§ 5.42 p.m.
§ LORD CLYDESMUIR rose to draw attention to the danger of employing in or about fever hospitals persons who have 1020 not been adequately protected against smallpox by vaccination; and to move for Papers. The noble Lord said: My Lords, I presume to occupy your Lordships' attention for a short time to-night on the subject of vaccination. There is some history to recount before I make my few remarks. On April 19 last, I asked the Government a question on the advisability of compulsory vaccination for those who work in or about isolation hospitals. The answer did not seem to me to be fully satisfactory, for while the noble Lord who replied agreed that effective vaccination was desirable, he did not seem to indicate that administrative steps were sufficient to ensure that effective vaccination took place, and that at least strong pressure was brought on those likely to he exposed to danger to take this precaution. I am moving this Motion to-night in the hope of obtaining a reassuring statement from the Government, not only in relation to Scotland but in relation to the United Kingdom as a whole, in regard to the administrative steps taken to give the greatest possible protection to those exposed to danger.
§ In answer to a supplementary question on April 19, the noble Lord, Lord Morrison, admitted that in a recent outbreak of smallpox in the West of Scotland, out of twenty-one cases, nine cases (eight nurses and a laundrymaid) were members of the staff of the fever hospital to which the original case had been admitted. Of these nine, five died; they had not been sufficiently vaccinated. I would add to these facts, which are already known, some remarks bearing on a recent review in the British Medical Journal in which other facts were adduced. Those facts seem to me, speaking as a layman, to prove beyond doubt that periodical vaccination offers a high degree of protection against this disease. Referring to the same outbreak in Glasgow, the British Medical Journal brought out the fact that, of eighteen confirmed cases, six had no vaccination scars. These patients all died, and they were the only patients who did die. That is a significant fact. Of the twelve who had vaccination scars, all but two took a light form of smallpox. The remaining two had a more severe attack but recovered, and it was ascertained that they had been vaccinated eighteen and forty-three years respectively before they were attacked, so that would be a considerable gap. 1021 Perhaps more remarkable still is that in no case did the disease develop where there had been successful vaccination within a period of seven years. I have no medical knowledge at all, and I treat this entirely from the point of view of a layman. It seems to me, however, that periodical revaccination—I cannot specify the length of the period, but seven years seems to he suggested here—gives a considerable measure of protection.
§ The West of Scotland outbreak, which I instance again because it is fresh in your Lordships' minds, once it took place, was handled with great energy, ability and determination, and would pay tribute to the health authorities both at the Scottish Office and in the localities. The outbreak was stamped out in a very short time, but it meant that mass vaccination had to be adopted. In the town of Hamilton, where a woman doctor unfortunately died after she had been the unwitting cause of a number of contacts throughout the town, practically every person in the borough was vaccinated. That was a considerable undertaking for the health authorities, and I pay tribute to them for their work. Not only in Hamilton, but in many towns in the county area round about thousands of people were vaccinated, and a first-class job was done. But this should not be necessary—that is the point I should like your Lordships to consider. It would not have been necessary to have this mass vaccination in order to check the spread of the disease if it had been possible by administrative measures to check it more nearly to its source of outbreak. If, for example, it had been possible to prevent the spread of the disease at the point where infection was first evident, much trouble would have been saved.
§ I come to the point that it is the place where the disease is most usually found, the isolation hospital, that should receive the first measures of protection. I agree that an isolation hospital is not the only place, but it is the natural place of danger. It is true that vaccination in infancy is not now compulsory in this country. If I may express a personal doubt, and I do not claim to take anyone with me, I doubt whether that will prove to have been a wise step. But that is not the issue before the House this afternoon. It is true that vaccination is, in effect, compulsory in many different sets of cir- 1022 cumstances. For example, before I was allowed to proceed to India to take up a Governor's post I was to all intents and purposes compulsorily vaccinated, and before I could come home again I was vaccinated once more. Before going to the United States or to a number of other countries, travellers are compulsorily vaccinated. Before a soldier or a public servant proceeds on service overseas he is compulsorily vaccinated. Of course, one can refuse and need not go abroad, but actually very few people faced with the issue would make the choice not to be vaccinated. The point is that in many sets of circumstances people are compulsorily vaccinated. Why should not the same care be extended to those exposed to risk in isolation hospitals, subject of course to their right to contract out for conscientious objection, though few people would do that when they have important assignments to undertake?
