Good Intentions Are Not Enough

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Good Intentions Are Not Enough Author(s): Jeffrey S. Tobias Source: BMJ: British Medical Journal, Vol. 311, No. 6998 (Jul. 15, 1995), p. 203 Published by: BMJ Stable URL: https://www.jstor.org/stable/29728135 Accessed: 20-08-2023 20:31 +00:00 JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms

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B-JiEDICI^AN .W?SB who's to say whether the cancer or the

Channel 4 True Stories: "Deadly Experiments"

treatment was to blame? According to the

6 July

narrator, the case was proved: "She had

suffered the classic symptoms of radiation sickness." Yet every radiotherapist knows that deterioration from progressive cancer can look all too similar to a side effect of

Good intentions are not enough

treatment.

Informed consent has become the major medical ethical issue of the 1990s, and the chief strength of the film was to remind us of

In 1987 a young American journalist,

the ever present threat posed by overzealous researchers. Did they mean any harm? Pro?

leafing through files tucked away in a military archive, unexpectedly turned up evidence of deliberate injections of radio? active plutonium in unsuspecting patients.

She telephoned the Los Alamos National Laboratory, was patted on the head, but

refused to be reassured. This low key but quietly dramatic encounter is typical of the

doggedly persistent style of American investi? gative journalism which uncovered Watergate;

it proved the jumping off point for Deadly Experiments^ a shocking expos? of unauthorised

(and unethical) radiation studies carried out during the 1940s and '50s.

No room for complacency here: these

were not just madcap American scientists, Strangelove-style boffins overstepping the mark somewhere in the remote New Mexico desert. It happened here in Britain too. In Coventry, Asian women were fed radioactive chapatis without so much as a by-your-leave and, according to the programme, driven off to Harwell for radioactivity measurement.

bably not. Did they genuinely feel that

injecting controlled amounts of a low level radioactive tracer might help to set more accurate dosimetric standards for radiation

Pritam Kaur, one of the people who, it is claimed, were included in experiments without their informed consent

isotope bone scan? What damage do these

tests do, compared with the diagnostic

benefits? The fundamental issue raised by

the film was one of informed consent rather

than the equally complex but quite separate problem of radiation tolerance and morbidity, though the film itself tended to confuse these

items?possibly, I felt, because the director

had failed to recognise how distinct they are.

In the first of the two programmes Vincent

and legal issues arising in adolescence and in old age. Both made compulsive view? ing, particularly for anyone who has tried to teach medical ethics to medical students.

The set, was in the style of a student

seminar, the cameras focused on a horseshoe of expectant faces sitting behind reassuringly solid tables. After the entrance of the seminar

leader?Vincent Hanna for Growing Pains, and Arthur Miller for Old Age Tension?the

proceedings began. The faces behind the tables were from mixed backgrounds: doctors, nurses, teachers, social workers and their managers, policemen, judges, politicians (council and parliamentary),

the other, an arrogant unconcern for the

patient's right to self determination. No matter that a tiny dose of radioactivity causes

permits doctors an ethical freedom they have no right to assume.

since she was taken into a room, left quite

patients' advocates, and journalists thrown together to represent their respective pro? fessions.

of a three night series, explored moral

acceptable research programme, and, on

alone?"no doctors, no nurses"?and put

BBC2 Hypothetical "Growing Pains" and "Old Age Tension" 12 and 13 July

These two discussion programmes, part

constantly be on our guard: the researchers

portrayed in this programme seemingly failed to recognise the fine but critical line between, on the one hand, a dispassionate and ethically

to a type of treatment which was frightening

be, for instance, without the technetium

Talking shop

terrifying legal consequences is paved with good intentions. It's right that we should

no discernible damage in most patients; the fact remains that one can't take for granted the patient's unquestioning compliance or argue that the umbrella of medical research

In one scene, clearly intended to shock and dismay, a conventional looking middle aged man told how his mother had been subjected

under a large machine for several minutes. This sounds like a perfectly normal radiation treatment to me, though the explanation and support might have been better. Sadly, she became ill and died shortly afterwards, but

Today we're all outraged, of course?but hang on a minute: aren't radioactive tracers given in hospitals up and down the land every day of the week? Where would oncologists

tolerance? Presumably. Yet the road to

oblivion, accusation, or?worse still?

