Select Committee on Science and Technology Minutes of Evidence


Memorandum by Sir William Stewart, Shadow Chair, Health Protection Agency

THE IMPORTANCE OF THE HPA TO INFECTIOUS DISEASE CONTROL: SOME PRELIMINARY THOUGHTS

BACKGROUND

  In the UK 40 per cent of people consult a health professional each year about infectious diseases. Approximately 5,000 people per year die from hospital-acquired infections. The Spanish "flu" epidemic killed more people than were killed in the whole of World War I. On top of such-like problems, there is now the additional potential threat from global travellers and immigrants bringing new, rare or forgotten-about world diseases in to the UK. Additionally, societal integration, admirable though it is, can, in some cases, facilitate the potential for transference of such diseases within the UK. Examples include HIV, TB and Hepatitis. All of this imposes a considerable burden on the NHS. Additionally, there is now an increased threat from bioterrorism.

DEPARTMENT OF HEALTH PROPOSALS FOR PUBLIC HEALTH PROTECTION 1998-2002

  In 1998 the possible importance of such changes (recognised by Ministers in 1997) was considered in the report by the Chief Medical Officer at that time, Sir Kenneth Calman. The Project to Strengthen the Public Health Function in England included in its remit the need to consider the range of current public health activities at local, regional and national levels, with a view to ensuring that there was a robust public health function to deliver the government's public health strategy.

  The conclusions included the need for improved co-ordination and communication networks amongst the diversity of sources of public health protection. Despite the broad knowledge base and an enthusiasm to improve health there was some apparent lack of focus and co-ordination. There was fragmentation and under-development of public health protection research, there was a case at the local, community and regional levels for strengthening surveillance and control of communicable disease, chemical and environmental hazards. At the national level the different strategic capabilities needed to be coordinated more effectively and a need, amongst other things to strengthen co-ordination between PHLS and NRPB. Consultations showed that the vast majority of the 200 responses to the consultation document—from a range of local government, NHS bodies and academic establishments, were supportive of the analysis.

  In 2001 Sir Liam Donaldson, Sir Kenneth Calman's successor as CMO published an updated final copy of the report, and in 2002 developed the earlier publications, on which there had been extensive consultation, in to a new impressive document "Getting Ahead of the Curve" where the provision of a new Health Protection Agency was mooted.

GETTING AHEAD OF THE CURVE (GAC)

  A key central point, implicit in GAC was that it was not sensible for DH to control everything centrally as it had been doing up to that point and instead it should retain strategic policy-making within the Department whilst devolving advice and operational aspects of delivering the policy to the HPA, which would be distanced from Government. In effect it would serve as a one-stop shop and as a command and control centre for operational aspects of what had previously been done by a fragmented group of organisations. As Sir Kenneth Calman said in his 1998 Report: "It is not enough to assume if each element of the system is doing its best the whole system is doing its best"

  Sir Liam's proposals are worthy of support. The world is changing and we need urgently to address the new and rapidly emerging issues related to public health protection at the start of the twenty-first century. For example, as I said above, the impact of global travel.

  My view is that the new and unified organisation will result in an increasing cross-fertilisation of ideas, skills and expertise in what up until now have been, in some cases, disparate "cocoons" between and within some of the organisations.

  Second, it will provide a single focal point for UK health protection issues not only at home (with government, the research councils, charities and the general public) but, importantly, also internationally (for example with the WHO, EU, NATO, the USA and Canada).

  Third, the EU is currently consulting on having a EU Infectious Disease organisation. I understand they are also now giving some thought to chemicals and radiation. We are ahead of thinking in this country and should seek to exploit this to the benefit of the UK as well as the EU generally. The UK should take a lead on what the EU might do and especially on how and where the organisation may be run and located.

  Fourth, the HPA will result in a single Board with a non-executive/executive mix, and will meet monthly in various parts of England and Wales. Its meetings will be open to the public. Why have a Board of eminent people if they are not to be fully used. The CAMR Board, which I chaired, operated in this way and re-shaped an ailing organisation into one which today is a key component of the HPA. Incidentally, at the time of September 11, CAMR had totally re-built its anthrax production facilities and was the only laboratory in the world at that time producing licensed anthrax vaccine. There is a huge benefit in having a single Board, with several committees reporting to it, peopled by real experts from member organisations, the universities, industry and elsewhere. The HPA must be independent and seen to be independent and its Board must shape the strategy of the organisation. It must not be simply a rubber stamping body.

  Fifth, it will bring currently fragmented organisations into a cohesive unit, it will operate more effectively, bring consistency in its operation across the country, and benefit from hybrid vigour.

  Sixth, it will be a national health protection one-stop shop which will be attractive professionally to those in this field.

SOME OF THE BROAD ISSUES WHICH THE HPA WILL HAVE TO ADDRESS IN SETTING UP THE NEW ORGANISATION

  The number of issues which the HPA will have to address in setting up this new organisation are many and it will take three to five years to make the sort of real change necessary. The issues are of two broad types:

  There are the current day-to-day issues which the existing organisations (which by and large are excellent) will have to deal with. The status quo, more or less, will have to continue in the short term (six to twelve months). There will also need to be an immediate need to tighten up emergency planning in the health protection field in the light of bioterrorism and new global diseases. This is being urgently addressed.

