SIR,-Dr D O'Neill and his colleagues say that their study ... to hospital,2 but Dr O'Neill and colleagues present .... SIR,-How well I agree with Paul Reeve on the.
Isoflurane is best used in circumstances where sedation is required for short periods and its rapid excretion allows assessment to be carried out easily. In our unit active expired gas ducting has been built in. I M(-LELLAN Girobv Road Hospital, ILeicester 1E3 9QE 1 Park (iR, BoLrn AMNl. Isoflurane compared with midazolam in thc intensive care unit. Br Med,7 1989;298:1642. (17 June.) 2 Becchey Al'G, Huill JiM, McLellan I, Atherlev DW. Sedation with isoflurane. Anaesthesia 1988;43: 159-60. 3 Kong KL, Willattts SM, Prys-Roberts C. Isoflurane compared with midazolam for sedation in the intensise care unit. Br Med j 1989;298:1277-80. (13 May.)
Effects of burglary on elderly people SIR,-Dr D O'Neill and his colleagues say that their study shows that elderly people have an increased vulnerability to burglary, based on their findings of a higher rate of reported burglaries among those elderly patients attending an outpatient department and admitted to a short stay geriatric medical service.' They quote an earlier paper whose authors argued that burglary is a stress that can precipitate a major health crisis in old age, which in turn can lead to urgent admission to hospital,2 but Dr O'Neill and colleagues present no new evidence to justify their conclusion that they "found an increased vulnerability to burglary among elderly people." The alternative hypothesis to explain their findings, which is more likely, is that the elderly are at greater risk of requiring hospital treatment as a result of a deterioration in mental or physical health, or both, triggered by being a victim of burglary. Neither the British crime survey of 1981 nor of 1984 reports the elderly to be at an increased risk of burglary; in fact they show that properties occupied during the day are less likely to be burgled, suggesting a reduced risk for the elderly. 4 The 1984 survey showed that burglary is also one of the crimes which is not feared more by people as they get older, in contrast to the fear of crimes of violence. A study of a representative group of burglary victims in three separate police sectors in England' showed that the elderly were more likely to experience severe emotional distress, and also that 6% of the total sample reported that their physical health had suffered as a result of the burglary. One finding by Dr O'Neill and his colleagues which merits further investigation is the fact that in a quarter of the cases the burglars had gained entry by posing as charity collectors or officials. This is greatly in excess of the 4% who came face to face with the intruder in the study by Maguire,' and suggests that such an encounter might be more likely to start a decline in health that leads to hospital referral.
An immediate and practical way in which help can be given is to install an alarm system in the houses of the vulnerable. In Angus the district housing department, with some financial help from the regional council and health board, has embarked on providing a radio alarm system to elderly people and disabled people of any age. The protected person is supplied wvith a solitaire unit and a pendant to wear. A pull on the pendant links the person with the Tayside central ambulance control and gives two way speech through the radio. No telephone is required, and there is no cost to the protected person. The initial aim was to protect those who were subject to falls, faints, etc, but the system can be used if the person is concerned about the motives of an intruder. Any readers interested in this system can contact the director of housing, Angus District Council, County Buildings, Forfar DD8 3LG. Department of Gieriatrics, Universitv of Dundee, Dundee DDI 4HN
C COHEN
1 O'Neill D, O'Shea B, Lawlor R, MicGee C, Walsh JB, Coakley D. Effects of burglary on elderlv people. Br Med j 1989;298: 1618-9. (17 June.)
1 O'Neill D, O'Shea B, Iawlor R, M\cGee C, Walsh JB, Coakley D. Effects of burglary on elderly people. Br Med 7 1989;298: 1618-9. (17 June.) 2 Coakley D, Woodford-Willianms E. Effects of burglary and vandalism on the health of old petople. Lancet 1979;ii: 1066-7. 3 Hough JMI, Mayhew P. The British crime survev. ILondon: HMSO, 1983. (Home Office research study No 76.) 4 Hough JM, Mayhew P. Taking acco'unt of crime: key findings front the 1984 British crime survey. London: HMSO, 1985. (Home Office research study No 85.) 5 Maguire M. The impact of burglary zipon victims. British 7ournal
of Criminology 1980;20:261-75.
SIR,-The effect of burglary on elderly people' is an important subject, but the measures recommended to overcome the adverse effects will require a long time to be effective.