Hanna led participants, mainly teachers and social workers, through a range of topics relating to childhood and adolescence includ? ing child sex abuse, arranged marriages, and adventure holidays for young offenders.

The social workers seemed defensive, the teachers disagreed with each other, and the politicians?inevitably?spoke in soundbites.

The second programme, looking at the

other end of life, was better. Arthur Miller, coffee cup glued to his hand, introduced us to

a fictional couple, Victoria and Albert, and

their friend Doris, all residents of "Old

Scarum." Using the time honoured technique of painting a thumbnail sketch, asking an awkward question, and analysing the dif? ferences between responses, he explored the issues around declining mental power in old

age.

James Carne, a general practitioner, Jo Hertzberg, a psychogeriatrician, and Beverley

Castleton, a specialist in care of the

The journalist, by the way, won a Pulitzer prize.?Jeffrey s tobias is clinical director for cancer services, Middlesex and University College

Hospitals, London, and author of "Cancer: What Every Patient Needs to Know " (Bloomsbury, ?6.00).

elderly, batted a straight wicket for the

medical profession and Stephen Thornton,

billed as chief executive of health authorities,

described the division between medical and social care with a clarity not apparent in many

clinical situations. The participants slipped effortlessly into and out of roleplay, and on occasions stepped back to observe the ethical conflicts created by the decisions they were being asked to make. This was exploration of moral dilemmas at its best, both elegant and thought provoking.

The strength of the programme wasn't in the topics covered but in the way Arthur

Miller drew out the participants' beliefs and attitudes. Some came across almost as caricatures: the evenhanded judge, the kindly coaxing nurse, and the social worker anxiously peering over his shoulder expecting criticism.

It would be wonderful to have the op? portunity to teach medical ethics to young people destined for such varied professions. Sadly, for the time being we can only watch. ?sim?n lundy, general practitioner and part time lecturer, University of London

BMJ volume 311 15 July 1995 203 This content downloaded from 198.7.56.244 on Sun, 20 Aug 2023 20:31:57 +00:00 All use subject to https://about.jstor.org/terms

"Deadly Experiments" Author(s): D. C. Evered and Keith E. Halnan Source: BMJ: British Medical Journal, Vol. 311, No. 6998 (Jul. 15, 1995), p. 192 Published by: BMJ Stable URL: https://www.jstor.org/stable/29728125 Accessed: 20-08-2023 20:29 +00:00 JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms

BMJ is collaborating with JSTOR to digitize, preserve and extend access to BMJ: British Medical Journal

This content downloaded from 198.7.56.244 on Sun, 20 Aug 2023 20:29:14 +00:00 All use subject to https://about.jstor.org/terms

Psychological problems after mefloquine

and chloroquine

Editor,?Most doctors will have taken chloro?

We believe that consensus improves compliance. We sympathise with the position of Graham

Morrison. The current guidelines are cautious about standby treatment because it was over

quine for short periods when travelling to exotic prescribed after the 1993 guidelines were issued. destinations. I had done so in Egypt, Jordan, and Charles Godden's experience, which was due to Syria: I had taken chloroquine for six weeks at any persistence of hypnozoites of Plasmodium vivax one time and felt confident about taking it for two that was insensitive to chloroquine, is uncommon years when I came to Papua New Guinea. but not unique. The guidelines primarily aim to Initially I felt well, but after one month I became

lethargic and would fall asleep in meetings. I had early morning waking and became very agitated. These symptoms I attributed to the humidity, then depression, and finally anxiety about being in a foreign country. I continued the treatment even though my hair began to fall out and my eyesight

seemed to be getting worse. Medical colleagues

advised me that the hair loss was due to stress or the

heat. Finally I developed a rash, which was

definitely petechial, every Monday after taking chloroquine, and my platelet count was on the lower limit of normal.

