World Health Organization · 2021 · 11 pages
Practical WHO guidance for primary care clinicians on recognising and managing anaphylaxis after vaccination.
- Issuer
- World Health Organization
- Edition
- 2021
- Audience
- Primary care clinicians, nurses, vaccination programme staff
- Evidence
- Expert consensus
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO technical document provides primary care clinicians with practical guidance on recognising, managing and responding to anaphylaxis following immunisation. Anaphylaxis is a rare adverse event following immunisation (AEFI), occurring at an estimated rate of 1–10 episodes per 1 million vaccine doses.
The document emphasises that anaphylaxis is a multisystem allergic reaction that typically presents 5–60 minutes after vaccination (usually within 15 minutes) with involvement of skin, respiratory, cardiovascular and/or gastrointestinal systems. Immediate management centres on placing the patient supine, assessing airway/breathing/circulation, and administering intramuscular adrenaline (epinephrine) 1:1000 at a dose of 0.01 mL/kg up to a maximum of 0.5 mL, repeated every 5–10 minutes if needed for up to three doses total.
The guidance includes differential diagnosis to distinguish anaphylaxis from acute stress responses (vasovagal syncope), a treatment protocol, an RAPD assessment tool (Rash, Airway, Pulse, Diarrhoea), dosing tables by age and weight, and requirements for emergency kit contents and preparedness in vaccination settings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Anaphylaxis following immunisation occurs at 1–10 episodes per 1 million vaccine doses
- Symptoms typically occur 5–60 minutes after vaccination, usually within 15 minutes
- First-line treatment is intramuscular adrenaline 1:1000 at 0.01 mL/kg up to maximum 0.5 mL (0.5 mL for patients >50 kg)
- Repeat adrenaline dose every 5–10 minutes if needed, up to TWO additional doses (three doses total)
- Place patient supine with legs elevated; if breathing difficulty, semi-supine position; never stand patient up
- Biphasic reactions can recur 1–72 hours after initial episode even without re-exposure to allergen
- Differentiate from vasovagal syncope: anaphylaxis shows tachycardia and hypotension; vasovagal shows bradycardia
- All vaccination sites must have emergency kit with adrenaline, disposable syringes with 0.1 mL graduations, IV fluids and equipment
Dose of adrenaline 1:1000 (aqueous) for treatment of anaphylaxis
Table extracted from the guideline
| Age | Dose (mL) |
|---|---|
| 12 months | 0.10 |
| 18 months–4 years | 0.15 |
| 5 years | 0.20 |
| 6–9 years | 0.30 |
| 10–13 years | 0.40 |
| 14 years and older | 0.50 |
Source: World Health Organization, Brief overview of anaphylaxis as an adverse event following immunization (AEFI) and practical guidance on its identification, case management and response in a primary care setting. Reproduced in summary form.
From the guideline
Verbatim
“Anaphylaxis given in the correct dose and intramuscularly is safe.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise this WHO guidance addresses a critical gap in our vaccination programme preparedness. Georgia has significantly expanded immunisation coverage, including introduction of new vaccines, yet anaphylaxis preparedness at peripheral sites—particularly in rural ambulatories and mobile outreach teams—remains inconsistent. The RAPD assessment tool and standardised adrenaline dosing table should be incorporated into our national AEFI protocols and field manuals for nurses and feldshers. I would emphasise to Georgian clinicians the critical importance of the 5–10 minute reassessment interval and the need for up to three adrenaline doses, as single-dose protocols have been insufficient in some settings. The realistic implementation challenge for Georgia is ensuring continuous adrenaline availability and stock rotation at hundreds of small vaccination points, given the short shelf-life and the need for temperature-controlled storage, which will require strengthened pharmaceutical supply chain coordination with regional public health centres.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is directly applicable to Georgia’s national immunisation programme and primary health care network. Georgia has strengthened its vaccine safety surveillance in recent years as part of immunisation programme expansion. Primary care facilities conducting vaccination sessions—whether in polyclinics, ambulatories, or outreach settings—must ensure emergency preparedness with adrenaline availability and trained staff. The RAPD assessment tool and treatment protocol can be integrated into existing AEFI reporting mechanisms coordinated through the National Centre for Disease Control and Public Health. Georgian programmes should ensure adrenaline stock management at peripheral sites, consider shelf-life monitoring (adrenaline expires rapidly), establish clear referral pathways from rural vaccination points, and integrate this protocol into pre-service and in-service training for nurses and feldshers delivering vaccines.
Questions this guideline answers
Quick answers
How can I tell the difference between anaphylaxis and fainting (vasovagal syncope) after vaccination?
Anaphylaxis typically occurs 5–60 minutes after vaccination with increased heart rate, low blood pressure, breathing difficulty, rash or swelling, and little response when lying flat. Vasovagal syncope occurs suddenly within 5 minutes, shows decreased heart rate, pallor and sweating, and the patient recovers quickly once lying flat. If in doubt, treat as anaphylaxis with adrenaline.
What dose of adrenaline should I give for anaphylaxis?
Give adrenaline 1:1000 intramuscularly at 0.01 mL/kg up to a maximum of 0.5 mL. For patients over 50 kg or aged 14 years and older, give 0.5 mL. For a 5-year-old child, give 0.20 mL. Repeat the same dose every 5–10 minutes if respiratory or cardiovascular symptoms persist, up to three doses total.
How long should I observe a patient after vaccination to watch for anaphylaxis?
Most anaphylaxis occurs within 15 minutes after vaccination, though symptoms can appear up to 60 minutes later. Observe all vaccine recipients for at least 15 minutes after immunisation. Be aware that biphasic reactions can recur 1–72 hours after the initial episode, so patients should be advised to seek care if symptoms return.
What emergency supplies must be available at every vaccination site?
Every site must have: adrenaline 1:1000 solution (at least 2 ampoules, not expired, without brown tinge), disposable syringes with 0.1 mL graduations, appropriate needles, IV cannulas and fluids (Ringer's lactate or normal saline), scalp vein sets, oxygen if available, drug dosage tables, and AEFI reporting forms. Check the kit at the start of each session and monitor adrenaline expiry dates every 3–4 months.
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- Issuer
- World Health Organization
- Type
- Technical document
- Status
- Current
- Published
- 2021-07-01
- Scope
- Primary care vaccination settings
- Audience
- Primary care clinicians, nurses, vaccination programme staff
- Pages
- 11
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789240028074
- Evidence
- Expert consensus
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Brief overview of anaphylaxis as an adverse event following immunization (AEFI) and practical guidance on its identification, case management and response in a primary care setting. Geneva: World Health Organization; 2021. 11 p. ISBN: 9789240028074.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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