- Email: [email protected]
Why isolate theatre suites?
178
IFPMA code
on
advertising
SiR,—Three years ago The Lancet reported on the promotion of benzydamine (’Benzitrat’; Searle) to a paediatricians’ congress in Brazil. The doctors were offered prizes of rally bicycles, surfboards, and skateboards (gifts requiring balance, presumably like the balanced product) in the "Benzicard" lottery. A month before the congress Health Action International protested to the International Federation of Pharmaceutical Manufacturers Association (IFPMA) about this promotion. Seven months after it, IFPMA replied. It did not consider that the promotion violated the IFPMA voluntary code of advertising, but the company had taken note of the criticism and the campaign had been withdrawn.2 Perhaps the company was mindful of skating too close to the clause in the Association of the British Pharmaceutical Industry code of practice which states that "gifts may be distributed to members of the medical and allied professions provided the gift is inexpensive and relevant to the practice of medicine or pharmacy". In November, 1990, Roche, through its agents in Sri Lanka, promoted ceftriazone (’Rocephin’) at the annual sessions of the Ceylon College of Physicians with a darts competition. Those hitting the bull’s eye in one shot were awarded the prize of an umbrella. The competition and the prize emphasise that the drug is administered only once a day-a one-shot drug to provide 24 hour cover. When this promotion was brought to the notice of the manufacturers, the regional manager of Roche Pharmaceuticals and Chemicals, Hong Kong, Mr S. Hoffmann, replied that the company was absolutely not in breach of the IFPMA code. However, he added that Roche would refrain from using the darts game in future. Roche felt that the umbrellas were of negligible commercial value. The umbrella costs the equivalent of a day’s wages for a labourer in Sri Lanka-and a vial of rocephin costs four
day’s wages. On the other hand, Roche may be correct in their interpretation. This promotion represents honesty in advertising, in a way. Darts is rarely played in developing countries, and these countries rarely have the microbiological resources required for the rational use of powerful antibiotics such as ceftriaxone. So at least in developing countries when rocephin is used, the chances of success could be as remote as that of a novice in darts. Department of Pharmacology, Faculty of Medicine, Colombo 8, Sri Lanka
rather than contamination counts. If the isolated suite system has no effect on infection the costs of such designs-the extra money to build them and to maintain them, the costs of theatre wear and overshoes worn by those not entering the theatres themselves, and the inconvenience to staff who would not otherwise have to change clothing-need to be discussed. If the isolated theatre suite is of no proven benefit-Iask as a theatre user not as an expert in infection control-is it just a cosmetic exercise that should be abandoned? Department of Anaesthesia, Ealing Hospital,
CHRISTOPHER HENEGHAN
Southall UB1 3HW, UK
Occupational infection
among anaesthetists
SIR,-Your editorial (Nov 3, p 1103) and subsequent correspondence (Dec 8, p 1456) show a surprising lack of concern for personal occupational safety by some anaesthetists. Crossinfection control can also be poor in general medical practice as shown by the infrequent use of autoclaves and protective gloves, inadequate knowledge of sterilisation, and poor uptake of hepatitis vaccination.1,2 Most UK clinical dental staff have, in contrast, been shown to have been immunised against hepatitis B virus,3 and to use gloves and other infection control measures.’ These practices will become more widespread, since UK clinical dental students are nearly always immunised against hepatitis B virus5 and are made aware of this occupational hazard at a very early stage in their careers. Therefore, it would seem important to immunise medical students against hepatitis B and to emphasise the need for regular booster immunisation and appropriate control of cross-infection in all clinical specialties. Centre for the
Study of Oral Disease, University Department of Oral Medicine, Surgery, and Pathology, Bristol Dental School and Hospital, Bristol BS1 2LY, UK
CRISPIAN SCULLY STEPHEN PORTER
Morgan DR, Lamont TJ, Dawson JD, Booth C. Decontamination of instruments and control of cross infection in general practice Br Med J 1990, 300: 1379-80. 2 Kinnerstey P. Attitudes of general practitioners towards their vaccination against hepatitis B Br Med J 1990; 300: 238. 3. Samaranayake LP, Scully C, Dowell TB, et al. New data on the acceptance of the hepatitis B vaccine by dental personnel in the United Kingdom Br Dent J 1988, 1.
164: 74-77.
KRISANTHA WEERASURIYA
1. Anon. Paediatricians get their skates on. Lancet 1987; ii: 735. 2. Chetley A. A healthy business?: world health and the pharmaceutical London: Zed Books, 1990: 60.
industry.
RW, Scully C, Dowell TB. Attitudes and practices regarding control of cross-infection in general dental practice. Health Trends 1989, 21: 10-12 5. Scully C, Matthews RW. Uptake of hepatitis B immunisation amongst United Kingdom dental students Health Trends 1990; 22: 92.
