Select Committee on Science and Technology Minutes of Evidence


Memorandum by the Department of Health

INTRODUCTION

  1.  This paper has been drawn up in response to the call for evidence to the Sub-Committee of the House of Lords Science and Technology Committee considering issues relating to human infectious disease in the United Kingdom.

GENERAL CONTEXT

  2.  Two hundred years ago, infectious diseases were among the most important health problems of the time. With the great sanitary reforms of the nineteenth century, improvements in general living standards and to a lesser extent more recent improvements in medical care, acute infectious diseases no longer dominate the scene.

  3.  Over the course of the 20th Century the yearly mortality from infectious disease fell from 369 per 100,000 population to nine per 100,000. Immunisation programmes and the availability of antimicrobials have made significant contributions to these spectacular gains. Nevertheless, infections currently account for 40 per cent of consultations with health professionals.

  4.  However, the last few decades have seen social and environmental changes that have the potential for halting or reversing these hard won gains. Large-scale production and distribution of foodstuffs, extensive foreign travel and global warming are but a few of the factors involved. Such changes, together with the capacity of causative organisms to adapt to changing circumstances, including the development of resistance to antimicrobials, mean that we must maintain continued watchfulness to protect the health of the population.

  5.  The House of Lords Select Committee on Science and Technology published a report on one of these issues, the development of resistance to antibiotics and other antimicrobials, in 1998 followed by a further report on resistance to antibiotics in 2001. These made a number of important recommendations, which are continuing to influence and direct the Department's ongoing policies.

  6.  The Department of Health is taking forward a strategy set out in the Government Chief Medical Officer's (CMO) report Getting ahead of the curve: A strategy for combating infectious disease. This strategy tackles head on the major challenges to health posed by infectious disease in the 21st Century and is underpinned by the need for an integrated, broad based approach to health protection as a whole. It takes full account of the highly devolved nature of the new NHS structure resulting from Shifting the Balance of Power.

PRIORITIES

  7.  The CMO's strategy, Getting Ahead of the Curve, reviews the factors driving change and identifies some important threats that need to be addressed, including:

    —  new and emerging diseases;

    —  animal diseases that can transmit to humans;

    —  poor hygiene, lapses in control measures or standards of medical care;

    —  terrorism.

  8.  The strategy proposes a raft of actions designed to create a modern, effective system to manage the threat from infectious diseases. These include:

    —  a national expert panel to assess the threat from new and emerging infectious diseases;

    —  a strengthened and expanded system of infectious disease surveillance;

    —  targeted action plans to reassert control over specific infectious disease problems;

    —  a programme of new vaccine development; and

    —  a new inspector of microbiology.

A CO -ORDINATED APPROACH TO HEALTH PROTECTION

  9.  A key recommendation of CMO's strategy is the creation of a new Health Protection Agency (HPA) that will combine the public health response to biological, radiological and chemical threats under one body for the first time. Proposals for creating the HPA are described in the consultation paper, Health Protection, issued by the Department of Health in June 2002. Responses to this consultation are currently being analysed.

  10.  The main functions proposed for the HPA, that will have a particular bearing on the considerations by the Sub-Committee of the Science and Technology Committee, include:

    —  provision of information on infectious disease;

    —  co-ordination of surveillance relevant to the prevention and control of infectious diseases in England to provide this information;

    —  identification of gaps in surveillance and the development of information systems to fill them; and

    —  setting of standards for surveillance reporting.

  11.  The implementation of the strategy by DH will provide a unified organisation for health protection with a short chain of command and a clear line of sight between national and local levels.

NATIONAL EXPERT PANEL

  12.  A National Expert Panel will be established to assess the threat from new and emerging infectious diseases. In the light of its assessment, the panel will provide advice on the areas for action and on measures to meet the threats, including;

    —  prevention and control;

    —  information needs and areas for surveillance; and

    —  relevant research, including technological developments.

  13.  The panel will report to CMO. In the light of the advice received, DH will determine what developments should be taken forward and agree development programmes, as appropriate, with the relevant agencies (eg Local Authorities, Food Standards Agency). DH will agree with the proposed HPA the surveillance developments that should be included in its annual programme.

STRENGTHENING SURVEILLANCE

  14.  The purpose of surveillance is to provide information for action. Those responsible for the protection of public health must have information to make the right decisions. They need to know of clusters of disease that may signify an outbreak or incident. They need to be aware of disease trends and emerging problems and, when they take action to control or contain problems, they need to be able to evaluate the effectiveness of the measures implemented.

