BUNDY TRAGEDY CHANGED VACCINE PROTOCOL
How the deaths of 12 Bundaberg children changed medicine forever
❝ I remember dad saying going to the Robinsons (and seeing) on the table the three little coffins was pretty hard to take. — David Proctor
IN THE past 90 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.
Within 24 hours, 18 of the children fell seriously ill and, despite medical intervention, 12 died within 48 hours.
Wide Bay Hospital and Health Service public health physician Margaret Young said, in the medical community, the case was recognised as one of the most significant immunisation-related tragedies in history and triggered immediate changes to immunisation protocols in Australia and globally, including manufacturing (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 (that) the serum was off – it was poisonous,” a Robinson family member, David Proctor, told the NewsMail.
“I remember dad saying going to the Robinsons (and seeing) on the table the three little coffins was pretty hard to take.
Two years after the Robinsons lost their boys, they had another son, Ray.
“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.”
“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 said.
“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, being second cousins, and still today go for lunch once a week .
Mr Proctor said while he didn’t think Ray was immunised, he 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 that contamination with Staphylococcus bacteria was the cause of the 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.
TRAGEDY: Three members of Bundaberg’s Robinson family, brothers William, Mervyn and Thomas, died after receiving an refrigerated vaccine in 1928.