Maui Health is forced to discard 1,300 Pfizer doses
Vaccines were compromised after fridge door didn’t seal
Maui Health said a malfunctioning refrigerator compromised more than 1,300 doses of the Pfizer vaccine, though the hospital operator said enough supply remains to keep all appointments already on the books.
Supplies of the vaccine are securely locked in an ultralow temperature freezer at Maui Memorial Medical Center until they need to be transferred to a refrigerator to be thawed. The doses had been placed in the fridge over the weekend in preparation for this week’s clinic appointments when staff discovered Monday that the door had failed to seal.
“Our team immediately contacted Pfizer and it was determined that the vials would need to be removed from clinic use and discarded appropriately,” Maui Health said in a news release Tuesday. “The Department of Health was immediately notified, as were our partners at the Healthcare Association of Hawaii.”
Maui Health spokeswoman Tracy Dallarda said Tuesday that workers usually double check the fridge, but because it happened on a Friday, with no vaccine clinic the next day, the issue went unnoticed until Monday.
“Unfortunately this happened on Friday. We don’t have a clinic on Saturday and Sunday, so when they came in first thing Monday morning they saw it,” Dallarda said. “Even if it had been the same day, it wouldn’t have been compromised. There wouldn‘t have been enough time for the temperature to rise. But because it was over the weekend, it was obviously unfortunate, because it was two days.”
Dallarda attributed the loss of the doses to a mechanical malfunction and not a staff error, pointing out that they tested the door after discovering the issue and it still wouldn’t stay closed.
“Nobody really knows how it happened,” Dallarda said. “For some reason it just stayed slightly ajar.”
The refrigerator is being repaired, but future doses will be stored in an alternative location, Maui Health said.
Dallarda added that if they need to thaw vaccines in the future, they will place doses in the hospital’s pharmacy refrigerator because there’s a worker in the pharmacy 24 hours a day. If there are any issues with the temperature, an alarm will go off.
“There’s constant surveillance so we don’t ever have this issue again,” Dallarda said.
Since the state began its vaccination rollout, a total of 2,400 doses have been lost, including the 1,386 doses at Maui Memorial and 1,014 doses “in separate incidents around the state since mid-December,” Department of Health spokesman Brooks Baehr said.
“The vast majority, or 881, of those 1,014 doses were lost when a vial or syringe was broken,” Baehr said Tuesday evening. “Other doses were not administered after a vial had been opened or vaccine had been drawn into a syringe but not administered.”
He said that the 1,014 doses represent less than 0.2 percent of doses administered in Hawaii.
“In other words, fewer than two doses per 1,000 vaccines administered had been lost prior to this unfortunate incident on Maui,” Baehr said.
When asked if DOH investigated the loss of vaccines on Maui and whether it was due to human error or mechanical malfunction, Baehr said that “the only information I have about how this happened is what Maui Health has said in its press release.”
Despite the loss of the doses, Maui Health said it still has sufficient supply of the vaccine to keep all current and future appointments as scheduled. After a shortage in January that forced Maui Health to cancel thousands of appointments, Dallarda said that “we don’t ever want to be in that position again” and that the hospital been requesting enough supplies to cover weekly appointments, plus a little extra for unexpected appointments and to get the next week’s clinics started before they receive another tray.
Hospital officials sat down with the Healthcare Association of Hawaii and the DOH weeks ago to calculate what Maui Health would need to increase capacity at its clinics. The state agreed to supply enough to support about 4,000 appointments a week and scale up if Maui Health could meet that.
Daily appointments have been ranging from 800 to 1,100 a day, Dallarda said. She added that the number of doses on hand fluctuates but that the hospital plans for about 4,000 appointments a week, “and we’re really close to that.”
All vaccines are stored in the hospital’s ultra-low temperature freezer donated by the University of Hawaii Maui College. When doses are needed for Maui Health’s satellite clinic in Kihei and vaccination events on Lanai, they are thawed and transported to the locations.
DOH’s Maui District Health Office does not have a freezer and thus uses Moderna, which doesn’t need to be stored at the same ultra-low temperatures as Pfizer, Dallarda said.
She added that she didn’t think more storage locations were needed on Maui because the hospital’s freezer is “like the size of a bank vault” and can hold thousands of doses to support vaccination events around the island.
“I think even if we were to do something on the west side, we would take the doses needed there on the day . . . . It’s just safer that way,” she said. “Ultra-low temperature freezers are not easy to come by.”
So far, Maui Health has administered more than 25,000 vaccines to Maui residents and plans to hold a drive-thru vaccination event on Lanai on Saturday for residents ages 16 and older.
Maui Health said it also plans to announce a new, expanded site soon.