Memorandum by Professor Roger Finch, Infectious
Disease Physician, Nottingham City Hospital
1. CURRENT SITUATION
1.1 The burden of infection in the UK is
substantial and poorly defined. This is particularly relevant
to many community infections. Few diseases are statutorily noticeable
and among those which are, there is considerable under-reporting.
Information on the burden of infectious disease managed in hospital
can be gleaned from ICD10 coding of admissions but this remains
imperfect, especially where the diagnosis is not supported by
microbiological information. Data on antibiotic usage, as a measure
of infectious disease management, is only readily available in
primary care, but here, much antibiotic prescribing is empirical
and often given for minor self limiting viral upper respiratory
infections and therefore remains an inaccurate measure of the
true burden of infection. Diagnosis related prescribing is largely
absent. Information from medical certification is likewise unreliable
in defining the burden of infectious disease.
1.2 In hospital practice, microbiologically
defined infection is more common, but here the nature of sampling
is highly selective and rarely denominator controlled. Lack of
diagnostic precision applies particularly to infections of the
respiratory and gastrointestinal tracts which are the leading
causes of infectious morbidity and use of health care resources.
2.1 Infectious disease surveillance serves
many purposes. Not only should it provide a more accurate picture
of the incidence, prevalence, geographic distribution and trends
in disease, but should also inform the epidemiology, the consumption
of health care resources and the wider economic impact. It also
permits strategic planning including control measures and, in
turn, is the yardstick whereby the effectiveness of any intervention
can be determined.
2.2 While surveillance is fundamental to
the management of infectious disease, it should be based around
a clear strategy and should not be an end in itself. The strategy
should be shaped by a number of questions, such as: Why is surveillance
required? How can this information be obtained most effectively?
How much information do we need? How will the information be used?
How will it support evolving approaches to the control of a particular
target disease? How should it link with other measures of health
and disease? How will success/failure be judged?
2.3 There is thus a strong case for reviewing
the current strengths, weaknesses and arrangements for infectious
disease surveillance not only to ensure that it more accurately
reflects the current infectious disease challenges, but also to
inform specialists, general practitioners, the public and government
more effectively. There are some examples of good practice, such
as the surveillance of tuberculosis and HIV infection where well
developed systems record the prevalence and epidemiology of these
diseases and also inform management.
3. ECONOMIC IMPACT
3.1 Strategic planning for the management
of infectious disease is largely frustrated by a lack of clarity
concerning its true economic impact on the population as a whole
in relation to the use of health care resources and on individual
citizens. Parameters such as medical consultations, hospital admissions,
use of laboratory investigations and therapeutic interventions
are poor yardsticks. Health economic analyses are applied to relatively
few infectious diseases and the cost effectiveness of disease
management and prevention is largely lacking.
3.2 Many infectious agents spread within
the home, workplace, nurseries, schools and through the use of
public transport, leisure and retail facilities. However, little
effort is made to measure the importance of these mechanisms of
spread and whether effective solutions might be developed.
3.3 Many chronic disorders have an infectious
basis and result in a substantial, but ill defined burden to the
individual and society. Examples include hepatitis B & C (cirrhosis/tumour)
and HIV (AIDS), papillomavirus (cervical carcinoma), helicobacter
(peptic ulcer/gastric cancer) and chlamydia (infertility and possibly
coronary artery disease).
3.4 Specific populations in whom the burden
of infection is inadequately defined, managed and funded includes
asylum seekers and prisoners. Asylum seekers from resource poor
countries in regions such as Eastern Europe and Africa are currently
stressing local health and social services with complex problems
including those linked to HIV infection. Likewise, the prison
population (currently 0.1 per cent UK population) is at particular
risk from the spread of blood borne virus infections (notably
hepatitis C and HIV) but to an extent that is ill defined. Prisons
are acting as an amplification system for infectious diseases
which, on release from detention, become a high cost responsibility
of health services which have little influence on how this problem
might be more effectively managed.
3.5 Intravenous drug misuse is a major challenge
and carries the risk of blood borne virus infection, notably hepatitis
C and HIV. Many affected are on the margins of society and outside
the reach of existing health and social services. The health and
economic impact of this population is substantial, largely undefined,
increasing and requires more effective management.
4. CURRENT AND
4.1 The respiratory tract provides the leading
infectious cause for consultation in primary care. This includes
endemic and epidemic infections, which are largely viral in nature.
Epidemic and possibly pandemic influenza is an ever present additional
threat. Strategies are needed to ameliorate this burden which
currently suffers from a somewhat laissez faire approach.
4.2 Gastrointestinal infections have been
estimated to affect some eight million of the population annually
but are largely medically unidentified and only a fraction are
documented microbiologically. Among bacterial causes, Campylobacter,
Salmonellosis and Shigellosis predominate, together with other
food-associated infections, such as Ecoli 0157. Antibiotic
resistance is also impacting on disease management. Protective
mechanisms within the food chain needs to be strengthened and
the population better educated concerning food hygiene.
