Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 100-119)


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

Baroness Walmsley

  100. Does the human papilloma virus come into that category?
  (Dr Beeching) I am not an expert on that area but, yes, there is another oncogenic virus of potential. One then has to look at, does screening positive actually guarantee that you will or not develop cancer in the future and any screening system will engender uncertainties and one tries to determine the bounds of those uncertainties as part of the process. Clearly, one could only screen if one has a specific reason for doing so, whatever that would be.

Lord Lewis of Newnham

  101. If I understand correctly, the present systems that are being developed are really concerned with acute infections and outbreaks but are they suitable for surveillance of chronic disease which may be caused by infection? Professor Finch referred to chronic disease at one stage and I wonder if you could amplify on this.
  (Dr Wright) In chronic disease that may be infectious, the first one that comes to my mind is Crohn's Disease which has behavioural aspects and appearances under the microscope that are very suggestive that this might have something to do with the myco bacterial group of infections. Something akin to it in the Chairman's speciality: there was a paper in The Lancet a few years ago talking about the similarities between Crohn's Disease and something called Johne's Disease, which is a myco bacterial disease in cattle. Presently because of the distribution of clinical load, Crohn's Disease goes to gastroenterologists and tuberculosis comes to infection orientated people and so we have no means of looking at these sorts of things. Dr Beeching commented earlier about the British Paediatric Association and having speciality data collection organisations. The gastroenterologists have been aware of the increasing incidence of Crohn's Disease over the last two decades and so, among the gastroenterologists, there has been data collection to try to look for causes to understand why and who gets this disease. People have attempted to look for microbial aetiologies with varied results. So, at the moment, it would not seem that routine infectious disease surveillance would be applicable in the context of Crohn's Disease and, even in something that we label post-infective fatigue, we do not have a means of surveillance because it is not a notifiable disease but it does seem in a proportion of people to have an infectious precipitant based on the history and the given symptoms that suggest that there was an initial febrile viral illness, but the definition of chronic fatigue syndrome is that the symptoms have been present for six months, so well away in time from that initial event. So our present surveillance system is not applicable for seeking out those sorts of links.
  (Professor Finch) In my professional lifetime, there have been a number of diseases that I would never have entertained as being infectious in nature. Examples I can give are those of peptic ulcers disease Hepatitis C virus which has already been mentioned and the link with chronic liver disease and cancer. You mentioned pelvic inflammatory disease and infertility, Chlamydia has also been linked to theroma and coronary heart disease. So, I think the message is that our eyes need to be open and alert to the fact that surveillance that we set up today may in fact speak across specialties and here it is important to state that I do not think specialists in infection have a monopoly on science and practice within particular discipline. We need to ensure that there is this cross-fertilization and where a disease primarily falls into a specific specialist discipline that that is supported by the sciences necessary to define its nature and inform its management and prevention. So, we live in exciting and vibrant times which will continue to benefit from good surveillance.

