Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 88-99)

TUESDAY 5 NOVEMBER 2002
DR NICK BEECHING, PROFESSOR ROGER FINCH AND DR STEPHEN WRIGHT

Chairman

  88. Good morning, gentlemen, and thank you very much for coming along. Before I ask you to introduce yourselves, we are aware that Dr Wright has to leave at about 12.30, so we will try and finish taking evidence a little ahead of that time, but if in fact we do go on, then please just absent yourself. Can I ask you to introduce yourselves first and then, if you have any opening statements to make, either collectively or individually, we can take them now.

  (Dr Wright) My name is Stephen Wright and I am a consultant physician working within the Health Service; I am based within the University College London Hospitals NHS Trust working at the Hospital for Tropical Diseases.
  (Professor Finch) I am Professor Roger Finch and I am Professor of Infectious Diseases at the University of Nottingham; I am a consultant physician but trained in microbiology medicine and infectious diseases; I am past-President of the British Infection Society but currently President of the European Society for Clinical Microbiology and Infectious Disease, which is a correction to what has been stated. I have prepared an introduction but maybe it should follow the introduction of Dr Beeching.
  (Dr Beeching) I am Dr Nick Beeching and I am a senior lecturer in infectious diseases at the Liverpool School of Tropical Medicine and I am also the Clinical Lead in the Regional Infectious Disease Unit at the Royal London Hospital. In terms of positions that I hold, I am currently Chair of the Specialist Advisory Committee on Infectious Diseases and Tropical Medicine and Secretary of the Joint Colleges Committee between the Royal College of Physicians and Pathologists in Infection and Tropical Medicine and currently chair the Steering Committee which is appointing members of the National Travel Health Network and Centre.
  (Dr Wright) In my written statement, I stress that the first step in any surveillance is to make a diagnosis and that diagnosis can take one of several forms. Initially, it is clinical. One sees a patient, listens to the history, makes an examination and then, through clinical inference, makes a diagnosis. That diagnosis may prompt instant treatment, for example if one suspected meningococcal disease, or it may indicate a need for detailed investigations, and obviously the clinical status of the patient determines one's actions. In enhancing our ability to make diagnosis, we need to raise the profile of infectious diseases as a clinical speciality represented in district general hospitals. In this country, infectious disease hospitals were built around the peripheries of our towns and cities away from main centres of population where the wind could blow away the germs because there was little else in the pre-antibiotic period that we could do for them. As the `spots' doctors came towards retirement, they saw their hospital populations dwindling. These hospitals were often used for long-stay geriatric care and the expertise in infectious diseases declined. Consultants in infectious disease retired and were not replaced. The growth of sub-speciality medicine in this country really was in the mainstream and so infection became under-represented. We never had the strand of infectious disease running through academic medicine that had always been present in the United States and which has provided such fertile ground (a) for research and (b) for a thriving and vigorous clinical practice, and I believe that if we are to enhance the contribution of doctors at the bedside to surveillance, then we must have more infection orientated physicians in the mainstream of general medicine. Nick Beeching will talk about training later, so I will not venture into training issues. I think that the prospect for enhanced infectious disease surveillance that Getting Ahead of the Curve introduces will be excellent. The executive summary emphasises the burden on us all to contribute to surveillance and notification and hopefully, with the introduction of electronic methods, the whole business will become easier rather than the little book with the tear-off slips that sits in the bottom drawer of the desk in the SHO's room in the clinical ward. I turn finally to my subspecialty area, that of imported disease and tropical medicine. Prevention, as I am sure others will say, is the ideal thing and the National Centre for Travel Medicine and the associated network of travel health advice that Nick Beeching is chairing the steering committee for will be a tremendous asset in the business of preventing imported infectious diseases. In Getting Ahead of the Curve, the Chief Medical Officer draws attention to the rise in importation of falciparum malaria, the potentially fatal form of this disease. Just two years ago, we saw a considerable rise in importations, just over a couple of months, October/November of the year 2000, occurring predominantly in older holiday makers taking trips to the Gambia, often without adequate protection against malaria, chemoprophylaxis and anti-mosquito bite measures. I think that the availability of and ready access to information from the National Centre and through its network to both the travelling public and to the people they usually turn to for advice, which is general practitioners, will perhaps make our job less busy.
