What is it?
Intradermal vaccination is the delivery of vaccines into the outer layers of the skin. Most vaccines are delivered via the intramuscular (IM) or subcutaneous (SC) route. The intradermal (ID) route is used for only a small number of vaccines. This method of vaccine delivery requires trained health professionals to ensure safety and efficacy.
Anatomy and function of the skin
The skin is a very complex organ that is made up of 3 main layers – the epidermis, dermis and the hypodermis. Each layer has its own anatomy and specific function. The epidermal and dermal layers contain many different cells including the antigen-presenting cells (APC’s) that are thought to play a significant role in mediating an efficient and protective immune response to specific vaccines. The 3 main APC’s are macrophages, dendritic cells and B cells. The APC’s as the name suggests, presents specific antigens to particular cells in the immune system that are responsible in eliciting an immune mediated response that in turn creates memory cells and antibodies. This is how some vaccines are thought to work when given via the ID route with enhanced immunogenicity compared to the IM or SC routes.
Which vaccines can be given intradermally?
Examples of vaccines given by the ID route include BCG and hepatitis B (for non-responders). Mantoux and Q Fever tests are also performed intradermally.
Hepatitis B vaccine is usually given by the IM route however there is a small percentage of the population who do not mount a protective immune response to the IM course of hepatitis B vaccines. If they have been deemed by their provider as a non-responder the intradermal route is considered as an alternative [refer to MVEC: Hepatitis B for more information].
Table 1: Intradermal vaccines, doses and recommended sites
| BCG (tuberculosis) | < 12-months 0.05ml ≥ 12-months 0.1ml | Left upper arm over the region where the deltoid muscle inserts into the humerus§ |
| Tuberculin skin test (TST/Mantoux) | 0.1ml | Volar surface of mid-forearm |
| Engerix®-B Adult (hepatitis B)¥ | 0.25ml (20mcg/1.0ml) per dose | Left upper arm over the deltoid region |
| Q-Vax skin test (Q fever test) | 0.1ml of diluted Q-Vax skin test | Volar surface of mid-forearm |
§This is the recommended site to minimise the risk of keloid formation
¥Refer to MVEC: Hepatitis B for more information on the management of non-responders
How do you administer an intradermal vaccine?
- Use a short (10mm) 26-27 gauge needle with a short bevel and a 1ml insulin syringe
- Wear protective eye wear when administering BCG vaccine as eye splashes can ulcerate
- Identify the correct injection site (see Table 1 above)
- Stretch the skin between a finger and your thumb
- Insert the bevel into the dermis with the bevel facing upwards, to a distance of approx. 2mm. The bevel should be visible through the epidermis
You should feel resistance as you inject, if you don’t, the needle may be in subcutaneous tissue. If the injection is not intradermal, withdraw the needle and repeat at a new site. When given correctly, an intradermal injection should raise a blanched bleb.
Who can administer intradermal vaccines?
Only medical or nursing professionals who are trained in the correct administration of intradermal vaccines.
Resources
- MVEC: BCG vaccine
- Australian Immunisation Handbook: Tuberculosis
- MVEC: Hepatitis B
- MVEC: Pathway for routine intramuscular (IM) hepatitis B vaccine non-responders
- Australian Immunisation Handbook: Non-responders to hepatitis B vaccine
- DermNet NZ: Skin Immune System
Authors: Francesca Machingaifa (Research Nurse SAEFVIC, Murdoch Children’s Research Institute), Mel Addison (Research Nurse SAEFVIC, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children’s Research Institute).
Date: April 2020
Materials in this section are updated as new information becomes available. The Melbourne Vaccine Education Centre (MVEC) staff regularly review materials for accuracy.
You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.