Select Committee on Science and Technology Minutes of Evidence



Memorandum by Dr Maria C Zambon Head of Respiratory Virus Unit, Deputy Director, ERNVL, PHLS Central Public Health Laboratory, Dr David W G Brown Laboratory Director, ERNVL, PHLS Central Public Laboratory, Dr Elizabeth Miller, Head of Immunisation Division, PHLS Communicatable Disease Surveillance Centre

CURRENT EFFECTIVENESS OF THE SURVEILLANCE SYSTEMS IN THE UNITED KINGDOM AND POTENTIAL PROBLEMS IN THE FUTURE

  Surveillance systems in the United Kingdom cover a wide span of organisms and microbiological problems from a variety of perspectives. It is our view that the most effective surveillance systems are those that are focused directly to specific public health questions and from which data feeds directly into policy decisions. Excellent examples of this would include the Measles, Mumps and Rubella surveillance systems which hinge around the verification of disease notification and the surveillance of influenza which is based around the capture of influenza virus isolates. Both of these examples are integral parts of national and international vaccine programmes. Another excellent example is the surveillance of meningococcal disease burden, disease notification and characterisation of meningococcal isolates, the data outputs of which have verified that the introduction of Meningococcal C vaccine, a significant public health intervention, has indeed been a notable scientific and public health success. All of these are examples of surveillance programmes which have strong academic science inputs, with the introduction and application of novel surveillance strategies and implementation of cutting edge technologies.

  However within the United Kingdom many disease verification and microbiology surveillance systems suffer from a historical approach, which is that of passive data collection, without analysis or outcome measurements. It is our view that this is not a particularly useful approach to public health microbiology. Examples of this include our current salmonella surveillance programme which has been successful over the years in identifying a range of outbreaks, but is unable to do more than passively document the rise and fall of particular salmonella strains with time, providing little scientific insights into disease mechanisms or ecological biology which may lead to useful interventions. In our view, surveillance needs to be linked to more basic work on pathogenesis in order to contribute to improvement in disease management and public health interventions. This in turn argues for a strong R&D element in national surveillance programmes. Moreover, successful surveillance systems depend on the liaison of different arms of medical, microbiological, scientific, clinical and public health practice. Close integration takes a number of years to achieve and useful outputs are dependent on good working of a number of different disciplines with agreed objectives. Clear leadership is important.

  Effective national surveillance programmes are also based upon the application of consistent and compatible methodologies, both microbiological and epidemiological within regions, with seamless interfacing of information management systems to allow national consolidation of data. We are unconvinced that this will happen without a strong central lead, clear indication of overall objectives and farsighted IT investment. It is notable that countries which already have devolved regional surveillance programmes of disease are moving away from this model to more strongly co-ordinated national programmes eg Spain and Germany. It is unclear in "Getting Ahead of the Curve" how the powers devolved to RDPHs for commissioning local reference services are to be integrated nationally or how prioritisation may take place where there may be local versus national conflict. Indeed it remains unclear as to how national surveillance programmes required to underpin vaccination programmes eg MMR/Polio/Influenza/Pertussis are to be co-ordinated through the new Health Protection Agency. It is our view that the proposed changes in structure afford some real risk to existing high quality surveillance arrangements which are essential to reduction in disease burden and good public health policy.

LINKS BETWEEN SURVEILLANCE AND TREATMENT OF INFECTIOUS DISEASE

  The strongest link between effective surveillance and treatment of infectious disease occur where there are clear interventions. This includes vaccines, anti-microbials, anti-virals, risk management or environmental actions required to reduce communicable disease burden. There are a number of surveillance programmes where the information collected is of limited relevance because it is not linked to public health interventions or does not contribute to academic knowledge of the biology of the microorganism eg surveillance programmes for campylobacter infections which until recently have paid insufficient attention to the development of appropriate tools for dissecting bacterial genomes, an academic question requiring investment, rather than the more traditional approaches of collecting and counting isolates. It is our view that surveillance should be question driven, with a strong basic science input rather than involving passive aggregation of data, which may often be uninterpretable.

LINKS BETWEEN SURVEILLANCE AND THE STRATEGIES FOR PREVENTING INFECTIOUS DISEASE

  Unfortunately, effective links between surveillance and strategies preventing infectious disease are limited, but work particularly well for vaccination programmes (see above). However, the main strategies employed by the Food Standards Agency (FSA) and attempts to limit sexually transmitted diseases (STIs) include behaviour modification. Many of our current surveillance programmes do not take this into account and do not monitor the effectiveness of behavioural approaches to disease control. Thus, substantial amounts of public health money may be spent on behavioural programmes without any evidence of their usefulness.

DEVELOPMENTS IN SURVEILLANCE VACCINE AND DIAGNOSTIC TECHNOLOGIES

  A weakness in the current existing arrangement for improving surveillance, vaccine and diagnostic technologies is a lack of clear mechanism for the prioritisation of research and developmental work. This is often lost in a hierarchy of bureaucratic committee structures where individuals making decisions are technically ignorant or where appropriate prioritisation cannot be achieved. Unfortunately the proposed arrangements of the new HPA do not show any improvements in the mechanism of the decision making, nor how development monies are to be prioritised or made available for public health. World class surveillance programmes require continued investment and the application of cutting edge technology. It is far from clear how investment is to be determined and with what priority. It is a real concern that technical understanding is seriously lacking in the higher echelons of public health in the UK, and when this is coupled with lack of far sighted investment, it is a significant impediment to the deployment of new technologies.

