§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Ernest G. Perry.]
§ 11.42 p.m.
§ Mr. Frank Judd (Portsmouth, West)
The laboratories with which I am concerned tonight are National Health Service hospital laboratories, Public Health 1320 Laboratory Service laboratories and teaching and university hospital laboratories.
The frequently inadequate conditions under which staff in such laboratories are expected to work were spotlighted by the Sunday Times on 6th April. The article said that in a pathology department of a provincial hospital:A patients' six ft. square waiting room doubles as a staff locker room.1321Staff rooms for the 28 technicians, five secretaries, two cleaners and a porter are non-existent.In the bacteriology room, where the danger from the bacteria is acute, food and clothes lockers clutter up the already limited space.Although it was a cool spring day the poorly ventilated room was uncomfortably close.Off the corridor is a toilet used by male and female patients and staff.This debate is particularly concerned with the danger of laboratory staff contracting turberculosis. Statistical proof that such a hazard exists was provided by the Reid Report in 1957. The survey showed that, during the period 1949–53, the incidence of observed frequency of pulmonary tuberculosis among laboratory technicians was higher than the national average, being 3.4 times higher for males, 1.7 times higher for females and 2.7 times higher for both together. The Reid Report did not advance any reason for the apparent discrepancy between male and female incidence, and probably the rate for females was falsely low.
An examination of the figures for the age group 15 to 24 shows that, although a higher incidence is expected among females than among males, in fact the reverse was observed. The observed rates are 4.6 times higher for males and 1.9 times higher for females. The most noticeable drop occurs in the female junior technicians. What the Reid Report seems to have overlooked was the very rapid turnover of females in laboratories at that time, and that by far the greatest turnover occurred in the second, third and fourth years of employment, a fact commented on in the 1954 Annual Report of the Ministry of Health. These are the very years when incidence is highest and young persons are at greatest risk. There is no way of knowing how many females contracted tuberculosis during their stay of two to four years in laboratories which was not diagnosed until after leaving the service. It is, of course, relevant to note that the turnover has declined since 1957.
It was the misgivings about the situation as it now stands that led my right hon. Friend the Member for Sunderland, North (Mr. Willey) to ask the Secretary of State for Social Services on 21st April what was the proportion of cases of tuberculosis diagnosed in the past ten years on staff working in hospital laboratories. The Minister replied that the in- 1322 formation was not available. Even if this information is not available to the Minister, there are a number of pointers which tend to indicate that the incidence has probably increased in recent years and that this increase is not entirely due to the increase in staffing which has taken place.
Evidence for this opinion is varied and includes a survey by the Association of Scientific Workers in 1959, which demonstrated that of over 100 laboratories, 25 per cent. reported having had cases of tuberculosis infection. A report in The Lancet in 1963 said that one hospital in the North of England had had six cases in ten years; there were two cases reported in Blackpool within the space of three years, both since 1960; two were recently reported at Preston; two similar cases at Chesterfield; four in one Glasgow laboratory of which three occurred after 1960; and there were further cases at Wolverhampton, Ormskirk, Belfast, Manchester, all since 1960.
Most laboratory infections are probably not due to accidents such as breakages but are usually caused by inhalation of organisms present in the air. These organisms are present in aerosols, the microscopic particles of fluid liberated into the atmosphere when certain common laboratory experiments are carried out. Because of their minute size, they remain in the atmosphere subjected to air currents, and unless there is adequate ventilation and extraction, they will persist for some time, always being a danger to staff. The accidental breaking of a culture tube can be seen and precautions taken immediately, if necessary evacuating the laboratory. Aerosols cannot be seen, and for this reason are far more dangerous.
Another hazard arises from those specimens received in laboratories for which the diagnosis being considered is in no way tuberculosis. Examples are routine urines subsequently found to be from cases of renal tuberculosis, sputa for malignant cells found to be from cases of pulmonary tuberculosis, faeces for dysentary organisms from cases of tuberculosis, enteritis and so forth.
