BRITISH MEDICAL JOURNAL
228
epitaphs of disastrous planning that have seriously crippled the finances of the Health Service. Your leading article (25 December, p 1524) has it clearly: "Our child health services are too important . . . for such a fate." Furthermore, we can ill afford the expense of such a frustrating exercise. I am also concerned with the proposals for the implementation of this report both as a member of district administration and as a pathologist concerned with dead, injured children. Where is the proposed staff to come from ? Where are the general practitioners who are prepared to train in paediatrics and, more importantly, in the newly developing complex field of child development ? Where are the GPs who are prepared to set aside two sessions a week for this work, bearing in mind the fact that much more than two sessions will be needed for visiting, consultations with all sorts of people, and so on? Then again how are the health visitors, child-health nurses, and school nurses to be found ? They are the key to the solution of most of the problems of child health care. Finally, where are the aspiring registrars and senior house officers and where are the paediatric consultant posts for them ? Many of them would wish to work in hospitals, even under the present consultant contract. It is time that we looked at our existing services in order to consolidate the little that we can afford. We can best do this by asking that politicians stop meddling in health care and in particular desist from encouraging the production of expensive reports that must inevitably follow the inert course of Zuckerman, Brodrick, RAWP, and the like. G A GRESHAM University Department of Morbid Anatomy and Histopathology, Addenbrooke's Hospital, Cambridge
Committee on Child Health Services, Fit for the Future. London, HMSO, 1976.
vided that certain safeguards were observed -and these were spelled out clearly in the report-workers from other disciplines, notably nurses, midwives, health visitors, and pharmacists, who had received suitable clinical training should also be empowered to prescribe the medication. In this way single women and, to a lesser extent, married women would be less inhibited from obtaining oral contraceptives than under the present circumstances of medical distribution of the pill. The report dealt only with the situation in the UK. But the global aspects of pill distribution should not be forgotten. In many countries, particularly in the Third World, no one now writes a prescription. Instead a communitybased service is operated aimed to bring oral contraceptives directly to the people either free or at prices which they can afford. Increased accessibility of the pill is now regarded as de rigueur by many Third-World governments. Slowly but surely the "medical closed shop" in relation to this form of birth control is being eroded. Given this global situation can Britain afford to "stand idly by ?" Or should she not act as the exemplar to the developed world by freeing the pill from medical prescription ? We consider that, so far, treatment of this important topic by the medical press has been perfunctory to say the least of it. The purpose of this letter is to reopen the issue for debate. We are hopeful that such a debate will take place during 1977. JUDITH BURY R F FLETCHER JOHN GUILLEBAUD N HARRISON J P LESTER
JOHN A LORAINE MALCOLM POTTS ELIZABETH ROSE ELEANOR STEINER G I M SWYER
Department of Community Medicine, University of Edinburgh Department of Health and Social Security, Report of the J7oint Working Group on Oral Contraceptives. London, HMSO, 1976.
