Fifteen children died in South Sudan after receiving contaminated measles vaccines that had not been properly refrigerated, and were mixed using the same syringe for four days.
In addition to the blunders handling the vaccine, Health Minister Riek Gai Kok said that two children, aged 12 and 13, had been recruited to administer it.
An investigation showed that local officials failed to follow immunisation guidelines during a four-day campaign to vaccinate around 300 people in the southeastern state of Kapoeta in May, Kok said.
“The team that vaccinated the children in this tragic event were neither qualified not trained for the immunisation,” he added.
The campaign came amid a measles outbreak that has killed 70 children this year, the latest tragedy to strike the world’s youngest nation, which has been gripped by civil war for over three years — affecting its ability to deliver decent healthcare.
The country has also been affected by repeated bouts of cholera.
“A single reconstitution syringe was used for multiple vaccine vials for the entire four days of the campaign instead of being discarded after single use,” Kok said, referring to the device used to mix vaccines before injecting them with a separate syringe.
“The reuse of the reconstitution syringe causes it to become contaminated which in turn contaminates the measles vaccine vials and infects the vaccinated children.”
Local health officials also failed to follow cold chain protocols.
“The vaccines were stored in a building with no cold chain facilities for four days,” said Kok.
He did not expand on the use of children to administer the vaccines, saying only: “Recruiting children of twelve and thirteen that is unacceptable but we are going to find out how did it happen.”
The investigation, supported by the World Health Organisation (WHO) and the UN children’s agency UNICEF, determined that the children in the remote village of Nachodepele died from “the administration of a contaminated vaccine”.
Another 32 children suffered similar symptoms of fever, vomiting and diarrhoea but recovered.
According to the WHO, measles vaccines are freeze-dried and need to be reconstituted with a diluting agent just before being administered. The vaccine is supposed to be kept in the dark at between 2°C and 8°C.
“This year alone we have received 70 children (who have died) of measles …. Vaccines are safe if (officials) follow the guidelines,” said WHO country director Abdulmumin Usman.
Nearly two million people have fled South Sudan, which is also suffering a famine induced by the conflict. Tens of thousands of people have been killed in fighting.