4.3 STD and hospital acquired infections
are a major health care burden and are identified for completeness
although subject to a separate inquiry by the House of Lords.
4.4 HIV and hepatitis C virus are major
challenges which continue to spread and present complex medical
and social challenges. Effective management is costly and will
continue to increase until vaccine prevention of HIV becomes a
4.5 Tuberculosis is a growing challenge
in response to factors such as travel to endemic countries, infected
asylum seekers, the increase in immune deficient citizens and
as a response to socio-economic factors. Furthermore, multi-drug
resistant tuberculosis is steadily increasing and is a particular
threat from the Baltic States and the former Soviet Union. Latency
in disease expression characterises tuberculosis infection and
inevitably means that in future, an increasing number of persons
will present with drug resistant disease with its inherent problems
of early diagnosis and appropriate drug therapy.
4.6 Among community acquired infections,
pneumococcal disease, particularly that caused by penicillin-resistant
organisms, will increase and create major difficulties for antibiotic
management in the community where treatment largely relies on
oral agents. The effectiveness of recently licensed conjugate
pneumococcal vaccines in controlling drug resistant disease is
4.7 MRSA infections, currently rampant in
hospitals, are now spreading into the community and affecting
persons who have no clear epidemiological links to hospitals or
nursing homes. This is extremely worrying, since many minor staphylococcal
infections will no longer be responsive to conventional oral agents
available to general practitioners. This will likely result in
increasing referrals for hospital management.
4.8 Climate change is likely to see an increase
in the distribution of various insect vectors. For example, this
could result in mosquito-associated diseases such as malaria,
dengue and possibly West Nile virus.
5.1 Education and hygiene
5.1.1 Prevention is better than cure. Priority
should be given to education and to emphasising the role of public
health measures and hygiene for disease control. Public awareness
remains poor and requires a strategic effort to remedy and sustain
across generations and ethnic groups. This should focus on factors
within the home, school, workplace, food outlets as well as hospitals.
5.1.2 The explosion of information has also
meant that most of those who are dealing with infectious disease
problems cannot keep up to date with the key clinical literature,
let alone the underlying scientific literature. Here it is appropriate
to highlight a recent initiative under the umbrella of the National
electronic Library for Health (NeLH).
The National electronic Library for Communicable
Disease (NeLCD), one of the virtual branch libraries of the NeLH,
aims to provide rapid access to the best available evidence on
the surveillance, investigation, control and treatment of infection.
The organisation of the NeLCD, is such that it has support and
representation from across the entire range of those involved
in Communicable Disease, including Infection Control Nurses and
Environmental Health Officers as well as Microbiologists, CCDCs
and Infectious Disease Physicians.
The NeLCD is developing an Internet infectious
disease portal with access to material provided by the various
expert groups engaged in infectious disease. It is developing
systems so that there will be rapid access to reviewers assessments
of the key evidence, as well as direct access to the published
evidence where available. The NeLCD is also intending to develop
forums for exchange of information and training materials.
If the practice of infectious disease is to
improve it will require effective use of information technology
to disseminate best practice. The NeLCD should be a key element
of any future strategy. To date, the NeLCD has been developed
on intermittent funding from the NeLH core budget and from the
PHLS. It is vital that there is a clear commitment to adequate
long term funding for the NeLCD so that the staff can be secured
and that the plans for developing the NeLCD can be implemented.
5.2.1. Vaccines rank among the most successful
of public health measures. However, the supply of vaccines should
be made more secure in order to prevent interruptions of childhood
immunisation. The manufacturing base for vaccines in the UK has
diminished and is a cause for concern. It clearly weakens the
UK base for promoting new initiatives for the vaccine control
of disease, as well as increasing our reliance on overseas manufacturers.
Childhood immunisation schedules lack international
standardisation and harmonisation which often delays licensing
and limits the amount of information on performance according
to UK schedules. International efforts to remedy this state of
affairs should be given a higher priority. New vaccines will continue
to be developed and are to be encouraged. However, this presents
new challenges in defining the safety and efficacy of exposure
to multiple antigens. A strong research led strategy is essential.
5.2.2 Adult immunisation is currently erratic,
selective, non-strategic and largely driven by travel or occupational
needs. Likewise, medical records relevant to past immunisations
are variable in quality. The effectiveness of vaccine control
should be made part of the schools' curriculum in order to improve
knowledge of the nature of immunisation and promote understanding
of the risk/benefit issues. Hopefully, this will lead to greater
acceptance of the vaccine control of disease. At present, vaccine
programmes are vulnerable to sensational reporting often based
on the release of premature information. This has had a devastating
effect on such diseases as pertussis and measles which can have
serious long term consequences in those affected.
At present, the effectiveness of surveillance, links
between surveillance and treatment and the links between surveillance
and strategies for preventing infectious disease is weak. The
solution should be based on strengthening the foundation base
around an agreed strategy and the establishment of robust systems
for communication, implementation and audit. Links with international
agencies is essential because of the nature of infectious disease
challenges. The UK is well positioned to provide leadership in
this important area of public health