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‘Human error’ caused children’s death in Benazirabad, says health ministry

‘Human error’ caused children’s death in Benazirabad, says health ministry

KARACHI: Terming the death of four children in Benazirabad district a ‘human error’ and not the result of unsafe measles vaccine, the Sindh health ministry has said the matter had been taken up at the highest level and “strict disciplinary action” is being carried out against those involved in the sad episode.

Meanwhile, Health Secretary Fazlullah Pechuho told a press conference on Wednes­day that the incident occurred because of transfer of bacteria in a vial owing to erroneous administering of vaccine.




“An unfortunate incident occurred in Nawabshah (Benazirabad) on March 1 where three infants died during the mother and child week. We are all saddened by this event. We offer our heartfelt condolence to the families and relatives who lost their loved ones,” said a statement issued by the health ministry on Wednesday.

Upon receiving the report of that tragic incident, it said, the Sindh government’s health ministry immediately formed an investigation committee comprised of government officers, paediatricians and technical partners and “the committee has established what went wrong”.

“The Sindh government would like to inform the public and the media that these deaths did not take place because of the measles vaccine and that the vaccine being given to children was not expired. It is perfectly safe. It is the same vaccine being administered throughout the world and subscribes to international standards,” claimed the health ministry.

It said the deaths of the four children “are a result of human error; one lady health worker was administering this vaccine without following the injection safety techniques”.

“This resulted in an adverse reaction because of which four children died and as many children fell severely ill,” said the ministry.

However, Dr Pechuho said the blame should not fall only on a single health worker, but all the health authorities in Benazirabad district should be held responsible for it. He was referring to poor tackling of the case by a hospital when those children were brought there for treatment.

He said eight employees of the health ministry in Benazirabad had been suspended and an FIR had been lodged against them regarding the incident involving death of four children. He said the vaccine carried expiry date of 2020, showing that the medicine itself was up to international standards.

He said the incident turned even worse when it was wrongly mixed with polio vaccination affecting, otherwise, smooth campaigns of polio and measles.

Officials in the ministry said the measles vaccination must always take place at a fixed site and a team of doctors on call should deal with any adverse effects.

“This protocol was not appropriately followed and has cost the lives of three children,” an official admitted.

The ministry lauded the efforts of the deputy commissioner of Benazirabad “for his swift action that ensured the five ill children receive proper medical care”.

“Measles is a dangerous disease and all parents must protect their children against it through vaccinating their children. The measles vaccine and special measles drives have helped curtailing its outbreak in Sindh.”

The health ministry said that at least 1.3 million children had received the measles vaccine in Sindh in the past 12 months.

Last year, it added, there were more than 3,000 cases of measles in Sindh and that number was effectively declining since.

“This year so far only 72 cases (of measles) have been reported showing the importance of vaccination in safeguarding the future of our children.

“The government estimates the vaccination programme prevents at least 5,000 measles-related deaths in Sindh each year,” it added.

The ministry assured the general public that the matter had been taken up at the highest level and action, including strict disciplinary action, for those involved was being carried out.

It said it was also reviewing its procedures to ensure that a repeat of the incident did not take place in future.

Adverse effect on polio vaccination

Fayaz Jatoi, coordinator of the emergency operation centre (EOC) for polio in Sindh, told reporters at the health secretary’s briefing that the incident in Benazirabad had created a wave of concern among the parents.

He said those vaccines were the only treatment to safeguard children from such lethal, but preventable diseases. He said the provincial government was seriously trying to eradicate polio.

However, he said a campaign had been launched on the social media in which people were wrongly being told that polio vaccine had caused those deaths.

“It is very unfortunate. We are the last country where polio has still not been eradicated; such campaigns will badly hamper our efforts.”

Published in Dawn, March 15th, 2018

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