  (Professor Finch) My introductory statement is very much a personal observation rather than representing any organisations to which I belong. Essentially, men and micro-organisms interact in a complex variety of ways. The interaction can be a purely symbiotic or produce rapidly fatal disease. I think it is also important to spell out that infection and disease are not synonymous. Infection can arise from the normal organisms we carry, endogenous infection as we name it, but also from external sources. These external sources can arise from food, water, direct contact, airborne spread, occupational, recreational and travel associated and indeed vertically from mother to child in utero or during delivery. Surveillance therefore must accommodate this diversity if it is to inform management and policy. Current surveillance systems have largely grown out of activity and organisational arrangements that do not fit comfortably with today's knowledge, service delivery and preventative approaches. Many are indeed microbiologically focused which inevitably presupposes that infection is suspected, that samples are taken, that specimens are appropriately handled and that the data are collected and appropriately disseminated. However, I think it is fair to state—I do not think many people would disagree—that much infection goes unrecognised; it is therefore not sampled, is not confirmed by laboratory investigation and thus the data currently generated therefore is inevitably biased and does not accurately inform the response in the most effective manner. Clinically defined infection and microbiologically confirmed infection clearly vary widely. Infection is rarely an all or nothing phenomena. We sometimes see this with diseases such as chickenpox and formerly smallpox, but more usually infection can be likened to an iceberg you have an exposed population, you have some who are infected but do not respond clinically and then you have those in whom disease is expressed. So, if surveillance is to be more effective, I believe it needs to be more infection focused/disease expression focused. To achieve this will require a range of expertise that function in an integrated fashion. It clearly needs clinical expertise, both in the community and in the hospitals; it needs microbiological expertise, epidemiological expertise, environmental health and I would also add veterinary expertise as well. If we look at the current situation, I believe that the UK has much in the way of infection expertise. It may not always be trained appropriately and co-ordinated strategically and in large part reflects the way it has evolved, historically. Neither is the expertise linked in proportion to the population to be served and more fundamentally it is not adequately supported by IT to allow a two-way flow of information. The Health Protection Agency will hopefully address some of these issues. My concern is that, in developing the HPA there seems to be greater emphasis on reconfigurating existing services rather than developing a more comprehensive approach to deal with the infection hazards, identified within the document Getting Ahead of the Curve. I believe that we need to ensure that the clinical aspects of infection are better addressed. This would require enhancing the cadre of expertise in primary care in district general hospitals as well as in academic centres in a manner that is measured and relevant to the functions of the particular communities served.
  (Dr Beeching) Just to emphasise that my own evidence is given on a personal basis despite listing a few of the offices that I hold and I quite agree with all of the comments made by my two colleagues. I think I will just summarise very briefly the three strands of the evidence that I have given. I think there is a lot of good in Getting Ahead of the Curve in terms of modernising the notification surveillance systems. My concern is that most of the thrust of the document is looking more at the top end in organisation of that and I think that the cornerstone of any surveillance or notification system is real involvement of those at grass roots level who are actually either diagnosing or detecting problems or indeed feeding that data into the system. While legislation has been shown to fail, I think the challenge will be to provide adequate resources to those at ground level to actually have time to notify in whatever fashion is appropriate, but that also using a reward system in timely return of aggregated data in a fashion that is useful for local practitioners, either for public health physicians or infectious disease physicians or microbiologists, and I think that is still a major challenge that I do not feel has been fully addressed in the document. Certainly surveillance systems that are part owned by clinicians, I use the British Paediatric Association's surveillance system as an example, work much more effectively and perhaps may be a little more targeted. So, I think that is one of my major concerns and also the need to incorporate syndromic surveillance looking for odd cases of gastrointestinal disease rather than focusing on final diagnosis which limits what you are looking for. As my colleagues have said, I am concerned about adequate personnel on the ground and, as an infectious disease physician, of course I feel there should be more and we could perhaps return to the absolute numbers later on, but it is fair to say that distribution of specialist infectious disease units is very patchy across the country. Until recently, in the south of London and the west of London, there was nowhere except Bristol for the whole of the south of England. That is changing but there is still nowhere west of Bristol, for example—there is just no clinical infectious disease physician there—and I think we need to take a better look at the distribution of specialist clinical expertise and bedside clinical expertise, both for adult and paediatric practice throughout the United Kingdom. To use an example, when looking at a possible response to the deliberately released episodes, the number of clinicians available is actually very small and the number of clinicians available to respond to give advice to the various committees that need advice is even smaller and there is absolutely no slack in the system whatsoever to deal with any outbreak or epidemic. The third strand is the need to somehow involve and inform the public in a more pro-active fashion and I believe that an example of success has been the campaign to publicise chlamydia where magazines that young women and older women read were targeted expressly and the population is very aware of those risks. Whether it has changed practice is another matter, but I think that is an example of success. I think there are other examples where there has been less success which I will not dwell on.

