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Death of 15 children from Sudan linked to contaminated measles vaccine

A contaminated measles vaccine is responsible for the death of 15 children in a village in South Sudan, according to a joint statement issued by the Health Ministry, WHO and UNICEF.

A WHO/UNICEF-supported investigation has determined that the cause of death in all 15 children was severe sepsis and toxicity resulting from vaccination. Fever, vomiting and diarrhea were observed in 32 other children in the same rural village of Nachodokopele, but these patients later recovered. Three hundred people were vaccinated over the course of the campaign.

“Ministry of Health, WHO and UNICEF express our deep regret and sadness at the passing of the children,” the organizations said in the statement. “This tragic event could have been prevented by adhering to WHO immunization safety standards.”

The investigation report noted that the team responsible for vaccinating the village were neither qualified nor sufficiently trained for the immunization campaign. While administering these vaccines over the course of 4 days, the vaccination team used a single reconstitution syringe for the entirety of the campaign, rather than adhering to protocol and discarding them after each use. The continual reuse of the single syringe contaminated the measles vaccine vials used for these vaccinated children.

Additionally, the investigation found that these vaccines had been kept in a building with no access to cold chain facilities to preserve their quality.

“The measles vaccine has been used all over the world to protect more than 2 billion children against measles,” the organizations said in the release. “When used according to WHO-approved immunization safety standards, the measles vaccine is safe and effective. In South Sudan, this is the fifth follow-up vaccination campaign. The past campaigns were successfully implemented and the safety of the vaccine was assured.”

The risk for measles, and other vaccine-preventable diseases, remains extremely high in South Sudan, as military conflicts have restricted what health services can be provided to their population. — by Katherine Bortz