1132
and that L.T.-producing strains may cause diarrhoea in children. The situation in infantile enteritis needs clarification because in some studies infants have not been clearly distinguished from older children and in other studies heat characterisation of the enterotoxin has not been carried out. Because the Ent plasmids are transmissible in vitro in some strains of E. coli, it has been suggested that the ability to produce enterotoxin could be transferred in vivo to any strain of E. coli. Therefore some workers have suggested that serotyping is of little value in the study of enteritis and that the ability to detect enterotoxin production may be all that is required.25 However, other factors may be equally important. There is preliminary evidence that "adhesiveness" may be an important property of human enteropathogenic E. Coli.26-28 There is substantial evidence that in piglet enteritis enteropathogenic strains frequently possess the K88 antigen, which is plasmiddetermined and which seems to be related to the ability to adhere to the intestinal mucosa. Such strains may lose their K88 plasmid and the associated adhesiveness, and can no longer cause enteritis. Conversely, even when a non-enteropathogenic strain acquires both the K88 plasmid and the Ent plasmid, the strain may not cause enteritis when an adequate challenge dose is given orally to a pig.29 Clearly, enterotoxin production should not be equated with enteropathogenicity. There are other important prerequisites; one of these is adhesiveness but there may be others. With all this on enterotoxin, it must be remembered, that some enteropathogenic E. coli produce too, enteritis by a completely different mechanism. These strains resemble shigellae in that they invade intestinal epithelial cells, and existing evidence suggests that this property is restricted to a small number of serogroups.30 Infantile enteritis remains the main problem associated with enteropathogenic E. coli-certainly in Western Europe,19 where hospital outbreaks are not uncommon. The clinical laboratory uses serotyping to assist in the recognition and control of these outbreaks. Most studies of E. coli enterotoxin have used strains from adults or older children, and these strains seem to be good toxin producers; hence the American view that enterotoxin testing may be all that is required.25 On the other hand, strains from infantile enteritis seem to be weak toxin producers, as judged by the same tests, and British workers’9 have urged a more cautious approach. They recommend that, until knowledge of enteropathogenic mechanisms is more complete,
emphasis
25. J. Am.
med. Ass. 1972, 222, 896. 26. Punyashthiti, K., Finkelstein, R. A. Infect. Immun. 1971, 4, 473. 27. Evans, D. G., Silver, R. P., Evans, D. J., Chase, D. G., Gorbach, S. L. ibid. 1975, 12, 656. 28. McNeish, A. S., Turner, P., Fleming, J., Evans, N. Lancet, 1975, ii, 946. 29. Smith, H. W., Linggood, M. A.J. med. Microbiol. 1971, 4, 467. 30. Ogawa, H., Nakamura, A., Sakazaki, R. Jap. J. med. Sci. Biol. 1968, 21, 333.
serotyping should continue and be accompanied by testing for enterotoxin and whatever other factors may be shown to play a part in the pathogenicity mechanism. The current methods for detecting enterotoxin are too time-consuming for use in routine laboratories, where, for the present, serotyping is the only tool for investigating E. coli in infantile enteritis. Until suitable routine methods are developed, enterotoxin tests should certainly be available at reference-laboratory level. It is necessary to establish the relationship between serotyping, enterotoxigenicity, and enteropathogenicity.
