Vanishing Vaccine

Vanishing Vaccine

The Knox County Health Department believes an employee inadvertently tossed out nearly 1,000 doses of COVID-19 vaccine.

by scott barker • February 11, 2021
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A nurse receives a COVID-19 vaccine at University of Tennessee Medical Center in December. (UTMC photo)

A Knox County Health Department employee apparently threw away 975 doses of Pfizer-BioNTech COVID-19 vaccine after mistaking its unmarked box for one containing dry ice.

Vaccination schedules won't be affected by the missing doses, according to the Health Department

That’s the conclusion drawn by Dr. Martha Buchanan, director of the Health Department, and her staff to explain how a recent shipment of the vaccine seemingly vanished into thin air.

Health Department staff discovered that a shipment apparently was missing last week. On Tuesday, the Tennessee Department of Health confirmed that it sent the 975 doses to Knox County that are now unaccounted for. Buchanan said her staff had not received notification the shipment was on its way and wasn’t looking for it when it apparently arrived in late January.

During a Wednesday press conference she called to announce the situation, Buchanan said the missing shipment hasn’t been located and was believed to have been hauled off with the department’s trash. “What we believe happened is that they were discarded or disposed of, believing that it was just a box of dry ice,” she said.

State and local officials are collaborating on an investigation. 

“We are aware of the situation in Knox County, and are working with our partners at the Knox County Health Department to determine what occurred and how such an event can be prevented going forward,” Bill Christian, assistant director of the state Department of Health’s communications office, said in an email.

The Health Department only recently began using the Pfizer vaccine after exclusively deploying the Moderna vaccine during the first weeks they were available. 

Unlike the Moderna vaccine, the Pfizer vaccine must be stored at minus-95 degrees Fahrenheit and the manufacturer ships it with dry ice. The boxes are unmarked and come without packing lists as a security precaution, Buchanan said. The boxes containing dry ice and those carrying vaccine differ in minor ways, she said, but appear similar.

The county received its first shipment of the Pfizer vaccine three weeks ago and administered first doses to people in the cohorts authorized to receive the shots by the state of Tennessee — healthcare workers, first responders and other designated groups, plus anyone age 70 or older.

The shipment that disappeared was sent two weeks ago. When a shipment arrived last week, employees realized they had missed a delivery, Buchanan said.

“And when we looked at that and realized the differences in the boxes and the appearance of the shipment, that's when our team member was like, ‘Oh goodness, maybe there was a secondary shipment that I thought was dry ice,’” she said.

Buchanan said the state typically notifies her office when a shipment is on its way. Pfizer uses GPS technology and temperature sensors to remotely track shipments, but the Health Department never heard about any problems with the shipment, she said.

Buchanan posed several questions that need to be answered: “Why didn't the GPS tracker work? Why didn't the temperature monitors work? Why were we the ones who found this out?”

She emphasized that the people who received first doses of the Pfizer vaccine will be able to receive their second doses. To be effective, first and second doses of the Pfizer vaccine must be administered 21 days apart, and the Health Department has enough on hand to complete the sequence for the initial group of recipients.

After a review, Buchanan said, the Health Department has made changes to the way it handles vaccine shipments as a result of the incident. “We put some more checks and balances in place,” she said, adding that more people will be added to the team handling deliveries, and redundancies will be built into the process. “We'll be keeping a close eye on it.”

Buchanan emphasized that Health Department employees did the right thing when the situation became apparent. “They made us aware of a mistake and they're working to correct that,” she said.

Buchanan said staff members have dedicated their lives to public health and were devastated about losing the vaccine, which is already in short supply. At one point in the press conference, she nearly broke down when describing how the incident had affected her staff. 

“It was a kick in the gut for all of us,” Buchanan said, pausing as she teared up. “Getting our community … I apologize … vaccine for our community is very important to us.”

Knox County Mayor Glenn Jacobs, who has expressed support for Buchanan even as he has opposed restrictions she has championed during the pandemic, defended her and the department.

“I am proud of Dr. Martha Buchanan and I am confident in the good work the Knox County Health Department does every day,” he said in a statement. “I certainly wish this had not happened, but I also think it’s unrealistic to believe that when you’re undertaking an operation of this magnitude mistakes won’t be made. KCHD is taking a close look at their processes and will do everything they can to make sure it doesn’t happen again.”

News of the incident overshadowed the Health Department’s launch of its new vaccine appointment registration system, which features a waiting list. Buchanan said more than 5,000 people had signed up on the site as of early Wednesday afternoon.

“We're happy with how it went,” she said of the rollout. “I guess, no news is good news. Nobody's called me and said we crashed or anything like that, so that's good.”