Access to oral contraceptives
Cord blood IgM and suspected congenital rubella
SIR,-We are writing to express our concern vis-a-vis the apparently negative attitude of the BMA to the recent report of the Joint Working Group on Oral Contraceptives.' In its press statement on the report (6 November, p 1154) the Association described the proposals of the group as "clumsy" and stated that a satisfactory case for making the pill available without a doctor's prescription had not been made. The Working Group was set up by the then Minister of Health, Dr David Owen. Its establishment followed the publication of a letter in the BMJ (19 October, 1974, p 161) signed by 24 members of the medical profession and entitled "Distribution and supervision of oral contraceptives." The Working Group contained highly prestigious members of the medical, nursing, and pharmaceutical professions as well as lay members experienced in Health Service matters. It met many times over the course of a 12-month period and reviewed extensive and detailed evidence emanating from a variety of sources. The group was fully cognisant of the welldocumented risks which can result from the administration of the pill. But its considered opinion was that these hazards were not of such a magnitude as to make it necessary to restrict authority for the prescription of oral contraceptives to medical practitioners. Pro-
SIR,-Dr J A M Snijder and his colleagues (1 January, p 23) present data to suggest that two newborn babies had congenitally acquired rubella since they detected rubella-specific IgM in cord blood sera. We agree with their conclusions in the first case, since the baby had clinical features consistent with congenitally acquired rubella and virus was recovered from post-mortem specimens. However, no abnormalities could be detected in the second patient except for a raised level of total IgM in the cord blood, and no virus could be isolated from the baby. Because there was a significant rise in rubella antibody titre during the course of the mother's pregnarncy (1/16 in the 8th week of pregnancy to ->1/512 at term), but as no rubella-specific IgM antibody could be detected, it is concluded that the mother probably experienced a rubella reinfection with viraemia, since specific IgM was present in this baby's cord blood. It is also suggested that a low level of antibody (1/16) may be insufficient to offer protection against reinfection with viraemia. However, particular care must be taken before a diagnosis of rubella reinfection is made. In this case a primary infection cannot be ruled out. Thus the prolonged interval (30 weeks) between the mother's first and second serum samples would make it unlikely that rubella-specific
22 JANUARY 1977
IgM could still be detected by gel filtration techniques, and in our experience it is not uncommon to fail to detect IgM in early acute-phase sera with low levels of haemagglutinating inhibiting antibody.' Although it is therefore possible that the mother experienced a primary but subclinical infection and that the fetus was indeed infected, as rubella-specific IgM was apparently present in the cord blood, it is also important to ensure that a false-positive IgM reaction was not present. The authors do not make it clear at which stage in their procedure heat inactivation of serum was carried out. However, it has been shown that heat inactivation prior to serum fractionation may aggregate IgG, which will then fractionate with IgM on gel filtration through Sephadex G200, thereby giving rise to false-positive IgM reactions.2 Contamination of sera and prolonged storage of sera at -20°C may also give rise to false-positive reactions. However, false-positive inhibition in the IgM fractions is not affected by 2-mercaptoethanol (2-ME) treatment, whereas true IgM antibody is reduced. Before it can be concluded that the second baby experienced an intrauterine rubella infection attempts should be made to test the 2-ME sensitivity of the inhibitor in the IgM fraction and determine the duration of persistence of rubella antibodies in the baby. These points emphasise the importance of taking particular care in ensuring that falsepositive IgM results are not present when assessing women who have been exposed to, or who have developed, rubella-like illness during their pregnancy, as well as in babies who may present for non-rubella-related reasons with high levels of total IgM in the cord blood. J E BANATVALA JENNIFER M BEST Department of Virology, St Thomas's Hospital and Medical School, London SE1
2
Pattison, J R, Mace, J E, and Dane, D S, Journal of Medical Microbiology, 1976, 9, 355. Bariatvala, J E, Best, J M, and Al-Nakib, W, British Medical Journal, 1974, 1, 635.