I was advised by a doctor to stop taking chloro? quine. What was I to take instead, on the edge of the bush in a high malarial zone? Mefloquine was readily available from one of the volunteers with the American Peace Corps, so I took one tablet that night. Throughout the night I had tachycardia, my dreams were vivid, and I was convinced that I was going to die. The next day the flowers were larger and brighter and the stones on the way to work were hairy. I was on a trip that I hadn't planned. Fortunately, that morning four issues of the BMJ arrived; in one of them was an article on prophy? laxis against malaria.1 This gave me the informa? tion I needed. My luck was in again. Doxycycline is readily available in Palmalmal, so I started a daily

dose. I now feel well and energetic and am

sleeping, and my appetite has returned?I feel normal. Many travellers overseas will have experienced the lethargy, depression, and anxiety that I did and

have put it down to the new country and the new

make doctors aware of the risk of malaria in

Voluntary Service Overseas

1 Bradley DJ, Warhurst DC, on behalf of a meeting convened by the Malaria Reference Library. Malaria prophylaxis: guide? lines for travellers from Britain. BMJ 1995;310:709-14. (18

March.)

was obtained. In the case of the Asian women discussed in the programme, I am told by the principal investigator that the local authority made

an Asian health visitor available to him when he

sought consent, and a member of the patient's

family or a close friend who was fluent in English

was also present on each occasion. It has not been possible to speak to others about studies that took

(maximum risk of falciparum malaria) or the first year (98-5% of all cases of imported malaria).

place up to 45 years ago. The situation with respect

We disagree with Ashley Croft's statement that the guidelines describe mefloquine as innocuous. The high incidence of side effects will not surprise users of antimalarial drugs, but Croft's study lacks a measure of severity. An operational definition, such as cessation of chemoprophylaxis or admis? sion to hospital, would give a sense of proportion. Incidentally, paranoid feelings in this relatively small series were significantly more common in those taking mefloquine. The hypothesis that side effects depend on the ratio of dose to weight could be tested on Croft's data. Given the greater efficacy of mefloquine, Croft's data are consistent with the

current guidelines. We agree that no one can be complacent about either malaria or antimalarial

drugs.

to the postmortem studies discussed in the

programme seems to have been that permission for postmortem examination was obtained in accord? ance with standard practice. It seems unlikely that

the precise nature of the samples to be obtained

would have been discussed, but one might

speculate that this would have been out of concern

for the sensitivities of the relatives and not for reasons of secrecy.

The alarmist nature of this programme must have caused needless anxiety to many people who have participated willingly in research and to those

who have received tracer doses for routine diag?

nostic purposes, as well as causing unnecessary distress to many bereaved parents.

Medical Research Council,

D C EVERED Second secretary

DAVID BRADLEY DAVID WARHURST London WIN 4AL Codirector Codirector

PHLS Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, 1 Tobias JS. Good intentions are not enough. BMJ 1995;311: 203. (15 July.) London WC1E7HT 1 Bradley DJ. Prophylaxis against malaria for travellers from the

United Kingdom. BMJ 1993;306:1247-52.

No evidence of harm from tracer studies

2 Lobel HO, Miani M, Eng T, Bernard KW, Hightower AW, Campbell CC. Long-term malaria prophylaxis with weekly Editor,?Many mefloquine. Lancet 1993;341:848-51.

readers will have seen the Chan?

nel M, 4 television 3 Steffen R, Fuchs E, Schildknecht J, Naef U, Funk Schlagen programme True stories hauf P, et al. Mefloquine compared with other entitled malaria chemo "Deadly experiments ... A prophylactic regimens in tourists visiting east Africa. Lancet 1993;341:1299-303.

on 6 July

series of

government funded experiments conducted on

human guinea pigs without their consent."1 Work that I did2 was mentioned, with a brief extract from a much longer filmed interview.

drug, or have they put up with these psychotic

Palmalmal, Papua New Guinea

speak to the lead investigators in two of the studies concerned and both are emphatic that such consent

returned travellers, and discussion has centred on whether to emphasise the first three months

job. Have they gone on to feel better, tolerating the

feelings, never thinking that chloroquine could be the causal agent? PATRICIA LENCH

informed consent should be obtained from all participants in research. We have been able to

