Select Committee on Science and Technology Fourth Report


Chapter summary

Prevention and control is necessary for any effective response to the threat from infectious disease. It can be made more effective by repairing the deficit in trained personnel and by improving education and training. Public awareness of infection should be raised. Lines of responsibility for outbreak control should be clarified. Vaccines could be used more, but public anxiety and issues about R&D need to be addressed. The Government should also ensure that there is secure access to vaccines in case of national outbreaks.


4.1 Prevention of infectious disease is one of the most effective courses of action that can be taken by public health services, both in terms of human suffering and live and economically. It relies principally on early detection and intervention, on vaccination and on changing social conditions and human behaviour.


4.2 Since Edward Jenner demonstrated in 1796 that vaccination prevented smallpox, development and use of vaccines has considerably reduced illness and death from many common infections. Smallpox was eventually eradicated through a global vaccine initiative and, similarly, many countries, including the United Kingdom, are now free of polio as a result of vaccination.


4.3 We heard that there are more vaccines that could be routinely used, yet even if they were available (see chapter 8) this might prove difficult because of public anxiety about safety [UK Vaccine Industry Gp, II p234-6].

4.4 Vaccines have powerful stimulatory effects on the immune system and there may be unwanted side-effects in some individuals. However, the majority of side-effects are minor and short-lived. Improved understanding about the interaction between vaccines and immune response should lead to more sophisticated and safer vaccines. Nevertheless, adverse side effects are a public concern and this should be a factor in considering whether to expand the childhood schedule [Ghosh, Q333-4]. Whilst the public seems to have accepted the recent inclusion of the meningitis C vaccine, it is not clear that they would be willing to accept yet more vaccines into the childhood schedule, particularly given recent public and media anxiety about the mumps, measles and rubella vaccine [CAMR, I p42, Soc Gen Microb, I p158].

4.5 Introducing more vaccines into the childhood schedule could improve public health, but the Government needs to assess whether increasing the number of vaccines is possible or desirable. Surveillance of the effect of implementing vaccines and of incidence of vaccine-preventable disease can inform this decision as well as helping to reveal whether there are any side-effects of vaccination [CAMR, I p42; Crowcroft, I p45-9].

4.6 In addition, we heard that there is need to communicate more with the public about the benefits and risks of vaccines, and we discuss this in chapter seven.


4.7 In the face of epidemics or global pandemics there could be urgent need to vaccinate a significant proportion of the population. Thus it would be important to have a secure supply of vaccines. The Centre for Applied Microbiology and Research (CAMR) (now HPA Porton) was responsible for developing and manufacturing influenza vaccines following the Hong Kong avian flu epidemic in 1997 but their capacity was stretched in order to do this [CAMR, I p44].

4.8 Very few vaccines are made in England and most vaccines used here are purchased from manufacturers in France and Belgium. England holds stocks of vaccine to meet anticipated needs. Needs are based on recent trends in infection as well as information about numbers of people likely to need vaccinating. So far, demand for supply has usually been met, although there was a recent shortage of BCG (an anti-TB vaccine).

4.9 One question that has been raised recently is whether the Government should establish a centre to urgently develop and manufacture vaccines [CAMR, II p382, Stewart, Troop, Q807-9]. In the event of a major global epidemic it is likely that overseas suppliers of vaccines would be under pressure to give priority to their own country's requirements. With this in mind, the National Institutes of Health in the USA opened a vaccine institute three years ago. This institute integrates basic immunology research with clinical trials and vaccine manufacture and is now attempting to develop and manufacture a vaccine for SARS. The Government recently turned down an application by CAMR to develop a similar facility on the basis of concerns over its cost [Blears, Q877; Stewart & Troop Q809].
Box 5

Problems in developing vaccines quickly

In some cases it may not be possible to develop and manufacture vaccines quickly enough to stem a pandemic because of the ease with which an infection such as influenza can spread across the world. In addition there are other surge capacity issues to consider; for example, the production of some vaccines requires fertilised hen eggs as growth medium for the vaccine; there may simply not be enough to enable quick production of vaccines for all the population. In addition vaccine production facilities are not generic: one vaccine manufacturing plant is not necessarily capable of producing a different sort of vaccine [Q576].

4.10 We note that it may not always be possible to prevent an epidemic through mass vaccination [Kingston, Q575]. Some epidemics spread too quickly to allow effective prevention by quick production and administration of vaccines, e.g. with a new strain of influenza [US, II p386]. There are also other issues that should be considered, such as the need for adequate supply of materials required to produce vaccines [see box 5]. Indeed, the question of whether there would be enough health personnel to administer a vaccine would also need to be considered.

