The Misuse of Drugs Regulations 1985 de?ne the classes of person authorised to supply and possess controlled drugs, and lay down the conditions under which these activities may be carried out. In the Regulations, drugs are divided into ?ve schedules specifying the requirements for supply, possession, prescribing and record-keeping. Schedule I contains drugs which are not used as medicines. Schedules II and III contain drugs which are subject to the prescription requirements of the Act (see below). They are distinguished in the British National Formulary (BNF) by the symbol CD and they include morphine, diamorphine (heroin), other opioid analgesics, barbiturates, amphetamines, cocaine and diethylpropion. Schedules IV and V contain drugs such as the benzodiazepines which are subject to minimal control. A full list of the drugs in each schedule can be found in the BNF.
Prescriptions for drugs in schedules II and III must be signed and dated by the prescriber, who must give his or her address. The prescription must be in the prescriber’s own handwriting and provide the name and address of the patient and the total quantity of the preparation in both words and ?gures. The pharmacist is not allowed to dispense a controlled drug unless all the information required by law is given on the prescription.
Until 1997 the Misuse of Drugs (Noti?cation and Supply of Addicts) Regulations 1973 governed the noti?cation of addicts. This was required in respect of the following commonly used drugs: cocaine, dextromoramide, diamorphine, dipipanone, hydrocodeine, hydromorphone, levorphanol, methadone, morphine, opium, oxycodone, pethidine, phenazocine and piritranide.
In 1997 the Misuse of Drugs (Supply to Addicts) Regulations 1997 revoked the 1973 requirement for noti?cation. Doctors are now expected to report (on a standard form) cases of drug misuse to their local Drug Misuse Database (DMD). Noti?cation by the doctor should be made when a patient ?rst presents with a drug problem or when he or she visits again after a gap of six months or more. All types of misuse should be reported: this includes opioids, benzodiazepines and central nervous system stimulants. The data in the DMD are anonymised, which means that doctors cannot check on possible multiple prescribing for drug addicts.
The 1997 Regulations restrict the prescribing of diamorphine (heroin), Diconal® (a morphine-based drug) or cocaine to medical practitioners holding a special licence issued by the Home Secretary.
Fuller details about the prescription of controlled drugs are in the British National Formulary, updated twice a year, and available on the Internet (see www.bnf.org).... controlled drugs
Occupational health includes both mental and physical health. It is about compliance with health-and-safety-at-work legislation (and common law duties) and about best practice in providing work environments that reduce risks to health and safety to lowest practicable levels. It includes workers’ ?tness to work, as well as the management of the work environment to accommodate people with disabilities, and procedures to facilitate the return to work of those absent with long-term illness. Occupational health incorporates several professional groups, including occupational physicians, occupational health nurses, occupational hygienists, ergonomists, disability managers, workplace counsellors, health-and-safety practitioners, and workplace physiotherapists.
In the UK, two key statutes provide a framework for occupational health: the Health and Safety at Work, etc. Act 1974 (HSW Act); and the Disability Discrimination Act 1995 (DDA). The HSW Act states that employers have a duty to protect the health, safety and welfare of their employees and to conduct their business in a way that does not expose others to risks to their health and safety. Employees and self-employed people also have duties under the Act. Modern health-and-safety legislation focuses on assessing and controlling risk rather than prescribing speci?c actions in di?erent industrial settings. Various regulations made under the HSW Act, such as the Control of Substances Hazardous to Health Regulations, the Manual Handling Operations Regulations and the Noise at Work Regulations, set out duties with regard to di?erent risks, but apply to all employers and follow the general principles of risk assessment and control. Risks should be controlled principally by removing or reducing the hazard at source (for example, by substituting chemicals with safer alternatives, replacing noisy machinery, or automating tasks to avoid heavy lifting). Personal protective equipment, such as gloves and ear defenders, should be seen as a last line of defence after other control measures have been put in place.
The employment provisions of the DDA require employers to avoid discriminatory practice towards disabled people and to make reasonable adjustments to working arrangements where a disabled person is placed at a substantial disadvantage to a non-disabled person. Although the DDA does not require employers to provide access to rehabilitation services – even for those injured or made ill at work – occupational-health practitioners may become involved in programmes to help people get back to work after injury or long-term illness, and many businesses see the retention of valuable sta? as an attractive alternative to medical retirement or dismissal on health grounds.
Although a major part of occupational-health practice is concerned with statutory compliance, the workplace is also an important venue for health promotion. Many working people rarely see their general practitioner and, even when they do, there is little time to discuss wider health issues. Occupational-health advisers can ?ll in this gap by providing, for example, workplace initiatives on stopping smoking, cardiovascular health, diet and self-examination for breast and testicular cancers. Such initiatives are encouraged because of the perceived bene?ts to sta?, to the employing organisation and to the wider public-health agenda. Occupational psychologists recognise the need for the working population to achieve a ‘work-life balance’ and the promotion of this is an increasing part of occupational health strategies.
The law requires employers to consult with their sta? on health-and-safety matters. However, there is also a growing understanding that successful occupational-health management involves workers directly in the identi?cation of risks and in developing solutions in the workplace. Trade unions play an active role in promoting occupational health through local and national campaigns and by training and advising elected workplace safety representatives.
Occupational medicine The branch of medicine that deals with the control, prevention, diagnosis, treatment and management of ill-health and injuries caused or made worse by work, and with ensuring that workers are ?t for the work they do.
Occupational medicine includes: statutory surveillance of workers’ exposure to hazardous agents; advice to employers and employees on eliminating or reducing risks to health and safety at work; diagnosis and treatment/management of occupational illness; advice on adapting the working environment to suit the worker, particularly those with disabilities or long-term health problems; and advice on the return to work and, if necessary, rehabilitation of workers absent through illness. Occupational physicians may play a wider role in monitoring the health of workplace populations and in advising employers on controlling health hazards where ill-health trends are observed. They may also conduct epidemiological research (see EPIDEMIOLOGY) on workplace diseases.
Because of the occupational physician’s dual role as adviser to both employer and employee, he or she is required to be particularly diligent with regards to the individual worker’s medical CONFIDENTIALITY. Occupational physicians need to recognise in any given situation the context they are working in, and to make sure that all parties are aware of this.
Occupational medicine is a medical discipline and thus is only part of the broader ?eld of occupational health. Although there are some speci?c clinical duties associated with occupational medicine, such as diagnosis of occupational disease and medical screening, occupational physicians are frequently part of a multidisciplinary team that might include, for example, occupational-health nurses, healthand-safety advisers, ergonomists, counsellors and hygienists. Occupational physicians are medical practitioners with a post-registration quali?cation in occupational medicine. They will have completed a period of supervised in-post training. In the UK, the Faculty of Occupational Medicine of the Royal College of Physicians has three categories of membership, depending on quali?cations and experience: associateship (AFOM); membership (MFOM); and fellowship (FFOM).
Occupational diseases Occupational diseases are illnesses that are caused or made worse by work. In their widest sense, they include physical and mental ill-health conditions.
In diagnosing an occupational disease, the clinician will need to examine not just the signs and symptoms of ill-health, but also the occupational history of the patient. This is important not only in discovering the cause, or causes, of the disease (work may be one of a number of factors), but also in making recommendations on how the work should be modi?ed to prevent a recurrence – or, if necessary, in deciding whether or not the worker is able to return to that type of work. The occupational history will help in deciding whether or not other workers are also at risk of developing the condition. It will include information on:
the nature of the work.
how the tasks are performed in practice.
the likelihood of exposure to hazardous agents (physical, chemical, biological and psychosocial).
what control measures are in place and the extent to which these are adhered to.
previous occupational and non-occupational exposures.
whether or not others have reported similar symptoms in relation to the work. Some conditions – certain skin conditions,
for example – may show a close relationship to work, with symptoms appearing directly only after exposure to particular agents or possibly disappearing at weekends or with time away from work. Others, however, may be chronic and can have serious long-term implications for a person’s future health and employment.
