Improvised H1N1 shots

http://www.lasvegassun.com/news/2009/dec/17/improvised-h1n1-shots-raise-officials-eyebrows/

Improvised H1N1 shots raise officials’ eyebrows
Children’s clinic gives half of an adult’s dose; problem is corrected

By Marshall Allen (contact)

Thursday, Dec. 17, 2009 | 2 a.m.
Sun Coverage

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A low-income clinic in Las Vegas improperly administered the H1N1 vaccine to 21 children, but state health officials said they corrected the problem so no harm was done.

At the height of the H1N1 panic in late October, the vaccine was in short supply and was not being delivered in dosages for children under the age of 4 at the Martin Luther King Family Center, just north of the Interstate 15-U.S. 95 interchange.

Michelle Agnew, head of operations at Nevada Health Centers, the nonprofit organization that runs the clinic, said the pediatrician at the clinic decided to use half of a dose that should be used for older children — and then saved the remainder of the dosage in a syringe. The plan was to use the syringe on the same child 28 days later.

The quantity of vaccine was appropriate, but the improvised method of administering it was not, health officials said.

Nevada State Health Division officials became alarmed Nov. 6 when they had a phone conversation with staff at the center. The potentially unsafe procedure had gone on for about a week. Health officials reported three problems to the Nevada Board of Medical Examiners:

• The dosage the clinic had received was not licensed for children under age 4.


• The vaccine in the prefilled syringes did not contain a preservative, which meant it could pass bacteria to children if it was readministered.


• Reuse of syringes is not allowed because it could spread infectious diseases.

Medical board investigators went to the clinic immediately and corrected the practice. The initial dosage was the correct amount, health officials said, and the second dose was never administered. Instead, the clinic had received the appropriate dosage in individual vials by the time the children returned to the clinic.

Agnew said the flurry of activity around the H1N1 virus caused confusion in the initial distribution of the vaccine, but most of the confusion has cleared up now that the vaccine is more widely available.

Agnew, who did not name the doctor, said the medical board closed its investigation without disciplining the physician.