On 30^th June 1998, Jacob’s grandparents arrived at his house to take care of him while his parents and brother went to Bali for a holiday. Because their oldest son had had a severe reaction to a vaccine, the parents had decided not to vaccinate Jacob. Jacob was in the care of his grandparents because they felt travel was an unnecessary disruption for a 2½-year-old. They returned to New Zealand on 13 July.

A few days before Jacob got tonsillitis, there had been a big rainstorm on the North Shore. The stormwater drains overflowed into the sewage system and raw sewage spilled onto a property next door – something too interesting for a 2-year-old to leave unexplored. Something too uninteresting for the Public Health people to investigate when brought to their attention later, even though New Zealand has two historical precedents of diphtheria following raw sewage flowing onto property.

Eleven days after returning from Bali, Jacob’s father developed an infected abrasion on his chin, which had spread to his nose and chin by the 28^th July when the doctor started treatment with antibiotics. Dr Michael Baker (ESR, Porirua), in a published report on Jacob, considered this important because there were no swabs taken from his father’s chin – the unproven implication is that this infection might have been the primary source of the bacteria which "infected" Jacob. During this time, Jacob had developed a cold, which turned into tonsillitis, and his mother took him to the doctor on the same day. The doctor did not think he was particularly unwell, but took swabs, which showed normal flora, and prescribed amoxycillin. On the 30^th, his mother became concerned that there was no improvement. Jacob had become quite hoarse, didn’t want to drink, and was coughing. So in the late afternoon, her sister took them back to the doctor, who decided to refer him to Starship. The doctor saw a yellow green exudate on the tonsils, swollen glands, and a swollen neck. He wondered about diphtheria, because the parents had been to Bali, the child was unvaccinated, and the antibiotics weren’t working.

His admission letter gave name and address, and stated:

Many thanks for seeing this young boy. I have swabs off at Diagnostic for CTS and Diptheria [as spelt by doctor]. Many thanks, with regards…."

The doctor also rang ahead to let the hospital know

that he was querying the possibility of diphtheria. The parents arrived expecting to be greeted with masks, white gowns and isolation. Instead they were put into a six-bed room with unwell children. They were interviewed both by a nurse and student GP, and on both occasions gave the full story. During this time, their son played happily with the other children. Jacob was finally seen by Dr Denny at 19.24 p.m. when his first question was "Why haven’t you immunised Jacob?" Jacob’s mother said that right now, they wanted Jacob seen, not their choices questioned. The first line this doctor wrote in the file was:

"Referral from GP ?Diphtheria."

So we know that he knew the referring doctor had alerted the hospital to this. (This is very important later).

Previous history written into the files included: "cough and fever, four days… 2½-year-old boy unimmunised (underlined twice)…no others in family unwell…Alert and happy playing, Temp 37, … throat pus on tonsils – exudate green, no grey. Confined to tonsillar bed, no pharynx…diagnosis, tonsillitis in well unimmunised 2-year-old – low likelihood of C. diptheria… explained above to parents."

His parents were told that it was probably some virus, or tonsillitis, but not diphtheria and that he should continue the amoxycillin that the GP had thought wasn’t working. They asked what could the hospital do if it was diphtheria, and he mentioned an ECG, but that he didn’t think it was necessary. The parents refused to leave until Jacob had one. They also discussed anti-toxin, and the doctor said he didn’t know much about it, if there was any in the country or where to get it from, but he considered it academic, since he didn’t think Jacob had diphtheria. Just before they left, he said in an offhand manner – almost as an after-thought – "Oh, I had better give Jacob a swab".

(For some reason, the hospital never gave the parents the results of that swab – the parents only have the results of the ones from the GP.)

That this doctor saw no clinical evidence to lead him to believe that there was diphtheria is confirmed by the discharge letter sent to the GP, dated 8 August, in which the Clinical Director of the Children’s Emergency Department signed off the following:

Under "Reason for attendance (Primary diagnosis)" was written "tonsillitis". Under "Medications" was written "Amoxycillin". Under "Disposition from the Emergency Department and Follow up" was written, "Discharge No Follow-up". Under "Other comments": "Concern re ?Corynebacterium diphtheriae in unimmunised child. Well in CED. No ‘mousy’ breath, Exudate confined to tonsils. ECG normal."