Statistical information on the prevalence of occupational disease in the UK comes from a variety of sources, including o?cial ?gures from the Industrial Injuries Scheme (see below) and statutory reporting of occupational disease (also below). Neither of these o?cial schemes provides a representative picture, because the former is restricted to certain prescribed conditions and occupations, and the latter suffers from gross under-reporting. More useful are data from the various schemes that make up the Occupational Diseases Intelligence Network (ODIN) and from the Labour Force Survey (LFS). ODIN data is generated by the systematic reporting of work-related conditions by clinicians and includes several schemes. Under one scheme, more than 80 per cent of all reported diseases by occupational-health physicians fall into just six of the 42 clinical disease categories: upper-limb disorders; anxiety, depression and stress disorders; contact DERMATITIS; lower-back problems; hearing loss (see DEAFNESS); and ASTHMA. Information from the LFS yields a similar pattern in terms of disease frequency. Its most recent survey found that over 2 million people believed that, in the previous 12 months, they had suffered from an illness caused or made worse by work and that
19.5 million working days were lost as a result. The ten most frequently reported disease categories were:
stress and mental ill-health (see MENTAL ILLNESS): 515,000 cases.
back injuries: 508,000.
upper-limb and neck disorders: 375,000.
lower respiratory disease: 202,000.
deafness, TINNITUS or other ear conditions: 170,000.
lower-limb musculoskeletal conditions: 100,000.
skin disease: 66,000.
headache or ‘eyestrain’: 50,000.
traumatic injury (includes wounds and fractures from violent attacks at work): 34,000.
vibration white ?nger (hand-arm vibration syndrome): 36,000. A person who develops a chronic occu
pational disease may be able to sue his or her employer for damages if it can be shown that the employer was negligent in failing to take reasonable care of its employees, or had failed to provide a system of work that would have prevented harmful exposure to a known health hazard. There have been numerous successful claims (either awarded in court, or settled out of court) for damages for back and other musculoskeletal injuries, hand-arm vibration syndrome, noise-induced deafness, asthma, dermatitis, MESOTHELIOMA and ASBESTOSIS. Employers’ liability (workers’ compensation) insurers are predicting that the biggest future rise in damages claims will be for stress-related illness. In a recent study, funded by the Health and Safety Executive, about 20 per cent of all workers – more than 5 million people in the UK – claimed to be ‘very’ or ‘extremely’ stressed at work – a statistic that is likely to have a major impact on the long-term health of the working population.
While victims of occupational disease have the right to sue their employers for damages, many countries also operate a system of no-fault compensation for the victims of prescribed occupational diseases. In the UK, more than 60 diseases are prescribed under the Industrial Injuries Scheme and a person will automatically be entitled to state compensation for disability connected to one of these conditions, provided that he or she works in one of the occupations for which they are prescribed. The following short list gives an indication of the types of diseases and occupations prescribed under the scheme:
CARPAL TUNNEL SYNDROME connected to the use of hand-held vibrating tools.
hearing loss from (amongst others) use of pneumatic percussive tools and chainsaws, working in the vicinity of textile manufacturing or woodworking machines, and work in ships’ engine rooms.
LEPTOSPIROSIS – infection with Leptospira (various listed occupations).
viral HEPATITIS from contact with human blood, blood products or other sources of viral hepatitis.
LEAD POISONING, from any occupation causing exposure to fumes, dust and vapour from lead or lead products.
asthma caused by exposure to, among other listed substances, isocyanates, curing agents, solder ?ux fumes and insects reared for research.
mesothelioma from exposure to asbestos.
In the UK, employers and the self-employed have a duty to report all occupational injuries (if the employee is o? work for three days or more as a result), diseases or dangerous incidents to the relevant enforcing authority (the Health and Safety Executive or local-authority environmental-health department) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). Despite this statutory duty, comparatively few diseases are reported so that ?gures generated from RIDDOR reports do not give a useful indication of the scale of occupational diseases in the UK. The statutory reporting of injuries is much better, presumably because of the clear and acute relationship between a workplace accident and the resultant injury. More than 160,000 injuries are reported under RIDDOR every year compared with just 2,500 or so occupational diseases, a gross underestimate of the true ?gure.
There are no precise ?gures for the number of people who die prematurely because of work-related ill-health, and it would be impossible to gauge the exact contribution that work has on, for example, cardiovascular disease and cancers where the causes are multifactorial. The toll would, however, dwarf the number of deaths caused by accidents at work. Around 250 people are killed by accidents at work in the UK each year – mesothelioma, from exposure to asbestos at work, alone kills more than 1,300 people annually.
The following is a sample list of occupational diseases, with brief descriptions of their aetiologies.
Inhaled materials
PNEUMOCONIOSIS covers a group of diseases which cause ?brotic lung disease following the inhalation of dust. Around 250–300 new cases receive bene?t each year – mostly due to coal dust with or without silica contamination. SILICOSIS is the more severe disease. The contraction in the size of the coal-mining industry as well as improved dust suppression in the mines have diminished the importance of this disease, whereas asbestos-related diseases now exceed 1,000 per year. Asbestos ?bres cause a restrictive lung disease but also are responsible for certain malignant conditions such as pleural and peritoneal mesothelioma and lung cancer. The lung-cancer risk is exacerbated by cigarette-smoking.
Even though the use of asbestos is virtually banned in the UK, many workers remain at risk of exposure because of the vast quantities present in buildings (much of which is not listed in building plans). Carpenters, electricians, plumbers, builders and demolition workers are all liable to exposure from work that disturbs existing asbestos. OCCUPATIONAL ASTHMA is of increasing importance – not only because of the recognition of new allergic agents (see ALLERGY), but also in the number of reported cases. The following eight substances are most frequently linked to occupational asthma (key occupations in brackets): isocyanates (spray painters, electrical processors); ?our and grain (bakers and farmers); wood dust (wood workers); glutaraldehyde (nurses, darkroom technicians); solder/colophony (welders, electronic assembly workers); laboratory animals (technicians, scientists); resins and glues (metal and electrical workers, construction, chemical processors); and latex (nurses, auxiliaries, laboratory technicians).
The disease develops after a short, symptomless period of exposure; symptoms are temporally related to work exposures and relieved by absences from work. Removal of the worker from exposure does not necessarily lead to complete cessation of symptoms. For many agents, there is no relationship with a previous history of ATOPY. Occupational asthma accounts for about 10 per cent of all asthma cases. DERMATITIS The risk of dermatitis caused by an allergic or irritant reaction to substances used or handled at work is present in a wide variety of jobs. About three-quarters of cases are irritant contact dermatitis due to such agents as acids, alkalis and solvents. Allergic contact dermatitis is a more speci?c response by susceptible individuals to a range of allergens (see ALLERGEN). The main occupational contact allergens include chromates, nickel, epoxy resins, rubber additives, germicidal agents, dyes, topical anaesthetics and antibiotics as well as certain plants and woods. Latex gloves are a particular cause of occupational dermatitis among health-care and laboratory sta? and have resulted in many workers being forced to leave their profession through ill-health. (See also SKIN, DISEASES OF.)
Musculoskeletal disorders Musculoskeletal injuries are by far the most common conditions related to work (see LFS ?gures, above) and the biggest cause of disability. Although not all work-related, musculoskeletal disorders account for 36.5 per cent of all disabilities among working-age people (compared with less than 4 per cent for sight and hearing impairment). Back pain (all causes – see BACKACHE) has been estimated to cause more than 50 million days lost every year in sickness absence and costs the UK economy up to £5 billion annually as a result of incapacity or disability. Back pain is a particular problem in the health-care sector because of the risk of injury from lifting and moving patients. While the emphasis should be on preventing injuries from occurring, it is now well established that the best way to manage most lower-back injuries is to encourage the patient to continue as normally as possible and to remain at work, or to return as soon as possible even if the patient has some residual back pain. Those who remain o? work on long-term sick leave are far less likely ever to return to work.
Aside from back injuries, there are a whole range of conditions affecting the upper limbs, neck and lower limbs. Some have clear aetiologies and clinical signs, while others are less well de?ned and have multiple causation. Some conditions, such as carpal tunnel syndrome, are prescribed diseases in certain occupations; however, they are not always caused by work (pregnant and older women are more likely to report carpal tunnel syndrome irrespective of work) and clinicians need to be careful when assigning work as the cause without ?rst considering the evidence. Other conditions may be revealed or made worse by work – such as OSTEOARTHRITIS in the hand. Much attention has focused on injuries caused by repeated movement, excessive force, and awkward postures and these include tenosynovitis (in?ammation of a tendon) and epicondylitis. The greatest controversy surrounds upper-limb disorders that do not present obvious tissue or nerve damage but nevertheless give signi?cant pain and discomfort to the individual. These are sometimes referred to as ‘repetitive strain injury’ or ‘di?use RSI’. The diagnosis of such conditions is controversial, making it di?cult for sufferers to pursue claims for compensation through the courts. Psychosocial factors, such as high demands of the job, lack of control and poor social support at work, have been implicated in the development of many upper-limb disorders, and in prevention and management it is important to deal with the psychological as well as the physical risk factors. Occupations known to be at particular risk of work-related upper-limb disorders include poultry processors, packers, electronic assembly workers, data processors, supermarket check-out operators and telephonists. These jobs often contain a number of the relevant exposures of dynamic load, static load, a full or excessive range of movements and awkward postures. (See UPPER LIMB DISORDERS.)