Specific Immunoglobulin in Prevention of Hepatitis B WHOLE-POPULATION control of viral hepatitis B is unlikely to be achieved until safe and effective vaccines are developed. Meanwhile, research into other methods of prevention among high-risk groups continues. Human normal immunoglobulin (I.S.G) can prevent clinical hepatitis A’ but is of doubtful value against hepatitis B. Tests for hepatitis-B surface antigen (HBsAg) and for its homologous antibody (anti-HBs) have provided two means of preventing infection-screening of sera to detect HBsAg, and administration of high-titre anti-HBs immunoglobulin (anti-HBs I.G.) obtained by plasmapheresis of volunteers or from donated blood. At particularly high risk of hepatitis-B-virus (H.B.v.) infection are patients transfused with blood or its products; staff accidentally exposed to HBsAg; and patients and staff of institutions for the mentally subnormal, in which the infection is often endemic, or of haemodialysis and transplant units, in which H.B.v. infection may break out explosively. The persistence of H.B.v. in both the institutions and the kidney units depends largely upon the tendency of patients with inherent or drug induced abnormalities of immune response to become persistent symptomless HBsAg carriers, who form a reservoir for continued cross-infection.23 Infants of women who acquire acute hepatitis B in late pregnancy or soon after delivery have high rates of infection.4The risk to infants of HBsAG-carrier mothers seems small in some populations and large in others.s6 Routine screening of all blood-donations for HBsAg is the best way to prevent H.B.v. transmission via blood and its products. Existing tests do 1. Stokes, J., Farquhar, J. A., Drake, M. E., Capps, R. B., Ward, C. S. Jr., Kitts, A. W.J. Am. med. Ass. 1951,147, 714, 2. Turner, G. C., White, G. B. B. Lancet, 1969, ii, 121. 3. Sutnick, A. I., London, W. T., Gerstley, B. J. S., Cronlund, M. M., Blumberg, B. S. J. Am. med. Ass. 1968, 205, 670. 4. Schweitzer, I. L., Mosley, J. W., Ashcavai, M., Edwards, V. M., Overby, L. B. Gastroenterology, 1973, 65, 277. 5. Skinhøj, P., Olesen, H., Cohn, J., Nikkelsen, M. Acta Path. microbiol. scand. B. 1972, 80, 362. 6. Stevens, C. S., Beasley, R. P., Tsui, J., Lee, W-C. New Engl.J. Med. 1975,
292, 771.
1133
reduce post-transfusion hepatitis viruses may cause long-incubaB-though other tion post-transfusion hepatitis.7 For protection of other groups, many investigators have turned to anti-HBs I.G. Two controlled trials in institutions for the mentally subnormal have been reported ! from the U.S.A. In the first,8 children were injected with infective serum and some of them received seem
to
high-titre anti-HBs I.G. four hours later: infectionrates were substantially lower in those who had the immunoglobulin. (The Lancet is very uneasy about this sort of experiment.9) In the second, SZMUNESS et al.10 followed up children for 1½-2 years after admission and found similar infection-rates among groups given either high-titre anti-HBs I.G. or I.S.G. (low-titre anti-HBs) at four-monthly intervals. The infection-rate among an untreated group was higher but not significantly different. Nevertheless, 7 of 52 untreated children but none of 81 treated children developed persistent HBsAg. These results suggest that children exposed to small inocula by
’
non-parenteral
or
inapparent parenteral
routes
may benefit from low-titre anti-HBsi.e.
There are reports of two controlled trials among staff accidentally exposed to HBsAg who received some preparation of I.G. within a week and again . a month later. One trial included two groups, given either high-titre anti-HBs I.G. or I.S.G. containing . : no anti-HBs I.G.;l1 in the other, subjects received high, intermediate, or low titre anti-HBs I.G.12 In both, attack-rates of overt infection were low, but significant differences between the high-titre and I.S.G. groups were maintained for about 6 months. . Far more I.S.G. recipients developed evidence of active/passive immunity than did high-titre recipients, and later overt infections among the hightitre groups were probably due to re-exposures. On this evidence, high-titre anti-HBs I. G. seems to afford protection after accidental exposure but clinical hepatitis can be expected in 1-2% and most of the remainder soon became susceptible again, probably within 3-4 months. Anti-HBs I.G. acquired actively before the accidents seemed to be ,
protective. 13 In a haemodialysis unit in Belgium, patients ! given two doses of high-titre anti-HBs I.G. at 6 j monthly intervals had a significantly lower H.B.v.-infection rate than did controls given i.s.G. containing no anti-HBs I.G. at similar intervals. In a multicentre trial in the U.S.A.,14 new patients :
,
and staff received two injections at 4-monthly intervals of high, intermediate, or low titre anti-HBs I.G. Infection-rates were little different in the intermediate and low titre groups but in the high-titre group of patients the infection-rate was significantly lower. Among staff, infection of the high-titre group was less common but the differences were not significant. The titres of the anti-HBs I.G. used in the two trials are relevant: by passive haemagglutination tests the Belgian titre was 1/25 000, whereas the highest American titre was 1/500 000. There is need for a standard reference preparation, so that the results of these trials can be related to anti-HBs I.G. produced in other countries. Information is also needed on the optimum dose and frequency of injections, and on the possibility of hypersensitivity reactions after multiple doses. Nevertheless, these results suggest that routine administration of high-titre anti-HBs I.G. could reduce the high rates of infection found in many haemodialysis units, though this method alone is unlikely to eliminate hepatitis-B cross-infection from the units completely. In the U.K. this aim has been achieved-certainly in 33 units included in a survey, and probably in the remaining quarter of the total in the country-without anti-HBs I.G. prophylaxis.1s A control and prevention programme, in operation in the U.K. for 6 years, is based on HBsAg tests before admission, further tests at regular intervals, dialysis in isolation of HBsAg carriers, and careful cross-infection precautions.1617 The incidence of H.B.V. infection reached a peak in 1970 and declined steadily afterwards.18 The study is not controlled but evidence of increasing cross-infection in units in other countries supports the view that the programme is responsible for the decrease.19 20 Consultants in charge of units in the U.K. are unlikely to exchange this programme for routine use of anti-HBs I.G.,which seems incompletely protective, but anti-HBs I.G. will be available as an extra precaution when a HBsAg carrier is found in a unit. A combination of routine anti-HBs I.G. prophylaxis and the control and prevention programme seems to offer promising means of eradicating H.B.v. from even the most heavily infected units. The value of anti-HBs I.G. in preventing infection of infants is not established, though a small investigation suggests protection.21 It seems reasonable to treat infants of mothers who acquire acute