  89. Thank you very much, gentlemen. You have all in fact put forward what is a consistent tale that is coming through in the evidence that we are receiving, but we will go onto the first question which I will take and that is, how can surveillance inform clinicians so that they can do their job better and are you able to influence the surveillance system in order to obtain the information you need? Looking over the evidence, it would seem that many facets are there but the co-ordination is very poor indeed and we have had a particularly critical bit of evidence from Dr Elizabeth Heywood of the CDSE South-East London pertaining to this. Who would like to start off with that question as to whether surveillance can inform clinicians and if I could couple that with informing the GPs as well as the hospital clinician?
  (Dr Beeching) I think there is a need, as stated in Getting Ahead of the Curve, to actually streamline and modernise the system and have a consistent way of gathering the data and of aggregating that centrally, whether that is notifying and collecting data on, for example, gastrointestinal disease from general practices, because that is where most of it will present, and aggregating those data either to regional level or regional level feeding through to the national level and perhaps involving local practitioners and asking them beforehand what sort of reports they would want. I would not want to be proscriptive about that. Working on my unit, I would want certain kind of reports sent to me on a regular basis of, for example, the salmonella, campylobacter and other specific pathogens, but I would also like to know if there is a sudden rise in undiagnosed diarrhoeal illness in general practices surrounding myself, and in fact units such as ours tend to act as the top of the iceberg that Professor Finch has mentioned, and we will start to see more cases coming through and should be prepared to diagnose them. So, I think it is involvement of local practitioners in determining the sort of data that they would want and they would find useful in real time. An example of success for me is the North West Regional Public Health Observatory which produces a superb annual report on all aspects of HIV management in the North-West and they have been doing that now for about six years. We get a nice book with all the data on district of residence of groups of patients, how many are presenting to different hospitals, highlighting difference in patterns of management of those patients which make us then look at our own management. That is the sort of thing that is very useful.

  90. Who does that go to?
  (Dr Beeching) That is sent to all the practitioners who provide data; it is published on a website, so it is fully accessible to the general public as well and I think it is a model which is envied by my colleagues in some other regions. They produce numerous other similar reports; I think they are quite well advanced in this sort of thing, but they do come to us on a regular basis every quarter and say, "What else do you want us to try and incorporate in next year's report?" and that motivates me to give them all the data that they need to fulfill their wider public health function.

Lord Lewis of Newnham

  91. Data is obviously very important but it is actually how you collect the data and who actually is responsible for giving you the data and how reliable the data is when you have it. You specifically argued about something in the North-West. How far, for instance, would that data be truly applicable to us? On a topic like that, I can see it has a lot of high sensitivity. Does that include throughout the whole country or is it patchy?
  (Dr Beeching) I think you could take that specific model anywhere in the country because it uses standard national definitions of status of disease, use of drugs and so on, so there is universal agreement across the country. I think you can qualify data; you can say how reliable the data are and, if you are looking for diarrhoeal disease, you can still use a very specific case definition and you will accept the vagueness that goes with that. I think you can build that into the interpretation of the data that are collected but, if they collect it at different levels by different people, then you have problems.

