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The Position Statement on Injection Technique
  1. L Diggle1,
  2. J Deeks2
  1. 1Oxford Vaccine Group, Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
  2. 2Centre for Statistics in Medicine, Institute of Health Sciences, University of Oxford, Oxford OX3 7LF, UK
  1. Correspondence to:
    L Diggle;

Statistics from

The Position Statement on Injection Technique (March 2002, Royal College of Paediatrics and Child Health) discusses needle size and length for childhood immunisation. It concludes that there would seem to be insufficient evidence to advise any recommendation to change current practice in the use of needle size. As the authors of a research study that aimed to provide some evidence base for immunisation practice we would like to respond to this.1

Our study of 119 babies aged 4 months receiving their third dose of DPT/Hib vaccine, found that significantly less redness and swelling occurred when infants were immunised using the longer 23 gauge 25mm (blue hub) needle rather than when the shorter 25 gauge 16mm (orange hub) needle was used. The magnitude of the reductions was substantial. The position statement is correct to note that in our study the difference in tenderness did not reach statistical significance. However we believe our study still justifies a recommendation for the use of the longer needle for immunisation in 4 month old infants.

We believe the non-significant difference in tenderness with the different needles must be interpreted with caution, and should not be taken as a rationale for ignoring the significant benefits in terms of reduced redness and swelling. Tenderness was in fact reduced by the same relative amount as redness, but as tenderness occurred less frequently, the results were not formally statistically significant. We have used Bayesian analyses (using an “uninformative” prior distribution) to formally compute the chance that there is a clinically significant reduction (of at least 25% as specified in the protocol) in tenderness between the long and short needles. At six hours the probability of a clinically significant decrease in tenderness with the longer needle is 73%, whereas the chance of a clinically significant increase is only 2%. The evidence is therefore clearly in the direction of the longer needle causing less harm.

We recognise the need for further evidence on which to base immunisation practice at each of the infant immunisation ages. To this end, we are now conducting a randomised controlled trial involving over 600 infants aimed at providing a definitive answer. In the meantime, we reiterate our recommendation to practitioners to use the longer needle for immunising 4 month old infants.


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