Memorandum by the Academy of Medical Sciences
The major successes of the last century in the
prevention and treatment of bacterial infection encouraged a belief
that the essential problems had been solved and that infectious
disease would largely be eliminated as a public health problem.
It is now widely appreciated that this optimism was misplaced.
We note that the committee wishes to limit the
focus of the report. However, we believe that infectious diseases
surveillance must have a global perspective, and to discuss the
infection risks to the UK divorced from considerations of the
problems of antibiotic resistance, or to focus on community-acquired
rather than hospital-acquired infections would be a mistake.
The answer to the question "which infectious
diseases pose the biggest threats in the foreseeable future"
is that because of evolutionwhich is essentially unpredictablenobody
The UK has a relative paucity of infection specialists.
There are large areas of the country where there is no local expertise.
We are particularly concerned by the weakness in academic public
health medicine in the UK, and in particular public health aspects
of infection. We suggest that a targeted effort to strengthen
this area, with both clinical and non-clinical scientists working
together, is an urgent need.
High quality national surveillance is the cornerstone
of infectious diseases epidemiology. The CMO strategy proposes
the abolition of the PHLS as a body concerned exclusively with
infection. We have serious concerns that the proposals run the
risk of destroying a national resource that, although not perfect,
provided a coherent and valuable service.
We have grave misgivings that transferring the
R&D funds currently managed by the PHLS and other agencies
into the general fund under the control of the NHS Director of
R&D may undermine the public health function.
There is an urgent need to strengthen the academic
base of molecular microbiology, infectious diseases and public
health epidemiology in the UK, to exploit existing strengths in
vaccinology, and to invest in the new technologies that underpin
modern molecular surveillance and diagnosis.
1. Continuing importance of infectious diseases
1.1 In 1970, the Surgeon-General of the
United States of America indicated that it was "time to close
the book on infectious diseases, [and] declare the war against
pestilence won. . .". There is broad agreement that this
optimism was premature. It is appropriate to restate the observations
made last year by a working party of the Academy when reviewing
academic medical bacteriology: (1)
"The major successes of the last century
in the prevention and treatment of bacterial infection encouraged
a belief that the essential problems had been solved and that
infectious disease would largely be eliminated as a public health
It is now widely appreciated that this optimism
was misplaced. There is a long list of items of unfinished bacteriological
business with clinical relevance in the UK and elsewhere. Familiar
pathogens like Mycobacterium tuberculosis have not gone
away, recent outbreaks showing how little we know about the routes
of spread of the organism globally or even within the UK. New
pathogens like Escherichia coli O157:H7 appear without
warning and highlight the danger of spread of disease between
farm animals and human populations. The development of multiple
antibiotic resistance has transformed relatively benign infections
into life-threatening diseases, particularly in the context of
hospital acquired infections. Microbiological food poisoning has
been unequivocally identified as a growing public health problem."
Although the Academy's report was concerned
with bacterial infections, virtually the same considerations apply
to infections caused by viruses, parasites and fungi.
1.2 It is important to note that the importance
of infectious diseases extends considerably beyond those that
are normally thought of as communicable diseases. While acute
outbreaks of communicable ("contagious") infections
continue to represent a real threat, it is becoming increasingly
apparent that micro-organisms are also responsible for a wide
range of chronic diseases. In developed countries such as the
UK, it is arguable that these may make an even greater contribution
to ill health and are a significant burden to the healthcare economy.
We describe some of these conditions below.
1.3 A recent WHO report summarised the global
impact of infectious diseases:
"Infectious diseases cause 63 per cent of
all childhood deaths and 48 per cent of premature deaths. Many
of these deaths are caused by epidemic infectious diseases such
as cholera, meningococcal disease, and measles.
There are continuing threats of large epidemics with widespread
mortality like the `Spanish flu' epidemic in 1918-19 which killed
an estimated 40 million people worldwide, or the HIV/AIDS epidemic
which has caused widespread morbidity and mortality, and reversed
hard-won gains in life expectancy in Africa." (2)
Globally, the growth in mega-cities and the
linear rise in travel between major cities world wide will act
to increase not only the rate of evolution of new pathogens (population
density is directly related to net rate of evolutionary change)
but also the speed of spread city to city, and country to country.
