commented that the cases were consistent with deltoid bursitis."11

Research by Barnes, et. al. (2012) revealed that between 2010 and 2012 there were 167 reports of shoulder injury from influenza vaccination, predominantly occurring in women, to the Vaccine Adverse Event Reporting System (VAERS).6 This reporting system is different from the vaccine compensation program and is sponsored by both the CDC and FDA.12 Reporting events is not mandatory, however, therefore there is no way to establish the number of events that are not reported.6
Meanwhile, in addition to administering the flu vaccine, many nurses will be the recipient of vaccination, including some who might decline it if the could. New York has mandated vaccination for healthcare providers in the state since 2009.13 And while mandating vaccination remains controversial, a goal of Healthy People 2020 is a 90% rate of healthcare worker coverage.14 The American Academy of Pediatrics has advocated for mandatory vaccination of healthcare workers since 2009.15

Until an updated standard of technique to prevent SIRVA becomes available from the CDC, institutions should develop their own guidelines. Policy development should include training to those who will be administrating vaccinations each year.
The volume of vaccinations given each year in a short time frame warrants the emphasis that this is not a benign process. Recipients should be informed that complications can occur from poor technique and therefore be able to use this knowledge to aid in prevention of injury.
Remember, it is the ethical duty of nurses to support optimal health and safety, according to ANA, and without the knowledge to prevent SIRVA on part of those performing vaccinations, this cannot be done.16

References for this article can be accessed here.
The original article by Cheryl Simmons may be found by clicking the link below.

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