Last update - 00:00 11/02/2008
New syringe packaging leads to faulty inoculation at Givatayim school
By Ran Reznick
An internal probe by the health services contractor in question blames the vaccination debacle a week ago at an elementary school in Givatayim on a change in the vaccine package, Spanish text on the syringe label and flaws in the work of the administering nurses.
In that incident, 70 first graders at the Borochov school received an injection of sterile water instead of an MMR booster shot (the standard measles, mumps and rubella vaccination for 6-year-olds).
The Association for Public Health Services has operated the privatized school vaccination program since April 2007.
In response, the vaccine supplier, Sarel Ltd., said that Hebrew instructions were printed on the cardboard packages, and that the shipment was checked by the Health Ministry and approved for marketing without restrictions. Sarel is the Health Ministry's primary supplier of medical equipment.
According to the APHS investigation, two registered school nurses received vaccines that were packaged in a manner that was "unfamiliar and partially misleading, and the nurses should have refrained from injecting the substance that was new to them, until the matter could be clarified."
The report was sent yesterday to the Health Ministry, which is still conducting its own inquiry. The erroneous vaccination procedure was not halted even though the nurses and school principal noticed at once that the children were in excessive pain and crying more than usual.
"The children's unusual reaction, along with the substance being unfamiliar and of an abnormal color, should have set off warning bells," the report said. "The nurses indeed noticed that something was not right, and sought consultation, but did not provide the information regarding the vaccine's different color. A reasonable registered nurse is expected to exercise judgment and act more carefully."
APHS has suspended the nurses from administering vaccinations until they have taken a course and test on the subject.
As for the packaging, it was different from the previous packages familiar to nurses who deal with vaccination. APHS and the nurses were not notified in advance of the change, as required. The vaccine was not accompanied by a pamphlet in Hebrew and Arabic, and the shipment did not comply with the regulations of the Pharmacists Law.
In the new type of packages, the syringes contained sterile water, which the nurses were supposed to dilute in the vaccine substance in small bottles. However, the water-filled syringes were marked clearly "PRIORIX" - the vaccine's commercial name. When the kits arrived at school, the nurses noticed the new packaging, but simply assumed that the process had been streamlined into ready-to-use vaccinations. They told investigators they "were delighted" to get the "new and wonderful ... diluted substance." The vaccine remained unused in the bottles send to the school along with the syringes.