  The other is a need to stand back and carefully set in place, in a considered way, with sound judgement, a well thought through plan for the future health protection needs of the nation, to be delivered over a three to five year period.

  The framework on which this is based must include the following generic issues:

  Speed and reliability of decision making and implementation will be central to the success of the organisation. Learn the lessons of the Foot and Mouth saga (you cannot cull humans!). The need for reliable real time systems to speedily address issues will be crucial. There must also be well-thought through protocols (regularly tested and updated) which are people independent (people move, die etc). Without standard acceptable protocols, regularly updated, we're asking for trouble, particularly across national boundaries.

  A second generic need is a strong research base. This must be a core and underpinning component of the HPA and the whole area needs to be reviewed by the Board. A problem for the existing laboratories is that they are largely funded by DH to address short/medium term research needs, perceived by DH officials centrally. That is fine because, in general, DH should not be the sole supporter of basic research. But there are important related health protection issues requiring basic research and coupled peer-review. Take but one example—antibiotic resistant bacteria. The emergence of microbial pathogens which express resistance to many anti-microbials is now a world wide problem. Strains of multi-drug resistant tuberculosis (MDR-TB) for example now pose a particular threat to many people, particularly those with HIV.

  In the UK, between 1997 and 2000, over 40 per cent of isolates causing hospital acquired bacteraemias were staphylococci, of which 25 per cent were Staphylococcus aureus. Nearly 50 per cent of the latter strains were methicillin resistant (MRSA). Increasing reliance on vancomycin has led to the emergence of glycopeptide- (especially vancomycin)-resistant enterococci (VRE), bacteria that infect wounds, the urinary tract and other sites. Between 1997 and 2000, 10 per cent of enterococci isolated from cases of bacteraemia in UK hospitals were vancomycin resistant. Linezolid, the new oxazolidinone antibiotic used to treat infections caused by VREs, represents the "last port of call". Now, linezolid-resistant, vancomycin-resistant Enterococcus faecium (VREFs) have been isolated from hospital patients in the US etc, etc. This is an area where solutions will demand a strong R&D base. A strength of the HPA is that it will be able to offer unique tested and proven, high containment facilities, vaccine production facilities, diagnostic and surveillance facilities and an ability to integrate chemical and biological (and in due course also radiological) facilities and expertise.

  Generally poor use has been made by most existing laboratories of the huge intellectual and technological resources available in our universities. This must change. This is the under-utilisation of a major UK asset. The low priority given to research links with universities has meant, in the past, an exclusion, in most cases, by the laboratories from funding by bodies such as the research councils and the charities. There have been positive discussions with the Wellcome Trust. The HPA is expected to set up a standing, independent Scientific Research Committee, the applications will be peer-reviewed, and, as with the universities, visiting groups to review the quality of the research will be introduced. In saying these things, it does not imply that the research being done in HPA laboratories is of poor quality. It is not. CAMR for example is publishing papers in Nature, some of the most interesting CJD work is on going in the HPA laboratories, etc.

SURVEILLANCE

  The centre for the surveillance of clinical infectious diseases in England and Wales, is the Communicable Disease Surveillance Centre (CDSC) which will become part of the HPA. It has an excellent international reputation and importantly has good links with those (the CCDCs, the HEPAs, the NHS and other public services) working at the coal face of public health protection. The usual route of notification is medical practitioner to CCDC to CDSC. CAMR provides its information directly and electronically to CDSC. Data are provided on re-emerging diseases such as syphilis, gonorrhoea, TB, including drug resistant TB and of general infectious disease trends in the UK.

  Some are worried that if some routine diagnostic laboratories are transferred to the NHS, there will be a loss of surveillance data, which can only be assured if the HPA retains/manages these laboratories. In fact there are over 300 local clinical laboratories in England and Wales carrying out routine microbiological tests, already run by the NHS. In addition there are around 46 PHLS-run laboratories, and 32 of these will join the 300-or-so under NHS management.

  It seems important to me to place these routine labs in the NHS, nearer the patient and local clinical teams, if quality and data provision can be assured. There is little evidence that transfer will adversely affect the HPA. Reporting outputs from existing NHS labs and PHLS labs are not very different. Some are good, some are less good. There is to be a national Inspector of Microbiology to monitor quality.

  Surveillance must have an international (WHO) and EU role as well as a national role and base. The UK cannot be introverted. It is important to remain alert to the potential for the onset of exceptional outbreaks of disease from dangerous pathogens elsewhere in the world, especially with respect to their geographical location, in order to assess the potential risks and risk factors that might be relevant to the UK. Special watch has to be taken of some areas of the Far East in particular where man/animals etc live in very close proximity. The danger is that agents will jump the species barrier from animals to humans (as happened with HIV and vCJD). Zoonosis is an area in need of much attention. The current absence of a particular pathogen from the UK, or its apparent absence, cannot necessarily be taken to imply that such pathogens pose no risk, or will not do so in the future, either as a consequence of natural events such as the importation from endemic areas or if exacerbated by acts of bioterrorism. There must be closer interaction between CAMR and PHLS.

