The CDC has reported that, in March 2009, several people accidentally received blood products with yellow fever vaccine in them. The investigation documents evidence for transmission of vaccine virus through infected blood products.
The mistake was a human error that could have been prevented. In response, the CDC decided to reissue its guidelines for donating blood.
It was the CDC, itself, that reported the incident in the Morbidity and Mortality Weekly Report.
But it should have attracted major media attention, because it potentially could have had devastating consequences, had all the people who received the contaminated blood contracted yellow fever, or come down with any of the side effects associated with the vaccine.
It’s not the first time a human error with a vaccine has occurred. Some of these mistakes are huge, such as when a major vaccine manufacturer, Baxter, admitted last year that the company had released a vaccine contaminated with an experimental flu virus.
Other mistakes are smaller, but just as serious, such as what happened last month in Great Britain, when the BBC reported that 59 children were accidentally given adult swine flu shots. The mistake was discovered when the children began coming down with side effects
And talk about accidents -- one just occurred in Massachussetts, when staff members in a school flu vaccine clinic got injected with insulin instead of H1N1.
It’s no wonder that the International Council of Nurses lists human error, through mistakes in vaccine preparation, handling or administration, as the most common errors linked to vaccine safety.