Janis C. Kelly
December 21, 2015
A notable disregard for basic vaccine safety that included reuse of syringes for influenza vaccinations given to employees at a New Jersey company sparked a massive, multiagency scramble to determine whether any of the vaccine recipients had been infected with HIV, hepatitis C virus, or hepatitis B virus as a result of possibly contaminated syringes, according to a report published in the December 18 issue of the Morbidity and Mortality Weekly Report.
One of the vaccine recipients noticed the syringe reuse and notified company managers about the unsafe actions of a nurse. The nurse had been hired from a contract health services company to provide employee vaccinations on September 30, 2015.
“Response to this event required rapid and extensive communication and coordination among public health partners,” lead author Laura Taylor, PhD, from the New Jersey Department of Health (NJDOH) Communicable Disease Service, and colleagues report.
The subsequent full-court press included the NJDOH Communicable Disease Service; the West Windsor, New Jersey, Health Department; the Centers for Disease Control and Prevention (CDC) Immunization Services Division, National Center for Immunization and Respiratory Diseases; the CDC Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases; the New Jersey State Board of Nursing; and various private entities.
Multiple Failures to Meet Standard Vaccine, Injection Safety Protocols
The authors note that there were multiple failures to meet standard vaccine and injection safety protocols. In chronological order as they occurred, the vaccine safety errors in this incident included shipping of influenza vaccine to the home of the contract nurse, where it was stored in a home refrigerator without temperature monitoring; vaccine transport from the nurse’s home to the vaccination site in unmonitored Styrofoam containers with cold packs; the nurse bringing to the vaccination site three multiple-dose vials of vaccine intended for another event, rather than the prefilled, single-dose syringes intended for the event in question; use by the nurse of just two syringes that happened to be in her supplies to administer vaccine to 67 employees; attempting to circumvent the potential contamination issues by wiping the syringes with alcohol and using a new needle for each subject; and administering inadequate vaccine doses by drawing 67 doses from only two of the 10-dose vials.
The contracted nurse voluntarily surrendered her license the following week.
On October 2, after consultation with CDC, the NJDOH emailed all 67 vaccine recipients and followed up with certified letters explaining the potential risk for bloodborne pathogens and explaining the recommended testing and vaccinations. NJDOH also provided letters for private physicians explaining the testing and treatment recommendations. In addition, NJDOH set up a dedicated telephone number and email address to handle questions from participants.
The West Windsor Health Department worked with a local urgent care center on October 5 and 6 to perform blood draws, provide postexposure prophylaxis with hepatitis B vaccine, and readminister influence vaccine in correct doses. The urgent care center also provided mental health and HIV counsellors. Forty-seven of the 67 original vaccine recipients received services through the urgent care center, whereas others are thought to have received services from their private care providers. The West Windsor Health Department also arranged follow-up clinics for hepatitis B vaccination and testing at 1 and 4 months after the original vaccination.
According to the report authors, 17% of adults now receive an annual influenza vaccine at work, and this shift has created special safety challenges. “Companies providing vaccination services should ensure their employees and contracted staff adhere to established guidelines for infection prevention, and vaccine storage, handling, and administration,” Dr Taylor and colleagues write.
They note that CDC recommends that vaccine be delivered directly to the vaccination clinic site or transported using a portable refrigerator or passive cooling system designed to maintain appropriate temperatures, including a validated temperature monitoring and recording device. CDC also recommends close attention to safe injection practices.
“Providers should review additional guidance in the Vaccine Storage and Handling Toolkit and General Recommendations on Immunizations Recommendations of the Advisory Committee on Immunization Practices,” they advise.
They also warn businesses to familiarize themselves with the recommended guidelines and make sure the guidelines are followed by contract health service providers.
Adverse events, including vaccination errors, should be reported to The Vaccine Adverse Event Reporting System.
The authors have disclosed no relevant financial relationships.
Morb Mortal Wkly Rep. 2015;64:1363-1364. Full text