Volume 1: Findings and Conclusions
8. Occupational risk
ACDP advice to laboratories, medical workers and undertakers
Chronology of drafting of ACDPWG advice

1037 The HSE had an established role on national guidance about handling dangerous pathogens. It also looked for expert outside advice to the ACDP, which reported jointly to it and DH. The ACDP Chairman was Dr Tyrrell.

1038 The ACDP had been closely involved in the categorisation of levels of risk from pathogens and advising on appropriate precautions. It had reviewed procedures for handling CJD and it was natural for the HSE and DH to look to it for advice on handling other TSEs. A Working Group of the ACDP (ACDPWG) was set up in February 1991 to:

. . . report to the ACDP on the need for additional guidance on health and safety aspects of work with animals or humans, their tissues or in vitro systems infected or potentially infected with spongiform encephalopathy agent, and to draw up guidance.

1039 Professor Peter Biggs was asked to chair the Working Group, but Dr Pickles stood in for him at the first couple of meetings. Displaying the same energy and purposefulness as on other matters, she launched the work with her own paper. This not only provided draft outlines of the scope of the document that might be prepared but suggested a handling plan and timetable to enable the guidance to appear at the earliest possible date. Unfortunately, that timetable soon faltered and sank into a drafting morass. The following chronology illustrates this. The 14-month history of a so-called 'fast-track' professional letter for neurosurgeons is distinguished by italics. The 'Guidance Document' had a gestation period of over three years.

Chronology of drafting of ACDPWG advice

4 December 1990	ACDP agrees to set up ACDPWG.
January 1991	Dr Pickles circulates draft paper.
28 March 1991	First meeting of ACDPWG discusses Dr Pickles's paper.
13 May 1991	Second meeting adopts Dr Pickles's paper for internal use as the 'Reference Document'. This is to be the basis for briefer practical guidance for wider circulation - the 'Guidance Document'.
6 August 1991	Third meeting reviews second draft of Reference Document.
	First draft of Guidance Document.
October 1991	ACDPWG secretariat circulates draft 'fast-track' professional letter (PL) for neurosurgery and ophthalmic staff.
24 October 1991	Fourth meeting discusses third draft of Reference Document and agrees extensive redrafting needed for wider circulation.
	Guidance Document needs recasting.
	Professional letter (PL) to be issued quickly. DH to take forward.
30 October 1991	ACDP meeting told fourth draft of Reference Document is 'more or less the final draft'.
	ACDPWG welcomes any comments on second draft of Guidance Document 'as soon as possible'.
28 November 1991	SEAC discusses draft Reference Document. Final draft promised for new year.
December 1991	Secretariat circulates third draft of Guidance Document.
14 January 1992	Fifth meeting: Reference Document to be available on request; Guidance Document to be widely distributed. Both need redrafting.
	First draft of PL considered.
27 January 1992	Second draft of PL circulated.
June 1992	Fourth draft of Guidance Document circulated.
15 June 1992	Sixth meeting: no further work being done on Reference Document. Guidance Document has higher priority.
	Third draft of PL considered and amended.
7 August 1992	Fourth draft of PL distributed.
8 December 1992	Fifth and final draft of PL issued to neurosurgery and ophthalmic staff.
15 February 1993	Fifth draft of Guidance Document circulated.
February 1993	Sixth draft circulated.
5 March 1993	Seventh meeting: members asked to consider all aspects of Guidance Document.
24 May 1993	Eighth meeting: ACDP should aim to issue Guidance Document only. Final comments sought on Guidance Document.
May 1993	Guidance Document agreed.
14 June 1993	ACDP accepts Guidance Document.
June 1993 to September 1994	Correspondence about publication details.
24 September 1994	Publication of 'Precautions for work with human and animal TSEs' (The Guidance Document).

1040 Witnesses suggested a variety of reasons for this sorry tale. They included uncertainty about appropriate decontamination procedures and about blood products; pressure of other work on the secretariat; and being side-tracked into protracted drafting time on the professional letter of warning on neuro- and ophthalmic surgery procedures. Once the Working Group had become caught up in a cycle of widely spaced meetings to consider substantial redrafting, they were constantly overtaken by emerging new information. Professor Biggs described it graphically:

In a way, the Working Group was on a treadmill in the sense that any delay arising from the time needed to address a subject, or any other reason, was time during which new information became available requiring re-addressing subjects already dealt with.

1041 A background factor influencing the handling of the exercise was the controversy over whether human TSEs were a category 2 risk or, as some argued, should be in category 3, requiring more rigorous safeguards. There was also debate over whether BSE should be categorised at all, it being open to question whether it was a human pathogen.

1042 Further delays were then incurred until September 1994, after the document had been agreed by the ACDP in mid-1993. We were told that this was while DH finalised advice on at-risk patient groups inadvertently treated with CJD-infected medicines or tissue grafts.

1043 While each of these reasons was no doubt thought to be valid justification at the time for taking a measured pace, collectively they produced what seems to us a quite unacceptable delay. The workers concerned were in occupations that potentially exposed them to particularly high risks, yet they were among the last to receive guidance. The best was allowed to become the enemy of the good.