The Chief Medical Officer's Report, "Getting
Ahead of the Curve", (3) emphasised that infection is
no less of a problem in the UK, albeit of a different nature,
40 per cent of people consult a health professional
each year because of infection;
infections account for 70,000 deaths each year,
5,000 as a result of a hospital-acquired infection;
the case notification rate for tuberculosis in
Newham, London (123 per 100,000) is the same as that in India.
Several factors contribute to the spread and
control of infectious diseases. Examples are (a) the increased
connectedness of cities and towns in the UK, with large numbers
of people frequently travelling between major centres of population
(b) increased population density in the major cities; (c) growth
in arrivals from overseas via airports (d) frequency of movement
of patients between hospital settings.
2. Which infectious diseases represent the
2.1 We note that the committee wishes to
focus on UK health issues and is not primarily concerned with
antimicrobial resistance, hospital-acquired infection, or sexually-transmitted
infection. However, while we recognise that there are some geographically-restricted
infections that are only rarely imported into the UK, we believe
that infectious diseases surveillance must have a global perspective,
and to ignore this would be a mistake. Similarly, to seek to identify
the infection risks to the UK divorced from considerations of
the problems of antibiotic resistance, or to focus on community-acquired
rather than hospital-acquired infections would weaken the analysis.
For instance, a recent study in a London renal unit of diabetic
patients who had migrated to the UK from TB-endemic areas reported
an incidence of TB of 1,187 cases per 100,000, more than twice
the rate reported in Zimbabwe or Botswana, two of the countries
with the highest rates in the world (4). Similarly, antibiotic-resistance
is no longer a problem restricted to hospitals. Increasingly,
patients are admitted from the community with infection caused
by antibiotic-resistant organisms. The key to the successful control
of infection and infectious diseases is a surveillance system
that can successfully integrate these different strands.
2.2 It is axiomatic that the answer to the
question "which infectious diseases pose the biggest threats
in the foreseeable future" is that because of evolutionwhich
is essentially unpredictablenobody knows. The prospect
of new or much changed pathogens appearing is always very real.
Such threats can only be countered by having a surveillance system
with a broader remit than just coping with existing pathogens
using existing tests. It must have flexibility and built-in capacity
for innovation so that it can respond rapidly to new problems.
Hence, rather than provide a list of specific infections that
may be a risk in the foreseeable future, we think it would be
more useful to describe differing risk groups, with some examples.
Acute outbreaks of communicable
diseases. These are the classic point-source outbreaks, often
food or water borne. It is impossible to predict which organisms
will be implicated; recent examples included Ecoli 0157
in Scotland and tuberculosis in Leicestershire. Both required
prompt recognition and a major public health exercise to bring
them under control. Currently there is inadequate understanding
of why the patterns of these endemic infections have been changing.
Without that understanding, control is impossible.
Sporadic community acquired infection.
Infections such as rotavirus diarrhoea and respiratory viral
infections are usually not of great severity but represent a very
considerable burden in terms of morbidity and days lost from school
Imported infections. Isolated
episodes of rare infections require surveillance at the local
level, but of more general concern is the potential for the rapid
spread in the community of unusual types of common infections.
Influenza A is a good example.
Antibiotic resistance. The
implications of this continuing problem have been addressed elsewhere
and do not need re-stating here.
Tuberculosis and HIV. These
are singled out for mention because in both cases the potential
for unappreciated spread in the community is considerable, and
because both are evolving anti-microbial resistance which requires
Chronic diseases. Micro-organisms
have been clearly implicated in the pathogenesis of several chronic
diseases including peptic ulcers and some forms of cancer. In
addition, evidence is accumulating that they may also be involved
in conditions as diverse as coronary heart disease and multiple
3. Diagnosis and surveillance of infection
3.1 Individual cases of infection are diagnosed
by a doctor or other healthcare professional; surveillance refers
to recognition of trends or outbreaks of infection in the community.
Both are areas of concern.
