APD Warns Of Vaccine Mishandling
Lebanon — More than 800 children received improperly refrigerated, and potentially ineffective, vaccinations for polio, hepatitis, measles and other diseases at Alice Peck Day Memorial Hospital during a 14-month period that ended Oct. 23, the hospital said Wednesday.
The affected vaccines were not harmful, but may have offered diminished immunity to recipients, the hospital said.
“To date, we have had no reports of any patients affected by this event contracting a vaccine-preventable disease,” the hospital said on its website.
“Patient safety is our first concern, and we have worked diligently to identify all vaccines for which we could not prove integrity with absolute certainty,” Sue Mooney, the hospital’s chief executive, said in a release.
The hospital announced the vaccine problem more than five months after state inspectors noticed that the hospital had failed to submit some required reports on its vaccination program.
The hospital made sure it had a plan in place before it notified patients and their families of the vaccination issue, Mooney said. The “absolute risk of a child contracting an illness was remote,” she said. The potentially flawed vaccinations were not “an urgent public health issue,” she added.
“We’ve been happy with the course that APD took,” said Ben Chan, the state epidemiologist. “It wasn’t a simple decision.”
The hospital consulted with state public health officials, the U.S. Centers for Disease Control and Prevention, and vaccine manufacturers, then assembled a database that included a record of past temperatures in the storage area, an inventory of the vaccines that had been stored there, the safe temperatures for storage of each vaccine and the dates on which patients had received specific vaccines, Mooney said. “We really believed it was important to ensure that we were thorough and comprehensive and accurate,” she said.
On Monday, Alice Peck Day sent out nearly 3,500 letters to parents of pediatric patients of its Robert A. Mesropian Center for Community Care or directly to some patients who now are over 18, according to hospital spokesman Peter Glenshaw.
That included 827 patients whom the hospital determined had received vaccines that might have been compromised. Those patients were provided with customized revaccination plans, each of which was developed by a pediatrician, Mooney said.
Mesropian Center patients who had not been exposed to compromised vaccines received letters informing them of the vaccine problem and telling them they were in the clear, Mooney said.
Each of the state’s more than 300 medical practices that immunize children with vaccines paid for by the state are required to file a monthly report showing the results of twice-daily checks of the readings of a thermometer in its vaccine storage area, said Colleen Haggerty, director of the state’s immunization program. Over the past two years, Alice Peck Day and other vaccination providers have installed devices that record temperature readings around the clock.
Haggerty declined to say how many of the monthly reports APD had failed to file on time.
After the hospital submitted the reports, a review of records dating back to Sept. 2, 2014, showed the refrigeration issues, Mooney said.
Because she had not been personally involved, Mooney said, she did not know the exact date when the hospital discovered that some vaccines had been stored at unsafe temperatures.
Mooney said that 1,616 Mesrobian Center patients had been vaccinated during the period reviewed by APD and that those who were believed to have received vaccines that were exposed to temperatures outside of safe ranges are being offered revaccinations at no charge.
The hospital has not yet estimated the cost of analyzing and correcting the vaccine issue, Mooney said.
The hospital said it has changed its vaccine monitoring and verification programs, completed a “new vaccine management plan,” replaced backup thermometers and put in place a system that pages staff members if vaccine refrigeration temperatures go above or below safe temperature limits.
The hospital said it believed that no refrigeration issues had occurred since Oct. 23.
Mooney said the hospital had focused on putting in place a revaccination program and improvements in its system for handling vaccines and had not yet done a “root cause analysis” to identify whether the refrigeration problem had resulted from a bad system, mechanical failure, human error or something else.
Alice Peck Day, a 25-bed hospital, has agreed to become a formal affiliate of Dartmouth-Hitchcock, its 396-bed neighbor.
Rick Jurgens can be reached at firstname.lastname@example.org or 603-727-3229.