Select Committee on Science and Technology Minutes of Evidence

Memorandum by Dr R L Salmon, PHLS Communicable Disease Surveillance Centre (Wales)


  1.  Given, the sub-committee's call for "evidence on any area of infectious disease", the scope of the inquiry is potentially limitless. I have substantially confined my submission to the sub-committee's six particular questions. In so doing, I have been mindful of the House of Lords functions as legislature and court and given most prominence to areas where there is greatest scope for these functions to aid "fighting infection". The views expressed are personal and based on twelve years as a regional epidemiologist in Wales. However, they have been seen by colleagues in the Regional Services' Division of the Public Health Laboratory Service Communicable Disease Surveillance Centre, which covers England and Northern Ireland and which division, I have headed for the last two years.

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

  2.  Many of the factors which change a society's experiences of infectious disease may have their roots in decisions some way removed from science or health or agriculture. By way of a historical illustration, the Black Death, the plague, caused by the bacillus Yersinia pestis killed 20-25 per cent of Western Europe's 80 million population, between 1348 and 1352. It is believed to have been introduced by the Mongols of the Golden Horde who had swept westwards from Central Asia and laid siege to Kaffa in the Crimea, a trading post established by the Genoese. Plague broke out among the Mongols investing the city. It is believed this was as a result of the Mongols' practice of killing marmots, which carry the plague bacillus without getting disease, for their furs. Contemporary accounts have them also throwing the corpses of plague victims over the walls of the city. Plague subsequently spread along the trade routes around Europe. This, apart from illustrating that the emergence of infectious disease is not a new phenomenon, also indicates a number of the categories of factors that are repeatedly seen to contribute. It shows the critical roles played by movements of peoples, in this case the Mongols, and patterns of trade, particularly of fur and silk. It shows the role of transportation whether medieval ships or Tartar horsemen. It also indicates the ever present threat of biological warfare. These four aspects, changed in their detail, are recognisable as key general problem areas in the prevention of infection today.

  3.  The comparatively monolithic nature of health services' organisation in the UK when compared with other developed countries means that human health surveillance usually functions at least adequately. It does of course rely on a cultural preparedness to share information, in the public interest, between health professionals. This culture has received certain setbacks, of late. The legal framework around the transmission of information has become progressively more complex and restrictive. The Health and Social Care Act 2001 has qualified the justifications of "medical purposes" and "public interest" which previously allowed patient identifiable information to be shared, without necessarily obtaining the patient's consent, under the Data Protection Acts and the common law.

  4.  Veterinary surveillance has also been problematic but has been reviewed and is the subject of redevelopment by DEFRA. A particular gap is the lack of surveillance for companion animals, particularly with the relaxation of restrictions on their movements brought about by the passports for pets scheme. A further issue is the integration of surveillance data from human health, animal health and food which in the UK, compared with a number of countries, notably the Netherlands and Denmark, is very underdeveloped.

  5.  Problems arise when moving from surveillance ("information for action") to taking action whether it be treatment or prevention or further investigation in the field. This always requires a modicum of intelligence and courage. Three things provide an additional handicap.


  Much of the fieldwork capacity resided between health authorities and local authorities (in their environmental health department or equivalent). As a result of NHS reorganisation, health authorities have disappeared in England and are due to disappear in Wales. This has left Consultants in Communicable Disease Control housed temporarily in various organisations and loss, particularly of support staff. Similarly following the modernisation of local government, local authority environmental health departments have enjoyed mixed fortunes. Often they have lost status and resource to areas of local government activity with a higher political profile such as education, social services or housing.

The Research Paradigm

  For a number of reasons public health investigations have increasingly become viewed not as public health practice (by analogy with clinical medical practice) but research. Reasons for this, amongst others, are the fact that public health investigations utilise similar (usually epidemiological) techniques such as questionnaires and surveys and an increasing involvement of academic bodies in research in the field of public health (in itself welcome). When a public health investigation becomes viewed as research it comes under the research ethics committees. This inevitably adds the bureaucracy of an application process, may introduce delay and sometimes effectively prevents the work from taking place at all.

The News Media

  The proliferation of radio and TV channels as well as the internationalisation of news means that the sheer volume of media inquiries can pose a considerable obstacle to the efficient pursuit of an investigation as well as diverting substantial skilled resource from solving whatever is the problem. There is a potential compensation in that this could result in greater public understanding and awareness. Unfortunately, the narrow economic requirements of the News Media as an industry determine coverage and if anything, often distort public understanding. Issues with a complex technical background and long gestation period fare particularly badly. Some examples are HIV and AIDS where some newspapers expended a lot of energy in denying that HIV caused AIDS and the MMR controversy which is substantially sustained by media coverage. These are sins of commission. As a sin of omission, I might cite the early years of BSE where sustained serious journalistic interest in the possible relationship with CJD might have been beneficial but no such interest was forthcoming.

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

  6.  This document contains quite a good synopsis of many of the wider issues that can result in infectious disease problems. The solutions proposed are, however, substantially of an administrative nature, involving the reorganisation of existing services. Much of the focus of the reorganisation is, also, not infectious diseases but wider aspects of health protection (particularly from chemicals and radiation). Much will depend on the resource given to the new agency as well as the energy and independence of its leadership. It will also be important to clarify the contribution required from other bodies such as primary healthcare and hospital trusts and re-develop effective means of teamworking.