Following the publication of the Reid survey in 1957, a special working party of the Public Health Laboratory Service was set up. Its terms of reference were:To indicate the dangers that accompany tuberculosis work in the laboratory so as to 1323 enable pathologists to take such precautions against them as seem desirable in the circumstances.In addition to reviewing some of the hazards the report made a number of recommendations designed to minimise or prevent tuberculosis infection among laboratory staff. In the main the suggested measures were directed at bacteriology departments, although some covered all types of staff. The major criticism of the report is that there was no obligation on the part of the employing authority or pathologist to implement any of the recommendations if they were not considered "desirable in the circumstances". In 1961, the Ministry of Health issued a Circular on Prevention of Tuberculosis among Hospital Staff, drawing attention to the recommendations of the working party and asking hospital authorities to act upon them. Among the recommendations made were the following: The first was that protective hoods—in other words, metal cabinets fitted with a suitable exhaust-fan-system in which dangerous procedures can be performed—should be used in a laboratory whenever more than a few cultures have to be made, particularly when the conditions are cramped. However, the Association of Scientific Workers survey in 1965 showed that 28 per cent. of surveyed laboratories doing culture work were without a protective cabinet.
The second recommendation was the B.C.G. vaccine should be offered to all negative skin-test reactors, and that this should be done on starting work in a laboratory where tuberculous material is handled. The recruit should not be allowed to handle tuberculous material until the reaction has become positive.
This recommendation is particularly important today since it has been found that an increasing number of young people are not naturally immune to the disease owing to better health standards, milk control and a reduction in the disease. For this reason the Ministry of Health offers B.C.G. vaccination to schoolchildren at about the age of 13. However, some parents do not take advantage of this, and their children, if they start work in a laboratory, are at a greater risk than those possessing immunity to the disease.
1324 Until the schools vaccination programmes has been going for about 20 years, there will always be a problem for recruits to laboratories. The Association of Scientific Workers survey in 1965 showed that 25 per cent. of the surveyed laboratories did not provide this facility. It is worth remembering that the age at which the incidence of laboratory tuberculosis infection has been shown to be the greatest is between 15 and 24 and this group is the one that would be best protected.
The third recommendation was that all recruits should be X-rayed before employment, and thereafter at regular intervals, depending on the degree of risk; an annual examination probably represents a fair compromise. Whilst this is not a preventive measure as such, it is nevertheless important to technicians that they should be aware as soon as possible that they may have contracted tuberculosis before it becomes an active open lesion. This gives a far better chance of early cure and less risk to family and working colleagues. Regular X-rays may also provide evidence that a particular laboratory has an unduly high degree of risk to the staff. For these reasons and the fact that the staff feel somewhat more protected and cared-for, regular X-rays are important. The Association of Scientific Workers survey in 1965 showed that 12 per cent. of hospital authorities surveyed still did not provide either regular—that is annual—or irregular examinations.
The fourth and final recommendation to which I wish to refer was that "entirely untrained persons should not handle tuberculosis material. A recruit who has attained some skill in bacteriological techniques may be allowed to handle tuberculous material under supervision". This practice is probably adhered to in most laboratories, but there are exceptions. "Under supervision" can mean only under qualified and experienced supervision, but there are known cases of junior technicians with three years' experience in the laboratory, only part of which may have been in bacteriology, who are responsible for the handling of tuberculous material entirely without supervision. Most hospitals have to rely on the unqualified student and the junior technician for the bulk of the routine work, including the bacteriology, and not all hospitals ensure that they are adequately supervised.
1325 The doubts surrounding the implementation of the working party's recommendations led my right hon. Friend the Member for Sunderland, North on 21st April to ask the Secretary of State for Social Services:how many hospital laboratories carrying out cultural tests of tuberculosis material do not have protective cabinets; how many hospitals do not provide annual X-ray tests for staff working in the laboratories; how many hospitals do not carry out tuberculosis skin tests on newly appointed laboratory staff; how many hospitals do not provide B.C.G. vaccine for negative reactors working in their laboratories; what steps he has taken to ensure that the recommendations made by the Working Party in 1958 about precautions in hospital laboratories are carried out.The Secretary of State repliedThe recommendations of the Working Party on Precautions against Tuberculous Infection in the Diagnostic Laboratory published in 1958 were commended to hospital authorities. A survey of most regional board areas in 1966 showed that the main recommendations were being carried out in the majority of hospital laboratories working with tuberculous material. All children requiring it are now given the opportunity of B.C.G. vaccination before leaving school and subsequent tuberculin testing is no longer necessary."—[OFFICIAL REPORT, 21st April, 1969; Vol. 782, c. 19.]It is my contention that this reply was totally inadequate. It did not answer the Question. What does the phrase "most regional board areas" mean? How many? What does "the majority of hospitals working with tuberculous" material mean? May we he given more specific information on this point as well?