My research was fully reported in 1958.2 By "Deadly Experiments" the 1950s iodine-131 tests had become routine for assessing thyroid function and superseded UK's programme was open and ethical measurement of the basal metabolic rate, which Editor,?The Channel 4 television programme required admission to hospital. The patient's radiation exposure was low, but we were reluctant True Stories, entitled "Deadly Experiments," which was transmitted on 6 July, to was usehighly iodine-131 in pregnancy, even though alarming and in many instances seriously thyroid function mis? and diagnosis of thyrotoxicosis in

remained uncertain. In 1956, however, leading.1 The programme referred to pregnancy indefensible theadminis? low dosage iodine-132, with a half life of and unethical experiments involving the

2-3 hours, became available. Sir Edward Pochin, tration of plutonium to hospital patients in the

Authors' reply Editor,?The guidelines on malaria prophylaxis represent a consensus reached by 44 British specialists. The letters show how difficult it is to

reach unequivocal conclusions in this field. The

guidelines of 1993 gave equal place to two regimens for Africa1 and left practitioners to decide between them, which they found unhelpful. The guidelines of 1995 gave a priority recommendation whenever

possible. The committee thought that cumulative evidence on the use of mefloquine,2 together with some deaths in British travellers taking proguanil plus chloroquine, had tipped the balance slightly in favour of mefloquine for highly endemic areas of sub-Saharan Africa. It is always difficult to balance

United States as an adjunct to thein Manhattan agreement with Professor W C W Nixon, project. The programme subsequently suggested claimed that iodine-132 might be used in preg?

that similar "radiation experiments" nancy. were Twenty carriedfive pregnant patients were selected out in secret in the United Kingdom, without the for investigation, but only 16 completed the consent of the participants. The facts, however, protocol. All had given informed consent. A test

are these. Firstly, the studies in question were legitimate projects addressing important health problems, which used radionuclides in doses equivalent to or

lower than those used for routine diagnostic purposes. Many long term follow up studies of patients exposed to radioactive isotopes in tracer doses have not shown any increased risk to health over many years. Secondly, the only study that did not fall into the

dose of 0-22 MBq of iodine-132 was used, giving

0-21 cGy to the maternal thyroid and 0-0011 cGy to

the maternal and fetal gonads. We found that thyroid iodine uptake was indeed increased in pregnancy, and the test became available for clinical use. The patients were not formally fol? lowed up, but their records were later traced and

there was no evidence of harm in mothers or

children. Use of radioiodine for diagnosis and for treat?

the risks of rare catastrophic events such as death

above category was a postmortem analysis of the

ment of thyrotoxicosis has not caused either cancer

with those of the more frequent unpleasant side effects of prophylaxis. Clinicians see the latter; national statistics of a reference laboratory cover

strontium in bone, carried out during the period in

tests and after the accident at Chernobyl has been followed by a small excess of thyroid carcinoma, especially in children.

the former as well.

The guidelines already state that British experience

points to a greater frequency of side effects from

mefloquine than that in the widely quoted Swiss

study, which showed greater prophylactic efficacy for mefloquine over chloroquine plus proguanil.3 Even Wetsteyn and de Geus, quoted by G C Cook, concur with the use of mefloquine in west Africa.

concentration of radionuclides of barium and

which nuclear devices were being tested in the atmosphere. It did not involve the direct adminis? tration of radioactive substances.

Thirdly, the claim that these studies were secret is absurd. All were published in reputable journals

between 1953 and 1971 on the conclusion of the

work.

Fourthly, it has been an explicit requirement of

the Medical Research Council since 1953 that

or leukaemia, but fallout after atomic weapons

KEITH E HALNAN

Hampton, Middlesex TW12 2LU

Consultant oncologist

1 Tobias JS. Good intentions are not enough. BMJ 1995;311:203.

(15July.)

