To aspirate, or not to aspirate

The curious history of the abandonment of the technique of aspiration and the case for its reinstatement to reduce vaccine injury: is it deservedly obsolete, or is failure to aspirate a dangerous oversight?

The technique of aspirating an injection was abandoned last decade the world over.

Aspirating an injection requires the administrator to draw the needle back after insertion to check the injection has not entered a vein before injecting to complete the procedure.

With little evidence either for or against the use of the technique, the primary motivators for its use were what an administrator had been taught, and a general fear among medical staff of ‘hitting a vein’.

Injections such as vaccines are designed to be delivered into the muscle; missing the muscle and injecting the product into the bloodstream can cause complications.

Retired nurse educator Dr John Campbell believes the widespread failure to aspirate in the case of covid vaccination has caused needless untold suffering among the global population.

Aspirating, a technique Campbell says he could teach in about an hour, involves inserting the needle and then ‘drawing back’ to ensure there is no blood in the vial. Any appearance of blood allows the administrator to re-inject rather than accidentally deliver the substance into the bloodstream.

When an injection enters the bloodstream, a protein in the blood called platelet factor 4 can be attracted to the site. In rare cases, the immune system creates antibodies to attack the protein, which clump together and cause the blood clots that can cause complications including death.

Blood clots are a recognised side effect of vaccination.

Although Campbell says the problem is very rare, he also claims its consequence -the incidence of vaccine injury – has had “more devastating impact on vaccine acceptance around the world than anything else”.

Campbell, who makes medical videos to help students learn more background about health issues (his YouTube channel currently has 2.42 million subscribers), had previously interviewed two victims who experienced life-changing blood clot vaccine injuries.

One had received the experimental MRNA version of the covid vaccine, and the other had received the adenovirus-vector vaccine. Both reported experiencing an immediately noticeable taste in their mouths following their injections, which Campbell believes is evidence the vaccine had entered their bloodstream.

Campbell advocates strongly for a return to vaccine aspiration in order to avoid these rare, often devastating, but seemingly avoidable injuries.

So, why was the technique of aspirating injections abandoned? Prior to 2015, the World Health Organisation (WHO), the world’s principal guide to healthcare in medical settings, had nothing to say on the technique of aspiration; it neither recommended nor advised against the practice.

But in April of the same year, the WHO received a report from its Strategic Advisory Group of Experts on Immunisation (SAGE), followed in September by a position paper called ‘Reducing pain and distress at the time of vaccination’, with the recommendation to discontinue the practice.

The impetus for this about-face can be traced back to a systematic review, ‘Aspirating during the intramuscular injection procedure: a systematic literature review’, authored by research nurse and vaccination enthusiast Dr Helen Sisson.

The review set out to examine the available evidence and to make recommendations for the practice of administering intramuscular (IM) injections, although it only found six relevant studies to include, a sample size the author herself admitted was small.

The review itself was tricky to find, with all links to its location on the WHO website resulting in a 404 error page. Ok, the WHO has undergone a website restructure of late, but the difficulty this writer had in finding the extrapolated version of the proffered evidence seemed curious. The specifics could only be found on internet archive, and the detailed report sits behind a paywall.

Most curious of all was the fact that this important review, which prompted the WHO to influence global policy around aspiration, itself made no attempt to assess the practice of aspiration in relation to patient safety.

Instead, the evidence cited for universally recommending the cessation of aspiration in vaccination practice stemmed largely from attempts to find out what could ease the pain of immunisation for children, and therefore “promote the completion of the immunisation schedule.”

An August 2015 press release from the WHO had claimed vaccine hesitancy was a growing challenge for global immunisation programmes, stating “even fear of needles can be a factor for vaccine refusal” and announcing that their position paper on pain mitigation would follow the next month.

Sisson’s 2015 review mentioned previous immunisation guidance from the WHO in 2008 which focused on the use of auto-disposable syringes. This type of syringe is designed to be used a single time, making aspiration impossible. Could this have been why any guidance in the intervening years on aspirating or not was absent?

Further, could widespread adoption of single-use syringes, promoted as safer for both patient and vaccine administrator, have contributed to the 2015 decision to advise against the practice of aspiration?

Because despite a clear conclusion in Sisson’s review that evidence-based guidelines do not advocate aspiration, the review noted a lack of relevant evidence, a number of conflicting arguments within the small set of studies reviewed, and plainly stated that the practice of aspiration “significantly reduces the risk of erroneously injecting into a vessel.”

