216:
20:
179:(TAT) serum used in Bundaberg were recalled within two days. 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.
130:, convulsions and unconsciousness. 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. Three were from a single family, the Robinsons, while two other families lost two children. Thomson's son was among those inoculated, but survived.
141:
and St
Vincent's Hospital, which did not have the staff or capacity to handle multiple paediatric emergencies. 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
125:
Thomson began the immunisation program on 17 January 1928, with each recipient intended to receive three inoculations spaced one week part. The program was without incident until 27 January, when a total of 21 children between the ages of one and nine were inoculated. Within seven hours, 18 of the
207:, a strong supporter of mass immunisation who sought to defend the reputation of his department and CSL. 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".
234:(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.
89:
was slow. 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
150:" 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 interment could proceed.
78:
outbreaks in the early 20th century, with up to 2,000 cases reported per annum. In the city of
Bundaberg there were 130 cases reported in 1926 and 89 cases in 1927. The disease had a high
261:. 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,
309:
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.
318:
296:
concurred with the findings of the commission. The commission concluded that the children's deaths were the result of the serum being contaminated with the bacterium
305:
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
269:, Brisbane, Sydney, and Melbourne. The sessions were open to the press and were extensively reported. Kellaway delegated much of the commission's work to
302:. The commission concluded that the manufacturer, CSL, had contributed to the deaths by distributing bottles of serum that did not contain antiseptic.
284:
The commission's report was presented to the House of
Representatives by Neville Howse on 13 June 1928. There was a four-month investigation. The
101:
had initiated a policy of free immunisation against diphtheria, with the department purchasing vaccines manufactured by the federal government's
230:
into the deaths on 31 January, the day of the last victim's funeral. Hearings began on 13 February. The manufacturer of the toxin–antitoxin was
683:
163:
The inoculation program in
Bundaberg was suspended immediately after the children's deaths, following shortly by those in the major cities of
204:
620:"'Immunisation is as popular as a death adder': the Bundaberg tragedy and the politics of medical science in interwar Australia"
703:
242:
231:
102:
117:
voted to authorise an immunisation program. The scheme was to be led by
Bundaberg's chief medical officer Ewing Thomson.
286:
258:
215:
19:
199:, a former surgeon, to Bundaberg as his personal representative. The federal government's response was coordinated by
645:
Hooker, Claire (2000). "Diphtheria, immunisation and the
Bundaberg tragedy: a study of public health in Australia".
688:
698:
91:
693:
292:
250:
143:
138:
262:
147:
134:
126:
children were seriously ill with symptoms that began with vomiting and diarrhoea and progressed to fever,
708:
298:
58:
85:
The federal government recommended immunisation against diphtheria as early as 1921, but uptake of the
176:
254:
599:
40:) was a medical disaster that occurred in January 1928, resulting in the deaths of 12 children in
662:
114:
110:
86:
53:
105:(CSL) and distributing them to local authorities. In 1928, the joint health board covering the
270:
106:
98:
654:
631:
238:
227:
219:
192:
49:
24:
246:
79:
677:
306:
200:
281:
in both the toxin-antitoxin mixture and in pus taken from the surviving children.
274:
188:
171:. As news of the deaths spread, programs were also suspended in New Zealand and
82:
and in a number of years was the leading cause of childhood death in
Australia.
196:
75:
71:
45:
266:
172:
168:
41:
636:
619:
164:
127:
666:
658:
187:
On 31 January, the day of the last victim's funeral, Prime
Minister
214:
18:
600:"Bundaberg's Gethsemane: the tragedy of the inoculated children"
52:
concluded that the deaths were caused by the contamination of a
142:
performed by Egmont Schmidt, the government medical officer of
514:
512:
510:
508:
468:
466:
402:
400:
398:
337:
335:
273:, his assistant director at the Hall Institute and a future
222:, chair of the royal commission into the children's deaths
553:
551:
495:
493:
146:, who concluded that the children had died due to "acute
195:
into the deaths. He additionally sent federal treasurer
453:
451:
319:1901 diphtheria antitoxin contamination incident
607:Royal Historical Society of Queensland Journal
8:
542:
530:
518:
484:
472:
406:
353:
341:
635:
321:, a similar incident in the United States
581:
569:
557:
499:
430:
331:
598:Akers, Harry; Porter, Suzette (2008).
457:
442:
418:
389:
377:
365:
137:overwhelmed the town's two hospitals,
277:laureate. Burnet was able to isolate
7:
175:, South Africa. All bottles of the
14:
249:, professor of pathology at the
226:The federal government called a
243:Walter and Eliza Hall Institute
232:Commonwealth Serum Laboratories
103:Commonwealth Serum Laboratories
99:Queensland Department of Health
203:, the director-general of the
1:
684:Health disasters in Australia
257:, bacteriologist at Sydney's
237:The three commissioners were
287:Medical Journal of Australia
259:Royal Prince Alfred Hospital
725:
624:Social History of Medicine
154:Reaction and investigation
139:Bundaberg General Hospital
92:medical officers of health
70:The Australian state of
28:coverage of the incident
618:Hobbins, Peter (2010).
543:Akers & Porter 2008
531:Akers & Porter 2008
519:Akers & Porter 2008
485:Akers & Porter 2008
473:Akers & Porter 2008
407:Akers & Porter 2008
354:Akers & Porter 2008
342:Akers & Porter 2008
293:British Medical Journal
251:University of Melbourne
97:By the late 1920s, the
704:1920s health disasters
223:
135:mass-casualty incident
29:
299:Staphylococcus aureus
279:Staphylococcus aureus
218:
74:experienced frequent
59:Staphylococcus aureus
22:
16:1928 medical disaster
205:Department of Health
487:, pp. 266–267.
