Shoulder injury related to vaccine administration (SIRVA).

Most vaccines are administered as intramuscular injections into the deltoid muscle. Shoulder injury related to vaccine administration (SIRVA) occurs when the vaccine is injected into the shoulder capsule, rather than into the deltoid muscle. This injury can lead to patients having restricted movement of their shoulder and long-term pain which affects their quality of life. Although, it is widely under reported, it is something vaccinators can prevent by correctly landmarking the deltoid.

The SIRVA is still rare in comparison to the number of vaccinations administered. It usually occurs within hours or days of being vaccinated. When a vaccine is administered into the shoulder joint rather than the deltoid, this causes inflammation and damage to the bursae, tendons, and ligaments of the shoulder. This will present in a patient as shoulder pain and limited movements. (1)

MHRA confirmed that there had been 56 reported cases of shoulder injury related to vaccine administration (SIRVA) up to and including 21^st May 2021. There were 7 reports from COVID-19 vaccine, Pfizer, 32 from AstraZeneca, 14 from Pneumococcal Polysaccharide, 2 from diphtheria, tetanus and poliomyelitis vaccine and 1 from the Shingles vaccine. (2)

Therefore, it is crucial that vaccinators are aware of how to landmark the deltoid and area for injection, safely and effectively to prevent cases of SIRVA.

To landmark the deltoid:

• Ensure you have good lighting and can visualise the patient from the top of the shoulder to the elbow
• You and the patient should be in a sitting position
• Identify the acromion process (dip along the shoulder) you can locate this by asking the patient to lift their arm out to the side and palpate along the shoulder.
• Once identified place you finger into the acromion process and ask the patient to lower their arm and relax.
• You can locate the deltoid by visualising 2.5cm below the acromion process (this will be the start of the deltoid)
• You will be able to feel the triangular shape of the deltoid of where you can feel the muscle (Practice this on family members).
• Ensure you inject into the deltoid just below where you have visualised 2.5 cm and that it is in the centre of the deltoid, not too far to the side or too far down as you may hit a nerve

Written by Lisa Humble, (Clinical Development Manager at ECG Training), Tuesday 31st August 2021.

References:

1. Bancsi, A, Houle,K,D, S and Grindrod, A, K. (2019) Canadian Family Physician journal Vol 65, Shoulder injury related to vaccine administration and other injection site events. Available at : Shoulder injury related to vaccine administration and other injection site events (cfp.ca) Accessed 31^st August 2021
2. Medicines and Healthcare products Regulatory Agency (MHRA) (28^th June 2021) Freedom of Information request on incidence rates of shoulder injury related to vaccine administration (FOI21/463) Available at : Freedom of Information request on incidence rates of shoulder injury related to vaccine administration (FOI 21/463) – GOV.UK (www.gov.uk) Accessed 21^st August 2021.