The doctor also told the parents that the child could return to playcentre.

The swab taken by the GP for some reason went walk-about for a week, during which time Jacob returned to playcentre, and to his normal bouncy self.

On August 7th at around 10.00 a.m. the doctor received notification that the swab taken on 30^th July had grown a heavy growth of Streptococcus group A (pyogenes), a common cause of tonsillitis and sensitive to amoxycillin, and a heavy growth of Corynebacterium diphtheria (usually treated with Erythromycin). The doctor wrote and faxed the mother the test results with an urgent letter for readmission to Starship for review, which states on the last line:

"It may be appropriate to notify staff who saw the patient whilst last in Starship."

He advised that all family members go to Starship straight away, and that they would be looked after, swabbed and given booster shots.

They arrived and were again made to wait with other people, even after the father pointed out that their son had had a positive test result for diphtheria. Meanwhile, Jacob was having great fun playing in the playhouse with other children. They were very surprised that such a lax attitude existed. This was supposed to be very serious – the first case in however many years. A nurse from Public Health came and asked them who they had seen, and where they had been. The father again pointed out that diphtheria was supposed to be serious, and why were they still in a public area, and shouldn’t all staff and families in the same ward as they had been be notified?

While the staff knew who had been admitted as patients on that night, they had no idea which rooms they had been put in, and didn’t seem much concerned. They certainly didn’t notify staff in contact with Jacob. The same staff member did all ECG’s and was only told about the test results by the parents after the last ECG. No-one had swabbed her, or offered her antibiotics or a booster. The father had, in the previous week, travelled north and south seeing lots of customers and friends, as well as friends that went overseas in that one week. The parents were more concerned about that than anyone else, because they thought it was their duty to be concerned, even though nothing seemed to be wrong with their child.

The hospital staff then decided to put Jacob into isolation – finally – and when he was seen, it was by people in NASA-type suits who could find nothing. The notes from that day show nothing of any sort of infection, but say under "parental perception of illness":

"1/52 throat infection, drinking down and fever. ? Diptheria."

Staff dropped the "NASA" suits in a wheelchair next to

reception, gave Jacob another ECG, said he was fine and sent them home at 5.40 p.m.

However, one doctor who did not see Jacob the first day decided to write in the file records at 1700:

"Presented 7 – 10 days ago with clinical naso-pharyngeal diphtheria – green membrane on tonsils Rx Amoxyl… Now back to self."

Yet according to the doctor who wrote the "presenting notes" Jacob had tonsillitis with a green EXUDATE, no signs representing clinical diphtheria, no mousy breath, no MEMBRANE – and no follow-up. How odd.

They were on their way home when their brother-in-law, who had gone to the doctor’s to check on them, phoned to see how the family was doing, and was told nothing was happening. The doctor then phoned back, and asked them to come back to the surgery instead of going home. Just as they got into his room, the doctor had to attend to a phone call. The husband asked for a drink, and as he was drinking the doctor came in and accidentally spilled the water down his front. This was the last straw, because the children were tired, fed up, thirsty and hungry, having not been offered anything in hospital, and everyone had had enough of being pushed from pillar to post with no-one seeming to know what to do next.

On the 8th (Saturday) the family decided that the whole management had been atrocious, and that if anyone wanted to do anything further they could come to their house, since they had done everything asked of them. The father repeatedly rang Grant Close at the Starship to discuss the matter, but he did not return the call. However, the supervisor at the hospital did ring back twice. The first time was to say that they didn’t have any antitoxin in the country. The second time was to say that it was on a plane from Australia, and could they bring Jacob back the next day to be evaluated by infectious disease specialists. At 3 p.m. that same day, the Public Health people went to their home, took swabs from everyone and wanted to give them all diphtheria boosters.

The next day, they took Jacob back to Starship for specialist review. At midday they were seen, and the written purpose of the visit was:

The notes state that: "Dr Lennon and I explained the rarity of this disease and that throat swabs are not usually cultured in such a way as to detect it. As strep A pyogenes was also cultured as a much more common cause of tonsillitis which fitted the clinical picture, the C. diphth could (emphasis hospital) have been carried, not causing disease, but having been found, illness and contacts have to be managed as such."

Illness? What illness? There was no presenting illness.

