In a shocking setback to the measles immunisation program in India, four children died of anaphylactic shock following vaccination with the measles vaccine.
This is reminiscent of the Cutter Incident that took place in America in the 1960’s. A number of cases of polio seemed to occur following vaccination with the miraculous Salk vaccine. It was later found to be a result of the use of improperly produced polio vaccines from the Cutter lab in the Bay area.

The vaccine vials that are implicated in the deaths were from the same batch of vaccine manufactured by Indian Immunologicals Ltd., a subsidiary of a national organisation. The company’s press release seeks to absolve itself of any manufacture or production fault. They argue and rightly so that it is unlikely for a batch of 2,50,000 doses to have been faulty and only caused 4 deaths all of whom were administered the vaccine from the same vial.

The health workers and their unions are equally quick to discount any mistake being made at their end. One report suggests that the vaccine diluent used by the nurse administering the vaccine might have been from a different company, albeit the same composition (sterile water).

The central government enquiry into the incident has yet to produce a report as it is awaiting lab results, but has cleared the cold chain and contaminated syringes as the cause.

Either way, the net result of this has been a ban on measles vaccination across the country. An indirect effect of this crisis is the slow down on the polio vaccination drive. I suspect the latter is more likely to be causing the government sleepless nights and will be the driving force behind the government’s action.

The Indian government has attached a disproportionate importance to polio rather than measles. The political incentive(both domestic and international) for eradicating polio seem to over weigh the individual health benefits from measles vaccination. India has very poor measles vaccination coverage (53%) and has a high incidence of measles cases, but despite these damning statistics the government has not pushed measles vaccination strongly enough.

My fear lies in the possibility of a cover-up investigation. Investigation into the probable causes of these deaths, causes of the vaccination failure and side-effects, detailed investigation into the manufacturing unit must be conducted in a truly transparent manner to re-build confidence in the vaccination programs. The alternative might set India back ten years and nullify the great progress that has been made in preventing diseases by vaccination.