7. Alter, H.
J., Purcell, R. H., Holland, P. V., Feinstone, S. M., Morrow, A. G., Monitsugu, Y. Lancet, 1975, ii, 838. 8. Krugman, S., Giles, J. P. New Engl.J. Med. 1973, 288, 755. 9. See Lancet, 1971, i, 749. 10. Szmuness, W., Prince, A. M., Goodman, M., Ehrich, C., Pick, R., Ansari, M. New Engl.J. Med. 1974, 290, 701. 11. Seeff, L. B., et al. Lancet, 1975, ii, 939. 12. Grady, G. F., Lee, V. A. New Engl.J. Med. 1975, 293, 1067. 13 Desmyter, J., Bradburne, A. F., Vermylen, C., Daneels, R., Beolaert, J. Lancet, 1975, ii, 377. 14 Prince, A. M., Szmuness, W., Mann, M. K., Vyas, G. R., Grady, G. F., Shapiro, F. L., Suki, W. N., Friedman, E. A., Stenzel, K. H. New Engl. J. Med.
1975, 293, 1060.
15. 16. 17.
Polakoff, S. Unpublished. Polakoff, S., Cossart, Y. E., Tillett, H. E. Br. med J. 1972, iii, 94.
of the Advisory Group on Hepatitis and the Treatment of Chronic Renal Failure 1970-2. Department of Health and Social Security, 1972. 18. Public Health Laboratory Service Survey Report. Br. med. J. 1974, iv, 751. 19. Gurland, H. J., Brunner, F. P. v Dehn, H., Harlen, H., Parsons, F. M., Schärer, K. Proc. Europ. Dial. Transplant Ass. 1973, 10, 156. 20. Szmuness, W., Prince, A. M., Grady, G. F., Mann, M. K., Levine, R. W., Friedman, E. A., Jacobs, M. J., Josephson, A., Ribot, S., Shapiro, F. L., Stenzel, K. H., Suki, W. N., Vyas, G. J. Am. med. Ass. 1974, 227, 901. 21. Kohler, P. F., Dubois, R. S., Merrill, D. A., Bowes, W. A. New Engl.J. Med. 1974, 291, 1378.
Report
1134
H.B.v. infections
in late pregnancy or early post but to reserve partum, judgment on the treatment of infants of HBsAg carrier mothers until prospective investigations in related populations establish the size of the risk. There is one further, and wider,
possible application of anti-HBs I.G. Infection may be acquired by sexual or close household contacts of either- acute hepatitis-B cases or HBsAg carriers.22 A trial in the U.S.A. among spouses of acute-hepatitis-B patients showed that high-titre anti-HBs I.G. conferred protection, but the attackrate of the control group was unexpectedly high.23 Any decision to give anti-HBs I.G. to similarly exposed spouses must depend on both availability of the material and assessments of the risk of infection.
