L.A. clinic diluted more than 2,000 doses of COVID vaccine

The executive director of a Los Angeles County community health center issued an apology this week after it was revealed it had administered more than 2,000 diluted doses of the Pfizer-BioNTech COVID-19 vaccine over the past year.

The incident, first reported by LA Taco, has been confirmed by the Los Angeles County Department of Public Health and Clínica Romero, the state-approved health center where the mix-up occurred.

“We were immediately in touch and communicated with everyone, and at that point we didn’t have a patient with any problems,” Carlos Vaquerano, managing director of Clínica Romero, said in an interview on Friday. “We understand your concern and I apologize for what happened.”

Dilute doses were administered at Clínica Romero’s Boyle Heights and Westlake locations, and around 2,100 people were affected, according to county health officials. Vaquerano said the shots were fired in September and October last year.

However, Vaquerano said his organization only learned what happened in May.

The problem, he said, stemmed from an employee continuing to dilute doses of Pfizer’s BioNTech vaccine when it was no longer necessary – resulting in a less effective formulation.

The employee in question was put on leave and eventually fired.

After Vaquerano learned of the issue, Vaquerano said that Clínica Romero notified public health officials as well as Pfizer and the US Centers for Disease Control and Prevention.

In a statement, the LA County Department of Health said it first learned of the problem on June 8.

“Nursing staff contacted the provider on the same day to determine what happened and confirmed that there were errors in diluting the vaccine at two different points,” the health ministry wrote in its statement. “DPH staff confirmed that the clinic had identified the issue and had already taken action to address the issues.”

Five days later, Ministry of Health officials conducted site visits at both sites.

“The issues were raised with the medical director, the vaccine coordinator and their clinical team. No other problems were identified during the visits,” the department said.

Because it wasn’t clear if the initial shots contained enough dose to protect against the virus, nurses at the clinic’s Department of Public Health advised the clinic to give the injections again.

If a lower-than-approved dose is administered, the CDC says patients should be promptly given a booster dose — although some experts recommend delaying the booster dose by eight weeks.

dr Robert Kim-Farley, an epidemiologist and infectious disease expert at the UCLA Fielding School of Public Health, said a lower-than-expected dose of vaccine could mean the shot given was “less effective at preventing infection … and less effective at preventing serious illness.”

Clínica Romero submitted an action plan to the Ministry of Health on June 14 to address the problem.

Officials said they would set up an 800 phone line to answer questions for patients on the matter and also set up dedicated clinics for those receiving the diluted doses.

Public Health “kept in touch with the provider as they distributed letters to affected individuals and finalized their plan of action,” the statement said.

Vaquerano said affected patients had been informed they could be given another dose but could not say how many had done so up to that point.

“It’s a human error and we’re sorry,” he said. “But what I can tell you is that we will continue to work together with our community. We have done what was recommended by the Department of Health and we are in contact with them, Pfizer and CDC and are doing what needs to be done.”

A man who received his booster vaccine from Clínica Romero in October 2021 was shocked when he received the clinic’s reply letter in August.

“Dear patient… Clinica Romero has been made aware that we may have diluted the Pfizer COVID-19 vaccines,” read the letter the patient received in August, according to LA Taco.

The letter informed him that his vaccine was at a “lower than recommended” dose and that he should get another one.

“I open it and I’m like, what the hell?” Pedro said in an interview with the news outlet. The article did not include his last name or a reason for it.

“How do I get this August 1st letter telling me that you rectified a situation that happened in October immediately?” he added.

Historically serving a predominantly immigrant population, Clinica Romero was founded in 1983 by Salvadoran immigrants as a focal point for Central American war refugees.

Its mission is to provide services to the “Uninsured, Insured and Underserved”.

The clinic faced the county in 2021 when it received just 100 doses of the COVID-19 vaccine despite serving 12,000 patients.

“How will 100 care for 12,000 patients and the surrounding community of 1 million?” asked Dr. Don Garcia, the clinic’s medical director. “That is embarrassing.”

Despite this issue, Vaquerano said he is confident that Clínica Romero retains the trust of the communities it serves.

“I invite you to look at our records,” he said, adding, “We will continue our work because our purpose is to serve with compassion and to serve the underserved.”

Times contributor Rong-Gong Lin II contributed to this report.

https://www.latimes.com/california/story/2022-09-02/los-angeles-clinic-diluted-more-than-2-000-doses-covid-vaccine L.A. clinic diluted more than 2,000 doses of COVID vaccine

Alley Einstein

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