4.11 It is important to consider the difficulties of ensuring a secure supply of vaccines and how those difficulties could be overcome. We note the need for effective global surveillance networks which can provide information as early as possible and thus instigate development and production of vaccines.

4.12 We note that the Government is currently addressing how, in the face of a serious epidemic, they would secure vaccines for the population [House of Lords Hansard, Col WA38]. We were also pleased to hear from the Minister for Public Health and the Chief Executive of the HPA, that the Department of Health is likely to consider a further application from HPA Porton (previously CAMR) to develop such a centre as discussed earlier (4.9) [Q809, 877]. We hope that this signifies that the Government will soon publish their strategy relating to vaccine supply.

4.13 We recommend that, given that there is little vaccine production capability in the United Kingdom, the Government should, by April 2004, develop and publish a strategy to ensure that there is secure access to supplies of vaccines in the face of national outbreaks of infectious disease.

Social conditions and behaviour

4.14 Prevention of infection requires improvements in social conditions [Assoc Brit Pharma Ind, I p10; Emery, I p111; Finch, II p55; Hawker, I p117]. Poor housing, poor sanitation and overcrowding can encourage infections to flourish and to be transmitted between people. Pertinent examples of such conditions are prisons and temporary housing for asylum seekers and the homeless [Birmingham, II p395].

4.15 A significant amount of infection is food-borne and is caused by poor hygiene relating to food production, storage and preparation. Environmental Health Officers (EHOs) work with food producers to ensure that levels of hygiene are sufficient and that people who work there are trained. In addition, EHOs also educate children in schools, although we heard that in Sandwell EHOs have had to stop doing this as a result of resource shortages [Bradford MDC, I p34-6; Birmingham, II p394].

4.16 Prevention is neither just an activity for health professionals nor something that can be achieved solely by adequate housing. Prevention relies on all individuals practising good hygiene, particularly in relation to food preparation and sex. High-risk behaviour such as intravenous drug users sharing needles also has a role in transmitting infection. It is clear that public understanding of the importance of behaviour in preventing infection is insufficient [Bryant, Q360]. We make recommendations about the interaction between social behaviour and infection in chapters seven and eight.
Box 6

The Health Protection Agency

The HPA was established on 1st April 2003. In relation to infectious disease this has brought together the main functions of the PHLS (the Communicable Diseases Surveillance Centre and the Central Public Health Laboratories), the Consultants in Communicable Disease Control, Regional Epidemiologists and CAMR. It also incorporates services relating to chemical and radiological risks. It is an independent body with responsibility for:

Advising government on public health protection policies and programmes

Delivering services and supporting the NHS and other agencies to protect human health from infectious disease

Providing impartial and authoritative information and advice to government, professionals, and the public

Responding to new threats to public health

Providing a rapid response to health protection emergencies

Improving knowledge of health protection, through research, development, and education and training.

Control activity

4.17 When prevention fails it is necessary to introduce control measures to avert further spread of infection [Sheffield, I p152]. Control measures are required in both community and hospital settings. Many health professionals are involved in control, with the HPA playing a supporting and coordinating role [see boxes 6 and 7].

Box 7

Preventing and controlling infection

Everyone has a role in preventing infection through practising good hygiene and safe sex and by reducing contact with others if suffering from a respiratory tract infection. Professionals with particular responsibilities for preventing infection include Environmental Health Officers who educate and train people working in food outlets about food safety. Immunisation nurses and GPs vaccinate people, which is the most effective way of preventing infection. Infection control nurses and medical microbiologists both oversee implementation of good practice to prevent emergence and spread of infection within hospitals.

The Consultant in Communicable Disease Control takes the lead in control of infection in the community and is responsible for collating information about infection and implementing control measures. Environmental Health Officers identify common factors and implement measures to prevent further spread. Community Infection Control Nurses also perform control function by tracing those with whom infected people have been in contact.

Community control

4.18 Control of infection requires finding out where and how infection has arisen, how it is being transmitted and who might have been exposed to it. It is then necessary to put in place some measures to stop infection from spreading and to ensure that those who have become infected are treated as soon as possible [see Box 7].

4.19 There are some good examples of plans about how to respond to infection outbreaks, such as the UK pandemic influenza plan. This describes the national response in the event of a new influenza virus appearing which has the potential to cause a world wide pandemic []. The plan was prepared to facilitate a prompt, effective national response. It describes a phased response and defines the roles of the organisations which would be involved. At the time of the appearance of H5N1 influenza in Hong Kong in 1997 the UK was one of the few countries to have such a plan in place and it was widely seen as a model to follow [USA, II p386].