Lord Oxburgh

  102. It is clear that with the rapid advances in biochemistry and associated technologies, near-patient diagnosis, in fact patient self-diagnosis for a range of conditions, is going to become progressively more available. I wonder if you would care to comment on this and indeed on the possibility of self-treatment that may come along as well. How is this going to affect things?
  (Dr Wright) You may think that I will become a cracked record but again I have to go back to malaria as an instance where the topic you raise is highly applicable. It takes considerable practice and skill to learn to recognise malaria parasites when concentrations are down to 0.001 per cent of red cells parasitised. There are now available antigen detection techniques based on proteins derived from the malaria parasite in one instance, the histidine rich protein, in another the parasite lactate dehydrogenase which can be differentiated from the human lactate dehydrogenase. There are now simple techniques available that have built into them a control to see that the system is working and a clear identification that the parasite is there or not. Certainly for some of the people, we see geologists, for example, who are going off miles from anywhere to explore for oil or gold, the use of these kinds of technologies is valuable and would be as an adjunct to saying to them, "Well, if you get a fever, start yourself on Quinine for five days and then Fansidar." So, one could imagine this technology being used. Similarly, it may help the general practitioner in this country who, in the depths of winter, sees a patient with a fever who says "Two weeks ago, I came back from the Gambia where I have been for a week, could that be relevant?" and the test that can be read within 10 minutes may help to guide the general practitioner. So, I think that this kind of technology is very valuable and certainly may help both the traveller and the doctor working in this country and indeed the diagnostic laboratory in this country to back up their microscopic skills with a test that we hope will correlate with the microscopic diagnosis. The question of DNA based technology of course is much more complex and there are worries about contamination because one molecule of DNA with the right sequence in it will create a positive response. I think that while we look to the DNA based technologies as being very valuable in sorting out so many patients that we presently characterise as having a viral illness, that will remain in the realm of the specialist laboratory because of the sophistication of techniques and the meticulous care. So, for near-patient testing? Not yet.
  (Professor Finch) Diagnostic precision can only be a good thing. Not only does it actually speed diagnosis and hopefully direct management, but it also provides information that can alert to an outbreak. So, when you think that in the 21st century 80 per cent of all infections are managed in the community, often a diagnosis based on symptoms and signs it raises the question "Is this still in fact the way we should be practising medicine?" I do not know. My view is that we need to apply any new diagnostic technology in a critical manner. This may be to sort out common management problems. In respiratory infections "Is it viral or bacterial?" That is an easier question to answer than it is to say, "What is the exact organism causing this and what is its antibiotic sensitivity?" I think we should not indulge in diagnostic greed, but we should develop rapid approaches to improving diagnostic precision around management questions. I can see this applying in the hospital arena. A test which just tells me about the absence of a particular problem may be a good thing. For example, a rapid MRSA diagnostic. If I knew whether a particular patient does or does not have MRSA then I can manage them much more effectively. I think what we need is a strategy around any promotion of near-patient testing that is seeking specific answers to questions that will inform management and practice. We may get chip technology eventually, if we can afford it. This will give us the name of the Pathogen, the resistance pattern and hopefully will sort out every type of jaundiced patient we can ever meet. On the other hand, I think it is a step-by-step approach. Good surveillance will inform this particular approach in defining the shopping list we send to industry, saying, "Give us a particular answer."
  (Dr Beeching) Yes, I agree with that. I think there is a great role for this. I think, within the context that each test is being used, they should be over-sensitive, they should not miss decisions, they should be too inclusive, and people will either refer themselves on, if they are doing an over-the-counter test, or, in a hospital setting, their needs can be confirmed by more rigorous tests. I would use a quick test for chlamydia as an example. While taking up a positive chlamydia test, one should then be looking for other sexually transmitted diseases, and one has to think how these are going to be applied in different settings but they could actually reduce a lot of unnecessary consultation at the same time. There are of course all the issues of quality control, which may be difficult to ensure, whereas one has more control over laboratory-based testing, but I think one can get around that problem. Also one could look at novel methods of surveillance, using over-the-counter purchase of these sorts of test or indeed of antimicrobials as a form of syndromic monitoring of what is going on in the population, so one could actually use the sale of these things to the general public as another way of looking for different kinds of syndromic illness that is around. Over-the-counter treatment: there are examples of antimicrobials where it is unlikely that general harm will ensue from using these and there are an increasing number of things being licensed, but clearly one has to go on monitoring antimicrobial resistance patterns and to try to tie those in with the possible abuse of such compounds. But if somebody has a straight-forward condition that can be treated by a straightforward pill over-the-counter, I see no reason why the general public cannot by-pass their general practitioner and save time.

Lord Lewis of Newnham

  103. I am very sympathetic to the remarks you made. It is very important on the reliability of these particular tests. You very rightly said that it is better to over-emphasise rather than to under-emphasise. What controls are there?
  (Dr Beeching) My understanding is that these are registered by the Medical Devices Agency and there will be standards of sensitivity/specificity which the manufacturers will have to supply. I think that is the level at which one would control the operation of these and I think it will be important for post-marketing surveillance, which I presume is done in the same way as one would do for medications, to see how they are actually used in real life.

Lord Patel

  104. Is it not correct that now the registering of these devices will come under the aegis of the Medical Medicines Control Agency.
  (Dr Beeching) I think so, but I would have to check to give you a definite answer.

