Br Med J (Clin Res Ed): first published as 10.1136/bmj.290.6468.579 on 23 February 1985. Downloaded from LONDON, SATURDAY 23 FEBRUARY 1985 MEDICAL JOURNAL Threat to the PHLS In its drive for economy the government has included among Furthermore, the creation of the Communicable Disease its targets the Public Health Laboratory Service of England Surveillance Centre by the PHLS on behalfofthe DHSS and and Wales. The proposal under consideration is the transfer the Welsh Office has required additional epidemiological of some (or possibly all) the Service's 52 regional and area resources for the national surveillance and control of laboratories to the control of health authorities. The argu- communicable disease, functions previously performed by ment seems to be that in the existing joint PHLS-hospital the departments. The laboratory reporting system has been laboratories most of the specimens examined are for the expanded with contributions from hospital laboratories, diagnosis of infection in individual patients, so that it would individual consultants, and the Royal College of General be logical to transfer these laboratories to the control of the Practitioners helping to provide a fuller epidemiological National Health Service. picture. Many more field investigations of outbreaks have The joint PHLS-hospital laboratories became the pattern been undertaken, as publications in the BMJ have shown. in the 1960s by agreement between the PHLS and the The result has been an unfortunate decline in the multicentre Department ofHealth and Social Security. The reasons were studies and epidemiological research for which the PHLS partly economic but mainly because joint laboratories alone structure is particularly suited. could guarantee adequate ascertainment of the prevalent So the PHLS is at a crossroads. Starved of funds, it can communicable diseases and so provide a basis for sound maintain its national laboratory service only at the expense of advice on effective measures for their prevention and control. curtailing its epidemiological activities-or conversely main- only at the Such advice can come only from properly coordinated and tain or increase its epidemiological activities http://www.bmj.com/ well planned epidemiological studies; and these in turn expense of the laboratory service. If the second course is cannot begin without accurate information from sufficiently chosen-as we believe it should be, given that the original numerous and representative sources about what infections purpose of the PHLS was to cope with the threat ofepidemic are prevalent. infections in time ofwar-then the number ofits laboratories The NHS has benefited from the links in many ways. The might need to be cut. One way forward might then, however, joint laboratories have been able to recruit well trained be the creation ofa network ofregional epidemiologists based consultants and eager ambitious trainees learning their jobs in laboratories throughout the country linked with a strong and making up their minds about where their talents will best central unit. on 28 September 2021 by guest. Protected copyright. find fulfilment. The health authorities have generally What seems plain is that district health authorities have received a better and cheaper service because of the central neither the incentive nor the powers to get going measures of link with a professionally directed service, able and willing to action and investigation covering regions wider than their answer problems quickly-often over the telephone- own. Which health authority will find money to send its chief instead of waiting for meetings of committees and sub- medical microbiologists to four or five staff meetings a year committees and references back. They have been able to do for discussion of ideas for joint investigations and for joining so because the relations are personal and professional and working parties to get on with the job? It is from such staff because ofcontinuing awareness in the PHLS that, in control meetings lasting a whole day that good propositions, often of infection, action delayed is action made futile. unexpectedly, emerge and effective teams are formed. The Recently, however, cuts in the financial allocation to the central reference laboratories concerned and the Com- PHLS have made it increasingly difficult to maintain a municable Disease Surveillance Centre work out details of clinical microbiological service and a public health microbio- methods and of recording and analysing results. It is only logical service in the 52 laboratories together with the then that reliable answers become available in a short enough support and coordination needed for national epidemio- time to give good advice on prevention and control-advice logical work. Understandably, the clinical microbiological often greatly welcomed and much needed by the Department service to sick patients tends to be given precedence over the of Health and Social Security. None of this beneficial work public health and epidemiological functions. will continue ifthe link between the centre and the periphery (©) BRITISH MEDICAL JOURNAL 1985. All reproduction rights reserved. VOLUME 290 NO 6468 PAGE 579 Br Med J (Clin Res Ed): first published as 10.1136/bmj.290.6468.579 on 23 February 1985. Downloaded from 580 BRITISH MEDICAL JOURNAL VOLUME 290 23 FEBRUARY 1985 is broken. Some laboratories may have to be transferred to with oestradiol this antiprogesterone bound to progesterone health authority control, but the PHLS cannot function iftoo receptors five times more avidly than did progesterone, and many of its roots are pruned. also bound three times more strongly than dexamethasone The PHLS is a uniquely English institution, uniquely to the glucocorticoid receptor of the thymus in adrenalecto- successful. It is admired and envied for its effective peri- mised rats. Despite such binding this synthetic steroid had pheral contacts by its counterpart in the United States, no progestomimetic activity in bioassay systems in vitro or despite the vastly greater resources made available to the in vivo. This suggested that RU 486 would be clinically latter; and it is repeatedly consulted-and not in vain-by useful as an antiprogesterone; and studies in monkeys the World Health Organisation. Those who would break the showed that RU 486 reliably induced menstruation by a essential PHLS links between centre and periphery-who local action on the endometrium.6 This action was seen with are they? Do they really know what they are doing? The doses as low as 01 mg/kg given intramuscularly. The PHLS now has over 45 years ofexperience, accomplishment, corpus luteum was not concerned in this response, and and partnership with the DHSS and health authorities. Its RU 486 did not bind to the primate ovary. essential structure must not be wrecked on the assumption- Three studies have reported the use of RU 486 to abort certainly false-that real economies will result. human pregnancies. Herrmann and associates gave 200 mg of RU 486 a day by mouth for four days to women who were six to eight weeks pregnant and abortion in 34 Redford Avenue, JAMES HOWIE produced nine Edinburgh EH 13 OBU of 11 patients.7 The median time to abortion was four days (range three to seven days). One of the patients experienced heavy bleeding and required emergency curettage. More recently, in a collaborative study by the World Health Organisation, this antiprogesterone was given to 37 women The antiprogesterones are seeking termination of pregnancy with amenorrhoea of 42 days or less.8 The patients were given either 25 mg RU 486 coming: menses induction, twice daily for four days (total dose 200 mg), 50 mg twice daily for four days (400 mg), or 100 mg twice a day for four abortion, and labour? days (800 mg). Twenty two of the women had a complete abortion while 11 had an incomplete abortion, and in the The five classes of steroid hormones are oestrogens, remaining three there was apparent continuation of the androgens, mineralocorticoids, progesterones, and gluco- pregnancy. At these doses the clinical efficacy of treatment corticoids. As antagonists to these hormones have been was not dose dependent. Plasma progesterone concentra- developed they have proved of considerable clinical value. tions did not decline greatly during treatment with anti- The actions of oestrogen may be inhibited by clomiphene or progesterone, though plasma cortisol concentrations did tamoxifen, androgens by cyproterone, and mineralo- increase. Two patients in this study had heavy bleeding and corticoids by spironolactone. Until now, however, no required a blood transfusion and curettage on clinical clinically acceptable receptor antagonists have been found grounds, but no patient complained of severe pain, nausea, for the progestogens or the glucocorticoids; but anti- or vomiting after the antiprogesterone-in contrast with progesterone drugs should soon be available and will give early studies of various prostaglandin regimens. Despite opportunities for the induction of menstruation and the these advantages these early results do not show any clinical http://www.bmj.com/ interruption of pregnancy and may lead to a revision of our advantage over vacuum aspiration or prostaglandin concepts of abortion. analogue methods for terminating early pregnancy. Progesterone is a key hormone in the establishment and One way to increase the percentage of abortions that are maintenance of human pregnancy. An antiprogesterone complete would be to use an antiprogesterone to dislodge drug