How the deaths of 12 Bund­aberg chil­dren changed medicine for­ever

NewsMail - - FRONT PAGE - MIKAYLA HAUPT JOUR­NAL­IST mikayla.haupt@news-mail.com.au

❝ 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.

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