I read with interest and curiosity the Viewpoint and IAPCOI stand
articles on AEFI with particular reference to measles vaccination
related deaths in Tamil Nadu(1,2). I want to share my personal
experience as a field investigator on similar measles vaccination
deaths in Manali New town PHC (about 10 km from Chennai) way back in
1991-1992. At that time 6 children died. All of them developed high
fever, diarrhea and vomiting, within 30 -60 minutes followed by septic
shock typical of toxic shock syndrome. The important finding on field
investiga-tion was that the vaccine administered was pink in color.
This gave me a clue. We injected Staphylococcus aureus from culture
medium in fresh vials of OPV, DPT and measles vaccine. There was no
change in OPV vials which remained pink. DTPw vials got flocculated.
The reconstituted multidose measles vaccine vial turned pink from the
original amber yellow color and demonstrated proliferative growth of
S. aureus. We submitted our findings to the state government, but were
restrained from publishing this information. However, instructions
were given to health authorities and health workers to discard any
measles vaccine vial which turns pink in color. I do not think that
the color of the measles vaccine was ascertained in the Thiruvellore
tragedy perhaps since everybody thought that the deaths were due to
anaphylaxis even though epidemio-logists will not agree to the
occurrence of anaphylaxis in cluster. Probably, this tragedy was due
only to human error and a muscle relaxant might have been
inadvertently used as a diluent.
As a National Trainer for 18 years since EPI launch
in 1978, I was involved in field surveys and training of staff of PHC,
taluk and district hospitals under UIP and CSSM programs till 1996
when I retired. Those were the golden years where training and
supervision at all levels was "state of art". After introduction of
RCH1 in 1997 the hitherto WHO/UNICEF sponsored National training
programs were decentralized and the responsibility was entrusted to
the respective state governments. Unfortunately the quality of
training as well as supervision gradually dwindled. The result is what
we saw at Thiruvellore since the health worker did not follow the
simple rule of observing the vaccinated child for at least for a
minimum of 30-60 minutes following immunization and did not have
emergency kit containing adrenaline and ambu bag etc though she
carried the vaccines in a vaccine carrier and reconstituted the
lyophilized measles vaccine with recommended diluent(?).
Since immunization is a global operation, a WHO
team should investigate such vaccine deaths occurring in their member
nations to find out the actual cause of death instead of the vaccine
manufacturers and the central and state government machinery. There
are so many ifs and buts that remain unanswered in the Thiruvellore
tragedy.
A Parthasarathy,
Past President IAP and Past Chairperson,
IAP Committee on Immunization.
Email: [email protected]
1. John TJ. Death of children after measles vaccination. Indian
Pediatr 2008; 45: 477-478.
2. Amdekar YK, Singhal T. Measles vaccine deaths: The IAP-COI
stand. Indian Pediatr 2008; 45: 479-480