What to do now? Dr Wilson continued on to explain to the parents that to use anti-toxin with no sign of infection could be dangerous and cause quite nasty, serious side-effects which you wouldn't want in a healthy child. She reports this in the records:

"However, there are no clear guidelines for its use so far into illness (resolved) and antibiotics and in mild disease which this must qualify as, as the exudate had gone by Friday. The antitoxin is only effective prior to absorption by cells so is unlikely to affect outcome now."

"Mild disease which this must qualify as?" There are certain things which should be done to decide whether clinical disease has occurred. For instance, Jacob could have had serial blood tests from the start which if he had had absorption by the cells of anti-toxin from the bacteria in the throat, would show up, over a period of 4 weeks, as a 40-fold increase in anti-toxin antibodies. But this was never done. Dr Wilson appears to have considered the presence of an exudate on tonsils as proof that there was disease – even though she had admitted in the previous paragraph that the symptoms were also what you would expect with tonsillitis from Strep A pyogenes.

In my opinion, Dr Wilson talked herself into believing that something she didn’t see was diphtheria. And this is where things get very blurry, because at no time did staff observe any clinical illness compatible with clinical diphtheria, nor did they initiate the tests which would have separated an "isolate" from "clinical disease". The only hospital doctor to actually see anything was so sure it wasn’t diphtheria that a letter was sent to the GP stating so.

At no time was this child treated with the antibiotics used for diphtheria, or antitoxin, so was it a case of diphtheria?

None of Jacob’s symptoms or clinical work-up conforms to either international diagnosis of a case (as opposed to a laboratory isolate), or New Zealand’s definition of disease.

Take Michael Baker’s article "A case of diphtheria in Auckland – implications for disease control" in The New Zealand Public Health Report, Vol. 5, No. 10 October 1998 pg. 73:

"The first notified case of respiratory diphtheria in New Zealand for 19 years occurred in Auckland in August 1998. The case was an unimmunised 32-month-old European male who presented with pharyngitis from which toxigenic Corynebacterium diphtheriae was isolated. "

However, he defines respiratory diphtheria as:

"In the respiratory tract, infection causes patches of thick, adherent greyish membrane."

Jacob didn’t have any.

Baker then classifies pharyngotonsillar diphtheria this way:

"Laryngeal and tracheobronchial diphtheria may cause dyspnoea, stridor, and progressive respiratory obstruction, particularly in young children and infants."

The symptoms Jacob had could fit pharyngotonsillar diphtheria, but as Dr Wilson admitted, also fitted the clinical picture of Strep A tonsillitis. And other problems, such as bronchiolitis. Indeed, Jacob was sent for a radiology report, which stated that:

"…the mild bronchial wall thickening with hyperinflation…was consistent with bronchiolitis."

Even Dr Baker states on pg. 75:

"Membranous pharyngitis is, however, also associated with infection by other organisms, such as Streptococci, Epstein Barr virus, Adenovirus and Corynebacterium pseudodiphtheriticum. In a non-endemic country such as New Zealand, diagnosis of mild cases of diphtheria will remain difficult… Patients with suspected respiratory diphtheria should be isolated and treated on the basis of their clinical presentation rather than waiting for laboratory confirmation which takes a few days. Antitoxin should be administered promptly with the dose based on the site and size of the diphtheritic membrane, the degree of toxicity, and the duration of illness."

And that is precisely why Jacob wasn’t isolated, or treated – because there were no membranes and no signs of toxicity that led anyone in the hospital to consider clinical diphtheria seriously.

But Dr Baker goes beyond credibility on pg. 74 when he states:

"Based on the extent of the tonsillopharyngeal membrane and resolution within a week, this case would be classified as mild."

There was no tonsillopharyngeal membrane. Dr Denny specifically wrote in the file that there was no involvement of the pharynx on admission, and a yellow green exudate confined to the tonsillar bed is not a pharyngeal membrane.

Contrast this with his statement at the beginning of the Discussion, where Dr Baker says:

"However, the detection of group A Streptococcus on the throat swab raises the possibility that the Streptococcus was the primary pathogen for the tonsillopharyngitis and the C. Diphtheriae carriage was an incidental finding."

Seems to me he can’t make his mind up what to think, say, describe or diagnose. Why not admit it? It seems a case of "let us not let facts get in the way of a case now destined to grace the annals of mythical medical history as respiratory diphtheria." Which should have thick adherent greyish membrane. (And didn’t.)