4. Matthews
Occupational hazards and protection of Why isolate theatre suites? SIR,-For 20 years or more new operating-theatres have been built to a plan which allows or requires all personnel to change their clothes and shoes before entering the theatre suite. Access to the areas in the theatre suite but outside the operating-theatres is usually denied to anyone who has not changed completely. The logic, presumably, is that infection associated with surgery is at least in part due to exogenous bacterial contamination and that outdoor clothes are more likely to carry bacteria while clean theatre wear (or other materials) can be contaminated by contact with outdoor clothes and shoes. However, a bacterial challenge must reach a certain level before infection occurs, and contamination is very unlikely to reach that point if floors and walls are kept clean. Furthermore changing clothes can increase shedding of bacteria. Despite these criticisms nearly all new suites are built to this isolation design. However, not all hospitals use them in this way for in areas outside the theatres themselves there is mingling of staff in outdoor clothes and those in theatre wear, and it is still possible to walk up to the door of a theatre to confer with colleagues inside. There are also still operating theatres of the pre-isolated design where access up to the theatre door is available to all. Open access makes life easier for theatre personnel and saves time. It could not be allowed if the price is a higher infection rate. But is it? I know of no hard evidence that the isolated suite system makes any difference to outcome, as measured by infection rates
the fetus
SIR,-Contrary to the implication of the title of your Nov 24 (p 1289), it is not the woman but the fetus who is the primary focus of protection against such agents in occupational editorial
settings. Your comments, moreover, combine the action of "teratogens" and "mutagens" by implying that agents affecting spermatozoa and ova exert a teratogenic effect, giving the impression that since agents that act before conception can affect both sexes it is of as much importance to protect the male parent as the female parent. The fact that mutagens and other reproductive toxms can affect paternally derived gametes does not negate the much greater potential effect on the fetus of maternal exposure to hazards during pregnancy. Your remarks imply that there is no more reason to protect the female than the male parent, suggesting implicitly that the courts take the view that actions targeted to the woman during pregnancy are discriminatory. But it is nature that has discriminated: it is the woman who carries the fetus and it is through her that teratogens reach the fetus. No one has yet documented any association of paternal alcoholism or alcohol ingestion independent of maternal behaviour with fetal alcohol syndrome, nor of paternal thalidomide ingestion independent of maternal exposure with limb reduction defects. This is not to deny the possible role of the male parent in the transmission of hazardous substances to the pregnant woman, through, for example, bringing
IFPMA code
on
advertising
SiR,—Three years ago The Lancet reported on the promotion of benzydamine (’Benzitrat’; Searle) to a paediatricians’ congress in Brazil. The doctors were offered prizes of rally bicycles, surfboards, and skateboards (gifts requiring balance, presumably like the balanced product) in the "Benzicard" lottery. A month before the congress Health Action International protested to the International Federation of Pharmaceutical Manufacturers Association (IFPMA) about this promotion. Seven months after it, IFPMA replied. It did not consider that the promotion violated the IFPMA voluntary code of advertising, but the company had taken note of the criticism and the campaign had been withdrawn.2 Perhaps the company was mindful of skating too close to the clause in the Association of the British Pharmaceutical Industry code of practice which states that "gifts may be distributed to members of the medical and allied professions provided the gift is inexpensive and relevant to the practice of medicine or pharmacy". In November, 1990, Roche, through its agents in Sri Lanka, promoted ceftriazone (’Rocephin’) at the annual sessions of the Ceylon College of Physicians with a darts competition. Those hitting the bull’s eye in one shot were awarded the prize of an umbrella. The competition and the prize emphasise that the drug is administered only once a day-a one-shot drug to provide 24 hour cover. When this promotion was brought to the notice of the manufacturers, the regional manager of Roche Pharmaceuticals and Chemicals, Hong Kong, Mr S. Hoffmann, replied that the company was absolutely not in breach of the IFPMA code. However, he added that Roche would refrain from using the darts game in future. Roche felt that the umbrellas were of negligible commercial value. The umbrella costs the equivalent of a day’s wages for a labourer in Sri Lanka-and a vial of rocephin costs four
day’s wages. On the other hand, Roche may be correct in their interpretation. This promotion represents honesty in advertising, in a way. Darts is rarely played in developing countries, and these countries rarely have the microbiological resources required for the rational use of powerful antibiotics such as ceftriaxone. So at least in developing countries when rocephin is used, the chances of success could be as remote as that of a novice in darts. Department of Pharmacology, Faculty of Medicine, Colombo 8, Sri Lanka
