Volume 1: Findings and Conclusions
8. Occupational risk
Those at risk
Chronology of occupational safety advice

1032 However, these early warnings during the period up to December 1989 reached only some of those handling risk material from cattle. Others were vets in private practice, waste tip and incinerator operatives, slaughtermen and butchers, knackermen, hunt kennel and maggot bait farm workers, renderers and animal feed handlers. Laboratory workers, teachers and students were handling cattle glands and tissues. Workers in zoological parks needed guidance. Later on, medical and healthcare professionals, mortuary workers and undertakers needed to take special precautions in respect of human victims of vCJD. There was also a wide spectrum of occupations handling bovine material being processed for food and other uses, such as fertiliser and collagen.

1033 Ultimately the main occupations at risk were identified and advice given. But this was a long-drawn-out process. It took over three years to complete the task of issuing simple warnings and basic advice to the most obvious high-risk trades. A further two years passed before full guidance went out to those handling risk tissues in laboratories, hospitals and mortuaries.

1034 The following, heavily condensed chronology of the events traced in Volume 6, Chapter 8 shows when advice was issued to the main at-risk groups. It illustrates how protracted the process was, even where it was agreed that a particular group of workers needed to be speedily alerted.

Chronology of occupational safety advice

May 1988	HSE issues guidance for cattle handlers about aggressive BSE cases.
July 1988	MAFF issues guidance to its veterinary and laboratory staff.
November 1988	Further MAFF guidance to its staff handling tissues.
February 1989	Southwood Report says HSE is considering appropriate action.
9 March 1989	MAFF asks HSE for meeting on guidance to farmers, knackermen and workers at disposal sites.
29 March 1989	HSE identifies slaughterhouses as a possible risk.
April 1989	MAFF puts draft interim advice to HSE about carcass handling.
9 June 1989	Meeting between HSE, MAFF and DH (first of series). Brainstorming identifies farmers, vets, slaughterers, knackers, butchers, stockmen, market handlers, fell mongers, renderers, lab workers, those working at incinerators, artifical inseminators, local authority inspectors. MAFF considers the first four need urgent advice.
25 July 1989	MAFF drafts advice to vets. British Veterinary Association (BVA) agrees to draft own guidance.
8 August 1989	HSE issues news release on advice to carcass handlers mooted in April.
11 September 1989	HSE undertakes to redraft MAFF draft guidance note to abattoirs.
December 1989	HSE issues general information sheet on handling zoonoses in agriculture. Passing mention of BSE says no evidence that it is transmissible to humans.
January 1990	MAFF issues guidance agreed with BVA for veterinary surgeons. HSE considers no immediate guidance for farmers and farm workers is needed. MAFF disagrees.
February 1990	HSE publishes pocket carry cards on BSE and carcass disposal.
March 1990	HSE publishes Guidance Note 5 on occupational risks of BSE for workers in abattoirs and meat trade.
10 May 1990	When a TSE is diagnosed in a cat, Dr Pickles suggests neurophysiologists and others might need advice.
31 May 1990	Agreement that guidance is needed for renderers. More meat trade advice desirable on deep cuts, use of bandsaws and inhalation of material.
June 1990	MAFF advisory note for farmers on handling BSE suspects, and breeding.
24 August 1990	MAFF guidance to zoo workers.
6 September 1990	HSE/MAFF/DH decide against further advice for meat trade, which is opposed to it as drafted, and to leave aside for the time being guidance to renderers.
February 1991	Working Group of Advisory Committee on Dangerous Pathogens (ACDP) set up to prepare health and safety advice on handling human and animal TSEs.
15 March 1991	HSE/MAFF/DH decide guidance for renderers is needed.
7 October 1991	HSE/MAFF/DH identify dangers of cuts from splitting cattle heads and spines. Agree guidance needed for knackers, hunt kennels and maggot bait farms.
October 1991	Draft fast-track letter for medical professionals circulated in ACDP Working Group (ACDPWG).
28 November 1991	Food National Interest Group (NIG) advice note to HSE Inspectors about forthcoming comprehensive advice on precautions for knackers, renderers and slaughterhouses. Emphasis on employer surveillance, hygiene of pithing rods and risks of hand-scooping of brains.
9 June 1992	HSE issues comprehensive advice for knackers, renderers and maggot bait farms.
8 December 1992	Fast-track letter issued to medical professionals.
September 1994	ACDPWG guidance on TSEs published.
April 1995	Guidance issued in 'Communicable Disease Report Review' for all those handling human cadavers.
December 1995	HSE/MAFF/DH working group meets for first time since October 1992. Agrees to reinforce present guidance.
January 1996	Update of HSE's Guidance Note 5 for slaughterhouse/meat trades issued.
June 1996	ACDP guidance issued for all workers in contact with BSE.

1035 As we built up this reconstruction of events from documents made available to us and witness statements, we were dismayed by the delays that occurred in advising workers at risk from contact with the BSE agent. Time was not available to explore this large field of evidence in depth at our oral hearings and with further witnesses. Our Report therefore does not attempt to pinpoint the actions of individuals but rather to look at weaknesses in the system that caused us concern. Two illustrative examples are described below.

1036 The first was the issue of advice from the Advisory Committee on Dangerous Pathogens (ACDP) to laboratories, medical workers and undertakers. Fuller details are in vol. 6: Human Health, 1989-96, Chapter 8. The second was the issue of advice from the Department of Education and Science (as it then was) to schools about dissecting bovine eyeballs. Fuller details are in vol. 6: Human Health, 1989-96, Chapter 9. We conclude by drawing attention to some general points that struck us on the handling of occupational safety advice.