  105. Preventing outbreaks and spread of infectious diseases, apart from increasing the use of vaccines, what other measures do you feel could be taken in this country with outbreaks and the spread of infectious diseases?
  (Dr Beeching) That is a very complicated question to answer. One can be very simplistic and say improving living conditions is at the root of many of these things. As one improves social standards, then certainly background endemicity of much infectious disease will improve. I think one can target specific groups for specific diseases in terms of health education. Health education unfortunately is not necessarily followed by improvements in risk behaviour, but I think there have been successes. I would use as an example the relatively liberal use of methadone in this country, in stabilising drug use for many drug users if not stopping it, and actually allowing that population to be an access for other aspects of health prevention, which would include vaccination but also other measures, the provision of free syringes and so on. So I think they have to be appropriate for the group at risk. I think the gay population showed us very well in the 1980s that appropriate health prevention messages driven by the group could actually lead to changes in behaviour, which perhaps have not been sustained. I think health education has to be part of it.

  106. You mentioned earlier on two diseases in connection with the question Baroness Walmsley was asking you, chlamydia and human papilloma virus. We know that surveillance of that particular infection will identify at-risk population but how are you going to prevent it spreading? because that requires education on an individual basis, otherwise they get reinfected again.
  (Dr Beeching) It is extremely difficult. One has to address wider issues; for example, the sale of alcohol to young people who are sexually active and there are many other issues that promote promiscuity and the spread of sexually transmitted disease. That is why I am saying it is a very difficult question to answer because one has to take a very lateral view of what are the behaviour patterns that encourage spread of any specific infection.
  (Dr Wright) Asymptomatic carriage of chlamydia is so common. While obviously females are the recipients of the disease process (pelvic inflammatory disease, infertility, ectopic pregnancy), among males there must be a large amount of asymptomatic carriage. How would one extend the screening process to include all of those potentially at risk, with sexual behaviour as it is in the 21st century UK? I suppose this would take us to the question of vaccines again. What we need are good vaccines against, clearly, meningococcus type B, which would be head of our wish list at the moment, along with HIV, but, with a disease like chlamydia with major problems in half the population and frequent carriage in men, where would that come on the scale of priority? I would find it difficult to fix its place on the ladder.

Baroness Walmsley

  107. My question is about chlamydia. Dr Beeching, you mentioned earlier that you thought that the public information campaign about chlamydia had been a success. Given the fact that we know the incidence is rising at a very worrying rate, I wondered what was the basis of your feeling about that? Why it is a success?
  (Dr Beeching) I think it was a success in informing the population. What I also said was that I did not think it had been successful in changing behaviour. I think that is the big challenge. There is a big gap between knowing what you should or should not do and not doing it. I think that is the real problem. I was just using that as an example where the population was well informed, even if they did not change behaviour.
  (Professor Finch) The control of infection is clearly a partnership between the professionals, the public and government. It is about education, it is about behavioural change as well as about specific strategies. If you look at the burden of disease and how it is acquired, then clearly gastro-intestinal disease figures prominently, as does respiratory disease while travel associated problems are increasing. I think what we have to do is to use the surveillance more creatively to inform a societal approach to education—which is likely to include nurseries, schools, adult education and the media. Such a strategy should encourage very simple measures of hygiene within the home, within the workplace, within the food industry and include the safe disposal of waste materials. Some diseases act as a socio-economic barometer, such as TB, which is on the increase, and in part driven by economic and social issues. The HIV epidemic is another area where a more effective policy needs to be developed to bring about change. It goes back to a point I was making, that control has to be disease or infection focused but it must be strategic, and sustained. I think here we need to learn from the world of commerce. How on earth do you actually remember products such as Coca-Cola ? It is because you are actually hearing about them every day through the media and billboards. Any educational campaign needs to be coordinated and sustained and monitored for its effectiveness. It should not be a sporadic experience.