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

  7.  Technological developments such as near patient or, indeed, home testing produce data that the current surveillance mechanisms do not have a ready means of capturing. It will be important to develop further primary care based surveillance to address this potential gap.

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

  8.  The Joint Committee on Vaccination and Immunisation has a mechanism for addressing decisions on vaccination that has substantially stood the test of time. Indeed the improvement in the organisation of the vaccine programme and in uptake of most vaccines since the early 1980s could be considered a considerable success. Nevertheless although in "the Green Book" and similar publications doctors and other health professionals have an accessible source of advice, many only have a hazy notion of the scientific and epidemiological basis of this official advice and how it is arrived at. This may be a handicap in giving the vaccination programme the support and professional commitment all such programmes need to sustain success. More open government, as reflected in documents such as the government's code of conduct for scientific committees, may potentially bring unanticipated benefits by remedying this and building trust.

5.   Which infectious diseases pose the biggest threat in the forseeable future?

  9.  There are a number of quite disparate threats, even without considering biological warfare about which much has been written, which must not be lost sight of.

  HIV is proving difficult to contain and despite success with treatment will remain a health burden until a vaccine is successfully developed.

  Verotoxin producing E.coli O157 remains a relatively rare disease in the UK, with the exception of parts of Scotland. Nevertheless infections result in a high burden of illness, often in children and there is an ever present threat of outbreaks. Containment requires action by a number of agencies at a number of levels which may prove difficult to sustain.

  Effective tuberculosis control similarly requires effective team working between different healthcare organisations and other agencies. This will need to be born in mind with moves toward greater autonomy for healthcare providers which, although they may be desirable for the efficient delivery of much clinical care, can handicap public health efforts.

  The scale of the variant CJD epidemic remains unclear even though there are some grounds for cautious optimism. Preventing potential human to human spread via surgery and blood transfusion is proving a complex and sometimes costly exercise.

  It seems inconceivable that there will not be another influenza pandemic.

  The development of a vaccine for group B meningococci remains a priority. It will become an even more pressing issue if any transfer of virulence genes from group C strains, a plausible consequence of the welcome and successful vaccination campaign, were to take place.

  The burden of treatment of hepatitis C is beginning to become apparent.

  Finally experience with Foot and Mouth Disease (FMD) and Classical Swine Fever (CSF), which are not zoonotic, should alert us to the risk of the introduction of zoonotic animal diseases. Had Nipah virus rather than CSF or FMD been introduced from the Far East, the consequences for human health, particularly in occupations dealing with pigs or pork would have been much greater. The steady expansion of the Pets Travel Scheme, although welcomed by the public, may well have disease introduction consequences which are difficult to predict.

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

  10.  As well as addressing the provision of structures that directly address infectious disease there is also a need to consider more widely those policies which may, as a by product, either make infectious disease problems more or less likely. With national and international policies a formalised approach to assessing the infectious diseases impact, such as microbiological risk assessment, may be helpful. Internationally, a policy framework might be an overall review of the International Health Regulation to take into account the more diffuse nature of human contacts through globalisation of markets. They were last subject to major revision in 1969 and cover only plague, cholera and yellow fever. They do not reflect the modern day nature of a number of markets with an impact on health such as food, tourism and health care. They are being revised and modernised by WHO and will move away from reporting of three specific diseases towards reporting of syndromes of international public health significance. Although WHO will consult WTO in this process there is a case for considering the development of a wider role for WTO in a broader regulation, on health grounds, of the movement of people, animals and goods. The latter body is influential on national governments in a way WHO is not. Further, as a recent joint WHO/WTO report, "WTO Agreements and Public Health" acknowledged (BMJ 31 August 2002, page 460), "governments may put aside WTO commitments in order to protect human life". Thus any new regulations may be a legitimate restriction of trade.

  11.  Where people and goods move quickly, information to contain infectious diseases must move quickly as well. Electronic communication has facilitated this but the legal framework around the transmission of information, as has been noted, has become progressively more complex and restrictive. Although the Health Service (Control of Patient Information) Regulations 2002 do now provide a mechanism for the Secretary of State to give permission for patient identifiable information to be shared without consent, that mechanism is cumbersome and bureaucratic and the permission has to be renewed at least annually. Simplification of these regulations or how they are administered would be welcome. Quite apart from the energies that such processes use up, they foster a culture inimical to the sharing of information of all kinds, on which surveillance and disease control are ultimately based. An alternative legislative approach might be a new public health act actively requiring modern systems of disease reporting as well as laying a general duty of sharing information that may be required for communicable disease control.

  12.  Finally the News Media represent a well organised and well capitalised industry whose actions have a demonstrable impact on health, sometimes for the worse. Arguably they have, just as any other industry, a duty of care which may be enforceable under the Health and Safety at Work Act 1974. This, or other mechanisms which might promote the reporting of health topics in such a way as not to diminish the health of the population, should be explored.

Dr R L Salmon

Director, PHLS Communicable Disease Surveillance Centre (Wales)

Head, Regional Services Division, PHLS Communicable Disease Surveillance Centre

11 October 2002

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