260
ALISON FIANDER
Bawkti Hospital, Otiagadougou, Burkina Faso
Chemical inactivation of HIV on surfaces SIR,-Our finding that HIV that has dried on a surface is not readily inactivated by alcohol' has been attributed by Drs de Jong and van Klingeren to the presence of a 20 tm clot ofdesiccated protein around the virus.2 It is unfortunate that criticism of our findings should be based on a misreading of our method: we found alcohol to be ineffective against HIV without the addition of organic protein. Although the virus stock suspension contained 10% fetal calf serum, this is insufficient to constitute an effective protein challenge to disinfectant. In clinical settings HIV will always be found with more protein than this. Because alcohol proved ineffective with the 10% serum contained in viral culture medium, repeating the test with neat serum would have been pointless and we did this only in the case of glutaraldehyde. We emphasise that alcohol failed to inactivate dried HIV under relatively unchallenging conditions; the amount of organic protein and tissue present in clinical contamination will further confound any virucidal activity. P J V HANSON Brompton Hospital, London SW3 6HP I Hanson PJV, Gor D, Jeffries DJ, Collins JV. Chemical inactivation of HIN on surfaces. BrMedJ 1989;298:862-4. (1 April.) 2 de Jong JC, van Klingeren B. Chemical inactivation of HIV on surfaces. BrrLdJ 1989;298:1646-7. (17 Jtine.)
KIM A FRASER
Department otf Forensic Psychiatrv, Maudsley Hospital, London SE5 8Az
a prevalence study on infection with HIV-I (using Dupont HIV Chek kits donated by a missionary organisation) suggested a 2% prevalence among healthy pregnant women and a 1% rate among gynaecological patients. We have no information on infection with HIV-II, which is important in west Africa. Political constraints prevent samples being tested abroad. IThe rainy season is just starting and shortly the wards will be inundated with patients, especially pregnant women and young children, suffering from severe anaemia induced by malaria on top of chronic nutritional anaemias. We have no means of screening blood before transfusion. The hospital policy towards transfusion has changed in the light of HIV infection, and transfusions are now given only to save lives. The decision to transfuse and its timing is often difficult-for example, caesarean sections in women with a haemoglobin concentration of about 60 g/l are a risk but so are unnecessary blood transfusions. We wait for the national anti-AIDS programme to reach our hospital. Meanwhile we work in the dark against a largely unknown enemy, our patients at risk and the AIDS epidemic unchecked.
HIV infection in Africa SIR,-How well I agree with Paul Reeve on the subject of HIV infection in Africa that "for millions of people it is already too late."' Though governments set up national programmes against AIDS, these are often centred on major cities beyond the reach of people living in isolated rural communities, who have neither the finances nor the understanding to travel for HIV testing. Social and cultural practices are not conducive to limiting the spread of infection, and educational material is often inappropriate for these communities. I work as an obstetrician and gynaecologist in a remote region of Ghana where we have no means of HIV testing. Clinically diagnosed cases of AIDS (based on the World Health Organisation's definitions) are not uncommon in the hospital, and
I Reeve PA. HIXT infection in patients admitted to a gcicral hospital in Malawi. Br.Mledj 1989;298:1567. (10 Juinc.)
Making cervical screening work SIR,-The review by Professor Alwyn Smith and his colleagues usefully covers the steps that need to be taken if cervical screening is to reduce mortality from cervical cancer. However, the most important message was contained in the subtitle: "Better management of the system is essential." There are 213 NHS cervical screening programmes in the United Kingdom. Each has one person responsible for the organisation and effectiveness of cervical screening, but these peoplethe programme managers-are hard pressed and inadequately supported. Thus they have been given the responsibility but not the power and resources that they need to do the job. A recent survey funded by the Nuffield Provincial Hospitals Trust has identified the needs of this group of people, most of whom are community physicians with a small number of cytologists, and the first step in implementing the recommendations in the review is to ensure that these people have the power, resources, support, and training that they need. Secondly, management needs to be coordinated more strongly at regional level. It is not possible to run an effective network of 213 different screening programmes, although a newsletter, called LINKS and funded by the Imperial Cancer Research Foundation, is sent to all screening programmes, but such a network is too big to run effectively. The Faculty of Community Medicine has therefore developed a group called the "big 18"-the 14 English regions, the three Celtic nations, and the independent sector. However, the people who act as contacts in the regions all have many other responsibilities and they too need resources and time, not to control the individual screening programmes but to build effective networks at regional level. The average region is spending several million pounds a year on cervical screening and a senior member of the department of public health at regional level needs at least two days a week to help programme managers carry out the necessary
changes. Nationally, where at least £50m is spent annually, there is a need for a coordinated approach to training, quality assurance, information, research,
BMJ VOLUME 299
22 JULY 1989
