The Bundaberg tragedy (or Bundaberg disaster) was a medical disaster that occurred in January 1928, resulting in the deaths of 12 children in Bundaberg, Queensland, Australia. A royal commission concluded that the deaths were caused by the contamination of a diphtheria vaccine with the bacterium Staphylococcus aureus .
The Australian state of Queensland experienced frequent diphtheria outbreaks in the early 20th century, with up to 2,000 cases reported per annum. [1] In the city of Bundaberg there were 130 cases reported in 1926 and 89 cases in 1927. [2] The disease had a high mortality rate and in a number of years was the leading cause of childhood death in Australia. [3]
The federal government recommended immunisation against diphtheria as early as 1921, but uptake of the diphtheria vaccine was slow. [1] Some medical authorities felt that the effectiveness of mass immunisation had yet to be proven, while the decentralised nature of the Australian healthcare system meant that decisions on immunisation were made by local health boards and medical officers of health. [4]
By the late 1920s, the Queensland Department of Health had initiated a policy of free immunisation against diphtheria, with the department purchasing vaccines manufactured by the federal government's Commonwealth Serum Laboratories (CSL) and distributing them to local authorities. [5] In 1928, the joint health board covering the City of Bundaberg, the Shire of Woongarra and the Shire of Gooburrum voted to authorise an immunisation program. The scheme was to be led by Bundaberg's chief medical officer Ewing Thomson. [6]
Thomson began the immunisation program on 17 January 1928, with each recipient intended to receive three inoculations spaced one week part. [7] The program was without incident until 27 January, when a total of 21 children between the ages of one and nine were inoculated. [8] Within seven hours, 18 of the children were seriously ill with symptoms that began with vomiting and diarrhoea and progressed to fever, cyanosis, convulsions and unconsciousness. [9] Eleven children died within 24 hours of their inoculations, while another died on the following day; many died only hours after being admitted to hospital. [6] Three were from a single family, the Robinsons, [10] while two other families lost two children. Thomson's son was among those inoculated, but survived. [6]
The mass-casualty incident overwhelmed the town's two hospitals, Bundaberg General Hospital and St Vincent's Hospital, which did not have the staff or capacity to handle multiple paediatric emergencies. [11] The hospitals' mortuary facilities were also inadequate to deal with multiple victims, with the problem exacerbated by an ongoing heat wave. With one exception, post-mortem examinations were performed by Egmont Schmidt, the government medical officer of Maryborough, who concluded that the children had died due to "acute toxaemia" of an unknown cause. Schmidt had little experience in forensic analysis, also lacking access to expert advice and facing pressure from families to certify death so that internment could proceed. [12]
The inoculation program in Bundaberg was suspended immediately after the children's deaths, following shortly by those in the major cities of Brisbane and Melbourne. As news of the deaths spread, programs were also suspended in New Zealand and Cape Town, South Africa. [13] All bottles of the toxin-antitoxin (TAT) serum used in Bundaberg were recalled within two days. [10] However, it was soon discovered that the Bundaberg batch had been used in other locations without incident. An early consensus developed that the deaths had not been caused by a fault in manufacture, but rather by the treatment of the serum after it left the CSL facilities in Melbourne. [14]
On 31 January, the day of the last victim's funeral, Prime Minister S. M. Bruce announced a royal commission into the deaths. [14] He additionally sent federal treasurer Earle Page, a former surgeon, to Bundaberg as his personal representative. [11] The federal government's response was coordinated by John Cumpston, the director-general of the Department of Health, a strong supporter of mass immunisation who sought to defend the reputation of his department and CSL. [13] According to Akers & Porter (2008), "the swift announcement of an imminent Royal Commission, its open terms of reference and Page’s visit, engendered scientific and political confidence". [14]
The federal government called a royal commission into the deaths on 31 January, the day of the last victim's funeral. [14] Hearings began on 13 February. [15] The manufacturer of the toxin–antitoxin was Commonwealth Serum Laboratories (CSL), owned by the federal government. As a result, responsibility for the deaths was seen to lie with the federal government rather than the Queensland state government (the administrators of the immunisation program), and inquiries were conducted by the federal government.