§ I do not claim that vaccination is the only defence against smallpox. Other steps can be taken which are extremely important, but it all tames back to vaccination and the administrative steps taken to ensure that it is effectively carried out. I hope the noble Lori. Lord Morrison, will he able to make it clear that throughout the United Kingdom a thorough review of anti-smallpox precautions has taken place, or is taking place, and that any particular danger points are being watched. I well realise that I may have fallen short in suggesting only one danger point in this Motion—namely, the isolation hospital—but I feel that that is the most dangerous point. As the British Medical Journal points out, the history of the recent outbreak in Glasgow, and that which took place in the north of England even more recently, shows how easily smallpox can enter the country in these clays of speedy travel. Hence, it becomes plain that the vaccination of infants is at least as necessary as it ever was, and that persons who may encounter the disease, in particular the staffs of isolation hospitals, should be periodically re-vaccinated.
§ We are a maritime race, with all the ports in the world as our hunting grounds for trade. It is inevitable, therefore, that we are exposed to a certain amount of danger from infectious disease. But let us at least maintain reasonable precautions to see that the degree of immunity which 1023 we have enjoyed from this scourge in the past fifty years or longer should not now be lessened. In this country, thanks to our laws, we are free from the scourge of rabies—a tremendous boon, as all who have served in the East know—and we have been reasonably free from the scourge of smallpox. However, in looking ahead I have grave anxieties, and I hope that the noble Lord will reassure us that the administration will, if necessary, be tightened up, and that the Government will show a really determined attitude on this question. I beg to move for Papers.
§ 5.52 p.m.
§ LORD AMULREE
My Lords, I do not want to take up a great deal of time at this rather late hour, because the case has been extremely well put by my noble friend Lord Clydesmuir in moving the Motion. However, I should like to quote one or two figures to support the powerful plea which the noble Lord has made for the nurses and staffs working in infectious diseases hospitals to be vaccinated regularly. In looking at some papers before coming to your Lordships' House, I came across some rather startling figures published by the old Metropolitan Asylums Board, the body responsible for running the infectious diseases hospitals for London up to the time of the 1929 Act. I found that from the year 1892 to the year 1929 there were twelve big outbreaks of smallpox in the Metropolitan area, and those outbreaks brought forth 19,900 patients.
The number of secondary infections acquired by the people in charge of the patients—namely, the people in the infectious diseases hospitals—was fifteen. One outbreak in particular brought out eleven such patients. What caused the outbreak I have been unable to find out, but it was a big outbreak in the year 1893, when there were 2,000 or more cases, and eleven cases arose among the people in charge of them. That leaves only four cases arising from the remaining 18,000 cases. This number covered the doctors, nurses and others who came in contact with the Patients. I feel the reason for that was that the Metropolitan Asylums Board—and I think most of the boards of guardians—insisted on the staffs being successfully and regularly vaccinated. In the case of the Metropolitan Asylums Board, if a successful 1024 vaccination took place and there was no particular outbreak, no further vaccination was required for four or five years. But supposing a suspected or a real smallpox patient was admitted, the staff were immediately re-vaccinated; in fact, it was done so frequently that sometimes the staffs said they were tired of being vaccinated, although I am sure they would rather have been tired of being vaccinated than die from smallpox. I am not sure what occurred when the London County Council took over the hospitals but, so far as I can gather, the same good record continued.
Matters were simpler then, because the infectious diseases hospital, with the disinfection service and the people who drove the ambulances, all came under the department of preventive medicine of the local authority, and were under the charge of the medical officer. That does not apply now that the hospitals come under the Regional Hospital Boards. This makes it more difficult to keep personal contact to see that every nurse and member of the staff is vaccinated or has the choice of vaccination or not taking the employment. The Regional Hospital Boards—I am in no way criticising them on this account—have a great deal of work to do, and it may be rather difficult sometimes to keep such a strict watch. I should like to hear that administrative action is being taken to tighten things up, so that nobody will be employed in infectious diseases hospitals who has not only been vaccinated, but successfully vaccinated.
§ 5.59 p.m.