Lord Haskel

  108. There is of course another way. I take your point about learning from the commercial world, but there is another way, the way used by the Drink and Drive Campaign, by just terrifying people, by showing people the result of traffic accidents when people have had too much to drink. Do you think that has a role to play? One could show how it ruins people's lives.
  (Professor Finch) I have likened the problem of hand hygiene to the speed limit: we all passed our driving test; we read the Highway code; there are clear recommendations about the driving speed by situation; and there are warning signs along the road. You also police it with manual speed traps. But it is only when speed cameras were installed that you actually bring about a radical change in driving behaviour. So maybe it is coercion, maybe it is the stick in relation to the practice of good hygiene sometimes.
  (Dr Beeching) If I could just expand on that, I think the real shock factor campaigns do not work. The early HIV campaigns in Australia and Britain terrified children and had no effect whatsoever on the people for whom they were intended. Many of you will remember the image of a needle stuck through an arm, which had no health prevention benefit whatsoever in reducing risky use of IV drugs. I think people really only take messages on board when they know somebody who has been affected or do that by proxy, by reading sympathetic articles in magazines or whatever. I do not think the hard shock actually works. I think the constant drip feed is likely to be more effective.

Baroness Walmsley

  109. Professor Finch, could I ask you about your reference to prisoners and asylum seekers as being a particular concern in disease control. How do you think we can improve surveillance of these groups without instituting a culture of blame or invading their human rights in any way?
  (Professor Finch) I raised this issue specifically because it is something that is actually impacting now on society and medical practice and social services. With the growing prison population (about 70,000) we have an environment in which some infections can be transmitted. Those are not just blood-borne viruses (HIV, hepatitis B and hepatitis C) but other consequences of close living, like TB, for example. In the States they have had recent outbreaks of MRSA within the prison population. Apart from the concerns about the welfare of prisoners, it is also an amplification system for disease that will eventually spill out into society and is then picked up by the NHS and other services. There is insufficient coordination at the moment between the way the prison medical services are run and the National Health Service. There does not appear to be a forum for debate to determine policy, strategy and management. Surveillance within the prison population is something that should be addressed because it does impact on the health service and is creating long-term costs in the management of some infections. The other population is actually the asylum seeker. We have seen a substantial increase in the number of such individuals just in our own area. Not only do they have the problems of adjusting to a new life and being integrated into the local community, but they are bringing with them a complex array of health problems. Some are psychological but many are infection related. There is an increasing population of people coming from Africa and Zimbabwe in particular. I have brought our own local data on national asylum seeker statistics: within the areas of Derbyshire, Leicestershire, Lincolnshire, Northamptonshire and Nottinghamshire where we have had around about 5,242 individuals. Within that population and without any active screening we have a 4.5 per cent HIV positivity rate. This problem is unplanned, unresourced is having a major impact on health delivery, not just in terms of acute services but in the way social services are trying to cope with these many complex social problems. This is another example of the dynamics of infection and where timely surveillance should inform policy and management.
  (Dr Beeching) I would like to expand on that a little, if I may, my Lord Chairman, because this is very much part of my everyday practice. I do go into the prisons and I despair of the separation of just clinical management of people in prison from the outside NHS. There is very little continuity of care between the group of people which cycles through, in and out of prison very fast, and serves as a massive amplification system for certain infections. Professor Finch has highlighted the major ones. I think it is a hugely wasted opportunity for easy interventions and less easy interventions. We need to integrate prison healthcare with other health care, communicating in the way that we do in routine NHS practice. Normally, if I see a patient in hospital I write to the general practitioner. Even those levels of communication between the prison services and general practice are not there and I am not sure that there is communication between different prisons either. I think there is plenty of room for intervention there. I would just echo the comments about the lack of continuity of care of the asylum seeker and refugee population. They move around the country very fast, and it is difficult to work out who they are and where they are, and the health service attached to that is really very disjointed. Without in any way stigmatising those groups, one could give them a health record to take around the country with them. That at least would benefit the individuals. But there is gross under-resourcing, both of statutory services and non-statutory services to support these people, and that is having a major effect on service delivery in my own area and I am sure in others—chronic problems, both infectious and non-infectious, which are often pre-eminent. I think joining up health care and resources with the other things for those groups is very important.

Lord Oxburgh

  110. Who pays for health care in prisons? Is it the prison service or the NHS?
  (Dr Beeching) The prison service has a budget of its own, I believe.

