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130 people received wrong dose of Covid-19 vaccine: MOH

There have been 130 people here who received a wrong dose of Covid-19 vaccine since Singapore began its vaccination exercise in late 2020, with 11 persons affected by overdosing and 119 having received a lower dose than the recommended amount of a vaccine.

This is out of about 16 million doses of Covid-19 vaccines administered here as of Sept 26, Senior Minister of State for Health Dr Janil Puthucheary said in Parliament on Monday.

Of these incidents, seven were children between the ages of five and 11 years old, none of whom had any adverse reactions, he added.

"The adults had either no adverse reactions or recovered uneventfully," he said.

His comments followed an incident on Sept 15 when two adults were each given a full vial of undiluted Pfizer-BioNTech Covid-19 vaccine at a ProHealth Medical Group clinic in Hougang. A full vial of undiluted vaccine contains five doses.

One patient was hospitalised after experiencing a headache and an increased heart rate, but was later discharged, while the other did not report any adverse reaction.

Dr Puthucheary said the Ministry of Health's (MOH) investigation of the incident is ongoing, and that MOH will take appropriate enforcement actions if any regulatory breaches are found.

He was replying to questions from Ms Joan Pereira (Tanjong Pagar GRC), Dr Wan Rizal (Jalan Besar GRC) and Mr Gerald Giam (Aljunied GRC) such as on the requirements for clinics to report when such cases happen, and safeguards to prevent similar incidents from occurring in the future.

Dr Puthucheary said vaccination providers are required to report to MOH no later than three hours after vaccine administration errors and medical emergencies following vaccination.

Providers are also required to inform patients immediately when a vaccination error has occurred and to monitor patients' health with daily calls for the next seven days to ensure their well-being.

In a supplementary question, Mr Giam noted that there was a four-day delay between when the incident at the ProHealth clinic occurred and when MOH was informed on Sept 19.

The Workers' Party MP asked how soon clinics must notify affected patients and extend assistance to them, and if there are any penalties for not reporting such incidents to MOH, or reporting them late.

"The patient should be notified as soon as the care provider knows that there is an error, that would be a reasonable expectation," Dr Puthucheary replied, adding the patient should then be provided immediate care.

As for penalties for late or non-reporting of such cases, he said this depends on the circumstances and reasons, and who knew but did not report.

"As the matter is still under investigation, it would be premature for me to comment," he said.

Dr Wan Rizal (Jalan Besar GRC) asked whether more stringent processes would be introduced to ensure such incidents do not happen again.

Dr Puthucheary said the clinic and personnel involved in the Sept 15 incident will be reviewed, while noting that "the vast majority" of clinics and vaccine providers here had administered the vaccines safely and correctly.

When incidents of wrongful vaccine dosing occur, the authorities identify whether they were caused by individual error, processes on site, or a systemic problem with the vaccination process, he said.

"All our data so far suggests that the last is not likely, and the vast majority of our doses have been delivered quite safely," he said. "Nevertheless, MOH continues to review all of this."

covid-19SINGAPORE PARLIAMENTMinistry of Health