§ LORD HADEN-GUEST
My Lords, I am sure that the House will be grateful to the noble Lord, Lord Clydesmuir, for raising this extremely important matter. There is no doubt whatever that great anxiety has been caused by the recent outbreaks to which the noble Lord has referred, the one in Glasgow and the other in the north of England. There are very good reasons why compulsory vaccination is not now insisted upon. I do not propose to enter into a disquisition on that subject this evening, or at any other time, with your Lordships, because that is a purely medical question. However, there is one fact that must be always borne in mind with regard to infectious diseases—namely, that they vary in virulence from time to time and, therefore, 1025 it is necessary to change the method of treatment from time to time. Incidentally, that applies to vaccination itself, which is, in fact, a slight form of smallpox, and affords protection against the major disease.
The point on which I should like the noble Lord who is to reply to give us some information is whether there were any bad effects consequent on the vaccination of adults in the many cases recently treated. The vaccination of an adult is a different thing from the vaccination of a child. Uneasiness has been expressed in various circles in case evil effects should follow the mass vaccination of adults. As the noble Lord, Lord Clydesmuir, has said, he was not allowed to go to India to undertake a not unimportant position until he had submitted to vaccination. I had the same experience myself when. I was proceeding to India on medical work, and now every traveller going abroad—at least to many countries —is obliged to be vaccinated before the air services will carry him. I wonder if the noble Lord who is to reply can give any information as to whether there have been any bad results from the vaccination of adults in the cases I have mentioned. That is an important point.
I really rose to say, however, how strongly I agree with the noble Lord who raised this question about the necessity of the staffs of fever hospitals being vaccinated, not only in order to protect themselves but also because they may, by not being protected, contract smallpox and give it to other people. But that is not the only trouble. As the noble Lord, Lord Clydesmuir, will remember—I think I am right in this—the first case which gave rise to the Glasgow epidemic was not taken to a fever hospital at all in the first instance.
I think it was diagnosed as pneumonia, and was not taken to an isolation hospital; but I am not sure about that.
§ LORD HADEN-GUEST
I think that to the case. Very often these cases are not diagnosed and, therefore, the question arises as to whether we need some further protection against that happening. Anyone can diagnose a case of smallpox in the middle of an epidemic, but it is extremely difficult when it comes quite 1026 casually, either to a doctor's surgery or a hospital out-patient department, which may not be a fever hospital at all, and without any sign or symptom. The noble Lord, Lord Webb-Johnson, told me of a case recently where a doctor in a hospital put his hand on the forehead of a patient and said: "This is an obvious case of acne," whereas in fact it was a case of smallpox. It is not easy to discover this disease, but that is all the more reason for having the staffs of hospitals protected by vaccination. While that cannot be made compulsory for people who disagree on conscientious grounds, it is at least possible to see that the people who do not submit to vaccination go neither to India as Governors, nor to infectious diseases hospitals, where they are likely to come into contact with smallpox. I do not think there is anything unreasonable in that, and I hope that we may have an assurance that action will be taken on those lines.
I hope the noble Lord, Lord Morrison, will be able to give some indication whether the Government can take steps to find out whether there were any evil results from the vaccination of many thousands of adults. I should like to k now whether it is possible for the Government to obtain further information with regard to the very large number of adults who have been vaccinated when taking trips abroad over the whole war period—including, of course, those in the Services, who must number many thousands. Perhaps we could he told, also, whether they did in fact contract smallpox after being vaccinated. I feel that such information as all this would be a valuable addition to our knowledge as to the facts about vaccination and its value.
§ 6.5 p.m.
§ LORD MORRISON
My Lords, this has been a short but well-balanced debate. We have had two medical experts and two laymen, of whom I am the second. May I say at once that I regret I am not able to give the noble Lord, Lord Haden-Guest, the information he seeks. I doubt if information can be obtained whether any illnesses have resulted from the large number of people who have been compulsorily vaccinated when going overseas. I doubt whether such information has ever been accumu- 1027 lated by anybody, but I will make inquiries. With regard to the question the noble Lord raised about the large numbers who were vaccinated, my information is that the large-scale vaccination of adults on the occasion of the Glasgow outbreak approached the figure of half a million, and that was attended by very few unpleasant results. I promise to try to obtain some more detailed information for the noble Lord.
The noble Lord, Lord Clydesmuir, asked me to make a somewhat fuller reply than I did last time, and I propose to do so. The first point I would emphasise is that the reply I shall now make will cover not only Scotland but England as well. The Government are fully alive to the need for adequate protective measures in hospitals against smallpox and other epidemic diseases. In accordance with the undertaking which I gave on April 19, to which the noble Lord referred, and the same undertaking which was given by the Secretary of State for Scotland in another place on April 25, the Government are taking special steps to bring the matter to the attention of hospital authorities in the National Health Service and to give them guidance on the measures to be taken.
