1134 TABLE I-CASES OF MEASLES AT
C.H.K., RWANDA
DANGEROUS PATHOGENS AND THE H.S.E. your editorial on the draft the Health and Safety Executive Whilst a lighthearted response is our initial reaction, we feel that several serious points emerge. Firstly, the existence of these draft notes on the way we should conduct our livelihood does not seem to have been well publicised. One of us encountered a reference to this consultative document by chance and learnt that comments were asked for promptly. We sent for a copy of the draft guidance, but, two weeks later, have yet to see the document. We assume that others are in the same position, and that H.S.E. will now produce sufficient copies for informed comment to result. We suspect from the details alluded to in your editorial that H.S.E. has once more embarked on that curious exercise which it has made unique to itself-namely, to begin every round of consultation with pathologists in an atmosphere of confrontation. Secondly, the H.S.E. should reconsider very carefully the basic tenets by which it operates in the area of work safety and infectious disease. We accept that all of us, both employers and employees, should do precisely what the Health and Safety Act required-namely, take all "reasonable and practicable" steps to ensure health and safety at work. Surely, the first two steps are (1) to define accurately the incidence of infective diseases in the community at large and (2) the incidence of those same infections in laboratory workers. If (2) is greater than (1), a problem exists and steps to define and limit it can be taken. If, however, the incidence is the same, or even less, in laboratory workers than in the community, then no problem exists and no solution is needed. As far as we know, no such figures have been obtained by H.S.E., and much of the current conflict arises from the insistence of H.S.E. on eliminating hazards which common sense and experience suggest never existed in the first place. We accept that there is satisfactory scientific evidence in a few areas (e.g., tuberculosis and hepatitis) but even these hazards were being reduced before H.S.E. was born. Information on other hazards must be accurately compiled before action is considered, otherwise the installation of, for instance, expensive equipment, is neither "reasonable" nor, in the current financial climate, "practicable". We understand that the Royal College of Pathologists has made a start and we would hope that H.S.E. will join in this exercise wholeheartedly, meanwhile forebearing to issue any further guidance. Perhaps a useful "stop-gap" exercise would be for microbiologists and pathologists to compile a list of all infections acquired by any member of their staff within the past five years and send it to the College working party. If, as we suspect, this rough-and-ready tally suggests that the problem is not of the order of magnitude which H.S.E. is assuming, would it not be reasonable and practicable to await the results of the more formal inquiry? Finally, since we are advocating a system in which decisions are based on accurate scientific data, we would welcome, along with the guidance document from H.S.E., some indication of the scientific sources from which they derive even their theory. Where, for instance, is proof of aerosol-transmitted human infection with Salmonella typhi, necessitating its inclusion in category Bl so that work is done in an exhaust-protective cabinet?
SIR,-We read with interest
guidance notes published by (H.S.E.) (Nov. 10, p. 1004).
*July. World Health
Organisation statistics1,2
for Rwanda
are
reported in table II. TABLE II-MEASLES IN RWANDA: W.H.O. FIGURES
W.H.O. figures for measles mortality in Rwanda for 1973 and 1974 were, respectively, 0-27% and 0.39%. The C.H.K. average measles mortality is 21%, a figure similar to that for hospital admissions in other developing countries in West Africa.3 The total number of deaths recorded by W.H.O. for the whole country (about 4.7million inhabitants) in a year is very similar to the number in Kigali noted by our team (population about 200 000 inhabitants). The discrepancy does not depend on differences between Kigali and the rest of Rwanda: population density and socioeconomic levels are about the same for the whole country. No recent factor could explain the mortality increase from 1973-74 to 1975-78. The discrepancy probably reflects the difficulty in collecting statistical data on national level in a developing country. Such figures should be published with caution, especially when they are so different from those collected in countries with comparable standards of living. Department of Pædiatrics, Kigali Hospital Centre, Kigali, Rwanda; and Department of Microbiology, Free University of Brussels, St Pierre Hospital, 1000 Brussels, Belgium
PH. LEPAGE
P.