  111. So it is in competition with other priorities within the prison service.
  (Dr Beeching) That may be so. Again, I do not know the precise answer to that.

Baroness Walmsley

  112. Dr Beeching, you have mentioned health records that should follow the person and you have mentioned increased resources, but, in your experience, would increased actual testing and surveillance be acceptable to prisoners on the whole? Because any kind of compulsion would obviously be against their rights but we have to stop this amplification to which you have referred. Would it normally be accepted, do you think?
  (Dr Beeching) It depends on who does it and where. The local prison I visit has 250 receptions a day and you can imagine that asking confidential questions of prisoners in reception is extremely difficult. So one has to overcome basic logistic problems. Nevertheless, if prisoners know there is a benefit to follow—such as immunisation against hepatitis B which will prevent them passing it onto their family when they go out—then they will access it. But one has to provide resources for time, which is difficult. So it is labour intensive but it can be linked to obvious benefits for the prisoners. At the same time one has to be sure that medical data gathered in that fashion remains confidential and in an enclosed prison system there are many problems to be overcome in doing so. I think the Scottish experience has shown that people will volunteer for testing programmes. I think the Scots have in general shown us the way to do these things and I think there is potential for involving prisoners more without stigmatising them.

  113. It sounds from what you say that a custodial sentence should come with a health warning!
  (Dr Beeching) Yes.

  114. How do they do it in Scotland?
  (Dr Beeching) There have been more surveys and they have been very actively involved both in long-term prisons—which is a very different setting actually from short-term local prisons . . . The turnover in long-term prisons and the health problems there are rather different. I think they have been more upfront about it. They have had specific problems which have prompted that—which we think we have avoided, but I am not sure that we know that—and I think there has been a more pro-active approach to controversial measures, such as the use of the provision of methadone in prisons, for example. These are very difficult areas politically.
  (Dr Wright) In the context of asylum seekers, the use of health professionals among their own number, of course, would be valuable where possible, so that it is somebody who speaks their own language who would be talking to them about the value and benefits of having a chest x-ray rather than somebody who is external and who speaks through an interpreter and has very little personal and social rapport. That is an area I think that others have suggested and it is well worth exploring because there are likely to be professionals among those who have taken the opportunity to migrate from places of civil unrest in the world.