Physical agents A number of physical agents cause occupational ill-health of which the most important is occupational deafness. Workplace noise exposures in excess of 85 decibels for a working day are likely to cause damage to hearing which is initially restricted to the vital frequencies associated with speech – around 3–4 kHz. Protection from such noise is imperative as hearing aids do nothing to ameliorate the neural damage once it has occurred.
Hand-arm vibration syndrome is a disorder of the vascular and/or neural endings in the hands leading to episodic blanching (‘white ?nger’) and numbness which is exacerbated by low temperature. The condition, which is caused by vibrating tools such as chain saws and pneumatic hammers, is akin to RAYNAUD’S DISEASE and can be disabling.
Decompression sickness is caused by a rapid change in ambient pressure and is a disease associated with deep-sea divers, tunnel workers and high-?ying aviators. Apart from the direct effects of pressure change such as ruptured tympanic membrane or sinus pain, the more serious damage is indirectly due to nitrogen bubbles appearing in the blood and blocking small vessels. Central and peripheral nervous-system damage and bone necrosis are the most dangerous sequelae.
Radiation Non-ionising radiation from lasers or microwaves can cause severe localised heating leading to tissue damage of which cataracts (see under EYE, DISORDERS OF) are a particular variety. Ionising radiation from radioactive sources can cause similar acute tissue damage to the eyes as well as cell damage to rapidly dividing cells in the gut and bone marrow. Longer-term effects include genetic damage and various malignant disorders of which LEUKAEMIA and aplastic ANAEMIA are notable. Particular radioactive isotopes may destroy or induce malignant change in target organs, for example, 131I (thyroid), 90Sr (bone). Outdoor workers may also be at risk of sunburn and skin cancers. OTHER OCCUPATIONAL CANCERS Occupation is directly responsible for about 5 per cent of all cancers and contributes to a further 5 per cent. Apart from the cancers caused by asbestos and ionising radiation, a number of other occupational exposures can cause human cancer. The International Agency for Research on Cancer regularly reviews the evidence for carcinogenicity of compounds and industrial processes, and its published list of carcinogens is widely accepted as the current state of knowledge. More than 50 agents and processes are listed as class 1 carcinogens. Important occupational carcinogens include asbestos (mesothelioma, lung cancer); polynuclear aromatic hydrocarbons such as mineral oils, soots, tars (skin and lung cancer); the aromatic amines in dyestu?s (bladder cancer); certain hexavalent chromates, arsenic and nickel re?ning (lung cancer); wood and leather dust (nasal sinus cancer); benzene (leukaemia); and vinyl chloride monomer (angiosarcoma of the liver). It has been estimated that elimination of all known occupational carcinogens, if possible, would lead to an annual saving of 5,000 premature deaths in Britain.
Infections Two broad categories of job carry an occupational risk. These are workers in contact with animals (farmers, veterinary surgeons and slaughtermen) and those in contact with human sources of infection (health-care sta? and sewage workers).
Occupational infections include various zoonoses (pathogens transmissible from animals to humans), such as ANTHRAX, Borrelia burgdorferi (LYME DISEASE), bovine TUBERCULOSIS, BRUCELLOSIS, Chlamydia psittaci, leptospirosis, ORF virus, Q fever, RINGWORM and Streptococcus suis. Human pathogens that may be transmissible at work include tuberculosis, and blood-borne pathogens such as viral hepatitis (B and C) and HIV (see AIDS/HIV). Health-care workers at risk of exposure to infected blood and body ?uids should be immunised against hapatitis B.
Poisoning The incidence of occupational poisonings has diminished with the substitution of noxious chemicals with safer alternatives, and with the advent of improved containment. However, poisonings owing to accidents at work are still reported, sometimes with fatal consequences. Workers involved in the application of pesticides are particularly at risk if safe procedures are not followed or if equipment is faulty. Exposure to organophosphate pesticides, for example, can lead to breathing diffculties, vomiting, diarrhoea and abdominal cramps, and to other neurological effects including confusion and dizziness. Severe poisonings can lead to death. Exposure can be through ingestion, inhalation and dermal (skin) contact.
Stress and mental health Stress is an adverse reaction to excessive pressures or demands and, in occupational-health terms, is di?erent from the motivational impact often associated with challenging work (some refer to this as ‘positive stress’). Stress at work is often linked to increasing demands on workers, although coping can often prevent the development of stress. The causes of occupational stress are multivariate and encompass job characteristics (e.g. long or unsocial working hours, high work demands, imbalance between e?ort and reward, poorly managed organisational change, lack of control over work, poor social support at work, fear of redundancy and bullying), as well as individual factors (such as personality type, personal circumstances, coping strategies, and availability of psychosocial support outside work). Stress may in?uence behaviours such as smoking, alcohol consumption, sleep and diet, which may in turn affect people’s health. Stress may also have direct effects on the immune system (see IMMUNITY) and lead to a decline in health. Stress may also alter the course and response to treatment of conditions such as cardiovascular disease. As well as these general effects of stress, speci?c types of disorder may be observed.
Exposure to extremely traumatic incidents at work – such as dealing with a major accident involving multiple loss of life and serious injury
(e.g. paramedics at the scene of an explosion or rail crash) – may result in a chronic condition known as post-traumatic stress disorder (PTSD). PTSD is an abnormal psychological reaction to a traumatic event and is characterised by extreme psychological discomfort, such as anxiety or panic when reminded of the causative event; sufferers may be plagued with uncontrollable memories and can feel as if they are going through the trauma again. PTSD is a clinically de?ned condition in terms of its symptoms and causes and should not be used to include normal short-term reactions to trauma.... occupational health, medicine and diseases
Central to an understanding of public health is recognition that public-health practitioners are concerned not just with individuals, but also with whole populations – and that improving health care plays only a part of public-health improvement. The health of populations (public health) is also dependent on many factors such as the social, economic and physical environment in which the people live and the nutrition and health care available to them.
For thousands of years, a fundamental feature of civilisations has been to seek to improve the health of the population and protect it from disease. This has led to the development of legal frameworks which di?er widely from country to country, depending on their social and political development. All are concerned to stop the spread of infectious diseases, and to maintain the safety of urban food and water supplies and waste disposal. Most are also associated with housing standards, some form of poverty relief, and basic health care. Some trading standards are often covered, at least in relation to the sale and distribution of poisons and drugs, and to controls on industrial and transport safety – for example, in relation to drinking and driving and car design. Although these varied functions protect the public health and were often originally developed to improve it, most are managerially and professionally separated from today’s public-health departments. So public-health professionals in the NHS, armed with evidence of the cause of a disease problem, must frequently act as advocates for health across many agencies where they play no formal management part. They must also seek to build alliances and add a health perspective to the policies of other services wherever possible.
Epidemiology is the principal diagnostic method of public health. It is de?ned as the study of the distribution and determinants of health-related states in speci?ed populations, and the application of this study to the control of health problems. Public-health practitioners also draw on many other skills, such as those of statisticians, sociologists, anthropologists, economists and policy analysts in identifying and trying to resolve the health problems of the societies they serve. Treatments proposed are likely to extend well beyond the clinic or hospital and may include recommendations for measures to resolve poverty, improve sanitation or housing, control pollution, change lifestyles such as smoking, improve nutrition, or change health services. At times of acute EPIDEMIC, public-health doctors have considerable legal powers granted to enable them to prevent infection from spreading. At other times their work may be more concerned with monitoring, reporting, planning and managing services, and advocating policy changes to politicians so that health is promoted.
The term ‘the public health’ can relate to the state of health of the population, and be represented by measures such as MORTALITY indices
(e.g. perinatal or infant mortality and standardised mortality rates), life expectancy, or measures of MORBIDITY (illness). These can be compared across areas and even countries. Sometimes people refer to a pubic health-care system; this is a publicly funded service, the primary aim of which is to improve health by the use of population-based measures. They may include or be separate from private health-care services for which individuals pay. The structure of these systems varies from country to country, re?ecting di?erent social composition and political priorities. There are, however, some general elements that can be identi?ed:
Surveillance The collection, collation and analysis of data to provide useful information about the distribution and causes of health and disease and related factors in populations. These activities form the basis of epidemiology, which is the diagnostic backbone of public-health practice.