How could this media circus and diagnostic dilemma have veered so far from scientific fact? Perhaps a look at subsequent events could give a clue. The Monday after Dr Wilson and Dr Lennon could find nothing wrong with Jacob, the story hit the media in a big way. Someone must have decided that this little unimmunised boy would be very useful for publicity purposes. On the Tuesday, Nikki Turner and I appeared on "The Good Morning Show". Nikki Turner took over, assuring everyone how serious the problem was. When I tried to point out that there were two organisms in the swab, and the child hadn’t been treated for diphtheria, the viewers were given quite the opposite – how antitoxin had to be used and so on, and how this was a public emergency. (And brilliant publicity for her.)

Mary Lambie got on the subject, and those watching heard one parent whose child went to the same childcare centre as Jacob, indignant about "parents who would not vaccinate, putting everyone at risk, and forcing me to have my child swabbed and re-vaccinated…and I have to pay for it…" (which she didn’t), and another from the same childcare centre rang in saying she’d listened to everything said, and that everyone should spare a thought for this "seriously ill boy" (who was bouncing around quite happily).

The first medical person to capitalise on the swab result was Diana Lennon in the Herald on 18^th August. She had evaluated Jacob with Elizabeth Wilson on 8^th August, and found – nothing. She couldn’t quite bring herself to call it a "case", but worded it loosely enough to leave the rest to hysterical imagination, while pressing her case for immunisation in general:

"When a disease such as diphtheria, which we believe we have conquered, reappears…."

The Herald asked me to write a rebuttal to Diana Lennon’s article – but then refused to print it. I guess truth is not win/win journalism.

Let’s be scientific about this. Diphtheria reappeared? It did, in Russia, primarily amongst vaccinated people. But here? Where? Oh yes, there have been 11 toxigenic isolates in this country, including Jacob’s, between 1991 – 1998. But none of the others were called a case. Could it be that all the others were (shock) vaccinated?

Dr Chris Kalderimis, having soaked up the TV, radio and written coverage, which in some papers had this kid near death’s door, wrote in the Dominion on 25^th August:

"Most doctors, including myself, have probably never seen diphtheria. But it was seen in Auckland two weeks ago, affecting a young child."

Really? Seen by whom? Yes, you guessed it. The medical technologist in the laboratory.

Every paper around got on the med-slide, with Jacob being diagnosed with "a killer disease" (Manawatu Standard August 11^th). The Daily News, 12^th August said the toddler had been "diagnosed with diphtheria, an acute and potentially fatal condition." Bay of Plenty Times 13^th August described Jacob as "The boy, struck down with diphtheria". The Chronicle’s headline on 17^th August proclaimed "We are not immune" and "Diphtheria rears its ugly head once again in this country…" with all the other propaganda that had since become enshrined in the myth.

Then came the editorials about how it was time to act against parents who wouldn’t vaccinate, let’s make it compulsory, how obligations override rights. In spite of the fact that no other family members, or children at the childcare centre had tested positive, it had suddenly become a national public emergency. Napier’s public health unit called for parents to vaccinate their children "following a diphtheria scare this week" (Daily Telegraph 12 August). And while we’re at it, let’s ban unimmunised children from day care.

(About this time I started to hear rumours that a few of the people treated with prophylactic antibiotics had had some nasty adverse reactions, and that the whole childcare centre had been revaccinated.)

The scaremongering machine was in full swing. And what a field day the media had then. Lots of doctors got in on the nationwide act. By this time a few journalists were asking questions, even if their editors weren’t going to let them publish. One of the areas of concern was that if this was as serious as Nikki Turner was making it out to be, why had the child not been isolated in hospital from the start. Thinking that I might know the parents and child, some of them came and discussed their concerns with me. Their main concern was that from the very start, it appeared that Grant Close had a prepared press release for just about every contingency to do with Jacob’s case. In the opinion of one of the more experienced journalists, this usually only happens when there is something to hide. Conversations with Nick Jones about the delay in the test results were such that they left much to be desired, but most importantly, Grant Close was at that time alleging that the family’s GP, at no point, alerted the hospital to diphtheria. (See page 1.)

