Memorandum by Sir William Stewart, Shadow
Chair, Health Protection Agency
THE IMPORTANCE OF THE HPA TO INFECTIOUS DISEASE
CONTROL: SOME PRELIMINARY THOUGHTS
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.
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 documentfrom a range of local government,
NHS bodies and academic establishments, were supportive of the
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.
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
Sixth, it will be a national health protection
one-stop shop which will be attractive professionally to those
in this field.
THE HPA WILL
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 exampleantibiotic 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,
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.
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
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.
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
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.
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 notfor 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.
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
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.