Special Protocol
(Effective through period of Commissioner’s Order)

Administration of Immunizations by Paramedics and Advanced EMTs Pursuant to a Public Health Order of the Commissioner: COVID-19 VACCINE

Special Protocol – AEMT & Paramedic COVID-19 Vaccine

Vaccines for the novel Coronavirus 2019 (COVID-19), caused by the virus SARS-CoV- 2, are given by injection into the muscle (IM). Paramedics working in connection with a Massachusetts Department of Public Health (MDPH)-approved mobile integrated health (MIH) or community EMS program (CEMS), are already authorized by 105 CMR 700.003(A)(4) of the Drug Control Program (DCP) regulations, to administer certain vaccines. All other Paramedics are currently authorized by Commissioner’s Order issued November 3, 2020, to administer influenza vaccine. Paramedics and Advanced EMTs are trained to administer certain medications intravenously, intramuscularly, subcutaneously, and intranasally. Paramedics and Advanced EMTs operate in accordance with the Department’s EMS System regulations and Statewide Treatment Protocols of the MDPH Office of Emergency Medical Services (OEMS), and in connection with an MDPH- licensed ambulance service. They also obtain authorization to practice from their ambulance services’ affiliate hospital medical director (AHMD).

The specific authorization granted by the Commissioner’s Order dated June 24, 2022, pursuant to the Department’s DCP regulations, 105 CMR 700.004(H), authorizes currently certified Massachusetts Paramedics and Advanced EMTs working for an ambulance service, as well as Paramedics working with an MIH or CEMS program, to administer vaccine for the prevention of COVID-19, in persons covered by a vaccine authorized via an Emergency Use Authorization (EUA) from the U.S. Food and Drug Administration (FDA) (COVID-19 vaccines), in accordance with this Special Protocol issued by OEMS. Prior to being deployed by their ambulance service to administer COVID-19 vaccine, such Paramedics and Advanced EMTs must have successfully completed a vaccination training program approved by their
ambulance service’s AHMD.

Protocol Continues

Massachusetts Department of Public Health Office of Emergency Medical Services

Special Protocol
(Effective through period of Commissioner’s Order)

ADVANCED EMT AND PARAMEDIC STANDING ORDERS
a.	Provide patient, parent or legal representative with a copy of the Vaccine EUA Fact Sheet and answer any questions.
b.	Screen for contraindications according to accompanying Special Protocol Appendix A1, A2 or A3, depending on the type of COVID-19 vaccine being administered and/or the CDC/ACIP document (or ascertain the result of such screening)
c.	Always check the package insert or procedural instructions prior to

and draw up vaccine dose.

/	length for IM injections depends upon the age, gender, and/or weight of the

A

administration of any vaccine. Follow insert or procedural instructions to prepare
d.	Administer IM vaccines at a 90° angle with 22-25-gauge needle. The needle

P

vaccine recipient. (See attached guide). Administer IM, according to the recommended age-specific dose and schedule.
e.	Administer vaccine.
f.	Observe patient for an allergic reaction for 15-30 minutes after administering vaccine. If an anaphylactic/allergic reaction occurs, treat according to Protocol
2.2A/2.2P Allergic Reaction/Anaphylaxis.
g.	Report clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or http://www.vaers.hhs.gov/.

Implementation Criteria
Paramedics and Advanced EMTs must be trained and authorized by their AHMD or designee, prior to administering COVID-19 vaccine in any form. Under this protocol, Paramedics and Advanced EMTs can only administer vaccine while working for their ambulance service.
Such training must include at minimum the procedures to be followed by paramedics within the setting in which the vaccines are to be administered, for determining type and dose of vaccine to be given, including the identity of staff who will make such determination.

For needle size and site guidelines please see attached guide; but note that for patients under 16 years of age, needle size must be established based on specific training, direct supervision, or local site protocols.

Massachusetts Department of Public Health Office of Emergency Medical Services

Vaccine Administration: Needle Gauge and Length
Vaccines must reach the desired tissue to provide an optimal immune response and reduce the likelihood of injection-site reactions. Needle selection should be based on the:

1.	Route	¢ Age

a.	Gender and weight for adults
(19 years and older)

f.	Injection site

The following table outlines recommended needle gauges and lengths. In addition, clinical judgment should be used when selecting needles to administer injectable vaccines.

Route	Age	Needle gauge and length	Injection site	

Subcutaneous injection	
All ages	23–25-gauge 5/8 inch (16 mm)	Thigh for infants younger than 12 months of age1; upper outer triceps area for persons 12 months of age and older	

Intramuscular injection	Neonate, 28 days and younger	22–25-gauge
5/8 inch (16 mm2)	Vastus lateralis muscle of anterolateral thigh	
	Infants, 1–12 months	22–25-gauge 1 inch (25 mm)	Vastus lateralis muscle of anterolateral thigh	

Toddlers, 1–2 years	22–25-gauge
1–1.25 inches (25–32 mm)	Vastus lateralis muscle of anterolateral thigh3	
		22–25-gauge
5/82–1 inch (16–25 mm)	Deltoid muscle of arm	

Children, 3–10 years	22–25-gauge
5/82–1 inch (16–25 mm)	Deltoid muscle of arm3	
		22–25-gauge
1–1.25 inches (25–32 mm)	Vastus lateralis muscle of anterolateral thigh	
	Children, 11–18 years	22–25-gauge
5/82–1 inch (16–25 mm)	Deltoid muscle of arm3,5	
	Adults, 19 years and older
a.	130 lbs (60 kg) or less
b.	130–152 lbs (60–70 kg)
c.	Men, 152–260 lbs (70–118 kg)
d.	Women, 152–200 lbs (70–90 kg)
e.	Men, 260 lbs (118 kg) or more
f.	Women, 200 lbs (90 kg) or more	22–25-gauge
1 inch (25 mm4)
1 inch (25 mm)
1–1.5 inches (25–38 mm)
1–1.5 inches (25–38 mm)
1.5 inches (38 mm)
1.5 inches (38 mm)	

Deltoid muscle of arm3,5	
1 May be administered into the upper outer triceps area if necessary
2 If the skin is stretched tightly and subcutaneous tissues are not bunched
3 Preferred site
4 Some experts recommend a 5/8-inch needle for men and women weighing less than 60 kg, if used, skin must be stretched tightly and subcutaneous tissues must not be bunched.

5 The vastus lateralis muscle in the anterolateral thigh can also be used. Most adolescents and adults will require a 1- to 1.5-inch (25–38 mm) needle to ensure intramuscular administration.

Reference: Advisory Committee on Immunization Practices General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html