14 Bay Area kids receive wrong vaccine dose

ANTIOCH >> In the latest incident of erroneous COVID-19 vaccine dosing that has frustrated parents of newly eligible children, 14 Bay Area kids received the wrong amount of the COVID-19 Pfizer vaccine at a Sutter Health pediatric clinic, the health system reported Tuesday.

The error was discovered Saturday morning after doses began to ran out faster than anticipated among the first group of kids to receive their shots, indicating that the vaccines were less diluted than they were supposed to be. A spokesperson for Sutter said that the affected kids — all of whom received the shots on Saturday — received roughly double the dose of the vaccine meant for 5 to 11-year-olds, or about 20 micrograms instead of 10 micrograms.

The doses contained too little diluting agent, which is added to vaccines on-site by clinic staff the same day they’re administered. According to the U.S. Centers for Disease Control and Prevention, children who receive vaccines with the wrong amount of diluent may experience more side effects, including arm soreness, fatigue and a fever — but they should still receive their second dose in the regimen.

Sutter confirmed that the kids received a larger amount of the vaccine than intended but would not answer detailed questions about what led to the error, including how many employees were responsible for diluting vaccines, and how many children were vaccinated total that day or over the weekend.

“As soon as we learned of this, we contacted the parents and advised them of CDC guidance in this situation,” Dr. Jimmy Hu, chair of the Sutter Health COVID-19 Vaccine Task Force, said in a statement. “The safety of our patients is our top priority, and we immediately reviewed our processes to help make sure this doesn’t happen again.”

In early clinical trials, Pfizer studied the effects of different vaccine doses for kids, including doses ranging from 3 micrograms to the full adult dose of 30 micrograms. Researchers settled on 10 micrograms because it provided a strong immune response but with fewer side effects than higher doses, they said at the time.

That means parents shouldn’t worry about any long-term consequences — whether related to side effects or vaccine efficacy — after receiving an accidentally bigger dose, said Dr. Peter Chin-Hong, an epidemiologist at UC San Francisco.

“You’re just giving more signals to your body to make an immune response … This error is not the same as giving a Tylenol overdose or something,” Chin-Hong said. “That said, it is scary for parents.”

Already, parents of the affected kids have been clamoring for an explanation from Sutter about what exactly happened Saturday. Denise Iserloth, whose 8and 11-year-old kids received the higher dosage at the Antioch clinic, told ABC 7 that both her kids came down with bad stomachaches after getting the double dose.

“They absolutely failed my children and the other 12 children involved,” Iserloth said.

Children between 5 and 11 became eligible for the Pfizer BioNTech vaccine at the start of November. So far in California, a little more than 3% of the age group — about 110,000 kids — have received their first dose, according to the state public health department.

The issue at the Antioch clinic adds to a growing list of dosing mistakes for kids in the US. Earlier this month, more than 100 children at a Virginia pharmacy received an incorrect dose of the vaccine when health officials gave them one-tenth of the formulation of the vaccine intended for adults, the Charlotte Observer reported, even though CDC has said that adult and children dosages are “not interchangeable.” Meanwhile in Maryland, another 98 kids received the wrong dosage at a school clinic over the weekend after the vaccines were over-diluted, officials said.

Still, errors in vaccine administration are exceedingly rare given the hundreds of thousands of doses that have already been given to kids, said Katherine Yang, a clinical professor of pharmacy at the UCSF School of Pharmacy.

“The vaccines are safe, and for the most part, these errors will not have much clinical significance,” Yang said. “I hope this does not scare parents away from giving their kids vaccines. It should not be a deterrent.”