2 Hainan KE. The radio-iodine uptake of the human thyroid in pregnancy. Clin S?1958;17:281-90.

192 BMJ volume 311 15 July 1995 This content downloaded from 198.7.56.244 on Sun, 20 Aug 2023 20:29:14 +00:00 All use subject to https://about.jstor.org/terms

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Deadly Experiments. Author: Jeffrey S. Tobias Date: July 15, 1995 From: British Medical Journal(Vol. 311, Issue 6998) Publisher: BMJ Publishing Group Ltd. Document Type: Television program review Length: 2,236 words Full Text: In 1987 a young American journalist, leafing through files tucked away in a military archive, unexpectedly turned up evidence of deliberate injections of radioactive plutonium in unsuspecting patients. She telephoned the Los Alamos National Laboratory, was patted on the head, but refused to be reassured. This low key but quietly dramatic encounter is typical of the doggedly persistent style of American investigative journalism which uncovered Watergate; it proved the jumping off point for Deadly Experiments, a shocking expose of unauthorised (and unethical) radiation studies carried out during the 1940s and '50s. No room for complacency here: these were not just madcap American scientists, Strangelove-style boffins overstepping the mark somewhere in the remote New Mexico desert. It happened here in Britain too. In Coventry, Asian women were fed radioactive chapatis without so much as a by-your-leave and, according to the programme, driven off to Harwell for radioactivity measurement. Today we're all outraged, of course--but hang on a minute: aren't radioactive tracers given in hospitals up and down the land every day of the week? Where would oncologists be, for instance, without the technetium isotope bone scan? What damage do these tests do, compared with the diagnostic benefits? The fundamental issue raised by the film was one of informed consent rather than the equally complex but quite separate problem of radiation tolerance and morbidity, though the film itself tended to confuse these items-possibly, I felt, because the director had failed to recognise how distinct they are. In one scene, clearly intended to shock and dismay, a conventional looking middle aged man told how his mother had been subjected to a type of treatment which was frightening since she was taken into a room, left quite alone--"no doctors, no nurses"--and put under a large machine for several minutes. This sounds like a perfectly normal radiation treatment to me, though the explanation and support might have been better. Sadly, she became ill and died shortly afterwards, but who's to say whether the cancer or the treatment was to blame? According to the narrator, the case was proved: "She had suffered the classic symptoms of radiation sickness." Yet every radiotherapist knows that deterioration from progressive cancer can look all too similar to a side effect of treatment. Infromed consent has become the major medical ethical issue of the 1990s, and the chief strength of the film was to remind us of the ever present threat posed by overzealous researchers. Did they mean any harm? Probably not. Did they genuinely feel that injecting controlled amounts of a low level radioactive tracer might help to set more accurate dosimetric standards for radiation tolerance? Presumably. Yet the road to oblivion, accusation, or--worse still--terrifying legal consequences is paved with good intentions. It's right that we should constantly be on our guard: the researchers portrayed in this programme seemingly failed to recognise the fine but critical line between, on the one hand, a dispassionate and ethically acceptable research programme, and, on the other, an arrogant unconcern for the patient's right to self determination. No matter that a tiny dose of radioactivity causes no discernible damage in most patients; the fact remains that one can't take for granted the patient's unquestioning compliance or argue that the umbrella of medical research permits doctors an ethical freedom they have no right to assume. The journalist, by the way, won a Pulitzer prize. RELATED ARTICLE: "Deadly Experiments" UK's programme was open and ethical EDITOR,--The Channel 4 television programme True Stories, entitled "Deadly Experiments," which was transmitted on 6 July, was highly alarming and in many instances seriously misleading.(1) The programme referred to indefensible and unethical experiments involving the administration of plutonium to hospital patients in the United States as an adjunct to the Manhattan project. The programme subsequently, claimed that similar "radiation experiments" were carried out in secret in the United Kingdom, without the consent of the participants. The facts, however, are these. Firstly, the studies in question were legitimate projects addressing important health problems, which used radionuclides in doses equivalent to or lower than those used for routine diagnostic purposes. Many long term follow up studies of patients exposed to

