A 13-year-old girl comes to the health centre accompanied by her mother, who asks to be vaccinated against tuberculosis. She is planning a study trip to the United States and is told that this is one of the requirements for access to education in certain centres in that country. She is informed that the vaccine is not available at the health centre, as it is not included in the current immunisation schedule of the Community of Madrid, as well as the possibility of attending the International Vaccination Centre. However, the mother stated that, due to her profession, she had access to this vaccine and only requested that it be administered at the centre, with the family themselves providing the vaccine.
After the vaccine was administered and the girl complained of pain at the injection site, accompanied by a feeling of dizziness, she was attended to according to the protocol. On checking the packaging of the vaccine, it was found that the 2 ml vial that had been inoculated was not a single dose, the usual form of presentation of the vaccine, but contained 20 doses, which were inoculated intramuscularly, given the volume of the presentation (the usual dose for adults is 0.1 ml, injected subcutaneously).
After verifying that the girl's condition is good and that her vital signs are normal, the family is informed of the error made and the relevant health authorities are informed. To obtain as much information as possible about the vaccine, we contacted the Institute of Toxicology and the Preventive Medicine Service of the Hospital Universitario 12 Octubre, the Management Department of the Reference Area, as well as the Infectious Diseases Service of the same hospital and the manufacturing laboratory (Pharmacia Spain) and the International Vaccination Centre.
The girl was clinically monitored at the Infectious Diseases Department of the Hospital Universitario 12 de Octubre for six months, with analytical studies and immunity tests, all of which were normal both at the onset of the event and during its evolution. She did not develop any type of reaction at the injection site either in the immediate period or during the follow-up period, and was discharged without any incident. She did not receive any anti-tuberculosis treatment during her follow-up.