56:with the bacterium
647:Health and History
637:10.1093/shm/hkq047
241:, director of the
224:
183:Political response
115:Shire of Gooburrum
111:Shire of Woongarra
87:diphtheria vaccine
54:diphtheria vaccine
38:Bundaberg disaster
30:
689:1928 in Australia
380:, pp. 60–61.
271:Macfarlane Burnet
107:City of Bundaberg
34:Bundaberg tragedy
716:
699:Medical scandals
670:
659:10.2307/40111374
641:
639:
614:
604:
585:
579:
573:
567:
561:
555:
546:
540:
534:
528:
522:
516:
503:
497:
488:
482:
476:
470:
461:
455:
446:
440:
434:
428:
422:
416:
410:
404:
393:
392:, p. 65-66.
387:
381:
375:
369:
363:
357:
351:
345:
339:
239:Charles Kellaway
228:royal commission
220:Charles Kellaway
211:Royal commission
193:royal commission
50:royal commission
25:Brisbane Courier
724:
723:
719:
718:
717:
715:
714:
713:
694:1928 in science
674:
673:
644:
617:
602:
597:
594:
589:
588:
580:
576:
568:
564:
556:
549:
541:
537:
529:
525:
517:
506:
498:
491:
483:
479:
471:
464:
456:
449:
441:
437:
429:
425:
417:
413:
405:
396:
388:
384:
376:
372:
364:
360:
352:
348:
340:
333:
328:
315:
247:Peter MacCallum
213:
185:
177:toxin-antitoxin
161:
159:Health response
156:
123:
68:
48:, Australia. A
17:
12:
11:
5:
722:
720:
712:
711:
706:
701:
696:
691:
686:
676:
675:
672:
671:
642:
630:(2): 426–444.
615:
593:
590:
587:
586:
584:, p. 438.
574:
572:, p. 436.
562:
560:, p. 435.
547:
545:, p. 275.
535:
533:, p. 270.
523:
521:, p. 268.
504:
502:, p. 430.
489:
477:
475:, p. 267.
462:
447:
435:
433:, p. 428.
423:
411:
409:, p. 264.
394:
382:
370:
358:
356:, p. 263.
346:
344:, p. 262.
330:
329:
327:
324:
323:
322:
314:
311:
255:Arthur Tebbutt
212:
209:
184:
181:
160:
157:
155:
152:
122:
119:
80:mortality rate
67:
64:
15:
13:
10:
9:
6:
4:
3:
2:
721:
710:
707:
705:
702:
700:
697:
695:
692:
690:
687:
685:
682:
681:
679:
668:
664:
660:
656:
652:
648:
643:
638:
633:
629:
625:
621:
616:
613:(7): 261–278.
612:
608:
601:
596:
595:
591:
583:
578:
575:
571:
566:
563:
559:
554:
552:
548:
544:
539:
536:
532:
527:
524:
520:
515:
513:
511:
509:
505:
501:
496:
494:
490:
486:
481:
478:
474:
469:
467:
463:
460:, p. 70.
459:
454:
452:
448:
445:, p. 67.
444:
439:
436:
432:
427:
424:
421:, p. 66.
420:
415:
412:
408:
403:
401:
399:
395:
391:
386:
383:
379:
374:
371:
368:, p. 54.
367:
362:
359:
355:
350:
347:
343:
338:
336:
332:
325:
320:
317:
316:
312:
310:
308:
307:Stanley Bruce
303:
301:
300:
295:
294:
289:
288:
282:
280:
276:
272:
268:
264:
260:
256:
252:
248:
244:
240:
235:
233:
229:
221:
217:
210:
208:
206:
202:
201:John Cumpston
198:
194:
190:
182:
180:
178:
174:
170:
166:
158:
153:
151:
149:
145:
140:
136:
131:
129:
120:
118:
116:
112:
108:
104:
100:
95:
93:
88:
83:
81:
77:
73:
65:
63:
61:
60:
55:
51:
47:
43:
39:
35:
27:
26:
21:
709:Child deaths
653:(1): 52–78.
650:
646:
627:
623:
610:
606:
582:Hobbins 2010
577:
570:Hobbins 2010
565:
558:Hobbins 2010
538:
526:
500:Hobbins 2010
480:
438:
431:Hobbins 2010
426:
414:
385:
373:
361:
349:
304:
297:
291:
285:
283:
278:
236:
225:
191:announced a
186:
162:
132:
124:
96:
84:
69:
57:
37:
33:
31:
23:
458:Hooker 2000
443:Hooker 2000
419:Hooker 2000
390:Hooker 2000
378:Hooker 2000
366:Hooker 2000
275:Nobel Prize
189:S. M. Bruce
144:Maryborough
678:Categories
326:References
263:Stanthorpe
197:Earle Page
76:diphtheria
72:Queensland
66:Background
46:Queensland
267:Toowoomba
173:Cape Town
169:Melbourne
42:Bundaberg
667:40111374
313:See also
165:Brisbane
148:toxaemia
128:cyanosis
121:Disaster
113:and the
592:Sources
665:
253:; and
109:, the
663:JSTOR
603:(PDF)
290:and
167:and
133:The
36:(or
32:The
655:doi
632:doi
680::
661:.
649:.
628:24
626:.
622:.
611:20
609:.
605:.
550:^
507:^
492:^
465:^
450:^
397:^
334:^
265:,
245:;
94:.
62:.
44:,
669:.
657::
651:2
640:.
634::
Text is available under the Creative Commons Attribution-ShareAlike License. Additional terms may apply.