Chairman

  115. Could we turn to question 8, knowing that Dr Wright has to leave us, which is: How can we ensure that a patient recently returned from the Tropics gets appropriate expert treatment wherever they present in England and Wales?
  (Dr Wright) It all depends what you mean by wherever. If wherever is Liverpool and London, then probably, with due modesty, one could say that things are reasonably all right. There is, within the training framework for infectious diseases—certainly for a number of trainees on our North Thames rotation—the opportunity to spend a year in a unit such as ours, and a regular stream of specialist registrars pass through Nick's unit. In those sorts of locations, training would involve them directly and personally in the assessment of the sorts of patients envisaged in the question framed. More widely, infectious disease specialists are aware of the problems in the Tropics but the reality is that many patients are presenting to district general hospitals, to the general physician firm on take for that night. Teaching of infectious disease and imported disease has improved in medical schools, is now a strand in specialist registrar training, but, when I looked around to find out if there is an opportunity to teach infection-oriented training among general internal medicine training, that does seem to be lacking. Everyone now is doing general medicine plus a sub-speciality in their specialist registrar years. The chest physicians will learn about tuberculosis of the chest and pneumonia, the neurologists about encephalitis and meningitis, the nephrologists about urinary tract infections and the problems with infection in the bladder and the kidneys. But, in terms of integrating the general assessment of sepsis there does not appear to be a strand of general medical training that is offered into which one might incorporate that. We are really dependent upon recognition of the potential for there to be a problem—somebody who has come back from (I used the example previously but it is relatively common) the Gambia with a fever, and we are commonly seeing general practitioners sending patients in query malaria. Performance of laboratories in testing for malaria on the national quality assurance scheme has improved progressively over the last two decades and so malaria is more readily and more frequently being diagnosed and we are being readily contacted for advice regarding management protocols and guidelines. We give that advice and we take over the care of patients where appropriate. While I would love to say that there should be an infectious disease specialist in every district general hospital who would be available for consultation, all the microbiologists in every district general hospital would have an active interest in imported infectious diseases, at the moment that is not the case, and so we are dependent upon awareness of travel related problems. There is a lot of publicity about this in the lay press as well as in the medical press. There is frequent discussion of the preparation needed for travel to the Tropics. There are in the annual reports of the medical protection societies, references to inadequate and improper management of malaria making us aware of the problem. The difficulty comes when the diagnosis of malaria as the cause of imported fever from Africa is considered and the initial diagnosis is negative and then one comes into the area of the possibility that this could be one of the viral haemorrhagic fevers that are of such concern. Over the years there have been a number of importations of Lassa Fever. For example, one 20 years ago, where a young woman from Northern Nigeria had returned from a holiday visit to that country and was admitted to hospital in London and extensively investigated over a period of 10 days before she exhibited signs that were characteristic and led to transfer to a high security unit. I suppose we can take some reassurance that there were no secondary cases occurring in the context of that case, but one would have liked the recognition of that possibility much earlier. There is a booklet available to us to guide us in managing cases such as I have described, prepared by the Advisory Committee on Dangerous Pathogens, and certainly that committee will be involved in the overall strategy for disease surveillance that is envisaged in Getting Ahead of the Curve. We are frequently telephoned by our colleagues in district hospitals to talk about cases such as this. There is a clearly set out programme of both risk assessment and management guidelines in the ACDP booklet on viral haemorrhagic fevers, and these provide a reasonable basis for action but they are rather proscriptive and seem to delay the need for testing, whereas we would like to see testing for these infections, which is done both at the Central Public Health Laboratory in Colindale and at the Centre for Applied Microbiology and Research in Porton. We would like to see that testing much earlier. It is, I think, continued training, continued teaching, continued efforts to make people aware of the range of possibilities for both acute imported disease and more chronic imported diseases. We have seen a considerable increase in importations of schistosomiasis to this country, particularly among young travellers in eastern and southern Africa. This can often be completely asympomatic: the part of the ice berg that is well below the waterline that was referred to earlier. In many instances it will cause no problems, but occasionally the worms can get into the spinal cord and produce a devastating illness. In those who are asymptomatic, we often see that they have encountered resistance to referral to our hospital for assessment. This may be because of the economic problems about sending a patient outside one's area to a specialist hospital but we would like to disabuse people of the notion that screening in those circumstances is not worthwhile. Our hospital offers an open door to looking at patients, both acutely and more chronically. We offer support because we recognise that most of the patients with imported disease are going to present across the country and we recognise that general physicians are going to be taking these people in and we rely upon a certain amount of input from the microbiologists in those hospitals to guide physicians and perhaps to advise them to contact us for further discussion.

  116. The crux, of course, is the very early diagnosis of somebody presenting, by the person or their GP. You have mentioned malaria, of course, where they have been to a malarial area but have been on anti-malarials and the possibility of malaria is discounted, not realising upon the probability of a drug-resistant malaria. I suppose the question is: are GPs sufficiently aware of the vast array of exotic infections that can come in, not only parasitic but viral or perhaps fungal, that present initially as flu or a common cold or whatever?
  (Dr Wright) I think the reality must be no, that the range of things which can initially present with a febrile illness covers organisms that I am sure they would never consider. As medical students one usually hears something about schistosomiasis but it can in its acute presentation, when the organisms are invading and starting to lay their eggs, evoke major inflammatory responses and it could present as a feverish illness. A group of schoolboys who went on a school project to Malawi, something like 60-70 per cent of them presented with a febrile illness and were shown to have acute schistosomiasis. It may be an ambic liver abscess, it may be typhoid, but the range of possibilities is wide, so at least thinking of malaria and sending the patient in for assessment is a major first step. It is considering the possibility of infection: "How can I best get that patient assessed? Is it something that I can reasonably do myself or is the condition of the patient such that I really need to get them assessed in a laboratory setting?" In my written comments I talked about the levels of diagnosis. A clinical diagnosis, a streptococcal sore throat, may lead to administration of penicillin and a successful outcome. The need to recognise a sick patient who therefore needs some more detailed investigation with microscopical examination of blood forms, culture of blood and specific serological testing for infectious agents, is usually a hospital-based effort.

