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Oliveira SH, Silva BS, Carvalho LMR, Gontijo TL, Pinto IC, Guimarães EADA, de Oliveira VC. Prevalence and underreporting of immunization errors in childhood vaccination: results of a household survey. Rev Esc Enferm USP 2024; 57:e20230253. [PMID: 38373188 PMCID: PMC10878123 DOI: 10.1590/1980-220x-reeusp-2023-0253en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/22/2023] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVE To investigate underreporting of immunization errors based on vaccination records from children under five years of age. METHOD An epidemiological, cross-sectional analytical study, carried out through a household survey with 453 children aged 6 months to 4 years in three municipalities in Minas Gerais in 2021. A descriptive analysis was carried out, and the prevalence of the error was calculated per 100 thousand doses applied between 2016 and 2021. The magnitude was estimated of the association between variables by prevalence and 95% Confidence Intervals (95%CI). To analyze underreporting, State reporting records were used. RESULTS A prevalence of immunization errors was found to be 41.9/100,000 doses applied (95%CI:32.2 - 51.6). The highest prevalence occurred between 2020 (50.0/100,000 doses applied) and 2021 (78.6/100,000 doses applied). The most frequent error was an inadequate interval between vaccines (47.2%) associated with adsorbed diphtheria, tetanus and pertussis (DTP) vaccine (13.7/100,000) administration. Vaccination delay was related to immunization errors (7.55 95% CI:2.30 - 24.80), and the errors found were underreported. CONCLUSION The high prevalence of underreported errors points to a worrying scenario, highlighting the importance of preventive measures.
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Affiliation(s)
- Stênio Henrique Oliveira
- Universidade Federal de São João del-Rei, Programa de Pós-Graduação
em Enfermagem, Divinópolis, MG, Brazil
| | - Brener Santos Silva
- Universidade do Estado de Minas Gerais, Departamento de Ciências da
Reabilitação e Saúde, Divinópolis, MG, Brazil
| | | | - Tarcísio Laerte Gontijo
- Universidade Federal de São João del-Rei, Programa de Pós-Graduação
em Enfermagem, Divinópolis, MG, Brazil
| | - Ione Carvalho Pinto
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
Programa de Pós-Graduação Enfermagem em Saúde Pública, Ribeirão Preto, SP,
Brazil
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Simões NCS, Tavares LODM, da Silva CMB, Rodrigues SB, Oliveira SH, Guimarães EADA, de Oliveira VC. Construction and validity of an educational video to prevent immunization errors. Rev Bras Enferm 2023; 76:e20230010. [PMID: 37820157 PMCID: PMC10561952 DOI: 10.1590/0034-7167-2023-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/03/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE to construct and validate an orientation video, based on a low-fidelity clinical simulation scenario, to prevent immunization errors. METHODS a methodological study with video construction, validated in two stages by different audiences. Content was selected based on a realistic simulation scenario of the vaccine administration process to a patient-actor. Items with concordance greater than 0.8 and 0.6 were considered valid, verified using the Content Validity Index (CVI) and the Content Validity Ratio (CVR), respectively. RESULTS judges' CVI had an average of 97.5%, and CVR, 0.9, and health professionals' CVI, 95.4%, and CVR, 0.8. Successes in administering vaccines were addressed, such as careful reading of labels, double-checking the vaccine, distractions/interruptions and error reporting. CONCLUSIONS the video was constructed and validated in terms of content, and can be used in training professionals working in vaccination.
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Yan EG, Arzt NH. A Commentary on Process Improvements to Reduce Manual Tasks and Paper at Covid-19 Mass Vaccination Points of Dispensing in California. J Med Syst 2022; 46:47. [PMID: 35635621 PMCID: PMC9149336 DOI: 10.1007/s10916-022-01823-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
My Turn is software used to manage several Covid-19 mass vaccination campaigns in California. The objective of this article is to describe the use of My Turn at two points of dispensing in California and comment on process improvements to reduce manual tasks of six identified processes of vaccination–registration, scheduling, administration, documentation, follow-up, and digital vaccine record–and paper. We reviewed publicly available documents of My Turn and patients vaccinated at George R. Moscone Convention Center in San Francisco and Oakland Coliseum Community Vaccination Clinic. For publicly available documents of My Turn, we examined videos of My Turn on YouTube, and documentation from EZIZ, the website for the California Vaccines for Children Program. For patients, we examined publicly available vaccination record cards on Instagram and Google. At the George R. Moscone Convention Center, 329,608 vaccines doses were given. At the Oakland Coliseum Community Vaccination Clinic, more than 500,000 vaccine doses were administered. The use of My Turn can be used to reduce manual tasks and paper for mass vaccinating patients against Covid-19.
