The amount of vaccine is sufficient to inoculate 150 people. So far, no acute adverse symptoms were reported.
Presenter: Staff at En Chu Kong Hospital in New Taipei City erroneously administered undiluted Pfizer-BioNTech vaccine doses to 25 people at the Yingge District vaccination site. As each vial of BNT vaccine contains at least 5 doses, it means that the 25 people were administered doses for 125 people.
Pfizer-BioNTech (BNT) vaccination has just begun in Taiwan and a case of medical negligence has occurred. Twenty-five people were accidentally administered with undiluted BNT vaccine doses by En Chu Kong Hospital staff at the vaccination site in Yingge District. The hospital apologized during a press conference and said the mistake was due to a poor handover between shifts, in which the staff thought the vaccine was already diluted after caps had fallen off the vials.
Wang Chung-Cheng, Deputy Superintendent, En Chu Kong Hospital:”Some of the caps had fallen off the vials, so the staff thought that vaccines were already diluted. They did not double-check with other BNT vials. BNT vaccine needs to be diluted first which is different from the three other brands of vaccines.”
The New Taipei City Department of Health ordered the hospital to form a task force to conduct detailed tests and check-ups on the group and to offer any assistance if necessary. The group of 25 vaccine recipients consisted of 11 men and 14 women aged between 19 and 65. The hospital also invited them to check into the hospital for observation and 9 recipients complied. All 25 recipients have experienced only arm pain so far.
Chen Ran-chou, Commissioner, Dept. of Health, New Taipei City:”The New Taipei Health Department has suspended En Chu Kong Hospital from administering vaccines for a week. We also formed a task force consisting of physicians from various disciplines for further tests and investigation. We will reinforce training on every aspect of vaccine administration.”
Doctor Liu Peng-chih from Shin Kong Hospital said similar cases have occurred in other countries where people were erroneously administered undiluted vaccines containing almost 5 doses in each vial. Most cases were not lethal but careful observation is still needed in case of any adverse immune reactions.
Liu Peng-chih, Doctor of Family Medicine, Shin Kong Memorial Hospital:”They may experience more swelling on the arm and more fatigue than others. There hasn't been any known case history of people having a higher risk for COVID-19 infection if injected with too much vaccine.”
Each vial of BNT vaccine should be diluted and would contain at least 5 doses for 5 people. This means that the 25 people were administered doses for 125. The vaccine recipients who decided to check into the hospital will be on observation for 3 to 7 days.
Citizens who have originally registered for shots at the Yingge vaccination site from Sept. 18 through Oct. 1 should go to the nearby Chingfu Hospital instead. Two other vaccination sites originally handled by En Chu Kong Hospital would also be taken over by other medical teams.
國內新冠疫苗施打作業持續進行，不過27號卻傳出疑似醫療作業疏失，三峽恩主公醫院在鶯歌永福宮接種站進行BNT施打時，替25位民眾注射的是「未經稀釋的疫苗原液」，院方說明是護理人員交班不完整，慌亂中看到蓋子脫落以為已經稀釋才會注射。
三峽恩主公醫院 副院長王炯珵：「當時因為有部分的疫苗，蓋子已經脫落，所以誤認為是已經稀釋過的疫苗，所以就沒有進行這個。BNT所比較特別，跟其他三種疫苗比較不一樣，需要稀釋的過程。」
新北衛生局立即責成恩主公醫院對25位民眾做健康監測及關懷，並且從即日起停止恩主公醫院疫苗施打作業一周。目前25位民眾包括11位男性、14位女性，年齡分布在19到65歲間，有9位民眾有意願已經在27號住院觀察，目前只有出現注射部位疼痛的狀況，沒有急性副作用發生。
新北市衛生局長 陳潤秋：「衛生局即日起停止恩主公醫院，疫苗施打作業一週，衛生局也立刻召集專家，組成專案小組進行調查，強化接種流程的確認機制。」
有醫師指出國外也有類似個案，甚至有民眾是打了將近五倍以上未經稀釋的疫苗，但後續追蹤沒有看到明顯致命性問題，但仍要嚴加提防被施打的民眾，副作用上是否有較為嚴重。
新光醫院家醫科醫師 柳朋馳：「可能或許會在局部的腫脹感，或者是說疲倦感這一部分上，可能會比較顯著一點，那至於說會不會反而，比較容易誘發所謂免疫風暴，或者是風險變更大，過去國外曾經發生過的相關經驗來看，目前是沒有相關的事情發生。」
BNT原液稀釋過程相對複雜，一劑本來可以打五人，等於25位民眾打了125人的劑量，已住院民眾將觀察三天到一週後出院，而原本已經預約9月28號到10月1號要在恩主公醫院接種的民眾，將會轉移到清福醫院接種，另外兩處接種站也會安排其他醫療團隊接手。