INTERNATIONAL APPROACHES TO SURVEILLANCE, TREATMENT AND PREVENTION OF INFECTIOUS DISEASE

  Historically, surveillance, treatment and prevention of infectious disease with an international perspective has been rather ad hoc and dependent on leading individual academics, without government funding or input into national strategies for responding to emerging infections. There has hitherto not been an outward looking approach to infectious disease burdens in the global context or within the context of imported disease into the United Kingdom. Recognition of the problem and improvement in identification of imported cases of infectious disease requires a strategic investment in microbiology and clinical expertise for a wide range of specific organisms eg Malaria, Dengue, West Nile and Pox virus infections, some of which currently cause an extremely limited disease burden in the UK.

PUBLIC ATTITUDES, RISK-PERCEPTION AND THE ROLE OF THE MEDIA

  Much more work is needed to communicate risk analysis to the general population. This is a long term objective and may need to involve much more consideration with respect to education at all levels of the population, including the way that science is taught in schools. Furthermore, successful interactions with the media are critical to the overall communication of scientific issues to the general public. In our view, it is essential to uncouple objective scientific/public health advice from the politicisation of public health objectives, so that advice from organisations such as the PHLS can be seen to be independent, rather than as a party political line.

  Government responses to recent public and animal health threats, eg nvCJD, foot and mouth disease have seriously undermined media confidence in the role of scientists, or scientific advisers and considerable work is needed to repair public confidence in the objectivity of high calibre scientific advice/work and ensure that it is seen as independent of government policy.

MAIN PROBLEMS FACING SURVEILLANCE

    —  Lack of clear leadership and failure to agree common goals with all participating parties.

    —  Lack of over arching umbrella with defined objectives.

    —  Failure to join up existing human agencies.

    —  Lack of integration with veterinary medicine or primary care.

    —  Dissolution of PHLS.

    —  Lack of resource.

WILL THESE PROBLEMS BE ADEQUATELY ADDRESSED IN GETTING AHEAD OF THE CURVE

  We recognise the need for change and applaud the aspirational nature of the published documents. However, the structure or mechanism for the implementation of proposed changes is not detailed. The mechanism for ensuring consistency and quality in surveillance systems is not apparent in the proposals, nor how existing excellent systems are to be maintained, let alone the development of new "better" structures. We wish to reiterate our concern regarding the continued delivery of comprehensive national surveillance programmes, on which our vaccination policy is critically dependent, following the creation of the HPA.

OBSTACLES TO BENEFIT FROM SURVEILLANCE ADVANCES

  These include:

    —  Resource allocation.

    —  Mechanisms for prioritisation and decision making.

    —  Lack of clear structure for research and development decisions.

    —  Lack of adequate informed technical and clinical input into decision making process.

    —  Lack of integration where appropriate between vet and human programmes.

GREATER USE OF VACCINES

    —  We believe that there should be greater population benefits achievable through an enhanced or expanded vaccination programme. Licensing new vaccines has a huge cost, for which cost recovery can only be driven through private enterprise. Nevertheless successful vaccination programmes require sustained public-private collaboration and liaison. Improved national and political recognition of this important generic collaboration is required and efficient mechanism found for protecting intellectual property interests of the public sector. Currently public-private interactions are governed by exceptionally cumbersome beaurocracy despite enabling policy (Treasury—Baker Report), and full potential of work in the public sector is not achieved.

    —  The anti-vaccine lobby in the UK is sufficiently strong to discourage industrial investment and limit reasonable debate on significant expansion of vaccination policy. This could be addressed, particularly through improved media strategies, education and targeted research.

WHICH INFECTIONS DISEASES POSE THE BIGGEST THREAT IN THE FORESEEABLE FUTURE

    —  Currently prioritised important infections (MMR/HIV/Influenza/Pertussis etc).

    —  Infections linked to chronic disease or cancer eg Helicobacter pylori, Chlamydia, Hepatitis B & C, Papilloma viruses and Cervical Cancer.

    —  Newly Emerging infections eg CJD, West Nile disease.

POLICY INTERVENTIONS

    —  Education policies for science education (hygiene and cross contamination).

    —  Effective promotion of education particularly relating to deployment of new vaccines eg Men C.

    —  Extension of the public-private collaborations which have assisted the implementation of Men C vaccines, to other vaccines on the horizon eg pneumococcal and respiratory virus vaccines.

  We include a series of questions we believe should be posed in the consideration of the implementation of Getting Ahead of the Curve.

  Q.1.   How will proposals in Getting Ahead of the Curve ensure current regional consistency and quality in collection of national data required to underpin national public health interventions eg vaccine strategy?

  Q.2.   What is the level of delegated authority to the HPA to ensure the collection of adequate quality data to underpin UK surveillance programmes?

  Q.3.   Was there a formal risk assessment undertaken with regard to the dissolution of the PHLS and the potential loss of microbiological data?

  Q.4.   Is the model for the HPA one of a body of full independent status such as FSA, or a different model such as the relationship between the VLA and DEFRA?

  Q.5.   How will the management of national (microbiology) pathology networks be accomplished, within the designated structures of the HPA?

  Q.6.   How will the integrity of national surveillance programmes which underpin vaccine policy be guaranteed after the 1 of April 2003?

  Dr Maria C Zambon, BM BCh MA PhD, Head of Respiratory Virus Unit, Deputy Director, ERNVL, PHLS Central Public Health Laboratory.

  Dr David W G Brown, MBBS MSc FRCPath, Laboratory Director, ERNVL, PHLS Central Public Health Laboratory.

  Dr Elizabeth Miller, Head of Immunisation Division, PHLS Communicable Disease Surveillance Centre.

October 2002





 
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