4. Report of the Strategic Advisory Group of Experts (SAGE), 6. Turnbull FM, Burgess MA, McIntyre PB, Lambert SB, Gilbert Geneva, 14–15 June 2001. Geneva: Department of Vaccines GL, Gidding HF, Escott RG, Achat HM, Hull BP, Wang H, and Biologicals, World Health Organization, 2001. Sam GA, Mead CL. The Australian Measles Control www.who.int/vaccines-documents. Campaign, 1998. Bull World Health Organ 2001;79:882–8. 5. National Institute of Allergy and Infectious Diseases. The 7. Hull BP, McIntyre PB. Immunisation coverage reporting Jordan Report 20th Anniversary Edition. Accelerated through the Australian Childhood Immunisation Register— Development of Vaccines 2002. US Department of Health An evaluation of the third-dose assumption. Aust N Z J Public and Human Services, National Institute of Health, 2002. Health 2000;24:17–21. www.niaid.nih.gov/dmid/vaccines/jordan20. TEARS OFTEN SHED Margaret Burgess on board the transport ships and, in the colony, sexually National Centre for Immunisation Research transmissible infections were rife. By 1800 there were and Surveillance of Vaccine Preventable Diseases about 1,000 children in the settlement—almost half that The University of Sydney and The Children’s Hospital number were orphans. Infant mortality was 11 per cent, at Westmead 20 times higher than today’s rate of 5.2 per 1,000, and 10 In seeking a theme for this Oration, I was drawn to a small per cent of infant deaths were due to syphilis. Pertussis volume on my bookshelf, given to me by Sir Lorimer appeared for the first time about 1827, measles and Dods, who was the first Professor of Child Health in diphtheria a few years later; the mortality from each was Australia. The book, entitled Tears often shed, was written very high, especially from diphtheria (estimated to be by Dr Bryan Gandevia and was published in 1978.1 about 150 per 100,000 population). There was a very large outbreak of measles in Sydney in 1880, by which time The book tells the history of child health in Australia children’s hospitals had been established in Melbourne, from the first European settlement in 1788, and it Brisbane, Adelaide and Sydney. However, child mortality emphasises the fact that the health of children very remained high and Henry Lawson, a popular poet of the accurately reflects the living conditions of the entire time, poignantly drew attention to this state of affairs: community. As Gandevia writes: ‘Children, their health and welfare, their morbidity and mortality, necessarily Our first child took—a cruel week in dyin’, … offer a most sensitive reflection of the social and physical I’ve pulled three through and buried two environment in which they find themselves.’ In tracing Since then—and I’m past carin’. the history of child health in Australia from the time of the first penal settlement at Port Jackson, Gandevia noted INTRODUCTION OF VACCINES the tears that ‘were often shed’ by parents of infants dying The first use of vaccines in Australia commenced with of communicable diseases which are now prevented smallpox in 1804. It was not until the 1890s that plague by vaccination. and typhoid vaccines and diphtheria antiserum 2 Today the Australian community is remarkably free of became available. deaths from measles, diphtheria, tetanus, poliomyelitis A major milestone in the early 20th century was the and congenital rubella, all of which caused significant establishment, by the Commonwealth Government, of the morbidity and mortality until 50 years ago. New vaccines Commonwealth Serum Laboratories (CSL) in Melbourne are providing a wider spectrum of disease protection than in 1916. CSL rapidly commenced production of vaccines ever before. In contrast, about two million children die for typhoid, cholera, plague, smallpox and diphtheria each year globally from infections that could be prevented antitoxin. In the 1920s childhood vaccination with a by vaccines that are currently available in the Australian combined toxin–antitoxin vaccine resulted in a marked vaccination schedule. However, as the diseases they fall in the incidence of diphtheria (Figure 1), but this prevent disappear, vaccines are more and more in the news, vaccine was withdrawn following a serious incident due sometimes unfairly reported. Vaccine safety is of to bacterial contamination of a multidose container of importance to all. Scientific rigour therefore must always the vaccine in Bundaberg, Queensland.2 Following the inform the processes leading to the development, approval introduction of school-based programs (using diphtheria and introduction of new vaccination programs. toxoid vaccine in single-dose vials) which became widespread by the mid-1930s, there was a further marked THE COLONIAL ERA decline in diphtheria. Infant vaccination for diphtheria The