by: Barbara Loe Fisher
An investigation into the deaths of three infants in Bangladesh that occurred only hours after they received measles vaccinations has concluded that “programmatic error” was the most likely cause.
The infants, all around the age of ten months, received the vaccinations at the Kalikapur Health Clinic at Hizla. The clinic was faulted for its lack of monitoring and failing to maintain a proper serial number registry of the vaccines it used on patients, according to the New Nation.
Anil Chandra Datta, the region’s civil surgeon, said the New Nation that a detailed report is forthcoming, pending the results of the autopsies. He said that the investigation committee has visited the clinic, collected evidence and recorded the statements of those involved. The bodies of the infants have been returned to their relatives.
The primary investigation revealed that an assistant health worker named Taslima violated program rules by using an Indian-made vaccine from a partially used vial that may not have been properly preserved or that may have not been used within the proper time-frame.
Because there is no serial number registry, the New Nation reports, it may be impossible to find which vial was actually used on the victims. It appears that vial was initially used for the vaccinations of three babies in an adjacent area who are still in good health.
The families of the victims have been offered financial assistance and are calling for the trial and punishment of the responsible health workers. The bodies of the babies were buried in their home village after their return.