http://www.digitaljournal.com/life/health/contaminated-measles-vaccine-kills-15-children-in-south-sudan/article/494129

Botched measles campaign kills 15 children in South Sudan

Posted Jun 2, 2017 by Karen Graham
Fifteen young children have died in a measles vaccination campaign that saw kids as young as 12-years-old administering the vaccines, according to the South Sudan government.
A botched measles vaccination campaign has led to the deaths of 15 children in South Sudan.
A botched measles vaccination campaign has led to the deaths of 15 children in South Sudan.
United Nations
The deaths occurred in the rural and remote Nachodokopele village, Kauto County in South Sudan, and prompted an immediate investigation by the National Adverse Events Following Immunization (AEFI) Committee, supported by WHO and UNICEF.
Investigators found that all the 15 children who died were under the age of 5-years-old. The cause of death was determined to be "severe sepsis/toxicity" resulting from contaminated vaccine used at the measles campaign event. The real tragedy, as Relief Web points out is that this whole incident could have been avoided.
The Health Ministry is blaming the deaths on "human error," but it actually goes deeper than just an error, though. The WHO and UNICEF investigators discovered that one syringe was used to vaccinate all the children over a period of four days. The investigation also found that the vaccine had been stored the whole time without benefit of refrigeration, reports the Associated Press.
There was no evidence that WHO-approved immunization safety standards were being used. The reuse of the reconstitution syringe causes it to become contaminated which in turn contaminates the measles vaccine vials and infects the vaccinated children.
There are also protocols for the cold-chain storage of vaccines, and these were not followed. The vaccines were stored in a building without refrigeration for four days.
About 300 children were vaccinated over the course of four days. In addition to the 15 children who died, another 32 children became ill with similar symptoms of sepsis/toxicity, including fever, vomiting, and diarrhea, but recovered.
Dr. Samson Baba, an immunization official in the ministry of health, refused to comment on the deaths earlier this week, instead, demanding the source of the information that had been given out by the AEFI. The Ministry of Health has commissioned a multiagency administrative committee to review the AEFI report and make appropriate recommendations for better vaccine administration.
There is a question on whether a qualified health care worker was on the scene nor is it clear if any UN officials were on the scene at the time of the incident.