DAMAGING ACTION the conflict between Government and doctors in the National Health Service must come from a compromise on two questions: what is a fair interpretation of the Government’s pay policy as it affects the juniors’ immediate prospects?; and how can their working conditions, notably the long hours on duty and on call, be improved? The pay policy must, in the national interest, be preserved; and the junior doctors declare that they have no wish to breach it, though their claim for clinical-assistant sessional rates (11.50 for 3yhours) for time over 80 hours a week looks a certain policy-buster. How much money can be provided, within the policy, for overtime payments? The Government’s figure of £12 million a year is challenged by the juniors, largely because not all those who have been entitled to retrospective overtime money have, for one reason or another, been granted it or claimed it in the past. Thus, say the juniors’ representatives, the Review Body’s pricing is faulty. Sir Ernest Woodroofe, chairman of the Review Body, has stated that he and his colleagues did take such factors into account, but he has suggested that misunderstandings may be removed by discussions between the Office of Manpower Economics, which serves the Review Body, and the B.M.A.’s statistical adviser. In the House of Commons last Monday, Mrs Barbara Castle, Secretary of State for Social Services, announced that the B.M.A. had accepted this proposal, and technical discussions would take place immediately. She repeated her assurance that it would be possible, under the pay policy, to begin to introduce new contracts for junior hospital doctors on a basis which would ensure "no detriment." Mrs Castle added that she was willing to enter into immediate talks with the juniors and with consultants’ representatives to see how far it would be possible to establish a maximum of 80 hours a week for junior staff. Such a timetable could not be introduced unless the consultants concurred and unless juniors in posts which did not entail long hours were willing to share the burden with those in other jobs. Neither the new audit on overtime nor the burden-sharing proposal will produce immediate happiness among A
SOLUTION to
junior hospital
22. Heathcote, J., Sherlock, S. Lancet, 1973, i, 1468. 23. Redeker, A. G., Mosley, J. W., Gocke, D. J., McKee, A. P., Engl.J. Med. 1975, 293, 1055.
Pollack, W. New
those juniors who are now applying sanctions by means of a 40-hour week and the treatment of emergencies only; but there is room here for continued negotiations and very soon, we trust, for the withdrawal of industrial action by the juniors. At the moment, they receive much public sympathy in their stand, but disasters to patients may befall at any hour during the disruptions and sympathy may turn to bitterness. Some N.H.S. consultants are now in industrial action against the Government’s plans for the separation of private and N.H.S. practice. The Council of the B.M.A. had recommended that, from Dec. 1, senior hospital doctors "should be advised to limit their work to caring for emergencies and to the care of patients already receiving inpatient treatment" and that the Central Committee for Hospital Medical Services be empowered to collect from consultants and other senior grades their undated resignations from the N.H.S. A statement issued on Nov. 26 by the Presidents and Deans of the Royal Colleges and Faculties deplored "the refusal of the Government, despite the profession’s earnest and explicit entreaties, to display any willingness to consult the profession in a meaningful way on these proposals"; but the Presidents and Deans could not associate themselves with those members of the profession who proposed to limit their services to the treatment of emergencies. The Presidents and Deans shared their colleagues’ concern, which they knew to be sincere, at the effect of the proposed actions on the care of patients; and, for the Colleges and Faculties, "this concern must... override all other considerations." Sir Rodney Smith, President of the Royal College of Surgeons of England, was due to meet the Prime Minister last Wednesday to emphasise these views. If the consultants fight the Government to the uttermost, with mass resignations from the N.H.S., then the Service may never recover. One widely held view is put by a distinguished orthopaedic surgeon:’ "If we can win this fight now we have some hope of picking up and eventually mending some of the inevitably broken pieces. But there will be no hope at all for patients or ourselves if we are squeezed into becoming acquiescent pawns of the D.H.S.S.". A renowned neurologist and dean sees it another way:2 "Under no circumstances could 1, or many of my colleagues in Newcastle, both senior and junior, subscribe to a course of action which, however indirectly, will damage patients, though I shall do what little I can to oppose each misguided Government directive in every way possible Industrial action by any group of doctors is intolerable; if taken by consultants it is unforgivable if it involves any withdrawal of clinical responsibility for patient care." Though The Lancet shares Professor Walton’s opinion of industrial action by doctors, we do not wish the Government to stand foursquare on its proposals for phasing-out of paybeds and licensing of private hospitals. If the Government cannot relent to the point of referring the issue to the Royal Commission, then let it give ground in the talks on the consultative document. The best course would be to concentrate for the moment on the investigation of methods for the elimination of the injustices (some, more real than others) in the borderland between private and N.H.S. practice. The Government should also make it more ...