Intervention The design, advocacy and implementation of policies to improve health. This may be through the provison of PREVENTIVE MEDICINE, environmental measures, in?uencing the behaviour of individuals, or the provision of appropriate services to limit disability and handicap. It will lead to advocacy for health, promoting change in many areas of policy including, for example, taxation and improved housing and employment opportunities.
Evaluation Assessment of the ?rst two steps to assess their impact in terms of e?ectiveness, e?ciency, acceptability, accessibility, value for money or other indicators of quality. This enables the programme to be reviewed and changed as necessary.
The practice of public health The situation in the United Kingdom will be described as, even though systems vary, it will give a general impression of the type of work covered. HISTORY Initially, public-health practice related to food, the urban environment and the control of infectious diseases. Early examples include rules in the Bible about avoiding certain foods. These were probably based on practical experience, had gradually been adopted as sensible behaviour, become part of culture and ?nally been incorporated into religious laws. Other examples are the regulations about quarantine for PLAGUE and LEPROSY in the Middle Ages, vaccination against SMALLPOX introduced by William Jenner, and Lind’s use of citrus fruits to prevent SCURVY at sea in the 18th century.
It was during the 19th century, in response to the health problems arising from the rapid growth of urban life, that the foundations of a public-health system were created. The ‘sanitary’ concept was fundamental to these developments. This suggested that overcrowding in insanitary conditions was the cause of most disease epidemics and that improved sanitation measures such as sewerage and clean water supplies would prevent them. Action to introduce such measures were often initiated only after epidemics spread out of the slums and into wealthier and more powerful families. Other problems such as the stench of the River Thames outside the Houses of Parliament also led to a demand for e?ective sanitary control measures. Successive public-health laws were passed by Parliament, initially about sanitation and housing, and then, as scienti?c knowledge grew, about bacterial infections.
In the middle of the 19th century the ?rst medical o?cers of health were appointed with responsibility to report regularly and advise local government about the measures needed to control disease and improve health. Their scope and responsibility widened as society changed and took on a wider welfare role. After more than a century they changed as part of the reforms of the NHS and local government in the 1960s and became more narrowly focused within the health-care system and its management. Increased recognition of the multifactorial causes, costs and limitations of treatment of conditions such as cancer and heart disease, and the emergence of new problems such as AIDS/HIV and BOVINE SPONGIFORM ENCEPHALOPATHY (BSE) have again showed the importance of prevention and a broader approach to health. With it has come recognition that, while disease may be the justi?cation for action, a narrow diseasetreatment-based approach is not always the most e?ective or economic solution. The role of the director of public health (the successor to the medical o?cer of health) is again being expanded, and in 1997 – for the ?rst time in the UK – a government Minister for Public Health was appointed. This reffects not only a greater priority for public health, but also a concern that the health effects of policy should be considered across all parts of government.
(See also ENVIRONMENT AND HEALTH.)... public health
1. Name of the patient.
2. Name and address of the herbal practitioner.
3. Directions for use of the remedy.
4. Liquid preparations for local or topical use to be clearly marked: For external use only.
Statutory Instruments: Medicine (Labelling) Regulations 1976 No. 1726. Medicines (Labelling) Regulations 1977 No. 996. ... labelling of herbal products by a practitioner
There are strict regulations about how death should be diagnosed before organs can be removed for transplantation, and potential donors must satisfy the BRAIN-STEM DEATH criteria, performed twice by two doctors who are independent of the transplant team. There is a great shortage of suitable organs for donation – partly because they must be in excellent condition if the operation is to be a success. Some medical conditions or modes of death make people unsuitable as organ donors; this makes it all the more important that people should be encouraged to donate their organs. People who wish to do so can carry a special card indicating their willingness to become donors in the event of their death. These cards can be obtained from various sources, including hospitals, GPs’ surgeries and many public buildings such as libraries. In the UK, informed positive approval from the patient, or relatives, is required.
Information about becoming a blood donor can be obtained by telephoning 0845–7 711
711. Those who wish to bequeath their bodies for dissection purposes should get in touch with HM Inspector of Anatomy. Other would-be organ donors may contact the British Organ Donor Society.... donors
Prescriptions for drugs should be printed or written clearly in ink and signed and dated by the prescriber (computer-generated facsimile signatures do not meet legal requirements). They should include the patient’s name, address and age (obligatory for children under 12), the name of the drug to be supplied, the dose and dose frequency, and the total quantity to be supplied. Any special instructions (e.g. ‘after food’) should be stated. There are special regulations about the prescription of drugs controlled under the Misuse of Drugs Regulations 1985 (see CONTROLLED DRUGS). A pharmacist can advise about which drugs are available without prescription, and is able to recommend treatment for many minor complaints. Information about exemption from prescription charges in the NHS can be obtained from health visitors, general practitioners, or social security o?ces.... drugs
Misuse of Drugs Act 1971 This legislation forbids activities relating to the manufacture, sale and possession of particular (controlled) drugs. These are classi?ed into three grades according to their dangers if misused. Any o?ences concerning class A drugs, potentially the most damaging when abused, carry the toughest penalties, while classes B and C attract lesser penalties if abused.
Class A includes: cocaine, dextromoramide, diamorphine (heroin), lysergic acid (LSD), methadone, morphine, opium, pethidine, phencyclidine acid and injectable preparations of class B drugs.
Class B includes: oral amphetamines, barbiturates, codeine, glutethimide, marijuana (cannabis), pentazocine and pholcodine.
Class C includes: drugs related to the amphetamines, anabolic and androgenic steroids, many benzodiazepines, buprenorphine, diethyl propion, human chorionic gonadotrophin (HCG), mazindol, meprobamate, pemoline, phenbuterol, and somatropin.
Misuse of Drugs Regulations 1985 These regulations de?ne those people who are authorised in their professional capacity to supply and possess controlled drugs. They also describe the requirements for legally undertaking these activities, such as storage of the drugs and limits on their prescription.
Drugs are divided into ?ve schedules and some examples follow.
I: Almost all are prohibited except in accordance with Home O?ce authority: marijuana (cannabis), LSD.
II: High potential for abuse but have
accepted medical uses: amphetamines, cocaine.
III: Lower potential for abuse: barbiturates, meprobamate, temazepam.
IV: Lower potential for abuse than I to III. Minimal control: benzodiazepines.
V: Low potential for abuse: generally compound preparations containing small amounts of opioids: kaolin and morphine (antidiarrhoeal medicine), codeine linctus (cough suppressant).
(See also CONTROLLED DRUGS.)... misuse of drugs
Health has driven much of environmental policy since the work of Edwin Chadwick in the early 1840s. The ?rst British public-health act was introduced in 1848 to improve housing and sanitation with subsequent provision of puri?ed water, clean milk, food hygiene regulations, vaccinations and antibiotics. In the 21st century there are now many additional environmental factors that must be monitored, researched and controlled if risks to human health are to be well managed and the impact on human morbidity and mortality reduced.
Environmental impacts on health include:
noise
air pollution
water pollution
dust •odours
contaminated ground
loss of amenities
vermin
vibration
animal diseases
Environmental risk factors Many of the major determinants of health, disease and death are environmental risk factors. Some are natural hazards; others are generated by human activities. They may be directly harmful, as in the examples of exposure to toxic chemicals at work, pesticides, or air pollution from road transport, or to radon gas penetrating domestic properties. Environmental factors may also alter people’s susceptibility to disease: for example, the availability of su?cient food. In addition, they may operate by making unhealthy choices more likely, such as the availability and a?ord-ability of junk foods, alcohol, illegal drugs or tobacco.
Populations at risk Children are among the populations most sensitive to environmental health hazards. Their routine exposure to toxic chemicals in homes and communities can put their health at risk. Central to the ability to protect communities and families is the right of people to know about toxic substances. For many, the only source of environmental information is media reporting, which often leaves the public confused and frustrated. To bene?t from public access to information, increasingly via the Internet, people need basic environmental and health information, resources for interpreting, understanding and evaluating health risks, and familiarity with strategies for prevention or reduction of risk.
Risk assessment Environmental health experts rely on the principles of environmental toxicology and risk assessment to evaluate the environment and the potential effects on individual and community health. Key actions include:
identifying sources and routes of environmental exposure and recommending methods of reducing environmental health risks, such as exposure to heavy metals, solvents, pesticides, dioxins, etc.
assessing the risks of exposure-related health hazards.
alerting health professionals, the public, and the media to the levels of risk for particular potential hazards and the reasons for interventions.
ensuring that doctors and scientists explain the results of environmental monitoring studies – for example, the results of water ?uoridation in the UK to improve dental health.