SIR,-Dr J A M Snijder and others (1 January, p 23) present and discuss two interesting cases of suspected congenital rubella. The first was undoubtedly a cases of rubella virus infection, and, although rubella virus was not isolated from the second infant, the serological evidence of congenital rubella infection was as strong as in the first case. The mother of the second infant had a serum rubella haemagglutination inhibition (HI) antibody titre of 1/16 during the 8th week of pregnancy and a titre of greater than 1/512 during the 38th week. The authors conclude that it is therefore doubtful whether a rubella HI titre of 1/16 offers sufficient protection against reinfection with viraemia. This conclusion requires qualification. The majority of virology laboratories would regard rubella HI titres of 1/16 as being close to the minimum immune titre. Depending on the sensitivity of the rubella HI test employed, some laboratories would report titres of 1/16 as indicating immunity while others would take such titres to indicate susceptibility and recommend rubella immunisation. Experience during the past seven years indicates that the commonest consequence of contact with rubella in individuals with rubella HI titres of 1/16 is that there is no clinical illness and no
228
epitaphs of disastrous planning that have seriously crippled the finances of the Health Service. Your leading article (25 December, p 1524) has it clearly: "Our child health services are too important . . . for such a fate." Furthermore, we can ill afford the expense of such a frustrating exercise. I am also concerned with the proposals for the implementation of this report both as a member of district administration and as a pathologist concerned with dead, injured children. Where is the proposed staff to come from ? Where are the general practitioners who are prepared to train in paediatrics and, more importantly, in the newly developing complex field of child development ? Where are the GPs who are prepared to set aside two sessions a week for this work, bearing in mind the fact that much more than two sessions will be needed for visiting, consultations with all sorts of people, and so on? Then again how are the health visitors, child-health nurses, and school nurses to be found ? They are the key to the solution of most of the problems of child health care. Finally, where are the aspiring registrars and senior house officers and where are the paediatric consultant posts for them ? Many of them would wish to work in hospitals, even under the present consultant contract. It is time that we looked at our existing services in order to consolidate the little that we can afford. We can best do this by asking that politicians stop meddling in health care and in particular desist from encouraging the production of expensive reports that must inevitably follow the inert course of Zuckerman, Brodrick, RAWP, and the like. G A GRESHAM University Department of Morbid Anatomy and Histopathology, Addenbrooke's Hospital, Cambridge
Committee on Child Health Services, Fit for the Future. London, HMSO, 1976.
vided that certain safeguards were observed -and these were spelled out clearly in the report-workers from other disciplines, notably nurses, midwives, health visitors, and pharmacists, who had received suitable clinical training should also be empowered to prescribe the medication. In this way single women and, to a lesser extent, married women would be less inhibited from obtaining oral contraceptives than under the present circumstances of medical distribution of the pill. The report dealt only with the situation in the UK. But the global aspects of pill distribution should not be forgotten. In many countries, particularly in the Third World, no one now writes a prescription. Instead a communitybased service is operated aimed to bring oral contraceptives directly to the people either free or at prices which they can afford. Increased accessibility of the pill is now regarded as de rigueur by many Third-World governments. Slowly but surely the "medical closed shop" in relation to this form of birth control is being eroded. Given this global situation can Britain afford to "stand idly by ?" Or should she not act as the exemplar to the developed world by freeing the pill from medical prescription ? We consider that, so far, treatment of this important topic by the medical press has been perfunctory to say the least of it. The purpose of this letter is to reopen the issue for debate. We are hopeful that such a debate will take place during 1977. JUDITH BURY R F FLETCHER JOHN GUILLEBAUD N HARRISON J P LESTER
JOHN A LORAINE MALCOLM POTTS ELIZABETH ROSE ELEANOR STEINER G I M SWYER
Department of Community Medicine, University of Edinburgh Department of Health and Social Security, Report of the J7oint Working Group on Oral Contraceptives. London, HMSO, 1976.