1. Fairbank, T. J. Times, Dec. 2. 2. Walton, J. N. ibid. Nov. 28.
and that L.T.-producing strains may cause diarrhoea in children. The situation in infantile enteritis needs clarification because in some studies infants have not been clearly distinguished from older children and in other studies heat characterisation of the enterotoxin has not been carried out. Because the Ent plasmids are transmissible in vitro in some strains of E. coli, it has been suggested that the ability to produce enterotoxin could be transferred in vivo to any strain of E. coli. Therefore some workers have suggested that serotyping is of little value in the study of enteritis and that the ability to detect enterotoxin production may be all that is required.25 However, other factors may be equally important. There is preliminary evidence that "adhesiveness" may be an important property of human enteropathogenic E. Coli.26-28 There is substantial evidence that in piglet enteritis enteropathogenic strains frequently possess the K88 antigen, which is plasmiddetermined and which seems to be related to the ability to adhere to the intestinal mucosa. Such strains may lose their K88 plasmid and the associated adhesiveness, and can no longer cause enteritis. Conversely, even when a non-enteropathogenic strain acquires both the K88 plasmid and the Ent plasmid, the strain may not cause enteritis when an adequate challenge dose is given orally to a pig.29 Clearly, enterotoxin production should not be equated with enteropathogenicity. There are other important prerequisites; one of these is adhesiveness but there may be others. With all this on enterotoxin, it must be remembered, that some enteropathogenic E. coli produce too, enteritis by a completely different mechanism. These strains resemble shigellae in that they invade intestinal epithelial cells, and existing evidence suggests that this property is restricted to a small number of serogroups.30 Infantile enteritis remains the main problem associated with enteropathogenic E. coli-certainly in Western Europe,19 where hospital outbreaks are not uncommon. The clinical laboratory uses serotyping to assist in the recognition and control of these outbreaks. Most studies of E. coli enterotoxin have used strains from adults or older children, and these strains seem to be good toxin producers; hence the American view that enterotoxin testing may be all that is required.25 On the other hand, strains from infantile enteritis seem to be weak toxin producers, as judged by the same tests, and British workers’9 have urged a more cautious approach. They recommend that, until knowledge of enteropathogenic mechanisms is more complete,
emphasis
25. J. Am.
med. Ass. 1972, 222, 896. 26. Punyashthiti, K., Finkelstein, R. A. Infect. Immun. 1971, 4, 473. 27. Evans, D. G., Silver, R. P., Evans, D. J., Chase, D. G., Gorbach, S. L. ibid. 1975, 12, 656. 28. McNeish, A. S., Turner, P., Fleming, J., Evans, N. Lancet, 1975, ii, 946. 29. Smith, H. W., Linggood, M. A.J. med. Microbiol. 1971, 4, 467. 30. Ogawa, H., Nakamura, A., Sakazaki, R. Jap. J. med. Sci. Biol. 1968, 21, 333.
serotyping should continue and be accompanied by testing for enterotoxin and whatever other factors may be shown to play a part in the pathogenicity mechanism. The current methods for detecting enterotoxin are too time-consuming for use in routine laboratories, where, for the present, serotyping is the only tool for investigating E. coli in infantile enteritis. Until suitable routine methods are developed, enterotoxin tests should certainly be available at reference-laboratory level. It is necessary to establish the relationship between serotyping, enterotoxigenicity, and enteropathogenicity.