4.20 Nevertheless, we heard that there are enormous disparities in community based infection prevention services across the country. A survey for the NHS Executive in 1997 found that there was significant underresourcing of those responsible for infection control and thus underperformance in many districts; charges which, we heard, districts have not adequately responded to [Hawker, II p118]. As we outlined in chapter three, there is also wide variation in numbers of infection control nurses [Infection Control Nurses Assoc, II p176 ].

4.21 We heard that there is a shortage of EHO posts in local authorities and a shortage of people training in environmental health at university [Emery, II, p111]. The local authority is isolated from other health protection services, and we heard that this can prevent EHOS from forming effective collaborative relationships with other professionals [Emery, II Q229, 244; Bradford MDC, I p34, Wiltshire Food Liaison Grp, I p171]. In particular, when attempting to trace the source of an outbreak and to implement control measures, EHOs can have difficulty accessing information from doctors concerned about patient confidentiality [Bradford MDC, I p34].

4.22 The lack of coordination and communication between different areas of community infection control is an issue that concerns a significant number of people [Emery, II Q231, Hawker II, Q231 p 118; Faculty Public Health Med, I p52-3]. Lines of responsibility for investigating outbreaks and implementing control measures are often unclear. Recent changes to health services organisation, including the creation of the HPA, are believed to have made lines of responsibility less clear and have led to the loss of informal support and collaborative networks [see chapter 9].

Box 8

Investigating parrots - unclear lines of responsibility

An individual develops psittacosis, which is a potentially fatal pneumonia usually contracted from birds such as parrots. The patient had a parrot recently bought from a dealer at a large bird show. The community infection control team wanted to ascertain whether the patient had caught the infection from his own parrot. Knowing whether the parrot was infected was important as, if it was, purchasers of other parrots from the show might have been at risk of infection. It was unclear whether DEFRA, the local authority or the Consultant in Communicable Disease Control was responsible for taking a sample from the parrot. Eventually an Environmental Health Officer from the local authority was "persuaded" to take droppings from the parrot's cage, "but it was not really their job to do it" [Hawker, II Q231].

Hospital Control

4.23 Infection control is a fundamental component of hospital activity, with health care acquired infectionscosting approximately £1 billion every year and leading to 5,000 deaths [Stewart II, 316, Bard Ltd, I p19; NAO, II p375; Brogan, Q680]. Outbreaks of infection such as the Norwalk virus (causing diarrhoea and vomiting, recently associated with outbreaks on cruise ships) can lead to wards being shut down. This significantly increases pressure on beds and can lead to a reduction in the numbers of available staff, with some becoming sick themselves and others being confined to working on wards where the outbreak has occurred[12].

4.24 Clinical microbiologists and infection control nurses play an important role in implementing control measures in hospitals. However, we heard that control cannot be the responsibility only of specialists, with all health care professionals needing to take measures, such as washing hands when moving between patients [NAO, II p375, Birmingham, II p393,5; see box 14]. We note that clinical microbiologists and infection control nurses are accountable to different people within the hospital, which may be a potential cause for confusion.

4.25 We found that in many hospitals there is inadequate provision of single rooms suitable for the isolation of patients [NAO, II p376]. Demand for single rooms for other purposes can be considerable and it is often difficult to keep these rooms available for infected patients [Naylor, Q679]. There was also concern that the availability of specialised facilities, such as negative pressure isolation rooms, essential when caring for patients with certain infectious conditions such as resistant tuberculosis, was inadequate [Birmingham, II p393]. For example St George's Hospital in London with a specialised infection unit has only four, significantly fewer than a comparable hospital in the US [USA, II p385].


4.26 The only formal recommendation that we make in this chapter is found in paragraph 4.13 and relates to security of vaccine supply. However there are a number of other ways in which prevention and control of infection can be improved and we make recommendations in further chapters relating to the following:

·  Facilitating development of new vaccines [see chapter 8];

·  Encouraging and improving education and training of specialist and non-specialist health professionals from undergraduate degree level upwards [see chapter 7]

·  Improving surveillance [see chapter 5]

·  Raising levels of public awareness about the importance of hygiene and improve understanding of risk [see chapter 7 and 8]

·  Clarifying lines of responsibility to encourage better co-ordination between different groups of health professionals [see chapter 9].

12   The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England, HC 306, Session 1999-2000 Back

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