rather than contamination counts. If the isolated suite system has no effect on infection the costs of such designs-the extra money to build them and to maintain them, the costs of theatre wear and overshoes worn by those not entering the theatres themselves, and the inconvenience to staff who would not otherwise have to change clothing-need to be discussed. If the isolated theatre suite is of no proven benefit-Iask as a theatre user not as an expert in infection control-is it just a cosmetic exercise that should be abandoned? Department of Anaesthesia, Ealing Hospital,
CHRISTOPHER HENEGHAN
Southall UB1 3HW, UK
Occupational infection
among anaesthetists
SIR,-Your editorial (Nov 3, p 1103) and subsequent correspondence (Dec 8, p 1456) show a surprising lack of concern for personal occupational safety by some anaesthetists. Crossinfection control can also be poor in general medical practice as shown by the infrequent use of autoclaves and protective gloves, inadequate knowledge of sterilisation, and poor uptake of hepatitis vaccination.1,2 Most UK clinical dental staff have, in contrast, been shown to have been immunised against hepatitis B virus,3 and to use gloves and other infection control measures.’ These practices will become more widespread, since UK clinical dental students are nearly always immunised against hepatitis B virus5 and are made aware of this occupational hazard at a very early stage in their careers. Therefore, it would seem important to immunise medical students against hepatitis B and to emphasise the need for regular booster immunisation and appropriate control of cross-infection in all clinical specialties. Centre for the
Study of Oral Disease, University Department of Oral Medicine, Surgery, and Pathology, Bristol Dental School and Hospital, Bristol BS1 2LY, UK
CRISPIAN SCULLY STEPHEN PORTER
Morgan DR, Lamont TJ, Dawson JD, Booth C. Decontamination of instruments and control of cross infection in general practice Br Med J 1990, 300: 1379-80. 2 Kinnerstey P. Attitudes of general practitioners towards their vaccination against hepatitis B Br Med J 1990; 300: 238. 3. Samaranayake LP, Scully C, Dowell TB, et al. New data on the acceptance of the hepatitis B vaccine by dental personnel in the United Kingdom Br Dent J 1988, 1.
164: 74-77.
KRISANTHA WEERASURIYA
1. Anon. Paediatricians get their skates on. Lancet 1987; ii: 735. 2. Chetley A. A healthy business?: world health and the pharmaceutical London: Zed Books, 1990: 60.
industry.
RW, Scully C, Dowell TB. Attitudes and practices regarding control of cross-infection in general dental practice. Health Trends 1989, 21: 10-12 5. Scully C, Matthews RW. Uptake of hepatitis B immunisation amongst United Kingdom dental students Health Trends 1990; 22: 92.
4. Matthews
Occupational hazards and protection of Why isolate theatre suites? SIR,-For 20 years or more new operating-theatres have been built to a plan which allows or requires all personnel to change their clothes and shoes before entering the theatre suite. Access to the areas in the theatre suite but outside the operating-theatres is usually denied to anyone who has not changed completely. The logic, presumably, is that infection associated with surgery is at least in part due to exogenous bacterial contamination and that outdoor clothes are more likely to carry bacteria while clean theatre wear (or other materials) can be contaminated by contact with outdoor clothes and shoes. However, a bacterial challenge must reach a certain level before infection occurs, and contamination is very unlikely to reach that point if floors and walls are kept clean. Furthermore changing clothes can increase shedding of bacteria. Despite these criticisms nearly all new suites are built to this isolation design. However, not all hospitals use them in this way for in areas outside the theatres themselves there is mingling of staff in outdoor clothes and those in theatre wear, and it is still possible to walk up to the door of a theatre to confer with colleagues inside. There are also still operating theatres of the pre-isolated design where access up to the theatre door is available to all. Open access makes life easier for theatre personnel and saves time. It could not be allowed if the price is a higher infection rate. But is it? I know of no hard evidence that the isolated suite system makes any difference to outcome, as measured by infection rates
the fetus
SIR,-Contrary to the implication of the title of your Nov 24 (p 1289), it is not the woman but the fetus who is the primary focus of protection against such agents in occupational editorial
settings. Your comments, moreover, combine the action of "teratogens" and "mutagens" by implying that agents affecting spermatozoa and ova exert a teratogenic effect, giving the impression that since agents that act before conception can affect both sexes it is of as much importance to protect the male parent as the female parent. The fact that mutagens and other reproductive toxms can affect paternally derived gametes does not negate the much greater potential effect on the fetus of maternal exposure to hazards during pregnancy. Your remarks imply that there is no more reason to protect the female than the male parent, suggesting implicitly that the courts take the view that actions targeted to the woman during pregnancy are discriminatory. But it is nature that has discriminated: it is the woman who carries the fetus and it is through her that teratogens reach the fetus. No one has yet documented any association of paternal alcoholism or alcohol ingestion independent of maternal behaviour with fetal alcohol syndrome, nor of paternal thalidomide ingestion independent of maternal exposure with limb reduction defects. This is not to deny the possible role of the male parent in the transmission of hazardous substances to the pregnant woman, through, for example, bringing