Specific Immunoglobulin in Prevention of Hepatitis B WHOLE-POPULATION control of viral hepatitis B is unlikely to be achieved until safe and effective vaccines are developed. Meanwhile, research into other methods of prevention among high-risk groups continues. Human normal immunoglobulin (I.S.G) can prevent clinical hepatitis A’ but is of doubtful value against hepatitis B. Tests for hepatitis-B surface antigen (HBsAg) and for its homologous antibody (anti-HBs) have provided two means of preventing infection-screening of sera to detect HBsAg, and administration of high-titre anti-HBs immunoglobulin (anti-HBs I.G.) obtained by plasmapheresis of volunteers or from donated blood. At particularly high risk of hepatitis-B-virus (H.B.v.) infection are patients transfused with blood or its products; staff accidentally exposed to HBsAg; and patients and staff of institutions for the mentally subnormal, in which the infection is often endemic, or of haemodialysis and transplant units, in which H.B.v. infection may break out explosively. The persistence of H.B.v. in both the institutions and the kidney units depends largely upon the tendency of patients with inherent or drug induced abnormalities of immune response to become persistent symptomless HBsAg carriers, who form a reservoir for continued cross-infection.23 Infants of women who acquire acute hepatitis B in late pregnancy or soon after delivery have high rates of infection.4The risk to infants of HBsAG-carrier mothers seems small in some populations and large in others.s6 Routine screening of all blood-donations for HBsAg is the best way to prevent H.B.v. transmission via blood and its products. Existing tests do 1. Stokes, J., Farquhar, J. A., Drake, M. E., Capps, R. B., Ward, C. S. Jr., Kitts, A. W.J. Am. med. Ass. 1951,147, 714, 2. Turner, G. C., White, G. B. B. Lancet, 1969, ii, 121. 3. Sutnick, A. I., London, W. T., Gerstley, B. J. S., Cronlund, M. M., Blumberg, B. S. J. Am. med. Ass. 1968, 205, 670. 4. Schweitzer, I. L., Mosley, J. W., Ashcavai, M., Edwards, V. M., Overby, L. B. Gastroenterology, 1973, 65, 277. 5. Skinhøj, P., Olesen, H., Cohn, J., Nikkelsen, M. Acta Path. microbiol. scand. B. 1972, 80, 362. 6. Stevens, C. S., Beasley, R. P., Tsui, J., Lee, W-C. New Engl.J. Med. 1975,
292, 771.
1133
reduce post-transfusion hepatitis viruses may cause long-incubaB-though other tion post-transfusion hepatitis.7 For protection of other groups, many investigators have turned to anti-HBs I.G. Two controlled trials in institutions for the mentally subnormal have been reported ! from the U.S.A. In the first,8 children were injected with infective serum and some of them received seem
to
high-titre anti-HBs I.G. four hours later: infectionrates were substantially lower in those who had the immunoglobulin. (The Lancet is very uneasy about this sort of experiment.9) In the second, SZMUNESS et al.10 followed up children for 1½-2 years after admission and found similar infection-rates among groups given either high-titre anti-HBs I.G. or I.S.G. (low-titre anti-HBs) at four-monthly intervals. The infection-rate among an untreated group was higher but not significantly different. Nevertheless, 7 of 52 untreated children but none of 81 treated children developed persistent HBsAg. These results suggest that children exposed to small inocula by
’
non-parenteral
or
inapparent parenteral
routes
may benefit from low-titre anti-HBsi.e.
There are reports of two controlled trials among staff accidentally exposed to HBsAg who received some preparation of I.G. within a week and again . a month later. One trial included two groups, given either high-titre anti-HBs I.G. or I.S.G. containing . : no anti-HBs I.G.;l1 in the other, subjects received high, intermediate, or low titre anti-HBs I.G.12 In both, attack-rates of overt infection were low, but significant differences between the high-titre and I.S.G. groups were maintained for about 6 months. . Far more I.S.G. recipients developed evidence of active/passive immunity than did high-titre recipients, and later overt infections among the hightitre groups were probably due to re-exposures. On this evidence, high-titre anti-HBs I. G. seems to afford protection after accidental exposure but clinical hepatitis can be expected in 1-2% and most of the remainder soon became susceptible again, probably within 3-4 months. Anti-HBs I.G. acquired actively before the accidents seemed to be ,
protective. 13 In a haemodialysis unit in Belgium, patients ! given two doses of high-titre anti-HBs I.G. at 6 j monthly intervals had a significantly lower H.B.v.-infection rate than did controls given i.s.G. containing no anti-HBs I.G. at similar intervals. In a multicentre trial in the U.S.A.,14 new patients :
,
and staff received two injections at 4-monthly intervals of high, intermediate, or low titre anti-HBs I.G. Infection-rates were little different in the intermediate and low titre groups but in the high-titre group of patients the infection-rate was significantly lower. Among staff, infection of the high-titre group was less common but the differences were not significant. The titres of the anti-HBs I.G. used in the two trials are relevant: by passive haemagglutination tests the Belgian titre was 1/25 000, whereas the highest American titre was 1/500 000. There is need for a standard reference preparation, so that the results of these trials can be related to anti-HBs I.G. produced in other countries. Information is also needed on the optimum dose and frequency of injections, and on the possibility of hypersensitivity reactions after multiple doses. Nevertheless, these results suggest that routine administration of high-titre anti-HBs I.G. could reduce the high rates of infection found in many haemodialysis units, though this method alone is unlikely to eliminate hepatitis-B cross-infection from the units completely. In the U.K. this aim has been achieved-certainly in 33 units included in a survey, and probably in the remaining quarter of the total in the country-without anti-HBs I.G. prophylaxis.1s A control and prevention programme, in operation in the U.K. for 6 years, is based on HBsAg tests before admission, further tests at regular intervals, dialysis in isolation of HBsAg carriers, and careful cross-infection precautions.1617 The incidence of H.B.V. infection reached a peak in 1970 and declined steadily afterwards.18 The study is not controlled but evidence of increasing cross-infection in units in other countries supports the view that the programme is responsible for the decrease.19 20 Consultants in charge of units in the U.K. are unlikely to exchange this programme for routine use of anti-HBs I.G.,which seems incompletely protective, but anti-HBs I.G. will be available as an extra precaution when a HBsAg carrier is found in a unit. A combination of routine anti-HBs I.G. prophylaxis and the control and prevention programme seems to offer promising means of eradicating H.B.v. from even the most heavily infected units. The value of anti-HBs I.G. in preventing infection of infants is not established, though a small investigation suggests protection.21 It seems reasonable to treat infants of mothers who acquire acute