National policies In the United Kingdom in 1996, an important step in linking environment and health was taken by a government-initiated joint consultation by the Departments of Health and Environment about adding ‘environment’ as a key area within the Health of the Nation strategy. The ?rst UK Minister of State for Public Health was appointed in 1997 with responsibilities for health promotion and public-health issues, both generally and within the NHS. These responsibilities include the implementation of the Health of the Nation strategy and its successor, Our Healthy Nation. The aim is to raise the priority given to human health throughout government departments, and to make health and environmental impact assessment a routine part of the making, implementing and assessing the impact of policies.
Global environmental risks The scope of many environmental threats to human health are international and cannot be regulated e?ectively on a local, regional or even national basis. One example is the Chernobyl nuclear reactor accident, which led to a major release of radiation, the effects of which were felt in many countries. Some international action has already been taken to tackle global environmental problems, but governments should routinely measure the overall impacts of development on people and their environments and link with industry to reduce damage to the environment. For instance, the effects of global warming and pollution on health should be assessed within an ecological framework if communities are to respond e?ectively to potential new global threats to the environment.... environment and health
COSHH (control of substances hazardous to health) (in occupational health) legislation and resulting regulations concerning the duties and responsibilities of employers and employees to ensure that hazardous substances used in a workplace (e.g. toxic chemicals in factories, anaesthetic gases in operating theatres) do not affect adversely the workforce or others.... coryza
MHRA section of the website... medicines and healthcare products regulatory agency
In the United Kingdom, the 1993 Education Act refers to ‘learning diffculties’: generalised (severe or moderate), or speci?c (e.g. DYSLEXIA, dyspraxia [or APRAXIA], language disorder). The 1991 Social Security (Disability Living Allowance) Regulations use the term ‘severely mentally impaired’ if a person suffers from a state of arrested development or incomplete physical development of the brain which results in severe impairment of intelligence and social functioning. This is distinct from the consequences of DEMENTIA. Though ‘mental handicap’ is widely used, ‘learning disability’ is preferred by the Department of Health.
There is a distinction between impairment (a biological de?cit), disability (the functional consequence) and handicap (the social consequence).
People with profound learning disability are usually unable to communicate adequately and may be seriously movement-impaired. They are totally dependent on others for care and mobility. Those with moderate disability may achieve basic functional literacy (recognition of name, common signs) and numeracy (some understanding of money) but most have a life-long dependency for aspects of self-care (some fastenings for clothes, preparation of meals, menstrual hygiene, shaving) and need supervision for outdoor mobility.
Children with moderate learning disability develop at between half and three-quarters of the normal rate, and reach the standard of an average child of 8–11 years. They become independent for self-care and public transport unless they have associated disabilities. Most are capable of supervised or sheltered employment. Living independently and raising a family may be possible.
Occurrence Profound learning disability affects about 1 in 1,000; severe learning disability 3 in 1,000; and moderate learning disability requiring special service, 1 per cent. With improved health care, survival of people with profound or severe learning disability is increasing.
Causation Many children with profound or severe learning disability have a diagnosable biological brain disorder. Forty per cent have a chromosome disorder – see CHROMOSOMES (three quarters of whom have DOWN’S (DOWN) SYNDROME); a further 15 per cent have other genetic causes, brain malformations or recognisable syndromes. About 10 per cent suffered brain damage during pregnancy (e.g. from CYTOMEGALOVIRUS (CMV) infection) or from lack of oxygen during labour or delivery. A similar proportion suffer postnatal brain damage from head injury – accidental or otherwise – near-miss cot death or drowning, cardiac arrest, brain infection (ENCEPHALITIS or MENINGITIS), or in association with severe seizure disorders.
Explanations for moderate learning disability include Fragile X or other chromosome abnormalities in a tenth, neuro?bromatosis (see VON RECKLINGHAUSEN’S DISEASE), fetal alcohol syndrome and other causes of intra-uterine growth retardation. Genetic counselling should be considered for children with learning disability. Prenatal diagnosis is sometimes possible. In many children, especially those with mild or moderate disability, no known cause may be found.
Medical complications EPILEPSY affects 1 in 20 with moderate, 1 in 3 with severe and 2 in 3 with profound learning disability, although only 1 in 50 with Down’s syndrome is affected. One in 5 with severe or profound learning disability has CEREBRAL PALSY.
Psychological and psychiatric needs Over half of those with profound or severe – and many with moderate – learning disability show psychiatric or behavioural problems, especially in early years or adolescence. Symptoms may be atypical and hard to assess. Psychiatric disorders include autistic behaviour (see AUTISM) and SCHIZOPHRENIA. Emotional problems include anxiety, dependence and depression. Behavioural problems include tantrums, hyperactivity, self-injury, passivity, masturbation in public, and resistance to being shaved or helped with menstrual hygiene. There is greater vulnerability to abuse with its behavioural consequences.
Respite and care needs Respite care is arranged with link families for children or sta?ed family homes for adults where possible. Responsibility for care lies with social services departments which can advise also about bene?ts.
Education Special educational needs should be met in the least restrictive environment available to allow access to the national curriculum with appropriate modi?cation and support. For older children with learning disability, and for young children with severe or profound learning disability, this may be in a special day or boarding school. Other children can be provided for in mainstream schools with extra classroom support. The 1993 Education Act lays down stages of assessment and support up to a written statement of special educational needs with annual reviews.
Pupils with learning disability are entitled to remain at school until the age of 19, and most with severe or profound learning disability do so. Usually those with moderate learning disability move to further education after the age of 16.
Advice is available from the Mental Health Foundation, the British Institute of Learning Disabilities, MENCAP (Royal Society for Mentally Handicapped Children and Adults), and ENABLE (Scottish Society for the Mentally Handicapped).... learning disability
There are three main categories of licensed medicinal product. Drugs in small quantities can, if they are perceived to be safe, be licensed for general sale (GSL – general sales list), and may then be sold in any retail shop. P (pharmacy-only) medicines can be sold from a registered pharmacy by or under the supervision of a pharmacist (see PHARMACISTS); no prescription is needed. P and GSL medicines are together known as OTCs – that is, ‘over-thecounter medicines’. POM (prescription-only medicines) can only be obtained from a registered pharmacy on the prescription of a doctor or dentist. As more information is gathered on the safety of drugs, and more emphasis put on individual responsibility for health, there is a trend towards allowing drugs that were once POM to be more widely available as P medicines. Examples include HYDROCORTISONE 1 per cent cream for skin rashes, CIMETIDINE for indigestion, and ACICLOVIR for cold sores. Care is needed to avoid taking a P medicine that might alter the actions of another medicine taken with it, or that might be unsuitable for other reasons. Patients should read the patient-information lea?et, and seek the pharmacist’s advice if they have any doubt about the information. They should tell their pharmacist or doctor if the medicine results in any unexpected effects.
Potentially dangerous drugs are preparations referred to under the Misuse of Drugs Act 1971 and subsequent regulations approved in 1985. Described as CONTROLLED DRUGS, these include such preparations as COCAINE, MORPHINE, DIAMORPHINE, LSD (see LYSERGIC ACID
DIETHYLAMIDE (LSD)), PETHIDINE HYDROCHLORIDE, AMPHETAMINES, BARBITURATES and most BENZODIAZEPINES.
Naming of drugs A European Community Directive (92/27/EEC) requires the use of the Recommended International Non-proprietary Name (rINN) for medicinal substances. For most of these the British Approved Name (BAN) and rINN were identical; where the two were di?erent, the BAN has been modi?ed in line with the rINN. Doctors and other authorised subscribers are advised to write titles of drugs and preparations in full because uno?cial abbreviations may be misinterpreted. Where a drug or preparation has a non-proprietary (generic) title, this should be used in prescribing unless there is a genuine problem over the bioavailability properties of a proprietary drug and its generic equivalent.
Where proprietary – commercially registered
– names exist, they may in general be used only for products supplied by the trademark owners. Countries outside the European Union have their own regulations for the naming of medicines.
Methods of administration The ways in which drugs are given are increasingly ingenious. Most are still given by mouth; some oral preparations (‘slow release’ or ‘controlled release’ preparations) are designed to release their contents slowly into the gut, to maintain the action of the drug.
Buccal preparations are allowed to dissolve in the mouth, and sublingual ones are dissolved under the tongue. The other end of the gastrointestinal tract can also absorb drugs: suppositories inserted in the rectum can be used for their local actions – for example, as laxatives – or to allow absorption when taking the drug by mouth is di?cult or impossible – for example, during a convulsion, or when vomiting.
