PhD Thesis - ResearchSpace@Auckland - The University of Auckland

include a number of endemic areas. 23 By the end of 1928 it was estimated that 11,500
schoolchildren at primary level had been immunised. 24 However, diphtheria
immunisation was still piecemeal, completed when time, money and staff were
available to undertake it. At this point the importance of public health itself within
government and society was only just beginning to be recognised and with it the need
for extra funding to implement preventative measures.
Events in Bundaberg, Queensland in 1928 spelled the end of immunisation for at least
two years in New Zealand. Early vaccines and the conditions for making and storing
them were crude. This meant contamination could occur at different stages in the
process before it reached a child’s arm. Three years before Bundaberg, six infants
died after being injected with pure toxin at Baden near Vienna. No antitoxin had been
added to complete the vaccine. As a result immunisation was forbidden for a time in
Austria. 25
Bundaberg, however, was much closer to home and had a greater impact in both
Australia and New Zealand. After a recent outbreak of diphtheria in 1928 the Medical
Officer of Health for Bundaberg recommended an immunisation campaign. Although
children immunised earlier were fine, of the 21 immunised on 27 January 1928, 18
became ill and 12 died. The vaccine had been stored in an unrefrigerated cupboard
and had been used repeatedly. The Royal Commission of Inquiry appointed to
investigate the tragedy found that the vaccine had become contaminated with
staphylococcus pyrones as no antiseptic had been added by the manufacturers,
Commonwealth Serum Laboratories (CSL) of Melbourne. 26 The Commission further
23 ibid.
24 Christchurch Sun, 18 January 1933, H1 131/11/6, B. 92, ANZ, Wellington.
25 Other incidents involving diphtheria toxin-antitoxin included the following: - in 1919 in Dallas,
Texas there were five deaths and 40 cases due to an injection of toxin-antitoxin mixture which was
actually toxic due to the failure to add toxin all at once. In 1924 at Concord and Bridgewater,
Massachusetts some 40 children developed severe and localised reactions as the toxin-antitoxin mixture
contained phenol as some of batch had been stored below freezing. In 1927 in Russia toxin was
supplied instead of toxoid, 12 of the 14 children injected died. From H. Parish, A History of
Immunization, Edinburgh, 1965, p.151.
26 A. H. Brogan, Committed to Saving Lives. A History of the Commonwealth Serum Laboratories,
Melbourne, 1990, p.25. Toxin-antitoxin when frozen produced phenol which could cause severe
reactions.
32