7. Alter, H.
J., Purcell, R. H., Holland, P. V., Feinstone, S. M., Morrow, A. G., Monitsugu, Y. Lancet, 1975, ii, 838. 8. Krugman, S., Giles, J. P. New Engl.J. Med. 1973, 288, 755. 9. See Lancet, 1971, i, 749. 10. Szmuness, W., Prince, A. M., Goodman, M., Ehrich, C., Pick, R., Ansari, M. New Engl.J. Med. 1974, 290, 701. 11. Seeff, L. B., et al. Lancet, 1975, ii, 939. 12. Grady, G. F., Lee, V. A. New Engl.J. Med. 1975, 293, 1067. 13 Desmyter, J., Bradburne, A. F., Vermylen, C., Daneels, R., Beolaert, J. Lancet, 1975, ii, 377. 14 Prince, A. M., Szmuness, W., Mann, M. K., Vyas, G. R., Grady, G. F., Shapiro, F. L., Suki, W. N., Friedman, E. A., Stenzel, K. H. New Engl. J. Med.
1975, 293, 1060.
15. 16. 17.
Polakoff, S. Unpublished. Polakoff, S., Cossart, Y. E., Tillett, H. E. Br. med J. 1972, iii, 94.
of the Advisory Group on Hepatitis and the Treatment of Chronic Renal Failure 1970-2. Department of Health and Social Security, 1972. 18. Public Health Laboratory Service Survey Report. Br. med. J. 1974, iv, 751. 19. Gurland, H. J., Brunner, F. P. v Dehn, H., Harlen, H., Parsons, F. M., Schärer, K. Proc. Europ. Dial. Transplant Ass. 1973, 10, 156. 20. Szmuness, W., Prince, A. M., Grady, G. F., Mann, M. K., Levine, R. W., Friedman, E. A., Jacobs, M. J., Josephson, A., Ribot, S., Shapiro, F. L., Stenzel, K. H., Suki, W. N., Vyas, G. J. Am. med. Ass. 1974, 227, 901. 21. Kohler, P. F., Dubois, R. S., Merrill, D. A., Bowes, W. A. New Engl.J. Med. 1974, 291, 1378.
Report
1134
H.B.v. infections
in late pregnancy or early post but to reserve partum, judgment on the treatment of infants of HBsAg carrier mothers until prospective investigations in related populations establish the size of the risk. There is one further, and wider,
possible application of anti-HBs I.G. Infection may be acquired by sexual or close household contacts of either- acute hepatitis-B cases or HBsAg carriers.22 A trial in the U.S.A. among spouses of acute-hepatitis-B patients showed that high-titre anti-HBs I.G. conferred protection, but the attackrate of the control group was unexpectedly high.23 Any decision to give anti-HBs I.G. to similarly exposed spouses must depend on both availability of the material and assessments of the risk of infection.
