Top 5 Takeaways

1. Improper Vaccine Handling: Inadequate vaccine storage, handling, and administration by untrained personnel led to injection-site infections and other adverse events.
2. Multistate Investigation: The investigation identified 101 patients with vaccination-associated adverse events, including 30 with confirmed nontuberculous mycobacteria infection.
3. Common Source Contamination: Contamination likely occurred during syringe preparation, worsened by inappropriate storage and handling practices.
4. Importance of Reporting: Timely reporting to the Vaccine Adverse Event Reporting System (VAERS) and public health authorities is crucial for detecting and managing vaccination-associated adverse events.
5. Preventable Outbreak: The outbreak was preventable with proper vaccine storage, handling, and administration practices, highlighting the need for trained healthcare workers.

Original Article Author and Citation

Corresponding Author

Erin F. Blau, okl2@cdc.gov

Suggested Citation

Blau EF, Flinchum A, Gaub KL, et al. Mycobacterium porcinum Skin and Soft Tissue Infections After Vaccinations — Indiana, Kentucky, and Ohio, September 2018–February 2019. MMWR Morb Mortal Wkly Rep 2021;70:1472–1477. DOI: http://dx.doi.org/10.15585/mmwr.mm7042a3

Summary

A multistate investigation identified 101 patients with vaccination-associated adverse events, including 30 with confirmed nontuberculous mycobacteria infections, following workplace vaccinations in Indiana, Kentucky, and Ohio. The infections were linked to improper vaccine storage, handling, and administration by inadequately trained personnel from a third-party healthcare company. The investigation highlighted the importance of proper vaccine handling and timely reporting of adverse events to public health authorities.

Methods

The investigation involved site visits, interviews with staff, and collection of vaccine samples and environmental swabs. Pulsed-field gel electrophoresis was used to subtype Mycobacterium porcinum isolates. Vaccine antigen levels were measured using mass spectrometry. Patient interviews and medical record reviews were conducted to identify cases and gather information on vaccination-associated adverse events.

Discussion

The investigation revealed significant breaches in vaccine storage and handling protocols, including the use of non-recommended storage equipment and improper syringe preparation practices. The findings suggested a common source of contamination during syringe preparation, exacerbated by inappropriate storage. The lack of timely reporting to VAERS and public health authorities delayed the detection and management of the outbreak.

Conclusion

This outbreak underscores the critical role of trained healthcare workers in ensuring safe vaccine storage, handling, and administration. Proper training and adherence to guidelines can prevent such adverse events. Timely reporting of adverse events to VAERS and public health authorities is essential for early detection and intervention.

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