3.2 The UK has a relative paucity of infection
specialists. There are approximately 350 microbiologists and about
80 infectious diseases physicians in England and Wales, fewer
per head of population than are found in many European countries
and in particular in the United States. Many of these specialists
are congregated in tertiary centres so that there are large areas
of the country where there is no local expertise. Furthermore,
there is a national shortage of public health doctors, and relatively
few of those that are in post have a particular interest in infectious
diseases epidemiology. Of course, most infections are diagnosed
and treated by non-specialists and that is perfectly appropriate,
but the lack of specific expertise means that there is a risk
that potentially significant events will be overlooked until a
major outbreak becomes apparent.
3.3 High quality national surveillance is the
cornerstone of infectious diseases epidemiology. To quote the
"it is clear that effective public health
surveillance is critical for the early detection and prevention
of epidemics. There is a clear and urgent need for surveillance
of (i) known existing communicable diseases, especially those
with high epidemic potential, (ii) early recognition of new infections
(over 20 new pathogens have been discovered since the mid-1970s),
and (iii) monitoring the growing resistance to antimicrobial drugs".
The UK has benefited from a particularly strong
surveillance network, largely based around the Public Health Laboratory
Service. However, as noted in the CMO's report, a number of other
agencies also play a key role including local authorities, parts
of the NHS and several other national bodies such as the Environment
Agency and DEFRA. This has resulted in fragmentation and duplication
of the surveillance function, resulting in inevitable inefficiencies.
It is only necessary to consider a simple scenarioan outbreak
of gastroenteritis at a school, for exampleto realise that
this will potentially involve the local authority, the DPH of
the primary care trust, the hospital microbiology laboratory,
the Food Standard Agency, and the Central Public Health Laboratory
at Colindale. Although these agencies have a good record of collaboration,
the potential for problems developing is clear.
3.4 Surveillance of human infectious disease
is done better in the UK than in most other countries. However,
it falls far short of what is achievable with current methods.
The main deficiencies are (i) an excessive reliance on reactive
surveillance. This is well illustrated in the DH document "Action
to strengthen the microbiology function in the prevention and
control of infectious diseases", which restricts itself exclusively
to this topic. (ii) The fragmented nature of the surveillance
network in the UK. It feeds on the rivalries that inevitably exist
between agencies eg between different government departments,
and between the NHS and universities. Surveillance of zoonoses
is a good example, eg reference laboratories for Ecoli O157
are funded on the basis of the host species rather than the microbe;
human and veterinary laboratory surveillance is not "joined
up". Funding for surveillance is often driven by political
pressure rather than by health needs, eg there is no comprehensive
UK laboratory surveillance of Campylobacter (about 50k infections
reported annually) but there are two Ecoli O157 reference
laboratories (about 1.5k infections reported annually).
3.5 The CMO strategy proposes the abolition
of the PHLS as a body concerned exclusively with infection. We
would caution that there are some risks associated with this strategy.
The transfer of PHLS laboratories to the NHS is being done at
breakneck speed. The reason for this is unclear. Its impact on
surveillance will be negative. It destroys a network of laboratories
with the public health function at their core. While we support
the proposal that the PHLS should focus on its core activities
of providing a national reference and surveillance function, rather
than supporting routine diagnostic services in the NHS, it should
be recognised that the "bread and butter" of national
surveillance will still need to come from local microbiology laboratories,
and if this public health function of NHS laboratories is not
clearly identified and funded, and made a statutory responsibility,
then much damage could be done. It is improbable that NHS hospital
managers will give this the priority that it received from the
PHLS. Inevitably, they will focus on diagnostic work for patient
management rather than surveillance or outbreak control.
3.6 We are on the verge of very major development
in diagnostic technology. Details of the entire microbial genome
are already available for some common pathogens, and others will
soon follow. This information, coupled with newer genetic screening
techniques will mean that rapid and precise identification of
micro-organismseven in GP surgerieswill have a major
impact on our ability to track outbreaks of infectious diseases.
In particular, it is important that we make significant investment
in IT software to track unusual changes in the frequency and spatial
distribution of morbidity and mortality eventsvirtually
none is in use at presentalthough other developed countries
have begun to invest heavily in this area. The digital patient
records at primary health care settings act as a possible sentinel
tool (the NHS Direct database). However development and implementation
of these approaches will take a commitment of resource that at
present does not seem to be available.