DAMAGING ACTION the conflict between Government and doctors in the National Health Service must come from a compromise on two questions: what is a fair interpretation of the Government’s pay policy as it affects the juniors’ immediate prospects?; and how can their working conditions, notably the long hours on duty and on call, be improved? The pay policy must, in the national interest, be preserved; and the junior doctors declare that they have no wish to breach it, though their claim for clinical-assistant sessional rates (11.50 for 3yhours) for time over 80 hours a week looks a certain policy-buster. How much money can be provided, within the policy, for overtime payments? The Government’s figure of £12 million a year is challenged by the juniors, largely because not all those who have been entitled to retrospective overtime money have, for one reason or another, been granted it or claimed it in the past. Thus, say the juniors’ representatives, the Review Body’s pricing is faulty. Sir Ernest Woodroofe, chairman of the Review Body, has stated that he and his colleagues did take such factors into account, but he has suggested that misunderstandings may be removed by discussions between the Office of Manpower Economics, which serves the Review Body, and the B.M.A.’s statistical adviser. In the House of Commons last Monday, Mrs Barbara Castle, Secretary of State for Social Services, announced that the B.M.A. had accepted this proposal, and technical discussions would take place immediately. She repeated her assurance that it would be possible, under the pay policy, to begin to introduce new contracts for junior hospital doctors on a basis which would ensure "no detriment." Mrs Castle added that she was willing to enter into immediate talks with the juniors and with consultants’ representatives to see how far it would be possible to establish a maximum of 80 hours a week for junior staff. Such a timetable could not be introduced unless the consultants concurred and unless juniors in posts which did not entail long hours were willing to share the burden with those in other jobs. Neither the new audit on overtime nor the burden-sharing proposal will produce immediate happiness among A
SOLUTION to
junior hospital
22. Heathcote, J., Sherlock, S. Lancet, 1973, i, 1468. 23. Redeker, A. G., Mosley, J. W., Gocke, D. J., McKee, A. P., Engl.J. Med. 1975, 293, 1055.
Pollack, W. New
those juniors who are now applying sanctions by means of a 40-hour week and the treatment of emergencies only; but there is room here for continued negotiations and very soon, we trust, for the withdrawal of industrial action by the juniors. At the moment, they receive much public sympathy in their stand, but disasters to patients may befall at any hour during the disruptions and sympathy may turn to bitterness. Some N.H.S. consultants are now in industrial action against the Government’s plans for the separation of private and N.H.S. practice. The Council of the B.M.A. had recommended that, from Dec. 1, senior hospital doctors "should be advised to limit their work to caring for emergencies and to the care of patients already receiving inpatient treatment" and that the Central Committee for Hospital Medical Services be empowered to collect from consultants and other senior grades their undated resignations from the N.H.S. A statement issued on Nov. 26 by the Presidents and Deans of the Royal Colleges and Faculties deplored "the refusal of the Government, despite the profession’s earnest and explicit entreaties, to display any willingness to consult the profession in a meaningful way on these proposals"; but the Presidents and Deans could not associate themselves with those members of the profession who proposed to limit their services to the treatment of emergencies. The Presidents and Deans shared their colleagues’ concern, which they knew to be sincere, at the effect of the proposed actions on the care of patients; and, for the Colleges and Faculties, "this concern must... override all other considerations." Sir Rodney Smith, President of the Royal College of Surgeons of England, was due to meet the Prime Minister last Wednesday to emphasise these views. If the consultants fight the Government to the uttermost, with mass resignations from the N.H.S., then the Service may never recover. One widely held view is put by a distinguished orthopaedic surgeon:’ "If we can win this fight now we have some hope of picking up and eventually mending some of the inevitably broken pieces. But there will be no hope at all for patients or ourselves if we are squeezed into becoming acquiescent pawns of the D.H.S.S.". A renowned neurologist and dean sees it another way:2 "Under no circumstances could 1, or many of my colleagues in Newcastle, both senior and junior, subscribe to a course of action which, however indirectly, will damage patients, though I shall do what little I can to oppose each misguided Government directive in every way possible Industrial action by any group of doctors is intolerable; if taken by consultants it is unforgivable if it involves any withdrawal of clinical responsibility for patient care." Though The Lancet shares Professor Walton’s opinion of industrial action by doctors, we do not wish the Government to stand foursquare on its proposals for phasing-out of paybeds and licensing of private hospitals. If the Government cannot relent to the point of referring the issue to the Royal Commission, then let it give ground in the talks on the consultative document. The best course would be to concentrate for the moment on the investigation of methods for the elimination of the injustices (some, more real than others) in the borderland between private and N.H.S. practice. The Government should also make it more ...
1. Fairbank, T. J. Times, Dec. 2. 2. Walton, J. N. ibid. Nov. 28.