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Affiliation(s)
- Eric G Yan
- Arnali, Inc., San Francisco, CA, 94122, USA.
| | - Noam H Arzt
- HLN Consulting, LLC, Mission Viejo, CA, 92692, USA
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Donnini DA, Silva CMB, Gusmão JD, Matozinhos FP, Silva RB, Amaral GG, Guimarães EADA, de Oliveira VC. Incidence of immunization errors in the state of Minas Gerais, Brazil: a cross-sectional study, 2015-2019. EPIDEMIOLOGIA E SERVIÇOS DE SAÚDE 2022; 31:e2022055. [PMID: 36351058 PMCID: PMC9887969 DOI: 10.1590/s2237-96222022000300008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To evaluate the incidence of immunization errors in the public health service of the state of Minas Gerais, Brazil. METHODS This was a cross-sectional study, based on errors reported on the National Immunization Program Information System between 2015 and 2019. A descriptive analysis and calculation of the incidence for the state's health macro-regions were performed. RESULTS A total of 3,829 notifications were analyzed. Children younger than 1 year old were the most affected (39.1%) and the intramuscular route accounted for 29.4% of the errors. The most frequently reported error was administration of vaccines outside minimum and maximum recommended ages (37.7%). There was a higher incidence of errors in Vale do Aço (26.5/100,000) and Triângulo do Norte (22.6/100,000) macro-regions. CONCLUSION Immunization errors showed a heterogeneous incidence among the macro-regions of the state of Minas Gerais, between 2015-2019, and the administration of vaccines outside minimum and maximum recommended ages was the most frequently reported error.
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Affiliation(s)
- Deborah Amaral Donnini
- Universidade Federal de São João del-Rei, Programa de Pós-Graduação
em Enfermagem, Divinópolis, MG, Brazil
| | | | - Josianne Dias Gusmão
- Secretaria de Estado da Saúde de Minas Gerais, Superintendência de
Vigilância Epidemiológica, Belo Horizonte, MG, Brazil
| | - Fernanda Penido Matozinhos
- Universidade Federal de Minas Gerais, Programa de Pós-Graduação em
Enfermagem, Belo Horizonte, MG, Brazil
| | - Roberta Barros Silva
- Secretaria de Estado da Saúde de Minas Gerais, Superintendência de
Vigilância Epidemiológica, Belo Horizonte, MG, Brazil
| | - Gabriela Gonçalves Amaral
- Universidade de São Paulo, Programa de Pós-Graduação em Enfermagem
em Saúde Pública, Ribierão Preto, SP, Brazil
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Batista ECC, Ferreira AP, Alexandre BGP, Lima MRDS, Oliveira VC, Guimarães EADA. The influence of nursing team’s behavior in adverse event following immunization surveillance. Rev Bras Enferm 2022; 75:e20210132. [DOI: 10.1590/0034-7167-2021-0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/22/2021] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objectives: to analyze the effects of nursing professionals’ behavior in adverse event following immunization surveillance. Methods: a cross-sectional study of 384 participants who received vaccines. Information on vaccination history, administered vaccines and vaccination guidelines were analyzed. Descriptive and bivariate analyzes were performed using simple logistic regression (unadjusted Odds Ratio). Results: guidelines on events (PR=1.8; p=0.001) and conducts regarding their occurrence (PR=1.7; p=0.001) are activities that influence adverse event following immunization surveillance. More than half of participants did not receive guidance on the vaccines administered, the events and the conduct in case of an occurrence. Only 38.5% were instructed about the vaccines administered and 40.6% about adverse events. In the presence of an event, 29.9% reported that they sought services for notification. Conclusions: proper screening, providing guidance on vaccines and adverse events are essential preventive measures to strengthen adverse event following immunization surveillance.
