In The News: Complexity of COVID Vaccine Program Leads to Concerns About Potential for Error

A story in STAT News looks at the increased complexity of proper COVID-19 vaccine storage and administration with the rollout of the bivalent booster program. At a recent ACIP meeting, the panel shared their concerns with keeping as many as 11 different brands and formulations of vaccine straight in doctors offices, clinics, and pharmacies nationwide that administer primary series to young children, regular boosters to older children, and the new bivalent to those over 12.

Data from the CDC recounted for the story show more than 5,300 errors in vaccine dose delivery in children have already been reported prior to the introduction of the latest booster. According to the CDC, no adverse events related to those errors (beyond normally reported in children given correct dosage) have been shared. However, it is noted that any vaccine-related error can undermine confidence in the vaccines and those who administer them.

With multiple vaccines administered in different volumes, some after dilution and some not, with intervals between doses ranging from three weeks to several months, and more vials with similar labels, the CDC has recognized the potential for mistakes and have produced visual guides and developed strategies to minimize the possibility of anyone receiving the wrong formulation.

The story runs through the various colored caps corresponding to vaccine age groupings, dosage, and interval administration. It covers gray caps, maroon caps, orange caps, dark blue caps, and vial labels bordered in gray, vial labels bordered in purple, and similar colored vial labels with different text. Practices, clinics, and pharmacies have created their own patchwork of solutions. Some only stock a particular brand vaccine. Others store different vaccines in different colored refrigerators with corresponding colored baskets for syringes. Still others only deliver certain vaccines on certain days of the week to help alleviate confusion.

The CDC urges vaccine providers to triple check their procedures and vaccine storage. Diligence and organization can help avoid mistakes from being made.

Grace Lee, PIDS member and ACIP chair is quoted in the story. She shared, “This immunization schedule is among the most complex that I’ve personally had to deal with, and it is constantly changing.” And, “These vaccines are the most complex to manage. I think about a solo practitioner in a very busy clinic, just trying to get through the day and try to figure out which vaccine is the right one to give this kid.”