Alibi V.16 No.39 • Sept 27-Oct 3, 2007 

News Feature

New Mexico Department of Health Plays it Cool After Losing $4.3 Million in Children’s Vaccines

The New Mexico Department of Health (DOH) is trying to keep its cool after a refrigerator malfunction in July that compromised $4.3 million worth of children’s vaccines. The DOH is still uncertain as to what caused the malfunction as well as precisely how and why the loss occurred. The malfunctioning refrigerator remains in use in the Immunization Department’s Santa Fe pharmacy, where the state’s vaccine supply is stored.

Out of Range

The vaccines were compromised when the temperature in one of three refrigerators dipped to 32 degrees Fahrenheit, three degrees below the safe storage range of 35 to 46 degrees, according to Dr. Maggi Gallaher, medical director for the department’s Public Health Division. Beyond this range, she says vaccines lose their efficacy.

To safeguard against sudden temperature fluctuation, the pharmacy’s alarm system is set to automatically read refrigerator temperatures every two minutes, says Deborah Busemeyer, communications director for the DOH. However, pharmacy employees had no way of knowing the alarm had been activated, as the pharmacy was unmanned over the Fourth of July holiday weekend. The department didn’t discover the malfunction until the morning of July 5, when a pharmacy worker returned to the building and heard alarms wailing.

Although pharmacists couldn’t be certain the vaccines were damaged, they were forced to replace the entire supply subjected to the temperature drop. “You never take a chance,” says Busemeyer. “That’s why we got rid of all of the vaccine, just to be on the safe side.” Vaccines for hepatitis A and B, diphtheria, pertussis, polio and tetanus were discarded just before the busy, back-to-school immunization season.

Pharmacy, Phone Home

Immediately following the malfunction, from July 6 to July 19 the DOH rented a refrigerated truck as a stopgap in the event of another malfunction. “If there were ever any issues, we could store [the vaccines] in there,” Busemeyer says. The DOH has also reintroduced an alarm system that automatically phones pharmacy employees at home if a problem occurs. This telephone system was not in place at the time of the July mishap, though the pharmacy had used the service in the past.

The department’s provider for refrigeration services is 7-D Heating and Cooling. On the weekend of July 4, the services provided by 7-D included a system that would automatically phone the home of a DOH worker in the event of a power outage but not in the case of temperature irregularity. The pharmacy did experience a power outage on Monday, July 2, but backup generators were used to stabilize the refrigerators’ temperatures. Whether this power outage contributed to the refrigerator’s subsequent malfunction is unknown.

A Costly Glitch for CDC and State Taxpayers

The U.S. Centers for Disease Control (CDC) replaced the lost vaccines within a week of the malfunction, paying $4 million of the tab with federal funds. The State of New Mexico chipped in the remaining $300,000. By Dec. 3 of this year, says Gallaher, the CDC will ship vaccinations directly to in-state providers, eliminating storage at the Santa Fe pharmacy as a step in the delivery process. Busemeyer says the DOH is working with the CDC to implement this “seamless” process. “Certainly, having a refrigerator malfunction was a good reminder … of how we can store the vaccine better and make sure providers can get access to vaccines quicker,” she says.

Despite an investigation by 7-D Heating and Cooling, the DOH remains unsure as to why or how the glitch occurred. “The company couldn’t tell us. They just weren’t sure what happened,” says Busemeyer. “The company didn’t do anything wrong. It was a glitch. It wasn’t within our control. This has happened in other states.”

Busemeyer estimates the New Mexico Department of Health provides free vaccinations to approximately three-quarters of all children in the state, from birth to age 18. These children, who qualify for free vaccines through the department’s Vaccines for Children program, are uninsured, underinsured or Native American. “We have a high percentage of these children [in New Mexico],” says Busemeyer. “We are the safety net provider. We have made immunizations a priority here.” Vaccinations are offered through a network of providers, clinics and programs throughout New Mexico.

Play it Again: Not the First Time

The most recent failure at the DOH marked New Mexico’s second vaccine loss due to faulty storage in the last two years. In July of 2005, potentially ineffective children’s vaccines were administered after being improperly stored at provider locations. Thousands of children throughout the state were subject to a second round of immunizations after being issued vaccines that had been stored at unsafe temperatures.

According to Dickson Data, a manufacturer of thermal regulation equipment, vaccine loss due to refrigerator malfunction is a frequent problem. Likewise, the CDC points to improper storage and poor monitoring practices as the most common causes of compromised vaccines. The CDC also advises states to maintain written emergency retrieval and storage procedures in the event that equipment or power fails and urges states to implement around-the-clock monitoring systems to alert staff to after-hours emergencies.