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Ultra-low COVID-19 vaccine dose given to six people

1 November 2021

Queensland Health has today contacted 175 people who received the Pfizer COVID-19 vaccination at the Flagstone Community College pop-up vaccination clinic on Saturday 23 October.

It has been identified that six people may have received an ultra-low dose of the vaccine, due to a vaccine preparation error.

The Pfizer vaccine requires a process of preparation, where saline is added to the vaccine vial and withdrawn to make up to six doses.

An initial review indicated one vial was used twice, meaning the doses drawn on the second use were over-diluted.

Unfortunately there is no ability to trace which six of the 175 people through the vaccination pop-up clinic were given the ultra-low dose, and we will contact all those impacted to discuss revaccination, if required.

A review is underway  to further understand what happened, what caused the error and how processes can be improved.

Chief Health Officer Dr Peter Aitken said an ultra-low dose is not harmful, but could affect your immunity to COVID-19.

“We have sought expert medical advice from the Commonwealth Department of Health on this matter, and will work with those impacted to ensure optimal immune response to the vaccination is achieved,” Dr Aitken said.

“Of those 175, 148 were receiving their first dose and 27 were receiving their second dose.

“We will offer a dedicated pop-up clinic locally for people who are recommended to receive a repeat dose to ensure they are fully vaccinated against COVID-19,” he said.

Queensland Health has attempted to make phone and email contact with each of the 175 people to advise them of the next steps.

Metro South Health COVID-19 Incident Controller Dr Michael Cleary apologised for the error and said it was detected following the conclusion of the pop-up clinic as part of the due diligence process.

“I apologise for any distress this has caused to those 175 people and their families. We will, of course, be supporting every single person impacted,” Dr Cleary said.

“I am incredibly grateful that the error was picked up quickly following the conclusion of the clinic as a result of our safeguards and due diligence.

“A full incident report is being prepared which will allow me and my staff to better understand what needs to be done to improve processes at future pop-up clinics.”


Last updated: 1 November 2021