I believe that the Ministry must undertake to make available on a continuing basis the figures of the rate of infection; continually to review the precautionary procedures; to enforce certain basic procedures where they are not being carried out—these include protective cabinets, regular x-rays, skin tests; to provide decent working conditions where these are obviously lacking. It must also ensure that the Industrial Injuries Act governing laboratory infection with tuberculosis is being effectively applied to medical laboratory technicians.
Laboratory technicians are giving a vital service to this country for life, health and medical research. They work away in back rooms, not always seen, not always thanked as they should be for what they are doing on behalf of the community. We must ensure that all 1326 reasonable precautions for their own health and welfare are always taken.
§ 11.58 p.m.
§ The Minister of State, Department of Health and Social Security (Mr. David Ennals)
I should like to thank my hon. Friend for raising tonight the subject of health hazards which exist for laboratory technicians in the National Health Service. His was a well-informed and well-briefed speech, and it raised a number of points which, if I do not deal with them tonight, I shall certainly want to look into. I agree that we owe a great deal to the laboratory technicians in the National Health Service, and, apart from the matter of health hazards, my hon. Friend will know something of the Zuckerman Committee, which has been looking into the career structure of technicians in the Health Service, and our response to it, recognising the significance, as we see it, of the scientists and technologists working in the Health Service.
I want first to say something about laboratory hazards generally and then to comment on tuberculosis and to raise one or two other hazards as well. Hospital staff whose work has the prime objective of improving the health of other people ought to be ahead of other workers, not behind, when it is a question of their own health; although the staff themselves may not speak loudly where facilities for themselves are concerned, hospital management ought to ensure that the best possible arrangements prevail. I am sure my hon. Friend agrees with that point.
We are concerned tonight particularly with the hazards in laboratories, and it is true to say that almost any toxic or explosive substance, almost any pathogenic organism, can potentially constitute a hazard. The first line of defence is the proper training of the staff. Best current advice on techniques of handling material must be given to staff, who must practise them so that correct laboratory procedure becomes second nature to them.
The next line of defence is the provision of the necessary physical facilities by hospital management. This means the construction of modern, well-designed laboratories with sufficient space and special protective measures where these are called for; for example, the provision 1327 of lead screening for protection against ionising radiations. The third line of defence is that management should provide for regular surveillance of workers subject to special hazards, with medical examination and monitoring of the working environment at intervals.
Let me deal first with the risk of tuberculosis infection, which I know is the special concern of my hon. Friend. I cannot deny that it exists, but, although we do not know precisely how many Health Service technicians have contracted the disease, we think that the number must be very small. It is relevant for me to draw attention to the fact that notifications of tuberculosis have continued in recent years to show a welcome decline in the population as a whole, from 20,500 in 1962 to 13,200 in 1967. That is a very substantial reduction. Between 1966 and 1967, there was a marked reduction in notifications of respiratory tuberculosis, the number of deaths from tuberculosis reaching a new now level of 2,043 in 1967.
For hospital staff, the greatest risk occurs in the post-mortem rooms, where technicians do not normally work. Specimens from post-mortem rooms are processed in laboratories but should not transmit infection since the process of fixation, by heat or chemicals, should render them safe. Liquid or semi-liquid specimens and cultures are the real danger, and should always wherever possible be handled under exhaust ventilation. This is usually provided in the form of hooded benches or cubicles, and technicians are trained to use these facilities.
My hon. Friend has referred to the report entitled "Precautions against Tuberculosis Infection in the Diagnostic Laboratory", published in January, 1958. It was prepared by a working party of the Public Health Laboratory Service and the Department's Central Pathology Committee. Its recommendations were brought to the attention of hospital authorities. In 1961 a Circular was issued to hospital authorities, and it reported that the Standing Tuberculosis Advisory Committee and the Central Health Services Council had reiterated the working party's advice, and hospital authorities were asked to ensure that it was being acted upon.