  15.  The utility of surveillance is not limited to the initiation of containment measures once an event has happened. It also makes a major contribution to anticipating future problems, enabling appropriate actions to be taken in advance in order to minimise the impact on human health. Such actions include the implementation of immunisation programmes to prevent disease and the provision of appropriate services to treat those with infection.

  16.  Not only do we need to provide information to professionals and organisations, we also need to provide information to the public so that they can make informed choices in their everyday activities and in relation to healthcare services. In addition to information about infections they need to be able to weigh the risk that a particular hazard presents. Such information must be seen as accurate and objective not only for confidence in vaccination policies but also in acceptance of wider control programmes.

  17.  Current surveillance arrangements in the UK achieve standards at the local, regional and national levels to match anywhere in the world. Nonetheless, existing systems will need to be strengthened and improved to meet the challenges of the 21st Century.

  18.  The core systems are based on statutory notifications of disease under the Public Health (Control of Disease) Act 1984 and communicable disease reporting co-ordinated by the Communicable Disease Surveillance Centre (CDSC). Information from other sources, including reports from the Office for National Statistics, reference laboratories, special studies and disease registers, are frequently used to augment the core systems.

  19.  Despite the strength of existing arrangements some weaknesses remain, in particular:

    —  data that are reportable under current arrangements are incomplete and not always reported in a timely way. This is partly because reporting by clinicians and laboratories is voluntary, other than for statutorily notifiable diseases, with the result that many diseases are probably under-reported;

    —  existing data-sets do not include particular pieces of information that now might be considered essential eg antimicrobial susceptibility of certain organisms;

    —  although there are increasing moves towards electronic reporting, much continues to be paper based; and

    —  there is limited linkage between human, veterinary, food, water, environmental and clinical surveillance systems, so that inter-related emerging trends or incidents are not always recognised as promptly as they might be.

BUILDING ON EXISTING SYSTEMS TO MEET THE NEEDS OF STAKEHOLDERS

  20.  DH is currently developing strategic guidance for the proposed HPA. It envisages that, working in conjunction with the NHS and other key stakeholders, the proposed agency will strengthen and expand infectious disease surveillance systems. The approach adopted will:

    —  build on current systems of statutory notification and reporting of laboratory confirmed infections;

    —  provide surveillance information on defined populations to allow meaningful comparisons;

    —  improve the timeliness and completeness of reporting;

    —  ensure that protocols for reporting are promulgated to all those required to report, setting out clear definitions of what cases and data should be reported and the timescales required; and

    —  the NHS will assist the proposed agency by ensuring that all clinical microbiological laboratories collaborate fully.

  21.  We envisage that the proposed HPA will establish a Health Protection Surveillance Group comprised of representatives of the key stakeholders to ensure that surveillance needs are met. The services to be provided by the proposed HPA will be set out in memoranda of understanding between the agency and each relevant stakeholder, eg Regional Directors of Public Health (RDsPH). These memoranda will also specify the obligations falling to the NHS in the provision of data to CDSC and appropriate specimens to be submitted to reference laboratories for public health purposes.

  22.  The Department will encourage the proposed HPA to work with the NHS and other agencies to increase the use of electronic reporting. The proposed agency will also need to work closely with the DH Information Policy Unit and the NHS Information Authority to ensure that IT developments in the NHS make their full contribution to strengthening the health protection function, as recommended in both the reports of the House of Lords Select Committee on Science and Technology (paragraph 5). As a result it is anticipated that IT procurement will take full account of surveillance needs for Health Protection.

FUTURE DEVELOPMENTS

  23.  Over time, greater emphasis will be placed on surveillance of illness in primary and secondary care settings, so that it becomes part of routine clinical care. It is also envisaged that greater use will be made of reports of illness received directly from patients and the public, building on systems such as NHS Direct. The use of common case definitions and datasets will facilitate linkage of information from a range of sources.

  24.  Changes in public attitudes and concerns means that more information on health protection will be required by the public in formats that meet their needs.

PREVENTION AND CONTROL

  25.  Currently, the vast majority of incidents and outbreaks are detected and managed at the local level. Although the precise arrangements for health protection at this level are currently the subject of discussion, this will remain unchanged. In its developments of surveillance, the proposed HPA will be required to keep the primacy of local responsibility in view.

  26.  Surveillance will remain an essential part of the health protection function at the local level. RDsPH have been assigned a clear and unambiguous responsibility for ensuring that appropriate arrangements are in place. It is anticipated that health protection services will be provided at local and regional levels by a division of the proposed HPA and that the level and standard of these services will be set out in health protection agreements. These agreements will not only be informed by surveillance but also specify what surveillance will be undertaken by the proposed HPA. Thus, RDsPH will be key players in determining the overall strategy for surveillance and will be ideally placed to ensure appropriate links are established with regional and local government, Public Health Observatories and other agencies.

