EARLY last month, following a measles vaccination outreach activity near Mariam Road, Nawabshah, three children were repor­ted dead, with a dozen severely ill. Within days, these children were brought to the Aga Khan University Hospital in Karachi in a critical state. Another death was reported in Sanghar.

Despite a measles outbreak in the vicinity of Badin threatening to become a full-scale epidemic, the vaccination outreach has since been halted. A committee, under the World Health Organisation’s supervision, involving local authorities has been formed to probe these deaths.

All the children had a similar clinical picture with fever, vomiting and diarrhoea developing within hours of vaccination, rapidly progressing to shock and, in some cases, organ failure. One child also developed a rash, characteristic of an infectious cause.

A quick search revealed two comparable public health incidents with circumstances similar to those leading up to what transpired in Nawabshah. The first of these followed a measles vaccination campaign in Tamil Nadu, India, in the 1990s. Investigations attributed the septic shock to the virulent bacterium Staphylococcus Aureus, pointing to the possibility of contamination during any step of the vaccination supply chain, or a breakdown during vaccine administration.

More recently, there were 15 deaths among children in South Sudan last year due to the use of a bacteriologically contaminated measles vaccine, as reported in a WHO-/Unicef-supported investigation, with similar symptoms as those identified in Tamil Nadu and Nawabshah.

Doubts have been raised over the measles vaccine in Sindh.

The report further revealed that the vaccination team in the area was neither qualified nor sufficiently trained for immunisation campaigns, using one syringe available to them throughout the campaign with an improperly refrigerated vaccine being used. In both India and South Sudan, contamination was either due to improper reconstitution, storage or dispensing of the vaccine.

Maintenance of temperature and following procedural standards such as sterility are critical for vaccine integrity. This has implications for lack of standardised protocols being followed for immunisation within Sindh.

It cannot be ruled out that the sterile diluting liquid used to dissolve measles-vaccine powder was either expired or contaminated. Expiry may result in the growth of virulent bacteria, as demonstrated in Tamil Nadu’s case. However, further investigative reports to identify where the break in the vaccination chain occurred prior to administration would be useful in determining not only if the specific vials used to immunise these children were contaminated, but also at which step of the process the systemic failure occurred.

This untoward event should be flagged at the provincial level as a health crisis for officials, in order to prevent further vaccine rejection by communities, especially near areas that are currently more exposed to the possibility of a measles outbreak. Further, global oversight bodies such as GAVI should immediately mobilise teams of independent evaluators to look into this incident and provide local recommendations around immunisation supply-chain strengthening in Sindh.

Other fallouts from this episode need to be highlighted around the lack of confidence in the government’s ability to run public health activities, requiring a concerted effort to address this fear and mistrust. Otherwise, events such as these could lead to a considerable setback to Sindh’s measles outreach, as well as impact immunisation across Pakistan.

Following an incident of this magnitude, a public outcry and anger ensues, fuelled by the media demanding punitive actions. Ther­e­fore, while it is essent­ial that the perpetrators be held accountable, we must unde­rstand that rep­o­rting on such incidents is meant to constructively highlight how the Sindh government can bet-ter utilise allocated res­ou­rces to prevent negligence-rela­t­ed deaths in the future.

The true perpetrator is in the form of the constrained resources in a fragmented healthcare system where workers are expected to function. Despite limited resources healthcare professionals perform remarkably well, although training in handling immunisation-related adverse events as well as prompt identification and management of critical illnesses is required for junior doctors who believed that expired vaccines are the reason behind the deaths (in Nawabshah).

The solution lies in providing basic resour­ces for those involved in public health activities within their communities, strengthening local governance procedures, having regularly supervised trainings of officials, and the provision of resources to ensure safe, standardised vaccine delivery.

Unlike these vaccine-related reactions, deaths from measles have hardly gained any interest from the media and public, with lives saved and disability prevented thanks to vaccines never being reported on. Detailing why vaccines remain the best public health intervention after water sanitation and hygiene are therefore essential to highlight.

The writer is assistant professor at the Dept of Paediatrics & Child Health, AKU.

Published in Dawn, April 11th, 2018