DIAGNOSTIC AND REFERENCE MICROBIOLOGY LABORATORIES

  Proper and assured diagnosis has to be a central plank of any infectious disease control strategy. Problems arise when there is diagnostic disagreement among professionals. That requires diagnostic testing and confirmation using standard protocols. Genetic fingerprinting will be key.

  At the local level, mainly under NHS management, there are the clinical laboratories in England and Wales undertaking routine microbiological tests. These laboratories are at the coal-face of infectious disease diagnosis and reporting. They focus largely on people being cared for as hospital patients or outpatients. Most also provide a diagnostic service for local general practitioners and are important in providing surveillance data. Some are provided, under contract, by PHLS laboratories. A very small number are run by independent private sector companies on a contractual basis.

  PHLS laboratories currently provide the majority of national reference microbiology services. They also undertake microbiological testing of food, water and environmental samples, as well as testing of samples from patients. There are 46 of them in England and Wales and 31 are expected to transfer to NHS management. The others are expected to remain under HPA management in the regions or centrally.

  Specialist and reference laboratories at CAMR and PHLS, largely located centrally, undertake either detailed testing of common micro-organisms to characterise and fingerprint them, or specialist testing for rare or unusual infections. They also provide a national microbiological support and expert advisory service. In addition some facilities are provided by laboratories in university medical schools (for example, for malaria and parasitology in the London School of Hygiene and Tropical Medicine and University College Hospital, London, respectively). Many of the specialist and reference laboratories are WHO reference and collaborating centres.

  In all of this, the most important issue is to set in place a seamless diagnostic and reference service across the health protection field, irrespective of who actually manages it. I believe also that management by universities of some specialist services has much to offer and should be sustained and indeed expanded, thus enhancing the possibility of charitable bodies funding for such health protection work.

ELECTRONIC NETWORKING AND COMMUNICATIONS

  This needs serious attention. The need to substantially update communications speedily and electronically is at the heart of HPA needs for the future. There is fragmentation of the current laboratory network. For example CAMR and PHLS have difficulty in electronically communicating. CDSC has some difficulty with other parts of PHLS. In terms of zoonotic disease (to which the HPA will give increased attention), the DEFRA information system and PHLS systems are different. There is virtually no communication network between NRPB and CAMR/PHLS.

  The biggest task of the HPA is to seek to deliver a real-time communications network. Monitoring the progress and control of outbreaks requires real time (certainly electronic) data on all relevant issues, for example, of the total number of cases (preferably laboratory confirmed) and their location. There is also more scope for a rapid reporting system which would efficiently capture cases of infectious disease without laboratory diagnosis (eg the use of prescribing figures, over the counter sales of pharmaceuticals, enquiries to NHS Direct etc).

  The National Poisons Network with its Toxbase is an example of what can be done electronically even with a currently underfunded base.

  The HPA needs help on electronic communications and must have discussions with MoD, the Met Office and industry about the updating of its systems. Without these systems firmly in place, its ability to deal with Health Protection emergencies whether related to biologicals, chemicals or radiologicals is likely to be sub-optimum. But who will pay for developing this priority area? The HPA's current budget alone will not be able to do so.

COMMUNICATIONS WITH THE PUBLIC

  Any health-related issue is of concern to the public. After all, people want to stay alive. Improvements have been made in communicating information and risk to the public but much more needs to be done. Placing information on the web is all very well for those who have ready access to the internet, but we need to provide easily available, well-considered, information to those who do not—for example by radio and TV. Getting this right is very important. The HPA must seek to be open about the information it provides and the advice which it gives. There has to be an appreciation that everything is not in black or white. Risk analyses and perception has to be strengthened. The role of the HPA is to present the facts openly, give the best possible advice based on these facts and let the individual make their own decisions. The public, for its part has to appreciate that some of the choices, whilst affecting people as individuals, may also affect society corporately and differently.

TRAINING NEEDS

  There is a huge training job to be done, at all levels within the HPA. The staff are generally outstanding. But each sector needs regular training and updating as the pace of technology and information flow quickens across all sectors. The HPA working in concert with the professional bodies and with other training organisations must seek, urgently, to develop a proactive training policy, remembering that within the HPA there is a very wide range of expertise which can be rolled out to train others.

CONCLUSION

  I want to emphasise that these are preliminary thoughts prior to the setting up of the HPA on 1 April. What is clear is that the HPA is needed and that getting it right is a huge responsibility. Although some problems can be expected, as with any organisation working in the health protection field, the HPA is an exciting prospect. Building on what has gone before, it offers the prospect of an organisation much better prepared for the undoubted and uncertain challenges which public health protection will have to face in the twenty-first century.


 
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