TREATMENT

  27.  Effective treatment of infection by antibiotics requires that the patient receives an antimicrobial to which the organism causing the disease is susceptible. However, in order to administer prompt treatment it is normally necessary to start before the susceptibility of the organism is known.

  28.  Surveillance data, based on appropriate laboratory testing, should provide information on the antimicrobial susceptibility of a range of pathogenic organisms. Based on these data, guidance can be developed on which empirical therapy is most likely to be effective.

  29.  Most infections will be treated locally by general practitioners or in local hospitals. However, there are certain diseases or categories of patient that will require the expertise of specialist infectious disease physicians. This will be particularly true for unusual infections, especially those acquired while overseas (eg malaria) and those requiring specialist supervision (eg tuberculosis).

  30.  RDsPH will be responsible for ensuring that there is an appropriate balance of general and specialist services to meet these needs. The proposed HPA will assist by providing surveillance data, based on good laboratory methods, to health service planners at both national and regional levels. This will be facilitated by the creation of a new post of Regional Public Health Microbiology Co-ordinator.

INVESTIGATION

  31.  The development of new diagnostic technologies will have an impact on both treatment and surveillance. For example, molecular methods to detect antimicrobial resistance markers will improve the timeliness of information for clinicians, whilst the advent of near patient testing will present new challenges to the capture of data for surveillance.

  32.  The advent of nucleic acid based technologies has provided fast, highly specific methods for the diagnosis and typing of pathogenic organisms. The Public Health Laboratory Service (PHLS) has been developing a number of assays together with standard operating procedures. It is envisaged that evaluation and development of new technologies will take place in the proposed new agency for dissemination to NHS laboratories. Even faster technologies currently being evaluated include chip based microarrays and mass spectroscopy. Chip based microarrays allow rapid testing of pathogenic organisms with a design flexibility that provides for their utilisation in equipment for point of care testing. Recent instruments employing mass spectrometric techniques are successfully being employed in reference laboratories for the diagnosis and typing of micro-organisms. It will be important to ensure that all relevant data from these new technologies will be harnessed for surveillance purposes.

  33.  Current general microbiology services are fragmented. The reference and specialist functions contribution towards the provision of a service in support of the health protection function needs strengthening. Plans have been developed to reduce the current fragmentation of microbiology services and to secure appropriate specialist and reference microbiology to support the health protection function. These have been published on the CMO's web site at http://www.doh.gov.uk/cmo/laboratories/index.htm.

CONFIDENTIALITY

  34.  There is some concern among clinicians about the ethics of the use of clinical information for surveillance purposes, without explicit patient consent. This may contribute to some under-reporting.

  35.  In all its dealings, the proposed HPA will need to fulfil its legal obligations in respect of the information it holds and to take the lead for discussions on confidentiality and health protection surveillance with statutory and professional organisations.

CROSS-DEPARTMENTAL WORKING

  36.  The strategy document identifies a range of agencies involved in health protection. Whilst each Government Department and Agency will continue to produce its own reports, eg on Salmonella isolates from cattle and poultry, we anticipate that the proposed HPA will work with these bodies so that information from such sources can be presented alongside human health information to illuminate particular health protection issues, eg salmonellosis in people.

TARGETED ACTION PLANS

  37.  DH is developing new national action plans to address the high priority areas of tuberculosis, healthcare associated infections, antimicrobial resistance and bloodborne and sexually transmitted viruses.

Tuberculosis

  38.  In England and Wales tuberculosis reached an all time low in 1987. Since then there has been an overall increase in numbers nationally, with certain groups and localities being at particular risk. The action plan being developed incorporates improved surveillance at both the local and national levels to describe accurately the pattern of disease, including identification of people at particular risk, changing trends in drug resistance and monitoring of outcomes. Surveillance information will provide a robust basis for planning a national programme that will ensure local services are configured to meet local needs whilst also securing an overall consistency of approach.

Healthcare associated infection (HCAI)

  39.  Advances in treatment and increasing intensity of use of healthcare facilities carry with them an increasing risk of infection. To minimise the impact, infection control personnel need to be able to identify incidents and trends so that prompt remedial action can be taken. DH has, in the light of advice from the Healthcare Associated Infection Surveillance Steering Group, developed a strategy for surveillance of HCAI and has negotiated an agreement with PHLS to facilitate improved HCAI surveillance, focussing on MRSA and C. difficile infections in the first instance. (Appendices 1 and 1A)

  40.  The National Patient Safety Agency (NPSA) is working to design a toolkit of measures to improve hand hygiene in NHS trusts, thus reducing health care associated infection. The project is well underway and completion is scheduled for July 2003.

