AISAI, Aichi Prefecture--An investigatory committee concluded that a woman who died immediately after receiving a COVID-19 shot could have been saved if appropriate measures for a severe allergic reaction had been taken at the vaccination site.
Yoshimasa Nagao, deputy director at Nagoya University Hospital, who heads the medical accident investigation committee, reported the results of the investigation at a news conference on Sept. 26. He said that the woman, Ayano Iioka, likely had anaphylactic shock.
Iioka, who was 42 and resided in Aisai city, received a COVID-19 shot at the city’s mass vaccination site on Nov. 5, 2022.
Six minutes later, she began coughing.
She was moved to a first aid room, but her heart stopped beating after she vomited a large amount of bubbly, bloody secretions.
Her death was confirmed at a hospital about an hour and a half later.
She had underlying health conditions, the committee said.
Aisai set up a committee comprised of external experts to look into the matter and has been investigating the incident since the end of December.
The committee explained on Sept. 26 that the cause of death was acute respiratory failure due to pulmonary edema and acute circulatory failure.
Given that the symptoms of coughing and breathing difficulty appeared several minutes after receiving the vaccination, the committee said, “It is highly likely that the vaccination triggered anaphylaxis, which later developed into pulmonary edema.”
At the city’s mass vaccination site, no measures such as adrenaline muscle injections were taken to counter anaphylactic shock.
The on-site doctor had received reports that Iioka felt unwell before the inoculation and assumed the possibility of anaphylaxis was low since there were no typical symptoms.
The committee noted that these responses were “not standard.” It recommended that if a patient experiences breathing difficulties, a muscle injection should be administered under the assumption of anaphylaxis.
The committee concluded, “It cannot be denied that her life could have been saved if adrenaline was administered early.”
At the vaccination site, there were no prior meetings between doctors and nurses, nor any training for the eventuality of anaphylaxis,
The committee also pointed out that there is “room for improvement” in such medical systems.
To prevent recurrences, the committee is urging local governments and health care workers nationwide to renew their awareness regarding anaphylaxis and to conduct relevant training.
In March, an expert panel from the health ministry said that the causal link between Iioka’s death and the vaccination was undeniable.
Her husband, Eiji, 45, said, “I would like the government to create an environment where anyone can receive vaccinations safely.”
“I hope that the committee’s recommendations will be effectively utilized to prevent more people from having to go through a similar experience,” he said.
(This article was written by Ayami Ko and Hiroya Ueyama.)