long voyage from England to Botany Bay was one was not routine until the early 1940s, and emergency that, even in the late 1780s, was almost too much to tracheostomy for diphtheria was still commonly seen in contemplate. Smallpox, cholera and tetanus were common children’s hospitals through to the early 1950s. Vol. 14 No. 1–2 NSW Public Health Bulletin 5 FIGURE 1 DIPHTHERIA NOTIFICATIONS, AUSTRALIA, 1917–2000 450 1932 – school-based diphtheria vaccination commenced 400 350 300 250 1953 – DTP vaccination introduced 200 150 100 Notifications per 100 000 population 50 0 1917 1921 1925 1929 1933 1937 1941 1945 1949 1953 1957 1961 1972 1976 1980 1984 1988 1992 1996 2000 1964–651968–69 Year Source: Hall R. Notifiable disease surveillance, 1917 to 1991. Commun Dis Intell 1993;17:226–36. Updated with NNDSS data 1992–2000. The late 1940s and early 1950s saw large outbreaks of CONTEMPORARY AUSTRALIA poliomyelitis, many polio deaths and many young people By the mid-1990s infant mortality had reached a rate handicapped for life. The introduction of inactivated (5.2 in 1000) only dreamt of by paediatricians such as poliovirus vaccine (IPV—Salk vaccine) in 1956 resulted Sir Lorimer Dods. The new generation of parents had no in an immediate fall in the incidence of polio (Figure 2). experience of the outbreaks and fears that surrounded Australia did not use live oral poliomyelitis vaccine polio, diphtheria and tetanus. Immunisation coverage had (OPV—Sabin) until 1966.3 plateaued, and warning signals were seen in small but Another important milestone for Australia in the first half important outbreaks of vaccine-preventable diseases. of the 20th century was the discovery, by the Sydney About the same time there was a rebirth of interest in ophthalmologist Norman Gregg in 1941, that rubella in alternative therapies and anti-vaccination sentiment. pregnancy could cause congenital malformations.4,5 After This situation set the scene for the Commonwealth’s the introduction of rubella vaccination in 1970, there was Immunise Australia program: the Australian Childhood a rapid fall in the incidence of congenital infection: up to Immunisation Register (ACIR) was established, parent and 200 cases had occurred nationally in some outbreak years. provider incentives were offered, the Measles Control As a result of vaccination, there have been no cases of Campaign was accomplished and the National Centre for congenital rubella syndrome in Australia over the past Immunisation Research and Surveillance (NCIRS) five years, apart from one recent imported case (Forrest was established. JM, personal communication). These initiatives have been very successful. Australia now In the 1990s, Australia was fortunate to have the early has the highest immunisation coverage ever recorded; the introduction of Haemophilus influenzae type b (Hib) lowest rates of measles, rubella and Hib disease; and the vaccine. Hib infection was responsible for more than one- lowest number of deaths from the diseases for which third of the cases of bacterial meningitis in children. It children are routinely vaccinated.6,7 Studies of coverage also caused epiglottitis, cellulitis, other localised indicate that 90–95 per cent of children receive all infections and the aggressive early meningitis seen so scheduled vaccines and that parent incentives have extraordinarily frequently in Aboriginal and Torres Strait influenced at least four or five per cent to make sure their Islander children. Hib disease rapidly disappeared children are up to date with vaccination.7 But two to three following the introduction of vaccination.6 per cent of parents have serious concerns about or disagree 6 NSW Public Health Bulletin Vol. 14 No. 1–2 FIGURE 2 POLIOMYELITIS NOTIFICATIONS, AUSTRALIA, 1917–2000 3000 1956 – mass vaccination with IPV commenced 2500 2000 1500 1000 1966 – OPV introduced 500 Notifications per 100 000 population 0 1917 1921 1925 1929 1933 1937 1941 1945 1949 1953 1957 1961 1972 1976 1980 1984 1988 1992 1996 2000 1964–651968–69 Year Source: Hall R. Notifiable disease surveillance, 1917 to 1991. Commun Dis Intell 1993;17:226–36. Updated with NNDSS data 1992–2000. IPV: Inactivated poliovirus vaccine (Salk) OPV: Oral poliomyelitis vaccine (Sabin) with immunisation. It is not always easy to address these to delivery) and attention to adverse events. This goal concerns—in doing so it is important to listen and respond requires finance, collaboration and technology transfer. to genuine concerns; to anticipate public reaction to new Vaccines, by improving child survival, can provide a key initiatives; to know the facts; to use graphic illustrations to global poverty. Child survival is closely linked with and convincing spokespersons; and to remember that population control and therefore