The three commissioners were Charles Kellaway, director of the Walter and Eliza Hall Institute; Peter MacCallum, professor of pathology at the University of Melbourne; and Arthur Tebbutt, bacteriologist at Sydney's Royal Prince Alfred Hospital. Kellaway was appointed as the commission's chairman. There was some criticism of the appointment of three medical professionals. The commissioners heard evidence in Bundaberg, Stanthorpe, Toowoomba, Brisbane, Sydney, and Melbourne. The sessions were open to the press and were extensively reported. Kellaway delegated much of the commission's work to Macfarlane Burnet, his assistant director at the Hall Institute and a future Nobel Prize laureate. Burnet was able to isolate Staphylococcus aureus in both the toxin-antitoxin mixture and in pus taken from the surviving children. [16]
The commission's report was presented to the House of Representatives by Neville Howse on 13 June 1928. There was a four-month investigation. [17] The Medical Journal of Australia and British Medical Journal concurred with the findings of the commission. [17] The commission concluded that the children's deaths were the result of the serum being contaminated with the bacterium Staphylococcus aureus . The commission concluded that the manufacturer, CSL, had contributed to the deaths by distributing bottles of serum that did not contain antiseptic. [18]
The report made five main recommendations. It was immediately forwarded to the state departments of health. The day after the report was issued, Prime Minister Stanley Bruce announced that the federal government would issued compensation payments to the families of the deceased and would cover the medical expenses of the surviving children. [19]
Emil von Behring, born Emil Adolf Behring, was a German physiologist who received the 1901 Nobel Prize in Physiology or Medicine, the first one awarded in that field, for his discovery of a diphtheria antitoxin. He was widely known as a "saviour of children," as diphtheria used to be a major cause of child death. His work with the disease, as well as tetanus, has come to bring him most of his fame and acknowledgment. He was honored with Prussian nobility in 1901, henceforth being known by the surname "von Behring."
Diphtheria is an infection caused by the bacterium Corynebacterium diphtheriae. Most infections are asymptomatic or have a mild clinical course, but in some outbreaks the lethality rate approaches 10%. Signs and symptoms may vary from mild to severe and usually start two to five days after exposure. Symptoms often develop gradually, beginning with a sore throat and fever. In severe cases, a grey or white patch develops in the throat, which can block the airway and create a barking cough similar to what is observed in croup. The neck may also swell in part due to the enlargement of the facial lymph nodes. Diphtheria can also involve the skin, eyes or genitals, and can cause complications including myocarditis, inflammation of nerves, kidney problems, and bleeding problems due to low levels of platelets.
An antitoxin is an antibody with the ability to neutralize a specific toxin. Antitoxins are produced by certain animals, plants, and bacteria in response to toxin exposure. Although they are most effective in neutralizing toxins, they can also kill bacteria and other microorganisms. Antitoxins are made within organisms, and can be injected into other organisms, including humans, to treat an infectious disease. This procedure involves injecting an animal with a safe amount of a particular toxin. The animal's body then makes the antitoxin needed to neutralize the toxin. Later, blood is withdrawn from the animal. When the antitoxin is obtained from the blood, it is purified and injected into a human or other animal, inducing temporary passive immunity. To prevent serum sickness, it is often best to use an antitoxin obtained from the same species.
Pierre Paul Émile Roux FRS was a French physician, bacteriologist and immunologist. Roux was one of the closest collaborators of Louis Pasteur (1822–1895), a co-founder of the Pasteur Institute, and responsible for the institute's production of the anti-diphtheria serum, the first effective therapy for this disease. Additionally, he investigated cholera, chicken-cholera, rabies, and tuberculosis. Roux is regarded as a founder of the field of immunology.
Antiserum is a blood serum containing monoclonal or polyclonal antibodies that is used to spread passive immunity to many diseases via blood donation (plasmapheresis). For example, convalescent serum, passive antibody transfusion from a previous human survivor, used to be the only known effective treatment for ebola infection with a high success rate of 7 out of 8 patients surviving.
CSL Limited is an Australian multinational specialty biotechnology company that researches, develops, manufactures, and markets products to treat and prevent serious human medical conditions. CSL's product areas include blood plasma derivatives, vaccines, antivenom, and cell culture reagents used in various medical and genetic research and manufacturing applications. The company was established in 1916 as Commonwealth Serum Laboratories and was wholly owned by the Australian federal government until its privatisation in 1994.
Gunnar Kaasen was a Norwegian-born musher who delivered a cylinder containing 300,000 units of diphtheria antitoxin to Nome, Alaska, in 1925, as the last leg of a dog sled relay that saved the U.S. city from an epidemic.
