TRAGEDY: In 1928 the Bundaberg family, the Robinson's lost all three of their sons due to an refrigerated vaccine.
TRAGEDY: In 1928 the Bundaberg family, the Robinson's lost all three of their sons due to an refrigerated vaccine.

How a local tragedy changed vaccine protocol

IN THE past 89 years, the safety measures surrounding vaccines and immunisation have increased significantly .

In January 1928, 21 Bundaberg children were immunised with diphtheria toxin-antitoxin that was later found to be contaminated with Staphylcoccus aureus and within 24 hours, 18 of the children fell seriously ill.

Despite medical intervention, 12 died within 48 hours. 

Wide Bay Hospital and Health Service Public Health Physician Dr Margaret Young said in the medical community, this was recognised as one of the most significant immunisation-related tragedies in history and triggered immediate changes to immunisation protocols here in Australia and globally, including manufacturing processes (bottling, capping, storage, labelling) and how vaccines were administered.

The Robinson family lost three of their sons, Thomas, William and Mervyn, in the tragedy.

"It was no one's fault, it was because of the lack refrigeration and the storage the serum was off - it was poisonous," a Robinson family member, David Proctor, told the NewsMail.

"I remember dad saying going to the Robinson's (and seeing) on the table the three little coffins was pretty hard to take.

"Ray's mother was a nurse during the First World War and turned one of the cotton mills into a hospital.

"She had seen so many injuries and nursed so many badly hurt people, they always said she was a strong person to get through it all."

Two years after the Robinsons lost their little boys, they had another son, Ray.

"My father and Ray's dad were first cousins and speaking with Ray you'd think after losing those boys he'd be the spoilt one, but it wasn't so," Mr Proctor joked.

"He toed the line and did exactly as he was told or he'd have one big red cauliflower ear.

"Ray's a wonderful person, really easy going, at the moment his health's not so good but at 87 years old he's not doing too bad."

Mr Proctor said he and Ray were very close, sharing the same grandfather and still today going for lunch once a week.

Mr Proctor said while he didn't think Ray was immunised, he himself was.

"There might not have been refrigeration back then, it was all meat was dripping in bags so it's quite easy for something to go off," he said.

Dr Young said the a Royal Commission identified contamination with Staphylococcus bacteria was the cause of this harrowing time in Bundaberg's history.

"Whilst the toxin-antitoxin mixture was properly prepared and was issued in a sterile form, it contained no antiseptic and was issued in a dark multi-dose bottle with a rubber cap.

"Whilst this was intended to be used all at once in a large immunisation program, there was no label indicating it should not be reused," Dr Young said.

"The bottle was therefore used multiple times over 10 days during a hot summer, enabling the bottle to become contaminated.

"Vaccines are now produced in sterile single dose vials, which prevents the risk of contamination seen in the 1928 event."

Dr Young said Australia's immunisation program was world class in terms of safety and effectiveness and vaccine safety was a critical component of the Australian immunisation program. 

Diphtheria Background

IN THE 1920s, diphtheria was a common and frequently serious disease that could cause ulcerating infections of the skin, severe inflammation and membrane formation in the upper respiratory tract, and toxic damage to the heart and nervous system.

Wide Bay Hospital and Health Service public health physician Dr Margaret Young said in 1926 and 1927, the Bundaberg region reported more than 200 cases of the highly infectious disease and in early 1928 Brisbane City Council recommended an immunisation program using toxin-antitoxin, based on studies in the United Stated that showed a significant reduction in mortality.

"The decision in Bundaberg to proceed with an immunisation program was based on discussions with relevant authorities at the time," Dr Young said.

The toxin-antitoxin was produced by the Commonwealth Serum Laboratories and replaced with vaccine containing diphtheria toxoid in 1953. 

"Since the widespread use of diphtheria vaccine, diphtheria has almost disappeared from Australia," Dr Young said.

"It is important to note a fatal case of respiratory diphtheria occurred in Queensland in 2011 and that sporadic cases of diphtheria skin infections occur in incompletely vaccinated people travelling .

"It is important that children are fully vaccinated and that travellers ensure their vaccinations are up to date."

Vaccine safety

Wide Bay Hospital and Health Service public health physician Dr Margaret Young said the following elements contribute to the safety of the immunisation program in Australia:

  • Modern vaccines use a range of technologies to stimulate the immune system and reduce the risk of vaccine preventable disease - these are quite different from the technologies available in 1928.
  • Safety testing prior to use - all vaccines available in Australia must pass stringent safety testing before being approved by the Therapeutic Goods Administration by law and is usually done over the years of vaccine development. 
  • Ongoing monitoring of vaccine safety and vaccine effectiveness. 
  • Guidelines on vaccine management, including cold chain management - all immunisation providers must be familiar with and adhere to National vaccine storage guidelines.
  • Guidelines on vaccine use - these guidelines indicate when vaccines should and should not be used, and how they should be given.

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