There appears to be variability in both recommendations and practice regarding the route of administration of immunizations to infants and children with hemophilia. The CDC Advisory Committee on Immunizations, the American Academy of Pediatrics Red Book, and the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation all recommend intramuscular vaccination; the risk of bleeding can be minimized by concomitant administration of antihemophilic factor. However, informal discussions among practicing hematologists suggest that common practice is subcutaneous administration.
METHODS: To determine the standard practice regarding immunizations a survey was completed by 12 Hemophilia Treatment Centers in Federal Region III (Mid-Atlantic states). The number of pediatric patients followed in each institution ranged from 9 to 182 (average 73).
RESULTS: All centers have a policy or standard practice regarding the administration of vaccines and 10 of 12 recommend subcutaneous administration of all vaccines. Of the two centers that recommend following manufacturer guidelines one does and one does not routinely recommend concomitant factor administration. One center, whose policy is subcutaneous administration, recommends simultaneous factor administration if the primary care provider insists on intramuscular administration. Half of the centers do not offer immunizations on site; those that do usually offer only hepatitis A and B vaccines. All but one center have seen hematoma formation following immunizations, but none have seen sterile abscesses, necrosis, or granuloma formation. Hematomas have been seen following both subcutaneous and intramuscular injection. Estimates of hematoma formation are difficult to calculate, but one large program (folowing 182 patients) sees about 1 hematoma per year or an estimated 2–5% incidence.
CONCLUSION: Contrary to CDC and MASAC guidelines, it is standard practice at most Hemophilia Treatment Centers in Federal Region III to recommend subcutaneous administration of all vaccines without coverage of factor replacement. Hematoma formation is uncommon and can be seen following either subcutaneous or intramuscular administration. There appears to be little indication for prophylactic factor treatment before vaccine administration.