Access to oral contraceptives
Cord blood IgM and suspected congenital rubella
SIR,-We are writing to express our concern vis-a-vis the apparently negative attitude of the BMA to the recent report of the Joint Working Group on Oral Contraceptives.' In its press statement on the report (6 November, p 1154) the Association described the proposals of the group as "clumsy" and stated that a satisfactory case for making the pill available without a doctor's prescription had not been made. The Working Group was set up by the then Minister of Health, Dr David Owen. Its establishment followed the publication of a letter in the BMJ (19 October, 1974, p 161) signed by 24 members of the medical profession and entitled "Distribution and supervision of oral contraceptives." The Working Group contained highly prestigious members of the medical, nursing, and pharmaceutical professions as well as lay members experienced in Health Service matters. It met many times over the course of a 12-month period and reviewed extensive and detailed evidence emanating from a variety of sources. The group was fully cognisant of the welldocumented risks which can result from the administration of the pill. But its considered opinion was that these hazards were not of such a magnitude as to make it necessary to restrict authority for the prescription of oral contraceptives to medical practitioners. Pro-
SIR,-Dr J A M Snijder and his colleagues (1 January, p 23) present data to suggest that two newborn babies had congenitally acquired rubella since they detected rubella-specific IgM in cord blood sera. We agree with their conclusions in the first case, since the baby had clinical features consistent with congenitally acquired rubella and virus was recovered from post-mortem specimens. However, no abnormalities could be detected in the second patient except for a raised level of total IgM in the cord blood, and no virus could be isolated from the baby. Because there was a significant rise in rubella antibody titre during the course of the mother's pregnarncy (1/16 in the 8th week of pregnancy to ->1/512 at term), but as no rubella-specific IgM antibody could be detected, it is concluded that the mother probably experienced a rubella reinfection with viraemia, since specific IgM was present in this baby's cord blood. It is also suggested that a low level of antibody (1/16) may be insufficient to offer protection against reinfection with viraemia. However, particular care must be taken before a diagnosis of rubella reinfection is made. In this case a primary infection cannot be ruled out. Thus the prolonged interval (30 weeks) between the mother's first and second serum samples would make it unlikely that rubella-specific
22 JANUARY 1977
IgM could still be detected by gel filtration techniques, and in our experience it is not uncommon to fail to detect IgM in early acute-phase sera with low levels of haemagglutinating inhibiting antibody.' Although it is therefore possible that the mother experienced a primary but subclinical infection and that the fetus was indeed infected, as rubella-specific IgM was apparently present in the cord blood, it is also important to ensure that a false-positive IgM reaction was not present. The authors do not make it clear at which stage in their procedure heat inactivation of serum was carried out. However, it has been shown that heat inactivation prior to serum fractionation may aggregate IgG, which will then fractionate with IgM on gel filtration through Sephadex G200, thereby giving rise to false-positive IgM reactions.2 Contamination of sera and prolonged storage of sera at -20°C may also give rise to false-positive reactions. However, false-positive inhibition in the IgM fractions is not affected by 2-mercaptoethanol (2-ME) treatment, whereas true IgM antibody is reduced. Before it can be concluded that the second baby experienced an intrauterine rubella infection attempts should be made to test the 2-ME sensitivity of the inhibitor in the IgM fraction and determine the duration of persistence of rubella antibodies in the baby. These points emphasise the importance of taking particular care in ensuring that falsepositive IgM results are not present when assessing women who have been exposed to, or who have developed, rubella-like illness during their pregnancy, as well as in babies who may present for non-rubella-related reasons with high levels of total IgM in the cord blood. J E BANATVALA JENNIFER M BEST Department of Virology, St Thomas's Hospital and Medical School, London SE1
2
Pattison, J R, Mace, J E, and Dane, D S, Journal of Medical Microbiology, 1976, 9, 355. Bariatvala, J E, Best, J M, and Al-Nakib, W, British Medical Journal, 1974, 1, 635.
SIR,-Dr J A M Snijder and others (1 January, p 23) present and discuss two interesting cases of suspected congenital rubella. The first was undoubtedly a cases of rubella virus infection, and, although rubella virus was not isolated from the second infant, the serological evidence of congenital rubella infection was as strong as in the first case. The mother of the second infant had a serum rubella haemagglutination inhibition (HI) antibody titre of 1/16 during the 8th week of pregnancy and a titre of greater than 1/512 during the 38th week. The authors conclude that it is therefore doubtful whether a rubella HI titre of 1/16 offers sufficient protection against reinfection with viraemia. This conclusion requires qualification. The majority of virology laboratories would regard rubella HI titres of 1/16 as being close to the minimum immune titre. Depending on the sensitivity of the rubella HI test employed, some laboratories would report titres of 1/16 as indicating immunity while others would take such titres to indicate susceptibility and recommend rubella immunisation. Experience during the past seven years indicates that the commonest consequence of contact with rubella in individuals with rubella HI titres of 1/16 is that there is no clinical illness and no
