Select Committee on Science and Technology Minutes of Evidence

Memorandum by Dr Derrick Crook

1.   What are the main problems facing the surveillance, treatment and prevention of human infectious disease in the United Kingdom?

  Surveillance as emphasised in "Getting Ahead of the Curve" is heavily dependent on passive reporting. This has served well in the past for detecting outbreaks; but, as there is no reliable population base, record of disease manifestation or outcome data, this design of surveillance is limited in its capacity to measure the following important aspects of endemic infectious disease:

    (a)  Measure accurately the burden (morbidity and mortality) of infectious diseases.

    (b)  Determine the transmission properties of organisms (both hospital and community).

  This information is crucial to forming policy on disease priorities and the cost benefit of prevention strategies. It also benefits understanding the variation in prevalence and patterns of disease.

  Comprehensive and enhanced passive surveillance with clear aims will, however, provide a sound basis for detecting outbreaks, be they naturally occurring or from a deliberate (bio-terrorist) release. As emphasised in "Getting Ahead of the Curve", this form of surveillance will need to be underpinned by good clinical reporting and specialist laboratory facilities. Well publicised examples of outbreaks in the USA further emphasise this point.

  Treatment of infectious diseases in the UK varies in standard, improving on this will need long-term strategies. The evidence base for treatment could be greatly improved, but will need substantial clinical investigation. The clinical competence of specialists in the field could be enhanced, but this will take years to achieve.

  Prevention is dependent on a complex interplay between recruiting high quality people, remaining abreast of improvements in knowledge and technology, and having a sound organisational and physical infrastructure for delivering prevention. Much of this rests on attracting high quality people into the field, which is increasingly not the case, as is well illustrated by the Academy of Medical Sciences report into Academic Bacteriology.

2.   Will these problems be adequately addressed by the Government's recent infectious disease strategy, Getting Ahead of the Curve?

  The document addresses these problems and many of the recommendations will part remedy the problems. However, the document does not provide clear recommendations on the following:

    (a)  Building a cadre of highly motivated, skilled and able specialists for the future. The CDC, Atlanta, USA has promoted a training scheme for Epidemic Intelligence Service (EIS) Officer that has attracted many of the most talented infectious diseases clinicians in the USA. These people have gone on to successfully seed the pool of people available to lead many aspects of "fighting infection" in the USA and even in other countries.

    (b)  Emphasise the need for co-ordination among specialists in the field and reduce fragmentation. This is well illustrated by the small subspecialties of Clinical Virology and to some extent applies to Infectious Diseases which work largely independently of Clinical Microbiologists. A model for greater co-ordination between these specialists in a joined up "practice" will foster improvements in the delivery of infection services. The report on Academic Bacteriology by the Academy of Medical Sciences deals with this point and it deserves wider support in the hope of overcoming artificial and inhibitory barriers.

    (c)  Improving the clinical microbiology laboratory infrastructure. The recent deliberate anthrax releases in the USA illustrated the inadequacy of Hospital and State Laboratories in that country in meeting effectively the demands arising from such an extreme and serious outbreak. A major programme of upgrading laboratories there has been embarked on. UK labs are in need of such upgrading to be adequately equipped for handling major outbreaks and maintaining high standards of microbiology that underpin surveillance, treatment and prevention of communicable disease.

3.   Is the United Kingdom benefiting from advances in surveillance and diagnostic technologies; if not, what are the obstacles to its doing so?

    (a)  Improvement in surveillance depends not only on training and recruiting high quality people, but also on improving the rigor of surveillance by insisting on achieving academic rigor in the work (as reflected by publication or grant raising record). This fosters an attitude receptive to new ideas which is an essential first step to benefiting from advances in knowledge and technology. This is the case, for example, at the CDC, Atlanta or The National Public Health Institute KTL, Finland. A specific point to be considered is establishing defined population based sampling frames (eg through sentinel PCTs, hospitals and laboratories for measuring communicable disease).

    (b)  Similarly, improvement in advances in diagnostic technologies depends on imposing similar academic rigor in reference laboratories to create a permissive environment for new developments. This could alternatively, in the future, be lead through centres of excellence as proposed by the report on Academic Bacteriology produced by the Academy of Medical Sciences.

4.   Should the United Kingdom make greater use of vaccines to combat infection and what problems exist for developing new, more effective or safer vaccines?

    (a)  As in the past, a continuing programme for introducing vaccines should be followed. The main obstacle is determining the efficacy of vaccines. In part, this is possible through challenge studies, but ultimately it will depend on large scale efficacy trials. The scale of these studies may involve a large part of the country and will inevitably be complex. Consequently, an infrastructure suitable for conducting such large scale studies is needed and may in part be provided by the MRC Clinical Trials Unit and/or through collaboration with University Departments.

5.   Which infectious diseases pose the biggest threats in the foreseeable future?

    (a)  "Getting Ahead of the Curve" lists them well. Which new or re-emergent infections may arise and pose major threat is stochastic and, therefore, difficult to predict. An approach of being able to respond to outbreaks in general is the best approach for this type of threat.

    (b)  An obvious and ongoing threat of infection arises from adaptation of organisms to antibiotic exposure or immune selection following vaccination. This could be quantified through rigorous surveillance with state-of-the-art molecular epidemiology and better predictions could be formulated about future emergence and spread of such antibiotic resistant organisms or variants that escape host immunity.

6.   What policy interventions would have the greatest impact on preventing outbreaks of and damage caused by infectious disease in the United Kingdom?

  The greatest impact would come from the following:

    (a)  Develop early and focused leadership through the HPA that re-invigorates the field of Communicable Disease Control at a national level and thereby promotes improvement in standards.

    (b)  Build a cadre of talented specialists by creating a training fellowship scheme akin to the CDC EIS Officer scheme.

    (c)  Develop high-class epidemiology, surveillance and reference microbiology with the achievement of high standards through the early imposition of rigorous academic standards.

    (d)  Introduce state of the art information technology necessary for both the clinical microbiology laboratories and capturing surveillance data, this will only be achievable in the medium term.

    (e)  Renewing the clinical microbiology laboratory infrastructure as an early aim.

    (f)  Promote the coalescence of the fragmented specialisations in Infection (eg Clinical Microbiology, Clinical Virology, Infectious Diseases, etc) as an early aim.

    (g)  Build centres of academic excellence as suggested in the report into Academic Bacteriology by the Academy of Medical Sciences. These could work in concert with the HPA in raising standards. This will take time to develop.

  Further practical considerations:

    (a)  Recognise different, but complementary requirements for conventional Clinical Microbiology versus preparing for the threat of Bio-terrorism.

    (b)  Some changes are urgent and need early implementation (eg organisational restructuring, immediate review and imposition of higher standards in reference work) and others need long term planning and execution (eg recruitment of highly trained and talented people for the future).

    (c)  A major effort needs to be placed on Information Technology, however this will need major investment.

    (d)  Establish guidelines for implementing closer joint working between NHS laboratories, the HPA, University Departments, related government departments (eg DEFRA) and even commercial laboratories.

    (e)  Undertake a thorough costing exercise to determine the price of making major changes envisioned to improve standards in the detection, surveillance, treatment and prevention of human infectious disease.

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