Twenty-four of 86 clients receiving influenza
vaccination at workplace immunization clinics developed adverse events after
immunization because the nurses began using alcohol as a disinfectant when they
depleted their alcohol swab supply, according to data presented at the 1st
National Immunization Conference Online.
Researchers from McMaster University in Hamilton,
Ontario, Canada, conducted a retrospective review using records from the agency
that administered the vaccines, from the workplace, adverse events after
immunization reports and integrated public health information system records.
At one clinic, three different nurses immunized 253
clients between 9 a.m. and 4:30 p.m., but the nurses depleted their alcohol
swab supply at approximately 1 p.m. Instead, they began using an alcohol
solution as a disinfectant.
No adverse events were reported after
immunization among those immunized before 1 p.m., but 24
clients vaccinated after this time period experienced an adverse event that day
— most arising within 30 minutes of immunization. Among 96% of the clients
who experienced the adverse event, the event was a rash, including mucosal
involvement, swelling at or near the injection site or both.
When the alcohol solution was analyzed, it was found to
contain 66% isopropanol, 15% acetone and other trace volatile organic
compounds. The researchers said the clients with adverse events likely
experienced irritant contact
dermatitis.
“The adverse events following immunization that 24
of the workplace immunization clinic clients experienced were likely cases of
irritant contact dermatitis that arose from the use of ‘alcohol’
solution containing acetone,” said Elizabeth Birk-Urovitz, an MD candidate
at McMaster University. “Consistent, meticulous adherence to vaccine
administration protocols is imperative to reduce the likelihood of adverse
events following immunization and maintain public confidence in vaccine
safety.”
For more information:
- Birk-Urovitz E. #30010. Presented at: 1st National Immunization
Conference Online; March 26-28, 2012.
Disclosure: Ms. Birk-Urovitz reports no relevant
financial disclosures.