radioactive isotopes in tracer doses have not shown any increased risk to health over many years. Secondly, the only study that did not fall into the above category was a postmortem analysis of the concentration of radionuclides of barium and strontium in bone, carried out during the period in which nuclear devices were being tested in the atmosphere. It did not involve the direct administration of radioactive substances. Thirdly, the claim that these studies were secret is absurd. All were published in reputable journals between 1953 and 1971 on the conclusion of the work. Fourthly, it has been an explicit requirement of the Medical Research Council since 1953 that informed consent should be obtained from all participants in research. We have been able to speak to the lead investigators in two of the studies concerned and both are emphatic that such consent was obtained. In the case of the Asian women discussed in the programme, I am told by the principal investigator that the local authority made an Asian health visitor available to him when he sought consent, and a member of the patient's family or a close friend who was fluent in English was also present on each occasion. It has not been possible to speak to others about studies that took place up to 45 years ago. The situation with respect to the postmortem studies discussed in the programme seems to have been that permission for postmortem examination was obtained in accordance with standard practice. It seems unlikely that the precise nature of the samples to be obtained would have been discussed, but one might speculate that this would have been out of concern for the sensitivities of the relatives and not for reasons of secrecy. The alarmist nature of this programme must have caused needless anxiety to many people who have participated willingly in research and to those who have received tracer doses for routine diagnostic purposes, as well as causing unnecessary distress to many bereaved parents. D C EVERED Second secretary Medical Research Council, London W1N 4AL (1)Tobias JS. Good intentions are not enough. BMJ 1995; 311:203. (15 July.) No evidence of harm from tracer studies EDITOR,--Many readers will have seen the Channel 4 television programme True stories on 6 July entitled "Deadly experiments ... A series of government funded experiments conducted on human guinea pigs without their consent."(1) Work that I did(2) was mentioned, with a brief extract from a much longer filmed interview. My research was fully reported in 1958.(2) By the 1950s iodine-131 tests had become routine for assessing thyroid function and superseded measurement of the basal metabolic rate, which required admission to hospital. The patient's radiation exposure was low, but we were reluctant to use iodine-131 in pregnancy, even though thyroid function and diagnosis of thyrotoxicosis in pregnancy remained uncertain. In 1956, however, the low dosage iodine-132, with a half life of 2.3 hours, became available. Sir Edward Pochin, in agreement with Professor W C W Nixon, suggested that iodine-132 might be used in pregnancy. Twenty five pregnant patients were selected for investigation, but only 16 completed the protocol. All had given informed consent. A test dose of 0.22 MBq of iodine-132 was used, giving 0.21 cGy to the maternal thyroid and 0.0011 cGy to the maternal and fetal gonads. We found that thyroid iodine uptake was indeed increased in pregnancy, and the test became available for clinical use. The patients were not formally followed up, but their records were later traced and there was no evidence of harm in mothers or children. Use of radioiodine for diagnosis and for treatment of thyrotoxicosis has not caused either cancer or leukaemia, but fallout after atomic weapons tests and after the accident at Chernobyl has been followed by a small excess of thyroid carcinoma, especially in children. KEITH E HALNAN Consultant oncologist Hampton, Middlesex TW12 2LU (1)Tobias JS. Good intentions are not enough. BMJ 1995; 311:203. (15 July.) (2)Halnan KE. The radio-iodine uptake of the human thyroid in pregnancy. Clin Sci 1958; 17:281-90. Rate of carriage of group A

haemolytic streptococci

EDITOR,--During the publicity last year about necrotising fasciitis the media frequently stated that 10% of the British population carry group A haemolytic streptococci.(1) Textbooks give a figure of 5-20%.(2)(3) We tested whether these figures apply to a rural population by taking throat swabs from 310 well people during 12 months. The mean age (37.2 years) and sex distribution (51% were male) approximated to those in the practice population as a whole. During the same period throat swabs were taken from 375 patients with upper respiratory tract infection. The swabs were taken into Allen's transport medium and reached the microbiology laboratory within five hours. With the agreement of the microbiologist a pseudodiagnosis of an upper respiratory tract infection was given for the swabs from the well people. Group A haemolytic streptococci were isolated from only two (0.6%) of the well people and from 36 (9.6%) of the patients with an upper respiratory tract infection. The two well people who were positive for group A haemolytic streptococci were aged 4 and 75. As we obtained reasonable numbers of organisms from patients with an upper respiratory tract infection our findings are unlikely to be due to faulty swab taking or poor laboratory technique. Either the figures quoted for the rate of carriage of group A haemolytic streptococci have never applied to rural communities or the rate has decreased since previous studies. Investigation into current rates of carriage in the population of a British city would be interesting. We thank Dr D Johnston, consultant microbiologist at Scarborough Hospital, for his cooperation.