Chairman

  92. Professor Finch and Dr Wright, do you have any comments on that?
  (Professor Finch) I will take a slightly different approach. On average between one and two new infectious diseases are identified every year as a result of new diseases or new twists in the behaviour of existing Pathogens. Recognition of disease and its epidemiology is equally important. Surveillance looks at disease patterns, defines risk populations and any association with occupation, travel or other clustering. In other words, good information informs policy and management. We also learn a lot about the natural history of disease and its economic impact through good surveillance, but to ensure that it does actually translate into policy, there has to be an effective flow of information. Without good information technology, we do not get information in a timely and user friendly manner. It is important because we need to inform not just specialists but we also inform those in primary care, in hospital practice and of course the public. I highlighted in my written statement one initiative which is the National electronic Library of Health and its branch domaine for communicable diseases which is under development. I believe this is an important tool in the communication, education and management of communicable disease. It will provide information for the health care professional and eventually also to the public. The information will be quality tagged because it has been assessed and judged by experts in the field. So, I think by linking surveillance with information, with IT, and with quality assessment of the information, surveillance would be a much more effective tool.

Lord Quirk

  93. Professor Finch is President of the European Society for Infectious Diseases and I wondered whether his experience in that office gave him any insight into models and strategies used in European countries that we might be adopting. I wondered whether any of our witnesses saw an EU dimension in this whole issue and, to follow up what Lord Lewis was saying a moment ago, surely dissemination of information should not merely be confined to the North-West or indeed to England and Wales. To what extent should we be aiming at a European surveillance dissemination of data?
  (Professor Finch) Thank you for raising that question. The European Society is active in a number of ways in that we are interfacing not just with national professionals and organisations but with the European Commission, both in terms of trying to influence the research agenda and indeed developing research outputs. We have a number of Study Groups and organise workshops and a major annual congress which is a vehicle for communicating science and practice. The last meeting we held in Milan made a very positive statement through the involvement of the European Commission. Within Europe, there is considerable variation among the Member States with regard to the sophistication of their respective surveillance systems. However, we are learning much from each other and there are a number of collaborative initiatives across the field of infection. Some deal with gut associated diseases and others with legionella for example. There is a European surveillance system which is looking at straphylococcal and pneumococcal infections. There is a lot of activity going on within Europe but we need to make sure that we are all communicating effectively. Therefore, common definitions and good data collection are important. It is by better control of these fundamental factors that the quality of information will improve. One final point is that, about three months ago, Commissioner Byrne made a statement in Berlin indicating that there will be a European Centre for Public Health. How that will emerge I am not sure; it might be a virtual centre rather than bricks and mortar. However Europe is saying that we do need to view public health within Europe and beyond, in terms of the global village. I believe the UK is in fact very well positioned; it has a cadre of excellence in the infection disciplines and has systems that are mature and evolving; and I believe people are thinking creatively. So, I am optimistic but we do need also to look beyond our own shores.
  (Dr Wright) In the context of European integration and exchange of information, there is a network among the imported disease centres and tropical medicine centres in Europe gathering information on things like malaria and parasitic infections, but also with the aim of looking out for outbreaks where a number of people were exposed to a given risk in a given geographic place in the tropics and then travelled widely to centres in Europe. This happened a while ago with a group of people who undertook one of these challenges in a fairly extreme part of the world, I think somewhere in South East Asia. Thirty or 40 per cent of the group were exposed to leptospirosis and they started to appear, two or three cases with us and others around Europe. They were detected fairly rapidly and information was disseminated and so centres were aware of this possibility when they saw cases. That provides an example of the way in which, certainly by speciality and interest, people are looking to set up collaborations and again the availability of electronic notification considerably enhances the speed of things. Really, surveillance is something that we all practise. Sometimes it is in the dining room at lunchtime talking about cases we have seen with our microbiologists who are constantly isolating organisms, some that are circulating within hospitals, some in the community and it is the sort of loop, which is one of those dreadful phrases at the moment, coming back to me to tell me to look out for X, Y or Z that is important in order that I and my fellow clinicians can respond.

