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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 To describe the investigation of a coupled death after hepatitis B and BCG vaccination in order to provide a reference for the handling of similar incidents. Methods A case investigation was conducted on cases of death after mating with hepatitis B and BCG vaccine in Ding’an County. The cases were collected by collecting the cases of birth, vaccination process, vaccination unit and personnel qualifications, vaccine cold chain information, pediatric rescue records and autopsy and other data analysis. Results On the 35th day after birth, the children were vaccinated with the second dose of Hepatitis B vaccine and the first dose of BCG vaccination at 10:00 on the 18th of November, 2014, with no abnormality after 30 minutes of observation. The relatives returned to their families at 10:40 on the same day At 11:30, parents found their lips cyanosis, cold hands and feet, emergency delivery to the farms in the area hospital for treatment, the final rescue ineffective death; combined with the autopsy and the merits of the case, Hainan Province, vaccination anomalies response to the investigation of diagnostic expert investigation , By the type of hemorrhagic necrotizing enterocolitis caused by septic shock and died, does not belong to the prevention of vaccination abnormal reaction, is a coupling syndrome. Conclusions Vaccine-coupled deaths often cause medical disputes and adverse effects. It is crucial to orderly coordinate, fully communicate, and promptly post mortemly and scientifically rigorously and legally handle such incidents.