There is an investigation into 47 cases of adverse events, including 15 deaths linked to a four-day integrated measles vaccination campaign in Nachodokopele Village, Kapoeta State, South Sudan.
In addition to the recorded deaths, 32 individuals suffered similar symptoms of fever, vomiting and diarrhea, and 35 individuals had abscesses at the site of injection.
A causality assessment concludes that there is a high likelihood that the events were associated with an Immunization error-related reaction, which manifested as severe sepsis / toxic shock syndrome following administration of a contaminated vaccine.
According to the World Health Organization, several programmatic gaps may have contributed, including the use of non-qualified and non-trained personnel, poor adherence to cold chain and vaccine handling standards, and non-adherence to Immunization safety standards. The use of a single reconstitution syringe for multiple vaccine vials for the duration of the campaign likely led to severe contamination of the vaccine being reconstituted.
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