I do not think there is any difference of opinion as to the need for protection but only as to the best means of ensuring it. The problem of protection is not confined to fever hospitals only. A case of smallpox is not invariably diagnosed as such before the patient is admitted to hospital. A patient with smallpox may turn up in a general hospital, as the noble Lord, Lord Haden-Guest, has said, or in a fever hospital. It is only in cases where the disease is diagnosed before the patient is admitted that he goes direct to a hospital which is specially designated for the treatment of smallpox. For example, the recent outbreak in Glasgow began with a seaman who was admitted to hospital because he was diagnosed as suffering from pneumonia. He was in fact sent to an infectious diseases hospital, but he might just as easily have gone to a general hospital. Any rules for protection, therefore, should be applied to general hospitals as well as hospitals for the treatment of infectious diseases, and, indeed, to workers in other branches of the 1028 Health Service as well—for example, health visitors and sanitary inspectors.
There was in this matter no uniform practice among the old hospital authorities before the passing of the National Health Service legislation. It was the general practice of local authorities who controlled the infectious diseases hospitals to make arrangements under which student nurses, taking up duty at these hospitals, could be vaccinated against smallpox and immunised against certain other infectious diseases. Very few, if any, prospective nurses declined the protection offered, but the general rule was not to apply compulsion. It was much less common for local authorities to arrange for the routine vaccination of staff other than nurses, although special steps were, of course, taken in hospitals designated for the reception of smallpox patients. The voluntary hospitals, which included the bulk of the general hospitals, often took a stronger line and employed only nurses who had been vaccinated. But in these hospitals, too, the practice as regards staff other than nurses was much less strict.
The National Health Service legislation provided for the repeal of the Vaccination Acts under which vaccination was compulsory for infants unless the parents objected on conscientious grounds. The Government do not think it right to impose by administrative action a restriction on the liberty of prospective nurses which does not apply to the rest of the community. The girl who wishes to be a nurse but objects to vaccination would be barred from the career of her choice. This might well affect recruitment to the nursing profession, and not only of conscientious objectors to vaccination, because people will object to compulsion even when they are quite prepared to take the necessary action voluntarily. This difficulty would be even greater with domestic staff, who tend to move freely from hospital to other work. A requirement of vaccination would certainly be an obstacle to their recruitment.
These points I have made to show that the approach in the noble Lord's Motion is not the right one. The Government are in full sympathy, however, with the end which Lord Clydesmuir has in view, and I shall now explain how we intend to achieve it. After consultation with local authorities and their medical officers of 1029 health, who have such an important part to play in the prevention of epidemics, detailed instructions to Scottish hospitals have been issued this week by the Department of Health for Scotland. Similar instructions are being prepared by the Ministry of Health for issue in England and Wales. The line laid down in these instructions is as follows.
First, in all hospitals where staff are likely to be at special risk—that is, both general hospitals (including children's hospitals) and infectious diseases hospitals—all recruits to the staff will be offered vaccination unless they present clear evidence of having been very recently vaccinated. Staff already in posts will be offered re-vaccination from time to time, at least once in every three years. There may have to be some modification of these arrangements for transient employees who serve in a hospital for only a short time and who are not in contact with patients, but this will be the only exception. Experience suggests that staff whose duties bring them into contact with patients are very unlikely to refuse vaccination, especially when care is taken—and care will he taken—to present the offer suitably and to make convenient arrangements for carrying out the vaccination without delay. It will be a rare case for a nurse to decline to be vaccinated, and if such a case does arise the hospital authorities will then arrange for her to be employed on duties where the risk of contact is reduced to the minimum.
All hospitals will be required to maintain accurate and up-to-date information in their records, showing the vaccination position of each member of the staff. The object of this is to ensure that prompt and effective action can be taken as soon as a case of or a contact with smallpox arrives in hospital. When this happens, vaccination or re-vaccination will be offered immediately to all members of the staff, and, at the same time, their vaccination position will be carefully checked so as to remove from any risk of contact anyone who is not protected. This will apply not only to nurses but to domestics, ambulance attendants and anyone else at the hospital who is exposed to the risk of contact.
