SYRIA

Immunization teams 'negligent' in vaccines that killed Syrian children

Fifteen Syrian children died this week in Idlib province, in northern Syria, after receiving what was thought to be a measles vaccine during an immunization campaign sponsored by the opposition Syrian National Coalition. An investigation conducted by the opposition’s interim government showed that the children were injected with a strong anaesthetic instead of the measles vaccination. Bashar Kayal was a member of the investigation team and

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Screen grab from a video showing doctors trying to revive children in a medical centre in Saraqib, Idlib province. 

Fifteen Syrian children died this week in Idlib province, in northern Syria, after receiving what was thought to be a measles vaccine during an immunization campaign sponsored by the opposition Syrian National Coalition. An investigation conducted by the opposition’s interim government showed that the children were injected with a strong anaesthetic instead of the measles vaccination. Bashar Kayal was a member of the investigation team and told FRANCE 24 about the circumstances of this “mistake”…

The immunization campaign in opposition-held Idlib province began on Monday, during which over 40,000 children were vaccinated without any incident. The fifteen victims died following second round of vaccinations that took place the next day in several small towns.

Volunteers putting up a sign asking parents to get their children vaccinated against measles in Khan Cheikhoun, Idlib province. Photo published on Facebook.

"If the team members had just read the labels, they would have realized it was not the right product"

Bashar Kayal is one of the doctors in charge of the anti-measles campaign in Idlib province.

All the vaccines transit through the medical centre in Jarjanaz. They are kept in a refrigerator and then distributed to the field teams who store them in the different centres in the region. These vaccines are then transported in thermoses before being administered to children in the local towns and cities. As soon as we learned of the deaths of the children in the Maârat al-Naâmane region on Tuesday, we ordered all teams to stop the vaccination campaign. We then verified the remaining vials and gathered all the empty vials that the medical teams had kept.

For one dose of the vaccination, there are two separate vials. One contains a diluting product and the other contains a powder. The two products need to be mixed together before being administered to the patient.

However, on Wednesday, near the city of Sanjar [where two children died], we found a thermos containing vials of atracurium, which is a muscle relaxant typically used in operating rooms. We discovered that this anaesthetic was in fact mixed with the vaccine, instead of the regular diluting product.

The anti-measles campaign in Idlib. Photo published on Facebook.

The children that died received 5 mL of atracurium [typically, the quantity of atracurium administered to a patient undergoing surgery is 0.5 mL], which corresponds to the amount of the diluting product that should have been administered. In the half hour following the injection, the victims suffered from diarrhea and muscular and respiratory paralysis, which killed them. The children ranged in age from six to eighteen months. The older children who received the erroneous treatment suffered from the same symptoms but their bodies were able to withstand the shock, and they survived.

"Several team members were cornered by parents of the victims"

We traced the path the atracurium vials had taken all the way back to the medical centre in Jarjanaz, where all vaccines are stocked in a refrigerator prior to their distribution. In this fridge, we found several vials of this type of muscle relaxant. This find allowed us to establish that the problem had originated there. Those vials didn’t belong there, because the refrigerator was only used to store vaccines and nothing else.

The vials of atracurium and the vials of diluent had the same shape and volume, and appeared essentially the same. However, the labels clearly stated the name of the anaesthetic. And those people in charge of administering the vaccines did not check the labels.

These teams have been administering vaccines on a daily basis since August 25. There are 160 teams deployed throughout the entire province, and each team must immunize roughly 500 children per day. On Tuesday, the team members did not take the time to read the labels, because transporting and administering the vaccines has become a routine for them. They had never had any problems before.

A child gets vaccinated in Jabal Al Zaouia. Photo published on September 15 on Facebook.

This does not in any way absolve them of responsibility. They were clearly negligent. Several of them were cornered by parents of the victims. However, the Free Syrian Army, which currently holds the area, arrested them on Wednesday, and they are now being detained in Jarjanaz while they await their sentence.

The question now is to figure out whether these vials were placed in the refrigerator by mistake, or with the intent to harm.

 

This tragedy has caused a serious shake-up in the ranks of the opposition government. The Minister of Health and his associates submitted their resignation on Wednesday to the head of the opposition’s interim government, Ahmad Tama.