DE
MOL
ATYPICAL MEASLES SYNDROME
SIR,-Your May 5 editorial referred to Nichols’ investigation of 56 cases of atypical-measles syndrome (AMS) in California during 1974-75.4 You stated that "In all patients measles was virologically confirmed, and 50 of the patients (89%) had been vaccinated, all but one of them with killed vaccine". Your readers will have assumed that the other 6 cases were unvaccinated. This is not so. Nichols lists these 6 cases, under the heading of "vaccine(s) received", as "vaccine type(s) uncertain". 56 cases of AMS had been vaccinated: 6 received vaccine of unknown type. Department of Microbiology, Division of Agricultural and Life Sciences, University of Maryland, College Park, Maryland 20742, U.S.A.
JOHN CHRISS HOFFMAN
Microbiology Department, Freeman Hospital, Newcastle upon Tyne NE7 7DN
R. FREEMAN H. R. INGHAM
B. G. YOUNG J. ANTHONY MORRIS
BALLOT IN SCOTLAND ON PROPOSED CONSULTANT CONTRACT 1. World Health Statistics Annual 1973-76: vol II: infectious diseases: cases, deaths and vaccination. Geneva: W.H.O., 1976: 12. 2. World Health Statistics Annual 1978: vol II: infectious diseases: cases and deaths. Geneva : W.H.O., 1976: 7. 3. Morley DC, Woodland M, Allen I. Measles m West Africa. W Afr Med J
1966; 17:8. 4. Nichols EM. Atypical measles Health 1979; 69:160-62.
syndrome:
a
continuing problem. Am J
Publ
SIR,-Dr Brown and colleagues (Nov. 10, p. 1027) write that after the rejection of the new contract pricing (June 14) very few consultants were aware that fresh discussions were taking place with Mr Patrick Jenkin, the Secretary of State for Social Services, or of their nature, until a letter appeared in the Scotsman on Aug. 24. The discussions concerned improve-
C.H.K., RWANDA
DANGEROUS PATHOGENS AND THE H.S.E. your editorial on the draft the Health and Safety Executive Whilst a lighthearted response is our initial reaction, we feel that several serious points emerge. Firstly, the existence of these draft notes on the way we should conduct our livelihood does not seem to have been well publicised. One of us encountered a reference to this consultative document by chance and learnt that comments were asked for promptly. We sent for a copy of the draft guidance, but, two weeks later, have yet to see the document. We assume that others are in the same position, and that H.S.E. will now produce sufficient copies for informed comment to result. We suspect from the details alluded to in your editorial that H.S.E. has once more embarked on that curious exercise which it has made unique to itself-namely, to begin every round of consultation with pathologists in an atmosphere of confrontation. Secondly, the H.S.E. should reconsider very carefully the basic tenets by which it operates in the area of work safety and infectious disease. We accept that all of us, both employers and employees, should do precisely what the Health and Safety Act required-namely, take all "reasonable and practicable" steps to ensure health and safety at work. Surely, the first two steps are (1) to define accurately the incidence of infective diseases in the community at large and (2) the incidence of those same infections in laboratory workers. If (2) is greater than (1), a problem exists and steps to define and limit it can be taken. If, however, the incidence is the same, or even less, in laboratory workers than in the community, then no problem exists and no solution is needed. As far as we know, no such figures have been obtained by H.S.E., and much of the current conflict arises from the insistence of H.S.E. on eliminating hazards which common sense and experience suggest never existed in the first place. We accept that there is satisfactory scientific evidence in a few areas (e.g., tuberculosis and hepatitis) but even these hazards were being reduced before H.S.E. was born. Information on other hazards must be accurately compiled before action is considered, otherwise the installation of, for instance, expensive equipment, is neither "reasonable" nor, in the current financial climate, "practicable". We understand that the Royal College of Pathologists has made a start and we would hope that H.S.E. will join in this exercise wholeheartedly, meanwhile forebearing to issue any further guidance. Perhaps a useful "stop-gap" exercise would be for microbiologists and pathologists to compile a list of all infections acquired by any member of their staff within the past five years and send it to the College working party. If, as we suspect, this rough-and-ready tally suggests that the problem is not of the order of magnitude which H.S.E. is assuming, would it not be reasonable and practicable to await the results of the more formal inquiry? Finally, since we are advocating a system in which decisions are based on accurate scientific data, we would welcome, along with the guidance document from H.S.E., some indication of the scientific sources from which they derive even their theory. Where, for instance, is proof of aerosol-transmitted human infection with Salmonella typhi, necessitating its inclusion in category Bl so that work is done in an exhaust-protective cabinet?