So, what did the paper review? The studies looked at three areas: aspiration technique and management, pain, and influences on aspiration technique. None of the studies involved patient outcomes beyond assessment of pain level, and none of them followed up with patients beyond the point of injection. In short, none of the studies assessed aspiration from a safety point of view.

The review which led to the WHO universally promoting the abandonment of the traditional practice of aspiration was based on nothing more than how much it hurt patients (mainly children), the basis for nurses’ motivation to use the technique, and whether nurses were taught to do it or not.

At this point, you may be reaching the same conclusion as the writer. A critical thinker would assume such a sweeping recommendation would have been based in evidence that there is no need to aspirate on the basis of safety, rather than just comfort, i.e evidence that aspiration does not provide any safer an outcome than non-aspiration.

Could it have been some wilfully malicious action on the part of the WHO, to completely ignore the topic of patient safety when making a recommendation like this?

Or was it an innocent error? A simple reflection that the impetus to improve vaccine uptake around the world, and the earnest belief that doing so could improve public health outcomes, overshadowed the necessary caution we can see, with hindsight, should have been applied, and no doubt would have resulted in some rigorous or even relevant research into patient safety?

Inadvertently or otherwise, did this move by the WHO – and its prioritisation of patient comfort over patient safety – contribute to the unprecedented vaccine injury seen as a consequence of the global covid vaccination programme?

Even the GAVI Alliance (Global Alliance for Vaccines and Immunizations) seems unequivocal in its absence of discussion around safety of vaccines. In June 2015, that organisation released its framework strategy for 2016-2020, announcing four goals which included faster and more equitable uptake and coverage of vaccines, increasing the effectiveness and efficiency of immunisation delivery, improving sustainability of immunisation programmes, and shaping markets for vaccines.

The exclusion within these goals of any aim to promote, improve or ensure safety of vaccine products is notable.

Let’s move on. About a year after the WHO announcement, a study in the Clinical Nursing Research journal, ‘Blood Aspiration During IM Injection’, investigated whether nurses were still aspirating, even though the WHO had told them to stop.

It found 74% of the 164 registered nurses surveyed continued to aspirate at least 90% of the time. Further, 40% reported they had aspirated blood at least once (drawn blood back into the needle, likely missing the muscle and inserting the needle into a vein), with 4% reporting they’d done so multiple times.

The conversation wasn’t over. In July 2018, a British Journal of Nursing study, ‘Intramuscular injection CLIMAT pathway: a clinical practice guideline’, noted that over the past 60 years of intramuscular injections being part of nursing practice, the practice of aspiration had been “controversial and understudied”.

This year, a letter to the editor of scientific nursing journal Enfermería Clínica,  published January 2022, posed the question, ‘Aspiration before intramuscular vaccines injection, should the debate continue?’ The letter’s inclusion implored the scientific community to “reopen the debate about the appropriateness of aspiration” and called for rigorous experimental studies into the side effects of intravascular administration of vaccines.

Another letter to the editor, this time in the Journal of Medical Virology, published in June 2022, discussed the potential rationale of covid vaccine-induced myopericarditis, and reiterated calls for robust monitored clinical or animal studies in order to “potentially improve the safety of COVID-19 vaccine administration, especially in the paediatrics population”.

It seems Dr John Campbell is not a lone voice in the wilderness on this topic. Not only do these studies indicate others in the medical landscape calling for debate and further research, at least two European countries have moved against WHO advice and directed their vaccinators to aspirate.

In July 2021, Denmark changed its advice, based on a ‘precautionary principle’, and in February 2022, Germany did the same, citing that, although the complications caused by failure to aspirate were rare, returning to the practice would increase vaccine safety for its population.

Meanwhile, here in New Zealand, the directive not to aspirate tops a list of WHO-derived recommendations to minimise pain and distress at the time of vaccination in the New Zealand Immunisation Handbook 2020 (last updated May 2022).

But over at the MOH-funded Immunisation Advisory Centre’s dedicated covid website, a frequently asked question refers to requests from members of the public to aspirate covid injections, and advises that while this is not best practice, “there is no danger associated with accommodating the consumer’s requests.”

As with so many concepts over the last few years, the merits or disadvantages of the practice of aspiration is another debate to add to a growing list of issues for which the science appears to be far from settled.