Select Committee on Science and Technology Written Evidence


Memorandum by Dr Stephen Monaghan, Deputy Director of Public Health and Consultant in Public Health Medicines, Cardiff

PREAMBLE

  This submission is concerned with the legal framework for infectious disease control. It argues that the law is inadequate, outdated and urgently in need of reform and will provide pointers for that reform.

  This submission draws upon my Nuffield Trust publication "The State of Communicable Disease Law[88], an associated article which I wrote for The Times Law Supplement[89], and the findings of the Trust's UK Partnership for the Health of the People Project[90], which I led.

  The views expressed are personal, however, and also draw upon my experiences as Deputy Director of Public Health and Consultant in Public Health Medicine with BroTaf Health Authority in Cardiff, including my chairmanship of the outbreak control team for the UK's largest outbreak of Meningococcal Meningitis, which occurred in the Taff Ely district, just north of Cardiff, in 1999.

INTRODUCTION

  The recent outbreak of Foot and Mouth Disease illustrates how fast disease can spread through a population when effective control measures are not put in place sufficiently rapidly. Fortunately, this outbreak was not a threat to the human population—but other disease are—including the possible use of Anthrax, Smallpox, Botulism and Plague by bio-terrorists.

  September 11th and the subsequent Anthrax incidents in the USA last year taken alongside the discovery of the sheer size of the Soviet Cold War bio-weapon programme[91]—and the high likelihood that its products and knowledge base have proliferated elsewhere—means that this threat must be taken seriously. Although the Committee intends to focus primarily upon naturally occurring infection rather than bio-terrorism the same basic legislative and organisation framework applies to both.

  Because by their nature infectious diseases spread between individuals or through the environment they cannot usually be controlled through a clinical medical focus upon the diagnosis and treatment of individual patients—further transmission will often have already occurred. Rather the population (and environmentally) based approach of public health is required in order to control infectious disease outbreaks.

  Public Health—a critically important function protecting us all—has been neglected worldwide for at least a quarter of a century. Our complacency in the face of existing and newly emerging microbiological threats is sorely misplaced.

    Since the early 1970s at least 30 previously unknown infectious diseases have become prominent[92],[93] , for which there is no fully effective treatment[94]

  While bugs do not respect borders, and we are vulnerable to rapid spread across the world through airline passengers and sea container cargoes, global public health has been allowed to wither[95]. Meanwhile, resources and health systems have been focussed overly upon ever more expensive clinical services offering gradually diminishing marginal health benefits for individuals.

  The basic principles of outbreak control are a system of disease surveillance to identify, investigate and confirm cases and outbreaks, followed by early intervention to control spread through measures such as isolation and quarantine, immunisation, and treatment. To work effectively it must be highly organised through local public health departments linked to central specialist resources and technology.

  Particularly in a public health emergency, such as a bio-terrorist incident, the effectiveness of the response relies strongly upon the legal authority underpinning co-ordination, leadership and control powers—including occasionally coercive powers such as enforced isolation or quarantine.

  Coercive powers would almost certainly be needed to effectively control the spread of a highly infectious agent such as Small pox in order to save hundreds of thousands of lives. On the other hand, the use of coercive powers clearly raise strong civil liberties and human rights concerns.

THE OVERALL LEGISLATIVE FRAMEWORK

  In England and Wales the key piece of primary legislation for infectious disease control is the Public Health (Control of Disease) Act 1984. This Act along with the associated secondary legislation notably the Public Health (Infectious Diseases) Regulations 1988, were largely consolidation measures, drawing together previous legislation relating to infectious disease.

  Most of the provisions date from the late 19th and early 20th century; some date back to the Sanitary Laws of the 1870s and to the original 1848 Public Health Act. Although some parts are still relevant and valuable much is grossly outdated and in need of reform.

  A review of the relevant law was carried out in response to the report of the Committee of Inquiry chaired by the Government's Chief Medical Officer, "Public Health in England" (1988) which had recommended that:

    "DHSS should revise the Public Health (Control of Disease) Act 1984 with a view to producing a more up-to-date and relevant legislative backing to control of communicable disease and infection"

  The review was completed and published as a consultation document but never enacted. There has thus been no systematic "root and branch" redrafting of the law since before the Second World War. Many of the provisions are probably contrary to modern conceptions of liberty, yet many measures are too weak and confused to be effective, while many others are simply irrelevant and would not be supported by modern scientific knowledge. Many potentially useful powers are absent; and the powers that exist are also inflexible.