1328 In 1966 the Department followed up the circular and asked hospital authorities to report on the situation in their regions. The survey did not seek to find out how many laboratory staff had contracted tuberculosis, but among the questions asked were the following: how many laboratories handling potentially tuberculous material had protective cabinets, and gave their staff annual X-rays and tuberculin tests on appointment. The replies varied, of course, but most regions reported that the majority of laboratories were implementing the recommendations. My hon. Friend wanted the figures. I will write to him and give him the analysis of the replies, which, on the whole, were encouraging.
However, I must agree that anything less than 100 per cent. compliance where the health of staff is at risk is not satisfactory. We have, therefore, decided to carry out a further survey next year to check that any defaulters in 1966 are now complying with the requirements. As part of that inquiry, we will consider seeking information about the incidence of infection among laboratory staff. As a result of that survey we shall have not only more information on compliance but information which we have not got at present of the incidence of infection among laboratory staff.
Some laboratories are so unsatisfactory that a new laboratory may be the only answer, particularly since the work load has increased greatly in recent years and the number of technicians involved has greatly expanded. The Government also have in hand a major hospital rebuilding programme. New laboratories are getting their share, but there are many other competing demands on the capital available.
I turn now to another infection which my hon. Friend did not raise but which is of similar concern. I refer to infective hepatitis. Anyone handling human blood or serum may contract this infection, and it is a particular risk for staff in haematology departments, blood transfusion centres and renal dialysis units. Infections occur, although they are comparatively rare, but there is no evidence that technicians have a higher infection rate than the general population.
Pathologists were reminded in November, 1966, by the Central Pathology Committee of the main precautions necessary 1329 in handling potentially infected material. The Central Pathology Committee did not think that it was a significant problem but agreed that staff should be warned of the dangers. A Working Party of the Public Health Laboratory Service reported in 1968 on infection risks in haemodialysis units, and, among other things, recommended on precautions to reduce the risk of hepatitis. This report was published in the British Medical Journal and a copy sent by the Department to all dialysis units.
The risk from ionising radiations is seldom substantial in pathology laboratories, but it may exist in other hospital departments where technicians work. Here hospital authorities are expected to comply with the Code of Practice for the Protection of Persons against Ionising Radiations arising from Medical and Dental use. This comprehensive Code, which was revised in 1964, was prepared by a Panel of the Radioactive Substances Advisory Committee. A survey which was carried out last year by the Department to check the extent to which hospital authorities were putting it into effect showed a reasonable degree of compliance. The Code prescribes maximum permissible doses for all staff in accordance with international recommendations, lays down physical measures for protection, and requires monitoring of radiation levels and in certain circumstances medical examination of radiation workers.
A watch is kept on current scientific views on carcinogenic substances. A circular is about to be sent to hospital authorities passing on advice of a subcommittee of the Central Pathology Com- 1330 mittee about the extent to which certain substances—now prohibited or controlled by the Department of Employment and Productivity in their use in factories—can safely be used in hospital laboratories.
It is not only in hospital laboratories where there are hazards of infection or dangerous substances. Workers in Public Health Laboratory Service laboratories which are constantly dealing with infected or contaminated materials are also subject to risks to their health. A constant watch is kept on the situation, and staff are well trained in the necessary precautions. These problems are, of course, a part of the whole wide subject of care for the health of all people who work in hospitals, and I should not like my hon. Friend to think that, because we have concentrated tonight on a particular and special section of the staff, we are not very much concerned with the care of the health of all hospital staff. It is, of course, a much larger subject, with which I have not time to deal tonight.
I thank my hon. Friend for raising this subject in the constructive and well-informed way that he did. One or two points that he raised, with which I have not dealt in detail in my reply, I will look into and write to him about.
§ The debate having been concluded, the Motion for the Adjournment of the House lapsed without Question put.
§ Mr. DEPUTY SPEAKERsuspended the sitting at eight minutes past Twelve o'clock till Ten o'clock this day, pursuant to the Standing Order.