一起接种乙肝及卡介苗疫苗偶合死亡病例的调查

Investigation of a coupling death case after inoculating hepatitis B and BCG vaccines

目的描述1例乙肝及卡介苗疫苗联合接种后偶合死亡病例的调查经过,为类似事件处置提供参考。方法对定安县一起接种乙肝及卡介苗疫苗后偶合死亡的病例开展个案调查,通过收集病例出生情况、预防接种过程、接种单位及人员资质、疫苗冷链信息、患儿抢救记录以及尸检等资料进行综合分析。结果患儿出生后第35天,于2014年11月18日上午10时完成第2针乙肝疫苗与1针卡介苗接种,留观30 min无异常,家属于当天上午10时40分将其抱回家,11时30分左右家长发现患儿其口唇发绀、手脚冰冷,紧急送到辖区农场医院进行救治,最终抢救无效死亡;结合尸检及案情资料,海南省预防接种异常反应调查诊断专家组调查诊断,受种者为出血坏死性小肠结肠炎致感染性休克而死亡,不属于预防接种异常反应,属于偶合症。结论接种疫苗偶合死亡常引起医疗纠纷及不良影响,有序协调、充分沟通、及时尸检、科学严谨、有法可依地处置此类事件非常关键。

Objective Describing the investigation of a case coupling death after inoculating hepatitis B vaccine combined with BCG（Bacillus Calmette Guerin） vaccine to provide a reference for the disposal of similar events in the future.Methods A case investigation and comprehensive analysis were conducted on a coupling death case after inoculating hepatitis B vaccine combined with BCG vaccine in Ding＇an Country. The data included birth conditions, vaccination process,vaccination units and personnel qualifications, the child＇s rescue records and so on. Results The second hepatitis B and the first BCG vaccine were inoculated to a child aged 35 days at 18：00 on November 18-（th）, 2014. The child was health when observing in 30 minutes and was taken home at 10：40. The child was found lip cyanosis, hands and feet cold at about 11：30,then taken to the farm hospital immediately. While the child died with invalid rescue. Combined the evidence of autopsy and the case data, the experts from the group for investigation and diagnosis of abnormal response to vaccination in Hainan Province concluded that the child was died of septic shock due to hemorrhagic necrotizing enterocolitis, but not abnormal reaction of vaccination, it belonged to coincidence syndromes. Conclusion The coupling death cases of vaccination often cause medical disputes and adverse effects. Orderly coordination, full communication, timely autopsy and be scientific, rigorous and law-abiding are the keys to deal with such incidents effectively.