LEGAL AUTHORITY AND ORGANISATIONAL FRAMEWORK

  Prior to 1974 the responsibility for infectious disease control lay clearly with local authorities and a public health doctor known as the Medical Officer of Health (MOH) discharged this responsibility. This post was abolished in the 1974 reorganisations which sought to unify healthcare services by transferring public health doctors (renamed as community physicians) and the responsibility for community health services to the HNS. Local authorities retained responsibility only for environmental health and environmental health officers who had formerly worked for the MOH remained in local authorities and continued to work on environmental inspection and control. Thus these reforms simply fragmented public health in the name of unifying clinical healthcare services thereby reversing the pre-existing position.

  "Transition" guidance issued by DHSS[96] at the time outlined working arrangements, roles and responsibilities. Health authorities were to be responsible for a range of services contributing to the prevention, control and treatment of infectious disease. However, statutory powers for infectious disease control remained unchanged. Therefore, in law, the responsible authority for infectious disease control continued to be the local authority, rather than the health authority[97]. The guidance therefore advised local authorities to appoint a doctor who would also be a community physician of the health authority, to be known as the Medical Officer of Environmental Health (MOEH), as "proper officer" to enable them to effectively discharge their infectious disease control duties.









  A number of failures in infectious disease control during the 1980[98] led to the setting up of the Committee of Enquiry into the Future Development of the Public Health Function. Its report "Public Health in England" (The Acheson Report) described [99] the problems which arose after 1974. These included:

    —  There were no clear statutory responsibilities to help local authority and the health authority (and especially the MOEH) to identify their respective roles.

    —  Effective co-operation between health authorities and local authorities had proved difficult to secure in others.

    —  The MOEH had divided accountability between health and local authorities, often had other more pressing responsibilities, and did not fit into organisational structures.

    —  There was widespread confusion about roles and responsibilities.

  "Public Health in England" also made recommendations to remedy the situation. However, the question of whether a health or local authority should have overall lead responsibility for the prevention and control of infectious disease remained undecided[100].

  Local authorities were advised to appoint a Consultant in Communicable Disease Control (CCDC) to take over the infectious disease duties formerly carried out by the MOEH and with executive responsibility for the surveillance, prevention and control of infectious disease in a district. Each health authority was also advised to appoint a Director of Public Health to provide overall leadership of the public health function—which had been lost since the abolition of the local authority Medical Officer of Health role.

  In practice, over the last decade, district infectious disease control has become largely the province of the health authority in the personage of the CCDC and using proper officer powers of the local authority.

  On the whole, relations improved between local authorities and health authorities. The latter placed a high priority on infectious disease control under the public health leadership of the Director of Public Health, in spite of being increasingly drawn into the purchasing of healthcare services as a result of the 1990 NHS reforms.

  The NHS in England (and Wales) has just undergone another re-organisation as a result of perceived problems in the delivery of personal healthcare services. Part of the solution this time is the abolition of health authorities and the increasing introduction of Primary Care Trusts in England and Local Health Boards in Wales.

  Although local infectious disease control has largely been a success in the last decade[101] the abolition of district health authorities in England and Wales now throws the delivery of this function into uncertainty once again.

  In England, the Government's response is a new strategy for combating infectious disease "Getting Ahead of the Curve"[102]. This proposes locating the infectious disease control function between a new England (and Wales) wide central agency "The National Infection Control and Health Protection Agency"[103] and a "local health protection service" also delivered by the new Agency (employing the CCDCs as "Field Officers"), which will work with the NHS and local authorities[104].

  This latest restructuring should also give the opportunity for the much needed and long delayed fundamental review of the law relating to infectious disease control. No firm commitment to legislation has been given, however.

POINTERS FOR REFORM

  Effective infectious disease control relies in part upon legal authority to underpin planning, co-ordination and leadership. Currently, no agency is clearly given this responsibility—no organisation is unambiguously "in charge". In practice, local and health authorities worked together reasonably effectively—though not always. A re-definition of who is responsible—and for what—would facilitate more effective outbreak control. The risk of confusion of roles and responsibilities probably increases with the size, complexity and immediacy of the infectious disease threat and the tensions this brings. When the system is most needed may be when it is least dependable. The abolition of health authorities and the establishment of the new National Infection Control and Health Protection Agency (NICHPA) gives the opportunity to reconsider the question of which organisation is responsible in law.

