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Notes from the Field: Injection Safety and Vaccine Administration Errors at an Employee Influenza Vaccination Clinic — New Jersey, 2015

Laura Taylor, PhD1; Rebecca Greeley, MPH1; Jill Dinitz-Sklar, MPH1; Nicole Mazur, MPH1; Jill Swanson, MPH2; JoEllen Wolicki, BSN3; Joseph Perz, DrPH4; Christina Tan, MD1; Barbara Montana, MD1

On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company that an experienced nurse had reused syringes for multiple persons earlier that day. This occurred at an employee influenza vaccination clinic on the premises of a New Jersey business that had contracted with the health services company to provide influenza vaccinations to its employees. The employees were to receive vaccine from manufacturer-prefilled, single-dose syringes. However, the nurse contracted by the health services company brought three multiple-dose vials of vaccine that were intended for another event. The nurse reported using two syringes she found among her supplies to administer vaccine to 67 employees of the New Jersey business. She reported wiping the syringes with alcohol and using a new needle for each of the 67 persons. One of the vaccine recipients witnessed and questioned the syringe reuse, and brought it to the attention of managers at the business who, in turn, reported the practice to the health services company contracted to provide the influenza vaccinations.

Reuse of syringes for multiple patients, with or without reuse of needles, is recognized as a serious infection control breach that poses risks for bloodborne pathogen transmission (13). Upon investigation additional concerns regarding vaccine administration and storage and handling were identified for this event. The nurse used only two multiple dose vials of vaccine (10 doses/vial) to administer vaccines to 67 adult participants; thus, participants did not receive the recommended dose of influenza vaccine. The health services company had shipped the vaccine to the nurse's home, where it was stored in her home refrigerator without temperature monitoring until the event. Vaccine doses were then transported from the nurse's home to the vaccination site using a styrofoam container and cold packs. After the event, unused vaccine doses were transported back to the nurse's home and stored in her refrigerator before being shipped back to the health services company in a container with cold packs.

In response to these injection safety and vaccine administration errors, the NJDOH, in consultation with CDC, recommended notification and testing of the New Jersey business employees who participated in the vaccination clinic for human immunodeficiency virus (HIV), hepatitis C virus, and hepatitis B virus. Postexposure prophylaxis with hepatitis B vaccine and readministration of influenza vaccination were also recommended. NJDOH sent an e-mail on October 2, informing the participants of the potential bloodborne pathogen exposures and recommendations for testing and vaccination. Certified follow-up letters also were sent. A dedicated NJDOH phone number and e-mail address were created to assist the affected patients. The West Windsor Health Department collaborated with an urgent care center to perform blood draws and administer the vaccines on October 5 and 6; HIV and mental health counselors were available on-site. NJDOH also provided letters for participants to bring to their private physicians outlining the situation, risk assessment, and public health recommendations. Forty-seven of 67 participants received services through the urgent care center and the West Windsor Health Department; an unknown number of participants received treatment from their private health care providers. Follow-up clinics were arranged at 1 month and at 4 months for hepatitis B vaccination and testing.

Recommendations for appropriate injection safety and vaccine storage, handling, and administration were not followed at the influenza vaccination clinic (16). Response to this event required rapid and extensive communication and coordination among public health partners, including CDC, NJDOH, the New Jersey State Board of Nursing, and the West Windsor Health Department, as well as private entities. The contracted nurse voluntarily surrendered her license within 1 week of the initial report.

Approximately 17% of adults receive an annual influenza vaccine at their workplace (7,8). Influenza vaccination has been demonstrated to reduce illnesses, medical provider visits, lost work days, and antibiotic use among working adults (7,9). Although vaccination events outside of traditional health care settings can increase access to vaccines, training and oversight of health care personnel, and vaccine storage and handling can present special 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 (16). CDC recommends that, if possible, vaccine be delivered directly to the vaccination clinic site. If this is not possible, CDC recommends transporting influenza vaccine using a suitable portable refrigerator or a passive cooling system specifically designed and tested to maintain appropriate temperatures. A calibrated temperature monitoring device with a current and valid certificate of calibration testing and continuous monitoring and recording capabilities should be used to monitor the temperature of the storage unit or transport container (4). The temperature of the vaccine should be regularly monitored and recorded at appropriate intervals based on the type of vaccine storage unit and method of transport.

Many different presentations of influenza vaccine are available, including manufacturer-prefilled syringes for single-dose administration, which might reduce the opportunity for vaccination errors. When multiple-dose influenza vaccine vials are used, vaccinators should ensure that they administer the correct vaccine dosage; in addition, no more than 10 doses should be drawn up immediately before administering vaccine (4). Safe injection practices, including the correct site identification and needle length, should be followed (1,3,5,6). Providers should review additional guidance in the Vaccine Storage and Handling Toolkit (4) and General Recommendations on Immunizations Recommendations of the Advisory Committee on Immunization Practices (ACIP) (6). Businesses should familiarize themselves with recommended guidelines and ensure that these guidelines are followed by the immunization service provider they choose. The Vaccine Adverse Event Reporting System ( accepts reports of adverse events that occur after vaccination, including reports of vaccination errors.

1New Jersey Department of Health, Communicable Disease Service; 2West Windsor Health Department, New Jersey; 3Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC; 4Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

Corresponding author: Laura Taylor,, 609-826-5964.


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