ROBERT DITCHBURN General practitioner JANET DITCHBURN General practitioner Dale End Surgery, Danby, Whitby, North Yorkshire YO21 2JE (1)Pennington T. Quoted by Brindle D: Alert to doctors over bug. Guardian 1994 28 May. (2)Shanson DC. Microbiology in clinical practice. Bristol: John Wright, 1982. (3)Finch RG, Ball P. Infection. Oxford: Blackwell Scientific, 1991. Risk for British travellers of acquiring hepatitis A EDITOR,--The risk of non-immune British people acquiring hepatitis A during visits to endemic areas has been calculated as 0.047% per visit.(1) Current British guidelines on immunisation against hepatitis A are specific to regions--for example, protection is not considered to be necessary for travellers to Spain, Portugal, or Italy, but tourists visiting all but first class accommodation in Turkey should be protected.(2) Cases of hepatitis A are routinely reported to the Public Health Laboratory Service's Communicable Diseases Surveillance Centre by laboratories in England and Wales. Information about whether the infection was acquired in Britain or abroad is provided in, on average, 29% of reports. We summarised the reported travel histories in 1471 cases acquired abroad between 1990 and 1992 by selected region or country of destination. The number of visits made by British travellers each year to each destination was provided by the international passenger survey.(3) This longitudinal survey of passengers resident in Britain also provides information specific for each country, about the average duration of visits and reasons for the visits. We adjusted the number of visits by their average duration (from 10 days for visits to France to 53 days for visits to the Indian subcontinent) and expressed the incidence for each destination as cases/100 000 visits/month. As hepatitis A may be underreported, travel histories may be incomplete, and the number of passengers departing for some destinations is small, we calculated the risk of hepatitis A relative to the risks in France and Scandinavia, which we assumed to be similar to the risk across Britain. We assumed that anomalies in reporting and bias in the collection of the denominator data were consistent across destinations and over time. For the Indian subcontinent we used age specific laboratory data and proxy data on ethnic group(4) combined with statified data on reason for travel to estimate the risk by age and by reason of visit. Our estimates suggest that British travellers to Greece, Spain, and Italy (8 806 068 visits in 1992) have a low risk of infection and do not require protection but that immunisation might be considered to be necessary for the smaller number of travellers to Turkey (329 053 visits in 1992). Children travelling to the Asian subcontinent are at an appreciable risk and therefore need to be protected against infection. The wide vartiation in incidence of hepatitis A by destination, reason for travel, and age (table) confirms the advantages of targeting advice and prophylaxis. High risk travellers need to be identified in future prospective epidemiological studies to help focus resources(1) and optimise protection. RON H BEHRENS Consultant physician in tropical and travel medicine Hospital for Tropical Diseases, London NW1 0PE MARIAN COLLINS Information assistant BERANGERE BOTTO Information assistant JULIA HEPTONSTALL Consultant microbiologist Immunisation Division, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ [TABULAR DATA OMITTED] (1)Behrens RH, Roberts JA. Is travel prophylaxis worth while? Economic appraisal of prophylactic measures against malaria, hepatitis A, and typhoid in travellers. BMJ 1994; 309:918-22. (2)Lea G, Leese J, eds. Health information for overseas travel. London: HMSO (in press). (3)Central Statistical Office. Business monitor; overseas travel and tourism. London: Government Statistical Service, 1992. (MA6.) (4)Nicoll A, Bassett K, Ulijaszek SJ. What's in a name? Accuracy of using surnames and forenames in ascribing Asian ethnic identity in English populations. J Epidemiol Community Health 1986; 40:364-8. Copyright: COPYRIGHT 1995 BMJ Publishing Group Ltd. http://www.bmj.com.offcampus.lib.washington.edu/archive/ Source Citation (MLA 9th Edition) Tobias, Jeffrey S. "Deadly Experiments." British Medical Journal, vol. 311, no. 6998, 15 July 1995, p. 203. Gale Academic OneFile, link.gale.com/apps/doc/A17202407/AONE?u=wash_main&sid=googleScholar&xid=dc9c76d0. Accessed 20 Aug. 2023. Gale Document Number: GALE|A17202407