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Fernandes EG, López-Lopes GIS, Silva VO, Yamashiro R, Madureira KCR, Gallo JF, Lindoso JA, Sato HK, de Araujo NVDL, Nerger MLBR, Brigido LFM. Safety and immunogenicity of an inactivated SARS-CoV-2 vaccine (CoronaVac) in inadvertently vaccinated healthy children. Rev Inst Med Trop Sao Paulo 2021; 63:e83. [PMID: 34878041 PMCID: PMC8660031 DOI: 10.1590/s1678-9946202163083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/04/2021] [Indexed: 01/13/2023] Open
Abstract
Twenty-seven children aged seven months to 5 years were inadvertently vaccinated
with a COVID-19 vaccine, the CoronaVac (Sinovac, China), an inactivated
SARS-CoV-2 vaccine, in two different cities of Sao Paulo State, Brazil. After
the event, these children were monitored by local pediatricians and serum
samples were collected at the first visit and 30 days after vaccination and
tested for SARS-CoV-2 S1 serology with Ortho total IgG anti-S1 protein and
Cpass, an ACE2 receptor binding domain inhibition assay. Only one child had a
mild symptom after vaccination, with no other adverse events documented up to
the 30 days follow-up. Of 27 children tested 3-9 days after vaccination, 5 (19%)
had positive serology suggesting a previous natural SARS-CoV-2 infection, with
all 19 tested on day 30 after vaccination and presenting with positive tests,
with an increment of antibody titers in those initially positive. A low Cpass
binding inhibition was observed in the first collection in 11 seronegative
cases, with high titers among those anti-S1 positive. All children showed an
important increase in antibody titers on day 30. The event allowed the
documentation of a robust serological response to one dose of CoronaVac in this
small population of young children, with no major adverse effects. Although it
was an unfortunate accident, this event may contribute with future vaccine
strategies in this age group. The data suggest that CoronaVac is safe and
immunogenic for children.
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Affiliation(s)
- Eder Gatti Fernandes
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac", Divisão de Imunização, São Paulo, São Paulo, Brazil.,Instituto de Infectologia Emílio Ribas, São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - José Angelo Lindoso
- Instituto de Infectologia Emílio Ribas, São Paulo, São Paulo, Brazil.,Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil.,Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, São Paulo, São Paulo, Brazil
| | - Helena Keico Sato
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac", Divisão de Imunização, São Paulo, São Paulo, Brazil
| | - Núbia Virginia D'Avila Limeira de Araujo
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac", Divisão de Imunização, São Paulo, São Paulo, Brazil
| | - Maria Ligia Bacciotte Ramos Nerger
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac", Divisão de Imunização, São Paulo, São Paulo, Brazil
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Buja A, Manfredi M, De Luca G, Zampieri C, Zanovello S, Perkovic D, Scotton F, Minnicelli A, De Polo A, Cristofori V, Biasi L, Baldovin T, Bertoncello C, Cocchio S, Baldo V. Using Failure Mode, Effect and Criticality Analysis to Improve Safety in the COVID Mass Vaccination Campaign. Vaccines (Basel) 2021; 9:vaccines9080866. [PMID: 34451990 PMCID: PMC8402500 DOI: 10.3390/vaccines9080866] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/17/2022] Open
Abstract
Vaccination against SARS-CoV-2 will likely be the most promising way to combat the pandemic. Even if mass vaccination is urgent, it should still always be supported by appropriate patient safety management. The aim of this study, based on failure mode, effects and criticality analysis (FMECA), was to identify possible failures and highlight measures that can be adopted to prevent their occurrence. A team of resident doctors in public health from the University of Padua and specialists in risk analysis in public health examined the mass vaccination process. A diagram was drafted to illustrate the various phases of mass vaccination, analyze the process, and identify all failure modes. Criticalities were ascertained by rating the severity, frequency and likelihood of failure detection on a scale of 1 to 10. We identified a total of 71 possible faults distributed over the various phases of the process, and 34 of them were classified as carrying a high risk. For the potentially high-risk failure modes, we identified 63 recommended actions to contain the cause of their occurrence or improve their detection. For the purpose of detecting potential failures, FMECA can be successfully applied to mass vaccination, which should be considered a high-risk process.