  117. I am informed that imported malaria deaths have stayed at a steady state or indeed increased in recent years. Is this because of the increased exposure or less experienced younger GPs who have never seen the disease?
  (Dr Wright) The numbers of people travelling to the areas of the Tropics that are malarious have progressively increased—and the document that is the basis to this discussion illustrates the numbers. Travel medicine preparation is most often thought of in terms of: "What vaccinations do I need to go to Kenya on holiday?" but the reality is that the vaccinations are going to prevent us from getting diseases that are probably not very common. The more likely things are malaria and gastrointestinal disease, excess alcohol and excess sun exposure—all things that in essence are behavioural rather than things that can be prevented with an injection. We were discussing earlier the role of human behaviour in susceptibility to disease and it is the most difficult thing to modify. The pressured general practitioner offering travel medicine services would probably find it more convenient to vaccinate, and the patient would feel they had got something, rather than spend 10 or 15 minutes talking about the risks of malaria, how it is transmitted, how it can be prevented by chemotherapy and by measures to minimise the risk of bites by malarious mosquitoes. These are the sorts of issues. Adequate time for the general practitioner or their practice nurse to spend discussing these issues with the traveller and ready access to adequate information on which to base advice given.

Baroness Walmsley

  118. I just wanted to follow up really on the advice to travellers, because I was amazed to hear you say earlier on, Dr Wright, that some older travellers had gone to the Gambia and taken no precautions at all about malaria, because my own personal experience is that there are a lot of mosquitos there and they bite. But it brings me on to the quality of that advice and the quality of the assessment of the products that are available. You can get an enormous lot of sprays that you can spray on yourself to stop mosquitos biting and some of them work and some of them do not. How does the ordinary patient get good quality advice about the quality of some of these sprays? The majority of them do not work on me.
  (Dr Wright) The basic product in them that discourages the bite of mosquitos is DEET (Diethyl ethylphalate). Some of the early preparations were water-soluble: if one had put them on in the evening before going to have a gin and tonic on the terrace of one's hotel before dinner and had wiped one's brow, the DEET would come off because it was water soluble. The products available now have a longer life on the skin, four to six hours, and the travellers should be looking for a product that says, "It will stay on your skin for four to six hours." That kind of information the traveller needs to know.

  119. Is there a case for a better partnership between the medical professions and the travel industry?
  (Dr Wright) Yes. Our hospital is seeking ways of relating to the Association of British Travel Agents so that we can perhaps be a means of supplying adequate information that could as a preliminary be given by the travel agent to the traveller and then the traveller discuss that with their own GP or their practice nurse. The Hospital of Tropical Diseases has carried out studies in conjunction with the School of Hygiene and insect repellant manufacturers, for example, to be able to show that the repellent concerned will repel mosquitos in actual clinical experiments where mosquitos are exposed to the skin and whether they settle or do not settle.
  (Dr Beeching) If I may pick up on a couple of points. Just sticking with the pre-travel advice, the function of this new consortium and network, the National Travel Health Network and Centre which is funded by the DoH will be looking to provide a national standard of advice to which everybody can subscribe, instead of having different charts on different people's walls. That is one of its primary aims, and also to provide guidelines for specific groups of travellers, the elderly, the diabetic or whatever. That is one of its key functions. I think another thing is targeting the high risk group. We talked about malaria. Over 75 per cent of malaria now imported is the lethal form but it is imported primarily not by tourists and businessmen but by people going home to visit friends and relations in Africa or in India. Those particular groups very rarely heed any advice or take any advice and I think our challenge is to realise that they need to think about these sort of things. I think in terms of prevention there are targets. If I may, Chairman, briefly come back to the issue of: does a patient get the appropriate expert treatment? I believe the answer is no and I think the answer is to have more clinically trained individuals with an interest in infection, and preferably throughout the UK in a hospital setting, but also I think that within each infectious disease centre one of those clinicians should have experience of tropical medicine. So far it is more concentrated in a few centres.



 
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