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New Taipei hospital ordered to stop vaccinations after administering 25 undiluted BNT jabs

25 recipients were given 6 times the recommended BioNTech vaccine dose

En Chu Kong Hospital staff bow to apologize for mistakenly administering undiluted BNT vaccine to 25 people. (En Chu Kong Hospital photo)

En Chu Kong Hospital staff bow to apologize for mistakenly administering undiluted BNT vaccine to 25 people. (En Chu Kong Hospital photo)

TAIPEI (Taiwan News) — A hospital in New Taipei City has been ordered to stop administering vaccines after it inoculated 25 people with undiluted doses of the Pfizer-BioNTech (BNT) COVID-19 vaccine on Monday (Sept. 27).

The management team of En Chu Kong Hospital in New Taipei apologized at a press conference on Tuesday morning (Sept. 28) after staff were found to have injected undiluted BNT doses into 25 people at a vaccination station in Yingge District on Monday. Wang Chung-cheng (王炯珵), vice superintendent of the hospital, said that on-site staff had found an abnormality when counting the number of doses at noon that day.

After questioning the pharmacist and nurse on duty, it was discovered that they had directly injected undiluted BNT vaccine from 25 vials into 25 recipients. The error is believed to have occurred when the purple caps inadvertently fell off the vials, leading the staff to believe that the vials contained diluted doses ready for inoculation.

Before usage, each vial of BNT vaccine should be diluted with 1.8 mL of 0.9% sodium chloride solution. Once diluted, each vial contains six doses and will have its purple cap removed to indicate it is ready for use.

However, because the vials were not diluted, the 25 individuals received six times the normal dosage, enough for 150 people. The recipients included 14 women and 11 men between the ages of 18 and 65.

None of the recipients have reported any severe reactions thus far, with only two reporting minor redness and swelling at the injection site. Nine are undergoing observation in a hospital for three days as a precaution.

After being discharged from the hospital, they will return one week later to undergo an additional examination. Those who choose not to undergo hospitalization are asked to arrange for follow-up examinations and carefully monitor their health each day.

In response to the incident, the New Taipei City Government Department of Health ordered the hospital to stop administering vaccines for one week. Wang pledged that the hospital will conduct a review of the incident and improve its procedures.

Chinese Medical University Hospital Deputy Superintendent Hwang Kao-pin (黃高彬) was cited by CNA as saying that the recipients should monitor their health for 28 days after the injection. During this period, they should be on the lookout for suspected symptoms of myocarditis such as chest tightness, chest pain, palpitations, shortness of breath, exercise intolerance, and fainting.