Lord Quirk: One would think especially in Germany where there are such large numbers of immigrants, more than in any other European country, we have a lot to learn and where they must have or should have a great deal of information on this issue.

Lord Oxburgh

  94. Professor Finch, from your European experience, do you see the same decline in the availability of ID expertise in other European countries and indeed whether other European countries have better or more effective reporting arrangements than we do?
  (Professor Finch) The question impinges on a number of different areas. I think I would like to correct your opinion that the UK has a declining expertise in infection. I think we have an expanding one although we do not have enough. In Europe, there is enormous variation in the number of infectious disease specialists per head of population ranking from the greatest in Italy, for example, to the least in a country like Belgium. I think that the challenges we see within Europe are in fact compounded not just by the emergence of new diseases but the dynamics associated with population movement and socio-economic issues and, particularly in relation to breakdown of the former Soviet Union. We are seeing disease knocking on the door of Europe which makes us concerned. There is a diphtheria epidemic in Russia and drug resistant tuberculosis in the Baltic States.

Lord Haskel

  95. This question is directed to Professor Finch. We are very interested in how surveillance and reporting systems could work better and quicker and, in your paper, you outline a number of questions that should be asked of the surveillance strategy. I wonder whether you could tell us how this might work in practice given the specific example, for instance, in relation to tuberculosis.
  (Professor Finch) Tuberculosis is probably one of the diseases that we manage more effectively than others, but it is a useful model to discuss those questions. I start by emphasising my introductory analogy in that tuberculosis is an `iceberg' phenomena. If you have a household member who is infected, there is a risk that one in four people will also have active disease. Of 100 people who are exposed, probably only 10 per cent will actually develop clinical disease. In other words, there is a lot of infection without disease expression but that also the phenomenon latency. In other words, disease may become manifest many years later when that individual ages, is perhaps placed on steroids for some reason or undergoes cancer treatment. So, the legacy of the past dictates disease problems of the future. Why am I saying this? Good surveillance systems, will provide information not just on the distribution of the populations affected but will also monitor the emergence of drug resistance. Drug resistant TB is now a cause of great concern internationally. In the UK, it is still running at a relatively low frequency but, when it increases, it is going to be very difficult to recognise this sufficiently early. We do need to have good surveillance to look at trends, to say whether policy and strategy should inform new diagnostic approaches, whether new treatment regimens should be recommended and whether you need more facilities for isolating patients who have drug resistant diseases are required. So, these are some of the questions that I think can only be answered by having good information and developing surveillance around specific questions.

  96. When we want to answer those questions, who would take these decisions? Who would actually try and implement?
  (Professor Finch) I think that infection and disease are so inter-related that you will probably have in fact a task force or a group of experts that cover the disciplines of epidemiology, clinical expression and public health, and their responsibility will be to look at the information relevant to that field and to make recommendations for management and prevention. By having good information at the starting point this must then be used effectively by a multi-disciplinary approach that is actually looking at the problem in the round and advising practice, advising investment and advising future policy. So, life is complicated but I do think we need expertise right across the field. We need to use the new sciences which include modelling and genetics in order to send messages to the industry saying, "We want better diagnostics" and "We want new drugs and vaccines to better manage disease".

  97. We had a very interesting note from a Dr Philip Mortimer who discussed this point and he said that a key to this is modelling responses by anticipatory exercises. I just wondered what you felt about that and indeed whether having a sort of dummy run might be an effective way of improving the way the system works.
  (Professor Finch) I think I would have to say that I cannot actually interpret what Dr Mortimer had in mind, but clearly modelling has been used effectively in a number of ways. Whether it is robust enough to apply in a sustained and consistent way right across the spectrum of infectious disease, I do not know.