At that time, I had no contact with the parents, so I continued speaking out on radio, and wherever I could, that there was considerable doubt as to whether this child actually had a clinical dose of diphtheria. These concerns were never aired, because the medical machine swung into action, going straight to people they knew would facilitate their opinions only.

Then some other journalists started asking that if the doctor had suspected diphtheria, why did the hospital take such a lax attitude to the swab going missing? The answer in several papers, according to Grant Close, was that:

"…a senior registrar found the child showed no signs of diphtheria on July 30. The accompanying referral note from the child’s general practitioner showed a diagnosis earlier that day of a sore throat."

While Grant Close was trying to play it down, Nikki Turner was trying to play it up. The Wairarapa Times-Age:

"Dr Turner…said the unvaccinated Auckland toddler at the centre of a diphtheria scare this week was likely to have got the acute infection from his parents after they holidayed last month in Indonesia. If the parents can bring diphtheria back and give it to their child, they can easily give it to their neighbours…"

And so she carried on – and the flames were fanned to become a bonfire.

Then the parents came to see me, and it turned out that the rumours about antibiotic reactions and enforced revaccinations were true. I explained to them that the childcare centre children should not have been re- immunised, because international protocols for a clinical case require only people not having had a diphtheria vaccination within 5 years to be vaccinated. All those kids had had shots – some within a few weeks of Jacob’s test showing bacteria, and did not need any more. So much for international protocol.

Over the next few months, the stories rolled on. I collected them, read them all, ran out of highlighter, and the pile grew. And by the time the parents had got the proof they needed, and wanted the truth published, it was too late. The parents, having become distressed at the lies being told, had rung Holmes, wanting to put their viewpoint, but he wasn’t interested. They started to write letters to newspapers, detailing the facts, but would anyone publish them? No. After all, the newspapers had been bitten by the ‘Fallacy of Authority’, and weren’t interested in mere parents or hospital files. And anyway, old news is no news. The medical machine had done it’s job.

Every few months, up popped an allegation that the parents had given it to the child. So the parents started to try to find out where the isolate came from. It’s a simple procedure, and they assumed it had been done, because everything they had read in the medical literature showed it to be standard procedure. They requested the results.

But the ESR had not had them done. They had sent samples to Australia, but the replies had no answer with regard to geographical regions. So, the parents wrote again, asking for the sample to be geographically typed against a reference library. The CDC in Atlanta, and in other countries, have samples of every strain which exists, and can tell by the genetic code which country it comes from. However, ESR said that Paris and London were being consulted, and they would get back to them. By 10^th August 1999, ESR still didn’t know, but enclosed their report on

Jacob, which infuriated the parents. They politely asked that the ESR amend their records based on the hospital files to show Jacob as an isolate, not a case, since at no time had he shown clinical signs of or been treated for diphtheria, and to send a sample for geographical typing immediately.

11 months later, the, ESR has still not replied to the letters. This year, Trish Batchelor and Nikki Turner, both writing in the "New Zealand Doctor" continue to perpetuate the myth that the parents, who never tested positive, or had any symptoms, brought it back from Indonesia and gave it to Jacob. Contrast this with 1997, when IAS suggested that some of the vaccinated children who got measles after the MMR might have got it from the vaccine. We were told that there wasn’t a shred of evidence to support such anecdotal theories – even though we had a letter from the vaccine manufacturers saying it could happen.

And as to the sewage spill which the parents wondered might have contained faecal diphtheria bacteria? This was mentioned several times in the early days to Nick Jones, and Dr Phyllis Taylor, who both thought such a suggestion, even with historical precedence, was far too ludicrous a suggestion, and anyway, it would be like looking for a needle in a haystack.

But what the parents really wanted to know was why they had been made such an example of and harassed. They were literally driven out of their home to seek peace and solace, and try to deal with the garbage which was being said about them.

As I see it, there are a few personal opinions which I believe are relevant as to why an example was made of Jacob. Michael Baker, Diana Lennon and Nikki Turner are very consistent. They have always been so pro-vaccine I don’t believe they’d acknowledge anything negative about vaccines if it bit them on the nose. Dr Baker appears to have had considerable difficulty getting accurate clinical notes, and even more difficulty classifying the "problem". But I believe that they knew that defining an isolate as a "case" was a publicity gift that money wouldn’t buy, and one which could be traded on for years.