Antimicrobial resistance

  41. Antimicrobial resistance makes infections more difficult to treat. It may also increase the length and severity of illness, the period of infectiousness, the length of hospital admissions and costs. The increasing prevalence of antimicrobial resistant organisms, especially those with multiple resistances, is a source of international concern. The Departments of Health published their UK Antimicrobial Resistance Strategy and Action Plan in 2000. (Appendix 2) The main tasks identified were: improving surveillance; prudent antimicrobial use in humans and across the food chain; infection control; and improving information technology and the research evidence base. This strategy responded to the issues raised by the Select Committee on Science and Technology and by others, such as the World Health Organisation.

  42. In order to develop the strategy, and in accordance with the recommendation of the Lords Select Committee, the Department created the Specialist Advisory Committee on Antimicrobial Resistance (SACAR). SACAR, which is a multi-disciplinary expert advisory committee with a remit to advise Government on all aspects of the use of antibiotics, is taking forward a work programme to limit the development and spread of antimicrobial resistance in the UK.

Blood-borne and sexually transmitted viruses

  43.  The strategy document highlighted the significant morbidity and mortality arising from blood-borne and sexually transmitted viruses. DH is implementing the National Strategy for Sexual Health and HIV to modernise services over the next 10 years. Alongside this, and in recognition of its public health importance a Hepatitis C Strategy for England has been published by DH. Both these strategies run alongside a number of other initiatives to control sexually transmitted infections caused by other organisms, including a national screening programme for chlamydia, together with a range of initiatives to reduce the resurgence of syphilis and gonorrhoea.

VACCINES AND IMMUNISATION PROGRAMMES

  44.  Immunisation programmes have brought about major reductions in the morbidity and premature mortality caused by communicable disease. New techniques will allow new vaccines to be developed for relatively rare but serious diseases (eg meningococcal disease) and also for more common but less serious diseases (eg varicella). To anticipate the advent of new vaccines DH is developing a strategy for a nationally co-ordinated approach. The strategy will include surveillance, economic analysis, scientific studies to support policy development, strategic planning for implementation and close collaboration with the international vaccine industry.

  45.  The Department, in conjunction with the Joint Committee on Vaccination and Immunisation (JCVI), provides advice to Ministers on the most appropriate use of vaccines. This advice draws on information and advice from a wide range of sources and is also informed by WHO policies developed for the European region.

  46.  The Department has also established the Vaccine Evaluation Consortium, which brings together the key surveillance, research, epidemiological and academic institutions to accelerate the introduction of new vaccines. Following the success of the meningococcal C vaccine programme, the Consortium is evaluating candidate meningococcal B and pneumococcal conjugate vaccines.

  47.  The Department also works in partnership with Immunisation Information. Data on public attitudes to immunisation, vaccine preventable diseases, and vaccine safety are regularly used in the promotion of immunisation and responding to vaccine scares over safety. Nevertheless, it is reasonable to anticipate that the public will remain vulnerable to vaccine scares as long as the target diseases are absent. In responding to each scare story, reassurance about vaccine safety can only be given when evidence is available that refutes the scares.

TERRORISM

  48.  The Department and the NHS have developed and promulgated UK-wide contingency plans for responding to the deliberate release of chemical, biological and radio-nuclear (CBRN) agents. Building on guidance issued in March 2000 and October 2001 to help plan the health service response, further consolidated and updated guidance was placed on the DH web-site in September 2002. This includes specific advice on the biological (eg anthrax, smallpox) and chemical agents (eg nerve gases) most likely to be deliberately released. A strategic response capability, including anthrax production vaccine is provided by the Centre for Applied Microbiology and Research (CAMR).

RESEARCH AND DEVELOPMENT

  49.  A research and innovation programme will be a key component of the plans for the proposed Health Protection Agency. The R&D activities of CAMR, PHLS and the National Radiological Protection Board (NRPB) are being reviewed with the aim of developing a coherent strategic programme of research and development in the future.

INTERNATIONAL LINKS

  50.  Improved communications and vastly increased international travel mean that UK must contribute to European and international initiatives in health protection. The Department contributes several European Union (EU) communicable disease networks and as well as to a number of World Health Organisation (WHO) initiatives. CMO is a member of the WHO Executive Board.

  51.  Within England, DH is supporting a new public health initiative between the PHLS and academic departments for the control and prevention of imported infections.

18 December 2002


 
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