Baroness Walmsley

  98. Professor Finch, you mentioned earlier this idea of the iceberg where you have the clinical expression at the top and at the bottom you have people who are totally immune and not infected at all and then there is the middle which I would like to concentrate on, where people have the infection but do not have any clinical expression. I understand that when resources are scarce, you have to concentrate on clinical expression, but surely you have a great reservoir here of infection and, as you have just commented, people will perhaps then sometimes show clinical expression later on when they become weaker or where the immune system breaks down. Are there dangers in concentrating on clinical expression of disease and totally ignoring that great big reservoir of infection that could become important at some other stage?
  (Professor Finch) I think that needs to be addressed around specific infections. I think the answer will be "yes" in many instances. One example it relates to is chronic infection with Hepatitis C virus. Our own studies in Trent have clearly demonstrated that not only is it a common disease but the epidemiology and natural history varies. In some individuals disease expression is much more rapid if they take alcohol or have co-infections with HIV. This spreads manifestations of chronic liver disease, such as cirrhosis and liver failure, and sometimes tumour. Sometimes it is important to know who is infected and not just those who are expressing the symptoms of disease. This is important in relation to HIV infection to understand the totality of the iceberg experience.

Chairman

  99. Dr Wright and Dr Beeching, have you any additional comments to make on this question?
  (Dr Wright) Certainly in malaria, we have recognised for many years that individuals from endemic areas who have a high degree of immunity to malaria may migrate to this country, be perfectly well and have malaria parasites circulating in the blood and that, if a woman of childbearing age were to come to this country, say from West Africa, she might, under the immunological alternations of pregnancy, express clinically apparent malaria. It would probably not be very practical to go looking for the malaria in her but of course, unless her blood were to be donated for blood transfusion while she is well and symptom free, then we must have screening processes in place and the use of serological techniques and perhaps increasingly the use of molecular technics, polymerase chain reaction and similar methods that can be used to look at the blood and the organs of patients that are to be transplanted. In some instances with organ transplantation, when one is shifting an infection from an organ donor to a recipient, toxoplasmosis is a disease that comes to mind—it is relatively common, perhaps 15 per cent of the population of this country can carry antibodies to the organism; the organism is living inside them at a very low level suppressed by our immune response. If my infected kidney were transplanted into somebody else, I could give them toxoplasmosis if they had not previously experienced this. Clinical experience has taught us that when that kind of mismatch of donation takes place, then we must intervene with chemotherapy to prevent the recipient of my infected kidney coming down with the disease that I could pass to them. So, in a range of situations, we need to be screening for disease and methods that are tolerant of high flows but operate to very high degrees of specificity and high sensitivity. The routine use of enzyme linked immunosorbent assay (ELISA) techniques for malaria antibody screening, as well as the question, "Have you ever had malaria?" which is on the list of diseases which exclude a blood donation.
  (Dr Beeching) Just to expand a little on that middle group or iceberg of the pyramid. I think that we do not deal with that adequately at the moment even for some of the well-recognised contact diseases and, if I could continue with Hepatitis C, we have had very mixed messages over the last few years from the centre on whether to screen the known high risk populations for Hepatitis C and the general message that I have received is that we should not do it because there is not too much that we can do about it but, on the other hand, we know that iv drug users will have a very high proportion of infection. One can at least start with health education and then have this built in as knowing that these people are infected and predicting those who are going to get into trouble because of additional risk factors. I think that with Hepatitis B for example, it is all too frequent that patients are diagnosed but that it is not taken further because of a failure of the system to ensure that people picked up in screening exercises are referred on for individual management and perhaps, more importantly from the public health point of view, that their contacts are screened and immunised as this is an infectious disease. So, I think, just using those two specific examples, we actually have a long way to go and that the reasons for screening are often not defined clearly enough. There may be quality issues about screening as well as a specific directed target of immunisation or treatment, but there may be these background issues of the future importance of those diseases for the individual.


 
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