Small amounts of drug can be absorbed through the intact skin, and for very potent drugs like OESTROGENS (female sex hormones) or the anti-anginal drug GLYCERYL TRINITRATE, a drug-releasing ‘patch’ can be used. Drugs can be inhaled into the lungs as a ?ne powder to treat or prevent ASTHMA attacks. They can also be dispersed (‘nebulised’) as a ?ne mist which can be administered with compressed air or oxygen. Spraying a drug into the nostril, so that it can be absorbed through the lining of the nose into the bloodstream, can avoid destruction of the drug in the stomach. This route is used for a small number of drugs like antidiuretic hormone (see VASOPRESSIN).
Injection remains an important route of administering drugs both locally (for example, into joints or into the eyeball), and into the bloodstream. For this latter purpose, drugs can be given under the skin – that is, subcutaneously (s.c. – also called hypodermic injection); into muscle – intramuscularly (i.m.); or into a vein – intravenously (i.v.). Oily or crystalline preparations of drugs injected subcutaneously form a ‘depot’ from which they are absorbed only slowly into the blood. The action of drugs such as TESTOSTERONE and INSULIN can be prolonged by using such preparations, which also allow contraceptive ‘implants’ that work for some months (see CONTRACEPTION).... medicines
The importation into Britain of opium is strictly regulated under the Dangerous Drugs Acts. Similar regulations govern the sale and distribution of any preparation of morphine or diamorphine (heroin) stronger than 1 part in
500. (See DEPENDENCE.)
Action The action of opium varies considerably, according to the source of the drug and the preparation used.
In small doses, opium produces a state of gentle excitement, the person ?nding their imagination more vivid, their thoughts more brilliant, and their power of expression greater than usual. This stage lasts for some hours, and is succeeded by languor. In medicinal doses this stage of excitement is short and is followed by deep sleep. When potentially poisonous doses are taken, sleep comes on quickly, and passes into coma and death (see OPIOID POISONING). The habitual use of opium produces great TOLERANCE, so that opium users require to take large quantities daily before experiencing its pleasurable effects. The need for opium also confers tolerance, so that people suffering great pain may take, with apparently little e?ect beyond dulling the pain, quantities which at another time would be dangerous.... opium
Originally quarantine, as its name implies, involved detention for 40 days; but the period now covers the incubation period of the disease, the presence of which is suspected.
Numerous international conferences upon the subject have been held with the view of arriving at a uniform practice as regards quarantine in di?erent countries. The diseases to which quarantine applies are CHOLERA, YELLOW FEVER, PLAGUE, SMALLPOX, TYPHUS FEVER and RELAPSING FEVER.
The general practice with regard to quarantine is that when a serious disease breaks out in any country, the government of that country noti?es surrounding governments as to the ports and other places that have become centres of infection. Any people travelling from these centres and attempting to enter another country, are subject to measures prescribed in the appropriate regulations. These measures vary with the disease involved.... quarantine
In addition to the above, a Code of Practice for advertising herbal remedies has been agreed by the British Herbal Medicine Association in consultation with the Department of Health and the Scientific
Committee of the BHMA. It represents an act of self-discipline within the trade and profession, acceptance and observance of which is a condition of membership of the British Herbal Medicine Association. vIt is the responsibility of all placing and accepting advertisements to ensure that wording complies with statutory requirements. For any ailment or disease no claim for cure may be made.
The following extracts are few of a wide range of conditions appearing in the BHMA Code.
“The expression ‘treatment’ is not permitted except in respect of a ‘course of treatment’ by herbal medicines within the meaning of the Act.
“Advertising shall in no way induce unjustified concern that the reader is suffering from any illness, ailment or disease or that, without treatment, he may suffer more severely.
“Advertising shall not discourage the reader from seeking advice from a qualified practitioner.
“Advertising shall not invite the reader to diagnose specific medical conditions except those readily recognised by the layman and which are obvious to the sufferer. Advertising shall not use words such as: ‘magic’, ‘Miracle’, ‘Mystical’, ‘wonder remedy’, ‘nature’s remedy’, ‘break-through’ or similar terms.”
“Advertising shall not indicate medical or surgical consultation is unnecessary, or guarantee the effects of a medicine. It shall not indicate an absence of side-effects, or suggest that a product is better than or equivalent to another treatment. It shall not suggest health can be enhanced, or that health may be impaired by not taking the product. It should not be directed principally at children, or refer to recommendations by a health professional, a celebrity, etc. It shall not suggest a product is a food or cosmetic, or has a special benefit because it is ‘natural’. One cannot refer to a ‘licensed medicine’ or approved by the Dept of Health or use similar statements.” ... advertising
The concept of the dose-response is important for understanding the risk of exposure to a particular substance. This is embodied in a statement by Paracelsus (c.1493–1541): ‘All substances are poisons; there is none which is not a poison. The right dose di?erentiates a poison and a remedy.’
Poisoning may occur in a variety of ways: deliberate – SUICIDE, substance abuse or murder; accidental – including accidental overdose of medicines; occupational; and environmental
– including exposure during ?re.
Ingestion is the most common route of exposure, but poisoning may also occur through inhalation, absorption through the skin, by injection and through bites and stings of venomous animals. Poisoning may be described as acute, where a single exposure produces clinical effects with a relatively rapid onset; or chronic, where prolonged or repeated exposures may produce clinical effects which may be insidious in onset, cumulative and in some cases permanent.
Diagnosis of poisoning is usually by circumstantial evidence or elimination of other causes of the clinical condition of the patient. Some substances (e.g. opioids) produce a characteristic clinical picture in overdose that can help with diagnosis. In some patients laboratory analysis of body ?uids or the substance taken may be useful to determine or con?rm the o?ending agent. Routine assays are not necessary. For a very small number of poisons, such as paracetamol, aspirin, iron and lead, the management of the patient may depend on measuring the amount of poison in the bloodstream.
Accurate statistics on the incidence of poisoning in the UK are lacking. Mortality ?gures are more reliable than morbidity statistics; annually, well over 100,000 cases of poisoning are admitted to hospital. The annual number of deaths from poisoning is relatively small – about 300 – and in most cases patients die before reaching hospital. Currently, CARBON MONOXIDE (CO) is by far the most common cause of death due to poisoning. The most common agents involved in intentional or accidental poisoning are drugs, particularly ANALGESICS, ANTIDEPRESSANT DRUGS and SEDATIVES. Alcohol is also commonly taken by adults, usually in combination with drugs. Children frequently swallow household cleaners, white spirit, plant material – such as belladonna (deadly nightshade) and certain mushrooms; for example, death cap and ?y agaric – aftershave and perfume as well as drugs. If possible, the suspect container, drug or plant should be taken with the victim to the hospital or doctor. The use of child-resistant containers has reduced the number of admissions of children to hospital for treatment. Bixtrex® is an intensely bitter-tasting agent which is often added to products to discourage ingestion; however, not everybody is able to taste it, nor has any bene?cial e?ect been proven.
Treatment of poisoning usually begins with decontamination procedures. For ingested substances this may involve making the patient sick or washing the stomach out (GASTRIC LAVAGE): this is usually only worthwhile if performed soon after ingestion. It should be emphasised that salt (sodium chloride) water must never be given to induce vomiting, since this procedure is dangerous and has caused death. For substances spilt on the skin, the affected area should immediately be thoroughly washed and all contaminated clothing removed. Following eye exposure, the affected eye/s should be thoroughly irrigated with saline or water.
Treatment thereafter is generally symptomatic and supportive, with maintenance of the victim’s respiratory, neurological and cardiovascular systems and, where appropriate, monitoring of their ?uid and electrolyte balance and hepatic and renal function. There are speci?c antidotes for a few substances: the most important of these are PARACETAMOL, iron, cyanide (see CYANIDE POISONING), opioids (see OPIOID), DIGOXIN, insecticides and some heavy metals. Heavy-metal poisoning is treated with CHELATING AGENTS – chemical compounds that form complexes by binding metal ions: desferrioxamine and pencillinamine are two such agents. The number of people presenting with paracetamol overdose – a common drug used for attempted suicide – has fallen sharply since restrictions were placed on its over-thecounter sales.
When a patient presents with an illness thought to be caused by exposure to substances at work, further exposure should be limited or prevented and investigations undertaken to determine the source and extent of the problem. Acutely poisoned workers will usually go to hospital, but those suffering from chronic exposure may attend their GP with non-speci?c symptoms (see OCCUPATIONAL HEALTH, MEDICINE AND DISEASES).
