Letter to the editor

Editor, – I was disappointed to read the editorial on H1N1 vaccination (Aust Prescr 2010;33:30-1), especially when the National Prescribing Service states that the publication is evidence-based and peer reviewed.

In particular, the article states: 'In the past, many infections, such as Staphylococcus aureus, hepatitis B and HIV, have been caused by vaccination programs using multi dose vials'. From my limited research, I am not aware of any past documented infections associated with general practice vaccination programs in Australia (as we are predominately using for H1N1 vaccination), nor any documentation of hepatitis B or HIV infections from any vaccination programs. Reference two in the editorial does not back up his claim it in fact refers to the author's own article which has no comment on transmission of disease from multi dose vials.

In addition, I question the balance of the author when discussing influenza vaccination. He quoted only one study that 'showed that the decrease in all-cause mortality attributable to seasonal influenza vaccine was 4.6%', without noting the limitations of this study, nor referring to the wide body of international evidence supporting influenza vaccination, including those referenced in the 9th edition of the Australian Immunisation Handbook.

Although it is fair to comment that we would benefit from more effective influenza vaccines, and that policy makers must carefully review pandemic planning, including the role of multi dose vials, I do not believe that the debate is assisted by claims that are not correctly referenced, nor highlighting of single studies. I would also question whether this editorial is consistent with the National Prescribing Service's claim to 'provide accurate, balanced, evidence-based information'.

Greg Rowles
General practitioner
Riddell Country Practice
Riddells Creek, Vic.

Author's comments

Professor Peter Collignon, author of the editorial, comments:

I agree with Dr Rowles that we need more effective influenza vaccines and a review of pandemic planning. I accept that it is best to reference primary sources rather than reviews. Unfortunately word and reference limitations in invited editorials make that difficult to do at times.

On the issue of efficacy, most studies on influenza vaccines have major biases.1 Generally vaccination rates are lower in people who are most at risk of death and thus the benefits from influenza vaccination are likely overstated.1,2 Morbidity and mortality are often lower in vaccinees, even before the start of the flu season, compared to controls. One of the few studies that have tried to untangle these biases was the one I quoted. This very large Californian study found a benefit for vaccination, but it was 10-fold less than previously attributed for influenza vaccination.2

Infection control guidelines recommend as best practice that single-dose vials are used wherever possible. There is extensive documentation on the transmission of many different viral and bacterial infections when multi dose vials are used. This includes vaccination programs using multi dose vials.3-7

In Australia we had the Bundaberg disaster in 1928. Diphtheria vaccine contaminated with Staphylococcus aureus from multi dose vials caused the deaths of 12 children and resulted in a Royal Commission.4 In Geelong in the late 1960s, two factory workers died from Streptococcus pyogenes following workplace flu vaccinations from multi dose vials. The coroner subsequently recommended against the use of multi dose vials.5,6 More extensive references on this international problem have been discussed previously.7

Multi dose vials are involved in the transmission of infectious organisms. I believe they should not be used in mass vaccination campaigns in Australia.


  1. Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning S, Thomas RE. Vaccines for preventing influenza in the elderly. Cochrane Database Syst Rev 2010, Issue 2: CD004876.
  2. Fireman B, Lee J, Lewis N, Bembom O, van der Laan M, Baxter R. Influenza vaccination and mortality: differentiating vaccine effects from bias. Am J Epidemiol 2009;170:650-6.
  3. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of blood borne pathogens: a review. Bull World Health Organ 1999;77:789-800.
  4. Kellaway CH, MacCallum P, Tebbutt AH. The fatalities at Bundaberg. Report of the Royal Commission. Med J Aust 1928;II:2.
  5. Plueckhahn VD, Banks J. Fatal haemolytic streptococcal septicaemia following mass inoculation with influenza vaccine. Med J Aust 1970;1:405-11.
  6. The Geelong disaster. Med J Aust 1970;1:401-2.
  7. Collignon P. Why can't we have a rational discussion about the merits of pandemic flu vaccination? 2009 Aug 31.http://blogs.crikey.com.au/croakey/2009/08/31/why-cant-we-have-a-rational-discussion-about-the-merits-of-pandemic-flu-vaccination/[cited 2010 May 3]

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