Contrast the speed at which they sprang into print about Jacob, with the six weeks it took to drag an admission out of anyone that a mother was on life support with paralytic poliomyelitis caught from her vaccinated baby. How are these two cases related?

In the case of Jacob, his parents never gave anyone permission for any information to be released, yet it poured out in a torrent. The media were camping on their North Shore street right from word go. Starship hospital saw to that. My journalist friends told me how zealous they were to make all details known.

Over a year later, when a North Shore polio case landed up in intensive care on life-support (and is still on life support), and who also could have passed infectious polio virus around here, there and everywhere, the situation was very different. The parents were told under no circumstances were they to go to the media. Staff were sworn to total secrecy. Though it turned out that some journalists did know, the story, it appears, never even got to the sub-editor’s desk. How was this achieved? Probably the Public Health Act from way back which gives the Health Department total censorship rights where they consider it in the public interest. The Health Authorities were so rigid about keeping it a secret it was inevitable that it would come out via people who were annoyed about the hypocrisy of the Auckland Hospital’s "risk management" position eighteen months previously.

As simple as that.

The real message centres around the title of Michael Baker’s article "…implications for disease control".

The parents reported back from hospital one day, thoroughly incensed that a specialist (who I could name but won’t) took the trouble to say, in their line of sight and hearing, to another staff member that the parents should be sued for all the cost of all the trouble they had caused. In the context of implications for disease control, I believe that the person who said that should think very carefully. In reality, if Jacob had had a true clinical case of diphtheria as per the old days, the hospital’s isolation procedures and ability to treat it were so lax, that had it been, say, Ebola as in Dustin Hoffman’s "Outbreak", a pandemic could have marched half way down the country before the hospital even woke up. There wasn’t even anti-toxin in the country. That is the real implication for disease control in this country. Instead of wanting to sue someone, a certain person perhaps should contemplate the implications of the failure of the medical profession to act in accordance with printed international protocols for suspected diphtheria. They cannot claim they didn’t know. All hospitals are on Internet, where it took me 10 minutes to find out what should have been done.

There is another side to that coin though. It is my opinion that from Jacob’s point of view, the hospital’s disbelief of their GP and the walk-about of the throat swab were to his medical advantage. Dr Baker said in his article that all cases of suspected diphtheria should be treated with anti-toxin before the swab comes back. Had the hospital followed protocols, Jacob would have been filled up with diphtheria specific antibiotics and anti-toxin from the start.

The problem with that is that anti-toxin can be very, very dangerous. If someone is dying anyway, it might be worth the risk. But it has the potential to kill a healthy person, can have serious side-effects and cause life-long immunological problems. Jacob had no clinical signs of diphtheria. And the delay in assessing him for treatment allows us to consider the fact that he was a carrier, not a case.

But had things been different, Jacob could have been treated (unnecessarily) and died as a result. He could also have been treated (unnecessarily) with no side effects, with the doctors proclaiming that he survived because the anti-toxin saved his life. No-one could have proven otherwise. But if he had died from the anti-toxin, how would they have presented that to the media? Would the doctors have said that Jacob had died – in spite of their efforts to save him – and this is what happens when you’re not vaccinated?

Picture the media result of that for a moment. Those who chose not to vaccinate would instantly have been portrayed as national pariahs, the media frenzy would have become an inferno, with parliament probably making vaccination compulsory. There are rumours coming out of parliament anyway that this is Annette King’s passport to medical canonisation.

This cautionary tale shows that all it takes is some careful sculpturing of the facts to change the slant, some obscuring of the facts – and freedom of choice is in the slammer. The factual mangling of the events as they actually were was unprofessional enough, but as the language against those who chose not to vaccinate becomes every more aggressive and strident, the implications of what could have happened media-wise had Jacob been promptly treated (unnecessarily) and died just don’t bear thinking about.

 This cautionary tale could apply to any unvaccinated child or family. If you feel strongly about what happened (and is still happening) to Jacob and his family, write to everyone you can think of and protest! Write to Nikki Turner, your local M.P., Annette King, Helen Clark, Grant Close, the Consumer magazine, Paul Holmes, Fair Go, etc etc. Use this story to try and educate and maybe make a small difference in the way unvaccinated children are treated.