These are the routine measures which will be taken in all hospitals where there 1030 is any likelihood of a smallpox case or contact being admitted. I should make it clear that those hospitals which are actually designated for the admission of smallpox patients should an outbreak occur, are in a special category. As an invariable rule their staffs must be adequately protected by periodic vaccination and also by re-vaccination when, or if possible before, the first case is admitted. The staff of these smallpox units are normally volunteers who have offered their services on the clear understanding that their vaccinal state will be maintained at a high level by re-vaccination, and the question of compulsion does not, therefore, really arise. What has been said applies primarily to smallpox, but it may he added that it is normal practice now for hospital nurses to be immunised against diphtheria and against typhoid and paratyphoid fevers. In addition, to help to protect nurses against tuberculosis, they are now being offered inoculation with B.C.G. vaccine in appropriate cases.
What has been said relates only to the direct protection of the individual members of hospital staffs. In addition, hospital authorities have also been reminded of the necessity of working closely in all matters regarding the control of epidemic diseases with the medical officers of health, who have a statutory duty to take measures for the protection of the community of which the hospital is a part. This co-operation takes several forms, The essential things are that the medical officer of health—more than one may be concerned—should be warned at once when there is any suspicion of a case of smallpox in a hospital, or of any other similar disease which may be the forerunner of an epidemic, and that he should be called into consultation by the hospital authorities on the measures to be taken to prevent the spread of the epidemic, both within the hospital and to the rest of the community.
The Government believe that most of the measures outlined fall within what is already recognised to be good hospital practice, and that they are taken as a matter of routine by most hospital authorities. The new instructions will ensure that they are taken by all hospitals, and this will reduce the risk to hospital staffs to the minimum. It is important, however, that this problem 1031 should be seen in its true perspective. While the Government are instructing hospital authorities to take every necessary precaution, the actual risks of hospital staffs being exposed to smallpox have proved in practice to be slight. There were peculiar circumstances about the recent unfortunate outbreak in Glasgow, and while this is not a matter for prediction there is no reason to fear repetition. The Government do not feel that they would be justified, as a result of this one case, in taking the extreme step of enforcing compulsory vaccination on one class of the community—nurses and other members of the hospital staff—who, perhaps more than any other, are fully conscious of the value of protective measures and can be trusted to take a responsible view of their duty to themselves and to the rest of the community. The noble Lord, Lord Clydesmuir, asked for a reassuring statement. I hope that the statement which I have just made will reassure him.
§ 6.18 p.m.
My Lords, may I say a word or two? The noble Lord, Lord Morrison, described a hospital's refusing to employ a girl who has not been vaccinated as an unpleasant form of compulsion. But that is precisely the same form of compulsion as is employed by the Foreign Office in excluding candidates for employment there unless they know French, and by insurance companies in requiring candidates for posts with them to know mathematics. By these requirements they may well debar people from the career of their predilection until they have "vaccinated" their brains in the necessary manner.
§ 6.19 p.m.
My Lords, I should like to thank the noble Lord for his very thoughtful statement, but before I can admit that it is a reassuring statement I should like to study the instructions which are being issued to hospitals, not only in Scotland but in the United Kingdom as a whole.
I am much obliged. They seemed to me to be clear, hut I should like to go into the subject 1032 rather more thoroughly. I should not be surprised if, after having done so, I do feel reassured; but, being a canny Scot, I would rather not commit myself until I have actually studied the instructions. I agree that in a number of professions and careers there is in fact compulsion. No one can go overseas and take up a post until he has been vaccinated; no one can travel to certain countries unless he has been vaccinated. It may be said that vaccination is not compulsory, because a person need not travel. For instance, I need not have gone to Bombay, and I need not have come back again. But on the assumption that I was going to do both those things, I had to be vaccinated twice. I cannot see that it would be unreasonable to apply compulsion in this case, but I recognise the difficulty. Also, I do not want to exaggerate or over-estimate the dangers to which nurses are exposed. Their magnificent work in this country is well recognised by everyone. I hope that this is an isolated instance. I trust that the effect of these instructions may make any recrudescence unlikely.
I do not wish to give cause for alarm to anyone undertaking that profession. I think the debate has served a useful purpose. I thank the noble Lord for the trouble he has taken in replying to me, and if I cannot admit that I am wholly reassured, perhaps I may feel so when I have read the instructions more fully. I beg leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.