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Teixeira TBC, Raponi MBG, Felix MMDS, Ferreira LA, Barichello E, Barbosa MH. ASSESSMENT OF PATIENT SAFETY IN VACCINATION ROOMS. TEXTO & CONTEXTO ENFERMAGEM 2021. [DOI: 10.1590/1980-265x-tce-2020-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: identify adherence to patient safety recommendations in the vaccination room. Method: this is a cross-sectional study that analyzed 463 vaccination procedures in six vaccination rooms in Minas Gerais from June to July 2018. Data were obtained with the application of the Patient Safety Checklist for Vaccination Rooms through systematic observation of the vaccination procedure. Descriptive statistics were used for data analysis. Results: 463 vaccination procedures were observed, and the mean overall adherence score was 58.5%, min. 43.3% and max. 74.1%. The items of higher adherence were related to the records of vaccine data (name, date, and batch) on the vaccination card; vaccine application with dose, route of administration, location and correct materials; and records in an information system. The items of lower adherence were related to health guidance; investigation of adverse events following immunization and the health status of the vaccinated person; records of vaccine laboratory and vaccination center on the vaccination card; vaccine workforce handwashing; and proper vaccine preparation. Conclusion: the mean overall score found in this study was 58.5% for the adherence to recommendations for vaccination procedures. This result highlights the need for educational interventions that promote patient safety in the vaccination room and studies analyzing the factors that prevent such adherence.
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Barboza TC, Guimarães RA, Gimenes FRE, Silva AEBDC. Retrospective study of immunization errors reported in an online Information System. Rev Lat Am Enfermagem 2020; 28:e3303. [PMID: 32578753 PMCID: PMC7304978 DOI: 10.1590/1518-8345.3343.3303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 03/20/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: to analyze the immunization errors reported in an online Information
System. Method: retrospective study conducted with data from the Adverse Event Following
Immunization Surveillance Information System. Immunization errors were
analyzed with respect to demographic characteristics and the vaccination
process. Frequencies and error incidence rates have been calculated.
Binomial and chi-square tests were used to verify differences in the
proportions of the variables. Results: 501 errors were analyzed, the majority involving routine doses (92.6%),
without Adverse Event Following Immunization (90.6%) and in children under
five years old (55.7%). The most frequent types of errors were inadequacy in
the indication of the immunobiological (26.9%), inadequate interval between
doses (18.2%) and error in the administration technique (14.2%). The overall
error incidence rate was 4.05/100,000 doses applied; the highest incidences
of routine vaccines were for human rabies vaccine, human papillomavirus and
triple viral; the incidence rate of errors with Adverse Events Following
Immunization was 0.45/100,000 doses applied. Conclusion: it was found that immunization errors are a reality to be faced by the health
systems, but they are amenable to prevention through interventions such as
the adoption of protocols, checklists and permanent education in health.
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Affiliation(s)
- Tânia Cristina Barboza
- Secretaria de Estado de Saúde de Goiás, Superintendência de Vigilância em Saúde, Goiânia, GO, Brazil
| | | | - Fernanda Raphael Escobar Gimenes
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
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Fernandes EG, Nogueira JS, Porto VBG, Sato HK. The search for yellow fever virus vaccine in breast milk of inadvertently vaccinated women in Brazil. Rev Inst Med Trop Sao Paulo 2020; 62:e33. [PMID: 32491144 PMCID: PMC7266614 DOI: 10.1590/s1678-9946202062033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/22/2020] [Indexed: 12/04/2022] Open
Abstract
Eleven lactating women were inadvertently vaccinated with 17DD yellow fever vaccine in a small city of Sao Paulo State, Brazil. Their infants were being exclusively breast-fed and the breastfeeding was interrupted for 10 days. Serum and breastmilk were collected from the vaccinated mothers and tested for the presence of genomic RNA of the vaccine strain 8, 10 and 15 days after vaccination. Viral RNA was not detected in any of the serum and human milk samples tested and the infants remained asymptomatic. Our result strengthens the effectineness of stopping breastfeeding for 10 days after the inadvertent yellow fever vaccination of lactating women.
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Affiliation(s)
- Eder Gatti Fernandes
- Secretaria de Estado da Saúde, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica “Prof. Alexandre Vranjac”, Divisão de Imunização, São Paulo, São Paulo, Brazil
| | - Juliana Silva Nogueira
- Instituto Adolfo Lutz, Núcleo de Doenças de Transmissão Vetorial, São Paulo, São Paulo, Brazil
| | - Victor Bertollo Gomes Porto
- Secretaria de Estado da Saúde, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica “Prof. Alexandre Vranjac”, Divisão de Imunização, São Paulo, São Paulo, Brazil
| | - Helena Keico Sato
- Secretaria de Estado da Saúde, Coordenadoria de Controle de Doenças, Centro de Vigilância Epidemiológica “Prof. Alexandre Vranjac”, Divisão de Imunização, São Paulo, São Paulo, Brazil
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