In recent years, legislation has been enacted in the UK to improve safety in the workplace and to ensure that data on the hazardous constituents and effects of chemicals are more readily available. These o?cial controls include the Control of Substances Hazardous to Health (COSHH) and the Chemicals (Hazard Information and Packaging) Regulations (CHIP) and are UK legislation in response to European Union directives.
The National Poisons Information Service is a 24-hour emergency telephone service available to the medical profession and provides information on the likely effects of numerous agents and advice on the management of the poisoned patient. The telephone numbers are available in the medical literature. In the UK this is not a public-access service. People who believe they, or their relatives, have been poisoned should seek medical advice from their GPs or attend their local hospital.
Toxbase The National Poisons Information Service provides a primary clinical toxicology database on the Internet: www.spib.axl.co.uk. This website provides information about routine diagnosis, treatment and management of people exposed to drugs, household products and industrial and agricultural products.
(See also APPENDIX 1: BASIC FIRST AID.)... poisons
In Britain, for instance, preventive medicine is usually taken to encompass a range of activities whose purpose is:
to reduce the chance of a person contracting a disease or becoming disabled.
to identify either an increased susceptibility to develop a disease, or an early manifestation of a disease at a stage which will still allow treatment to be e?ective. The American College of Preventive Medi
cine (1983) de?ned it as ‘a specialised ?eld of medical practice composed of distinct disciplines which utilise skills focusing on the health of de?ned populations in order to promote and maintain health and well-being and to prevent disease, disability and premature death’.
However de?ned, the spectrum of activities encompassed by preventive medicine is wide and includes actions, such as counselling about lifestyle, where there may not be a clear cut-o? between a preventive and a curative act. For example, advice about smoking and exercise to a recent victim of a myocardial infarction (see under HEART, DISEASES OF) is both essential to treatment and preventive against a future attack. Action aimed at a whole population – such as the addition of ?uoride to drinking-water to protect against dental caries (see under TEETH, DISORDERS OF) – is part of a population-based public-health strategy but would also be widely regarded as preventive medicine.
A common and widely accepted classi?cation of preventive medicine is as follows:
Primary prevention which aims at the complete avoidance of a disease (for example, by immunising a child against an infectious disease – see IMMUNISATION).
Secondary prevention which aims at detecting and curing a disease at an early stage before it has caused any symptoms. This requires ‘screening’ procedures to detect either the early pre-symptomatic condition, or a risk factor which may lead to it. (An example of the former is cervical cytology, where a sample of cells is scraped from the cervix of the UTERUS and examined microscopically for abnormality.
An example of the latter is CHOLESTEROL measurement as part of assessing an individual’s risk of developing ischaemic heart disease (see under HEART, DISEASES OF). If it is signi?cantly raised, dietary or drug treatment can be advised.)
Tertiary prevention aims at minimising the consequences for a patient who already has the disease (e.g. advising people to take more exercise and stop smoking after a heart attack).
Many prefer to limit the term ‘preventive medicine’ to primary and secondary prevention, emphasising the focus on risk-reducing interventions targeted at ‘well’ individuals. Others prefer the wider emphasis because of the importance of a preventive approach in reducing further disability by recognising and treating symptoms early. This can be particularly important in older people, where, for example, vigorous treatment of an orthopaedic problem can enable the patient to maintain physical mobility with all the bene?ts to health that brings. Whether primary, secondary or tertiary prevention, some form of screening question or test is normally necessary to identify a problem.
The range and extent of opportunities for prevention are expanding as research identi?es the causes of diseases and more e?ective treatment becomes feasible. Inevitably there is economic and political debate about the cost-e?ectiveness of prevention versus cure, as well as about the ETHICS. The situation varies in relation to the natural history of the speci?c disease. Some conditions can easily be prevented but once contracted cannot be cured
(e.g. RABIES); others are easily cured but are not yet preventable.
Screening Screening involves carrying out tests either to identify a treatable disease at a very early stage, before it has caused symptoms or damage; or to identify a risk factor which can lead to a disease. The tests might be by simple questioning (e.g. ‘Do you smoke cigarettes?’ – this predicts a considerable increase in the risk of chronic bronchitis, heart disease, bronchial cancer and many other diseases, and enables targeted advice and help to stop smoking to be given). Other screening tests involve carrying out complex special investigations such as blood tests or the microscopic investigations of cells – for example, for precancerous changes.
Many conditions can be identi?ed at an early stage before they cause symptoms or signs of disease and in time for e?ective treatment to be carried out. Inevitably, some of the screening tests proposed can be expensive (particularly if used in large populations), painful or inaccurate and may not improve the results of treatment. Screening can also provoke considerable anxiety in those waiting for tests or results. Therefore, over the years considerable research has been carried out into the appropriateness and ethics of screening, and the World Health Organisation in 1968 identi?ed a set of rules for evaluating screening tests:
The condition sought should be an important health problem, for which there should be an accepted treatment for patients with recognised disease.
Facilities for diagnosis and treatment should be available if a case is found.
The screening test or examination must be suitable and valid. A false positive test will cause massive anxiety and also considerable expense in proving that there is no disease. Similarly, false negatives can lead people to be reassured and to ignore serious symptoms until too late. If large numbers of positive tests or false positives occur during a screening programme, health services can be swamped.
The test, and any treatment as a possible result, should be acceptable. For example, there is little point in screening for a fetal abnormality which, if found, would lead to a recommendation for termination if the mother will refuse it on religious or moral grounds.
Screening tests also need to be considered from an economic perspective and the cost of case-?nding (including diagnosis and treatment of patients diagnosed) balanced in relation to possible expenditure on medical care as a whole.
Finally the programme should re?ect the natural history of the disease, and case-?nding should normally be a continuing process and not a ‘once for all’ project. If these rules are followed, considerable
bene?ts can result from well-planned and well-managed screening programmes, and they form an important part of any health-care system. The extent to which manipulation of genetic material will be added to more traditional approaches such as counselling, immunisation and drug treatment cannot yet be predicted but, as time goes by, it is often likely to be ethical and social controls which limit developments rather than technical and scienti?c limits.... preventive medicine
The smoking of tobacco is the most serious public-health hazard in Britain today. It causes 100,000 premature deaths a year in the United Kingdom alone. In addition to the deaths caused by cigarette smoking, it is also a major cause of disability and illness in the form of myocardial infarction (see HEART, DISEASES OF), PERIPHERAL VASCULAR DISEASE, and EMPHYSEMA. Tobacco-smoking is also a serious hazard to the FETUS if the mother smokes. Furthermore, passive smoking – inhalation of other people’s tobacco smoke – has been shown to be a health hazard to non-smokers.
Composition In addition to vegetable ?bre, tobacco leaves contain a large quantity of ash, the nature of this depending predominantly upon the minerals present in the ground where the tobacco plant has been grown. Of the organic constituents, the brown ?uid alkaloid known as NICOTINE is the most important. The nicotine content of di?erent tobacco varies, and the amount absorbed depends upon whether or not the smoker inhales. Nicotine is the substance that causes a person to become addicted to tobacco smoking (see DEPENDENCE).
Tobacco smoke also contains some 16 substances capable of inducing cancer in experimental animals. One of the most important of these is benzpyrene, a strongly carcinogenic hydrocarbon. As this is present in coal tar pitch, it is commonly referred to in this context as tar. Other constituents of tobacco smoke include pyridine, ammonia and carbon monoxide.
Nicotine addiction is a life-threatening but treatable disorder, and nicotine-replacement treatment is available on NHS prescription. This includes the provision of bupropion – trade name Zyban®. The availability of this drug – which should be used with caution as it has unwelcome side-effects in some people – and the introduction of specialist smoking-cessation services to provide behavioural support to people who wish to stop smoking should result in a reduction in tobacco-related diseases. Given the critical position of nicotine in leading people to become addicted to smoking, it is anomalous that there are no e?ective government regulations covering the sales of tobacco. Because it is not a food, tobacco is not regulated by the Food Standards Agency; it is not classi?ed as a drug so is not controlled by legislation on medicines. Furthermore, despite being a consumer product, tobacco is exempt from the Consumer Protection Act (1987) and other government safety regulations. So the NHS is left to try to ameliorate the serious health consequences – lung cancer, cardiovascular disease, peripheral vascular disease, chronic bronchitis, and emphysema – of a substance for which there are no e?ective preventive measures except the willpower of the individual smoker or non-smoker. (Escalating taxation of tobacco seems to have been circumvented as a deterrent by the rising incidence of smuggling cigarettes into Britain.)