The 1925 serum run to Nome, also known as the Great Race of Mercy and The Serum Run, was a transport of diphtheria antitoxin by dog sled relay across the U.S. territory of Alaska by 20 mushers and about 150 sled dogs across 674 miles (1,085 km) in 5+1⁄2 days, saving the small town of Nome and the surrounding communities from a developing epidemic of diphtheria.
Jayant Mukundray Patel is an Indian-born American surgeon who was accused of gross negligence whilst working at Bundaberg Base Hospital in Queensland, Australia. Deaths of some of Patel's patients led to widespread publicity in 2005. In June 2010, he was convicted of three counts of manslaughter and one case of grievous bodily harm, and sentenced to seven years' imprisonment. In August 2012, all convictions were quashed by the full bench of the High Court of Australia and a retrial was ordered due to "highly emotive and prejudicial evidence that was irrelevant to the case" laid before the jury. A retrial for one of the manslaughter counts resulted in acquittal and led to a plea deal where Patel pleaded guilty to fraud and the remaining charges were dropped. On May 15, 2015, he was barred from practising medicine in Australia.
The following lists events that happened during 1928 in Australia.
On October 2, 1901, a former milk wagon horse named Jim showed signs that he had contracted tetanus and was euthanized. He was used to produce serum containing diphtheria antitoxin. Jim produced over 30 US quarts of diphtheria antitoxin in his career. After the death of a girl in St. Louis, Missouri, was traced back to Jim's contaminated serum, it was discovered that serum dated September 30 contained tetanus in its incubation phase. This contamination could have easily been discovered if the serum had been tested prior to its use. Furthermore, samples from September 30 had also been used to fill bottles labeled "August 24", while actual samples from the 24th were shown to be free of contamination.
Diphtheria antitoxin (DAT) is a medication made up of antibodies used in the treatment of diphtheria. It is no longer recommended for prevention of diphtheria. It is given by injection into a vein or muscle.
Charles Halliley Kellaway, was an Australian medical researcher and science administrator.
Alfred Jefferis Turner was a pediatrician and noted amateur entomologist. He was the son of missionary Frederick Storrs-Turner. He introduced the use of diphtheria antitoxin to Australia in 1895. He was known by the nickname "Gentle Annie".
Diphtheria vaccine is a toxoid vaccine against diphtheria, an illness caused by Corynebacterium diphtheriae. Its use has resulted in a more than 90% decrease in number of cases globally between 1980 and 2000. The first dose is recommended at six weeks of age with two additional doses four weeks apart, after which it is about 95% effective during childhood. Three further doses are recommended during childhood. It is unclear if further doses later in life are needed.
Pertussis vaccine is a vaccine that protects against whooping cough (pertussis). There are two main types: whole-cell vaccines and acellular vaccines. The whole-cell vaccine is about 78% effective while the acellular vaccine is 71–85% effective. The effectiveness of the vaccines appears to decrease by between 2 and 10% per year after vaccination with a more rapid decrease with the acellular vaccines. The vaccine is only available in combination with tetanus and diphtheria vaccines. Pertussis vaccine is estimated to have saved over 500,000 lives in 2002.
Baron Kitasato Shibasaburō was a Japanese physician and bacteriologist. He is remembered as the co-discoverer of the infectious agent of bubonic plague in Hong Kong during an outbreak in 1894, almost simultaneously with Alexandre Yersin.
Dalla Lana School of Public Health is the school of public health at the University of Toronto. It was founded in 1927, and was home for 50 years to Connaught Laboratories, a manufacturer of vaccines, insulin, and many other pharmaceutical products. Having grown to be the largest cluster of public health scholars in Canada, the school was revitalized in 2008 with the support of a major gift from the Dalla Lana family.
The Department of Medical Microbiology, formerly known as the Department of Bacteriology or the Institute of Bacteriology, was a research department of the pharmaceutical company Schering AG.
The Connaught Medical Research Laboratories was a non-commercial public health entity established by Dr. John G. FitzGerald in 1914 in Toronto to produce the diphtheria antitoxin. Contemporaneously, the institution was likened to the Pasteur Institutes in France and Belgium and the Lister Institute in London. It expanded significantly after the discovery of insulin at the University of Toronto in 1921, manufacturing and distributing insulin at cost in Canada and overseas. Its non-commercial mandate mediated commercial interests and kept the medication accessible. In the 1930s, methodological advances at Connaught updated the international standard for insulin production.