4.1 The UK has a good record on immunisation
policy and practice, and such problems as there are at present
are related to public perception rather than failure of process.
4.2 Vaccines have made and will continue
to make a significant impact on reducing the burden of infection.
In global terms, the most important vaccines that need to become
available are against malaria, HIV and tuberculosis.
4.3 Sequencing of microbial genomes provides
new and important opportunities for the rational design of vaccines.
It is critical that the UK research community continues to make
important contributions to this field, as it has done in the past.
The Academy's report on Academic Medical Bacteriology draws attention
to this and makes a number of specific recommendations.
4.4 Advances in immunology and molecular
biology provide a basis for developing novel vaccines for many
infectious diseases. The UK has particular strengths in the area
of vaccine development and could play a major role in developing
new vaccines for AIDS, malaria and tuberculosis as well as other
diseases, were adequate funding available.
5. Research and training issues
5.1 The Academy has previously drawn attention
to the relatively weak state of academic bacteriology in the UK,
and there is an urgent need to attract more high quality scientists
into this areaincluding some with statistical, mathematical
and molecular/genetic skills to improve the rigour of infectious
disease epidemiology research, surveillance and control. We note
with concern that the CMO report suggests that research and development
funds currently managed by the PHLS and other agencies should
be incorporated into the general fund under the control of the
NHS Director of R&D. We have grave misgivings that this will
further undermine the ability to capitalise on recent developments
in diagnostic technology and will undermine the public heath function.
5.2 Britain has an excellent track record
in basic research on pathogens. For example, our fundamental work
over the years on TSEs and animal pathogens like FMD has been,
and is, of international quality. But our ability to link this
work to policy has been dismal, as shown by BSE/vCJD and the 2001
FMD outbreak.It is vital that lessons must be learned from these
events. Policy makers must learn how to make the best use of scientific
information. BSE and FMD also showed the importance of linking
policy making with accurate field knowledge. The PHLS played a
very important role over the years in the generation, assessment,
and promulgation of scientific knowledge and, through its network
of laboratories, the collection and interpretation of local data,
events and issues. We have grave concerns that replacing it with
public health services whose levels and costs "will be the
subject of service level agreements . . . normally . . . sustain(ing)
existing service commitments" runs the risk of destroying
a national resource that, although not perfect, provided a coherent
and valuable service.
5.3 We are particularly concerned by the
weakness in academic public health medicine in the UK, and in
particular public health aspects of infection. Academic departments
of public health medicine with a focus on infection are very few
in number, and the CMO report has thrown the whole area into turmoil.
We suggest that a targeted effort to strengthen this area, with
both clinical and non-clinical scientists working together, is
an urgent need.
5.4 The training function of the PHLS will
disappear. This will be a major loss to UK medical microbiology;
doctors and scientists with expertise, experience, and an interest
in public health microbiology will in future emerge only capriciously
and randomly through factors like personal interest. The training
of medical microbiologists with broader interests than the diagnosis
of infection and the provision of advice on therapy is already
in very serious difficulties in the UK because of the collapse
of academic bacteriology.
5.5 Deans of medical schools need to be
encouraged to recognise that public health aspects of medicine
are a core component of the undergraduate curriculum and to ensure
that sufficient time is devoted to this area.
(1) Academic Medical Bacteriology in the 21st Century.
A report of the Academy of Medical Sciences, July 2001.
(2) WHO Report on Global Surveillance of
Epidemic-Prone Infectious Diseases. WHO/CDS/CSR/ISR/2000.1
(3) Getting Ahead of the curvea
strategy for infectious diseases (including other aspects of health
protection). Department of Health, June 2002.
(4) Moore DA, Lightstone L, Javid D et
al. Emerg Infect Dis 2002 8: 77-78
This response has been prepared for the Academy
by a working group overseen by Professor Jonathan Cohen, FMedSci,
Dean, Brighton & Sussex Medical School, the University of
Brighton. The members of the group included Academy Fellows Professor
Roy Anderson, Professor Adrian Hill, Professor Hugh Pennington
and Professor Patrick Sissons.
The document was approved by the Officers of the