Action on Smoking and Health (ASH) is a small charity founded by the Royal College of Physicians in 1971 that attempts to alert and inform the public to the dangers of smoking and to try to prevent the disability and death which it causes.... tobacco
Misleading claims and the use of such words as “organic”, “wholesome”, “natural” or “biological” cannot be accepted on product labels. The Licensing Authority treats herbal manufacturers no differently than manufacturers of allopathic products for serious conditions.
The Advertising Standards Authority does not allow quotation of any medicinal claims, except where a Product Licence (PL) has been authorised by the Licensing Authority.
All labels must include: Name of product (as on Product Licence), description of pharmaceutical form (tablet, mixture etc), Product Licence No., Batch No., quantity of each active ingredient in each unit dose in metric terms; dose and directions for use; quantity in container (in metric terms); “Keep out of reach of children” or similar warning; Name and address of Product Licence Holder; expiry date (if applicable); and any other special warnings. Also to appear: excipients, method/route of administration, special storage instructions, and precautions for disposal, if any.
Where licences are granted, the following words should appear on the label of a product: “A herbal product traditionally used for the symptomatic relief of . . .”. “If symptoms persist see your doctor.” “Not to be used in pregnancy” (where applicable). “If you think you have . . . consult a registered medical practitioner before taking this product.” “If you are already receiving medical treatment, tell your doctor that you are taking this product.” These warnings are especially necessary should symptoms persist and be the start of something more serious than a self-limiting condition.
Herbal preparations should be labelled with the additives and colourings they contain, if any. This helps practitioners avoid prescribing medicines containing them to certain patients on whom they may have an adverse reaction.
Labels of medicinal products shall comply with the Medicines (Labelling) Regulations 1976 (SI 1976 No. 1726) as amended by the Medicines (Labelling) Amendment Regulations 1977 (SI 1977 No. 996), the Medicines (Labelling) Amendment Regulations 1981 (SI 1981 No. 1791) and the Medicines (Labelling) Amendment Regulations 1985 (SI 1985 No. 1558).
Leaflets issued with proprietory medicinal products shall comply with the requirements of the Medicines (Leaflets) Regulations 1977 (SI 1977 No. 1055).
See also: ADVERTISING: CODE OF PRACTICE. BRITISH HERBAL MEDICINE ASSOCIATION. ... labelling of herbal products
Medicines fall into three categories: POM (Prescription Only Medicines), P (Pharmacy Only), and OTC (Over The Counter). POM and P medicines must be prescribed by a registered medical practitioner and dispensed by a pharmacist. P medicines can be sold only by a registered pharmacist. Health stores are concerned with the OTC products, the sale of which is governed by S.I. Medicines General Sales List, Order 1980, No 1922.
All medicines and substances used as medicine bearing a medicinal claim on label or advertising material must be licenced. Without a licence it is not lawful for any person, in his business, to manufacture, sell, supply, export, or import into the United Kingdom any medicinal products unless some exemption is provided in the Act or subsequent regulations. The prefix ML, followed by the Manufacturer’s number must appear on the label together with the product licence number prefixed by the capitals PL. For example, if any person other than a pharmacist sells a medicinal product which claims to relieve indigestion or headache, but the label of which bears no licence number, that shopkeeper (and the manufacturer) will be breaking the law.
All foods are exempt from licencing provided no claims are made of medicinal benefits.
A special licence (manufacturer’s) is required by any person who manufactures or assembles a medicinal product. (Section 8) He must hold a Product Licence for every product he manufactures unless some special exemption is provided by the Act. He may of course act to the order of the product licence holder. (Section 23)
“Manufacture” means any process carried on in the course of making a product but does not include dissolving or dispersing the product in, or diluting or mixing it with some other substance used as a vehicle for the purpose of administering it. It includes the mixture of two or more medicinal products.
“Assembly” means enclosing a medicinal product in a container which is labelled before the product is sold or supplied, or, where the product is already enclosed in a container in which it is supplied, labelling the container before the product is sold or supplied in it. (Section 132)
From the practitioner’s point of view, herbal medicines are exempt from the Act and no licence is required.
The consulting herbalist in private practice who compounds his own preparations from medicinal substances may apply to the Medicines Control Agency, 1 Nine Elms Lane, London SW8 5NQ for a manufacturer’s licence to authorise mixture and assembly, for administration to their patients after he has been requested in their presence to use his own judgement as to treatment required. Products thus sold, will be without any written recommendation and not advertised in any way.
The “assembly” aspect of his licence refers to his ability to buy in bulk, repackage and label. Where he uses prepackaged products and does not open the packet, or relabel, a licence is not required. He will not be able to use terms, “Stomach mixture”, “Nerve mixture”, etc, implying cure of a specific condition.
It is necessary for the practitioner to have a personal consultation with his patient before making his prescription. Subsequent treatment may be supplied by a third person or by post at the discretion of the practitioner.
A licence is required where one or more non-herbal ingredients (such as potassium iodide, sodium citrate, etc) are included. Dispensing non-herbal remedies constitutes “manufacture” for which a licence is required. (MAL 24 (3))
The main thing the licensing authority looks for before granting a licence is evidence of safety. The manufacturers’ premises must be licenced. A wholesaler or distributor, also, must have a licence.
Where a product is covered by a Product Licence certain medicinal claims may be made. Where claims are made, the Act requires a warning to appear on the label worded: “If you think you have the disease to which this product refers, consult a registered medical practitioner before taking this product. If you are already receiving medical treatment, tell your doctor you are also taking this product.” (SI 41, s.5)
Labels of all medicines, tablets, etc, must carry the words: “Keep out of the reach of children”.
Under the Act it is illegal for medicines to be offered for sale for cancer, diabetes, epilepsy, glaucoma, kidney disease, locomotor ataxy, paralysis, sexually transmitted diseases and tuberculosis; these diseases to be treated by a registered medical practitioner only.
Definition of a herbal remedy. A “herbal remedy” is a medicinal product consisting of a substance produced by subjecting a plant or plants to drying, crushing or any other process, or of a mixture whose sole ingredients are two or more substances so produced, or of a mixture whose sole ingredients are one or more substances so produced and water or some other inert substances. (Section 132)
No licence is required for the sale, supply, manufacture or assembly of any such herbal remedy in the course of a business in which the person carrying on the business sells or supplies the remedy for administration to a particular person after being requested by or on behalf of that person, and in that person’s presence, to use his own judgement as to the treatment required. The person carrying on the business must be the occupier of the premises where the manufacture or assembly takes place and must be able to close them so as to exclude the public. (Section 12 (1))
No licence is required for the sale, supply, manufacture or assembly of those herbal remedies where the process to which the plant or plants are subjected consists only of drying, crushing or comminuting and the remedy is sold or supplied under a designation which only specifies the plant or plants and the process and does not apply any other name to the remedy; and without any written recommendation (whether by means of a labelled container or package or a leaflet or in any other way) as to the use of the remedy. (Section 12 (2)) This exemption does not apply to imported products. Except where a herbal product is supplied for a medicinal use, legally it is not even a medicinal product.
The 1968 Act has been a great step forward in the history of herbal medicine, The British Herbal Medicine Association and the National Institute of Medical Herbalists fought and won many special concessions. In years following the Act standards rose sharply. Practitioners enjoy a measure of recognition, with power to manufacture and dispense their own medicines and issue official certificates for incapacitation for work.
See: BRITISH HERBAL MEDICINE ASSOCIATION. NATIONAL INSTITUTE OF MEDICAL HERBALISTS. ... medicine’s act, 1968.
rabies An acute viral infection of the nervous system, once known as hydrophobia, that primarily affects dogs but can be transmitted to humans by a bite or a lick over broken skin. The virus travels to the brain; once symptoms develop, rabies is usually fatal.
The average incubation period is 1–3 months, depending on the site of the bite. The symptoms are slight fever and headache, leading to restlessness, hyperactivity, and, in some cases, strange behaviour, hallucinations, and paralysis. The victim develops convulsions, arrhythmias, and paralysis of the respiratory muscles and is often intensely thirsty, but drinking induces painful spasms of the throat. Death follows 10–14 days after the onset of symptoms.
Following an animal bite, immunization with human rabies immunoglobulin and a course of rabies vaccine is necessary; this may prevent rabies if given within 2 days. If symptoms appear, they are treated with sedative drugs and analgesic drugs. The main emphasis is on preventing the disease through quarantine regulations and human and animal immunization. (See also bites, animal.)... quinsy
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• List of notifiable diseases in England and guidance on how to report them... notifiable disease
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