SIR,-We read with interest
guidance notes published by (H.S.E.) (Nov. 10, p. 1004).
*July. World Health
Organisation statistics1,2
for Rwanda
are
reported in table II. TABLE II-MEASLES IN RWANDA: W.H.O. FIGURES
W.H.O. figures for measles mortality in Rwanda for 1973 and 1974 were, respectively, 0-27% and 0.39%. The C.H.K. average measles mortality is 21%, a figure similar to that for hospital admissions in other developing countries in West Africa.3 The total number of deaths recorded by W.H.O. for the whole country (about 4.7million inhabitants) in a year is very similar to the number in Kigali noted by our team (population about 200 000 inhabitants). The discrepancy does not depend on differences between Kigali and the rest of Rwanda: population density and socioeconomic levels are about the same for the whole country. No recent factor could explain the mortality increase from 1973-74 to 1975-78. The discrepancy probably reflects the difficulty in collecting statistical data on national level in a developing country. Such figures should be published with caution, especially when they are so different from those collected in countries with comparable standards of living. Department of Pædiatrics, Kigali Hospital Centre, Kigali, Rwanda; and Department of Microbiology, Free University of Brussels, St Pierre Hospital, 1000 Brussels, Belgium
PH. LEPAGE
P.
DE
MOL
ATYPICAL MEASLES SYNDROME
SIR,-Your May 5 editorial referred to Nichols’ investigation of 56 cases of atypical-measles syndrome (AMS) in California during 1974-75.4 You stated that "In all patients measles was virologically confirmed, and 50 of the patients (89%) had been vaccinated, all but one of them with killed vaccine". Your readers will have assumed that the other 6 cases were unvaccinated. This is not so. Nichols lists these 6 cases, under the heading of "vaccine(s) received", as "vaccine type(s) uncertain". 56 cases of AMS had been vaccinated: 6 received vaccine of unknown type. Department of Microbiology, Division of Agricultural and Life Sciences, University of Maryland, College Park, Maryland 20742, U.S.A.
JOHN CHRISS HOFFMAN
Microbiology Department, Freeman Hospital, Newcastle upon Tyne NE7 7DN
R. FREEMAN H. R. INGHAM
B. G. YOUNG J. ANTHONY MORRIS
BALLOT IN SCOTLAND ON PROPOSED CONSULTANT CONTRACT 1. World Health Statistics Annual 1973-76: vol II: infectious diseases: cases, deaths and vaccination. Geneva: W.H.O., 1976: 12. 2. World Health Statistics Annual 1978: vol II: infectious diseases: cases and deaths. Geneva : W.H.O., 1976: 7. 3. Morley DC, Woodland M, Allen I. Measles m West Africa. W Afr Med J
1966; 17:8. 4. Nichols EM. Atypical measles Health 1979; 69:160-62.
syndrome:
a
continuing problem. Am J
Publ
SIR,-Dr Brown and colleagues (Nov. 10, p. 1027) write that after the rejection of the new contract pricing (June 14) very few consultants were aware that fresh discussions were taking place with Mr Patrick Jenkin, the Secretary of State for Social Services, or of their nature, until a letter appeared in the Scotsman on Aug. 24. The discussions concerned improve-