  A NICHPA lead would recognise the medical and epidemiological expertise of a CCDC ("Field Officer") which is lacking within the local authority.

  A lead based on type of disease would give the local authorities powers for food borne disease, and the Agency responsibilities for other infectious diseases reflecting the expertise of both. However it may not immediately be clear in an individual outbreak what type of disease is involved; nor whether it is spread from person to person or from an environmental source. Furthermore, the epidemiological and microbiological expertise of the Agency would still be needed for an outbreak of food borne disease.

  The position of the local authority is also complicated by the recent foundation of the Environment Agency and Food Standards Agency.

  New legislation should probably move the legal authority from local authorities to NICHPA, which should also be given a specific statutory duty to provide an infectious disease control service to each and every local district. This would also remove the need for a defined local authority "Proper Officer" though a named individual professionally and managerially accountable for infectious disease control in a particular district remains important in terms of leadership and accountability. This individual (Field Officer presumably) would also still need to be legally empowered to exercise the statutory powers essential for infectious disease control and to receive notifications (see later).

  English regional directors of public health who are to be removed from NHS regional offices to regional government offices in the latest NHS reforms have had no formal role in infectious disease control. With the abolition of district health authorities they ought to be given some statutory responsibility for co-ordinating health protection activities in their regions. Local primary care organisations (PCOs)[105] and NHS Trusts would also be ctitically important as the major source of the large pool of skilled manpower necessary to deliver a public health response such as mass immunisation in the event of a major emergency.

LEGALLY DEFINED NOTIFIABLE DISEASES

  The first step in the process of infectious disease control is the early detection of a possible outbreak via a process of public health surveillance. This involves the identification of individuals who have been infected by, or carry, an important infectious disease agent and for this information to be communicated to the relevant authority. Hence, as a centre piece of the current legislation all doctors are legally required to inform the proper officer when they diagnose or suspect a "notifiable" disease. He is then legally empowered to investigate further by seeking information from other parties before taking measures as necessary to control spread including if required making use of selected specific statutory powers.

  As stated previously the local authority proper officer was usually the health authority's Consultant in Communicable Disease Control, so as to address the dilemma that whereas the responsible authority under the act is the local authority, the epidemiological and medical expertise lay within the NHS. The lack of clarity regarding which organisation was in charge was replicated regionally and nationally, and remains (in law) following the latest re-organisations.

  Six "notifiable diseases"[106] are specified in the Act and 24 more diseases in the associated Public Health (Infectious Diseases) Regulations 1988 which indicate the precise control powers that can be applied to individual diseases.

  The Secretary of State, has the power under section 13 of the Act to extend the Act to other diseases and has done this under the Public Health (Infectious Diseases) Regulations 1988 which have also been subsequently amended.

  These provisions add a further 24 diseases which have to be notified by a doctor upon diagnosing them. Thus, in practice, the term "notifiable diseases" is commonly used to cover all 30 diseases.

POINTERS FOR REFORM

  Reform options have been outlined[107]for deciding the scope of infectious disease notification and how this should link with control powers might include:

1. Limiting control powers to those diseases requiring notification by a doctor—the status quo.

2. Making the full range of control powers available for all infectious diseases rather than only those classified as notifiable.

3. Restricting control powers solely to those notifiable diseases which require early action to prevent spread such as tuberculosis and food poising, thereby excluding those where notification is used mainly for evaluative statistical trends over time such as mumps and measles rather than requiring immediate control measures.

  Option 1 would retain the current confusion of different packages of powers for different diseases.

  Option 2 would allow the flexibility to respond to cases of disease which are not notifiable, but where some action is needed to control spread. However, this enlargement of powers might be seen as a substantial potential encroachment on civil liberties without relation to the severity of the disease threat. It might also be argued that, if control powers are necessary for a particular disease, that disease should be defined in statute. If an unexpected need for such powers arises in relation to a non-notifiable disease, the local authority already has emergency powers to make this disease immediately locally notifiable thereby attracting the carious powers. Similarly the Secretary of State can issue new regulations enabling this across the country as a whole.

  Option 3 would mean a reclassification of notifiable diseases[108] with those diseases requiring early action retaining the title "notifiable diseases" and attracting associated control powers.

  Diseases currently notified for the purposes of surveillance could remain reportable by the doctor over particular time intervals. These might be renamed as "reportable diseases".

  In all events, notifiable diseases should probably continue to be named in regulations rather than primary legislation, to allow flexibility.

DISEASE SURVEILLANCE AND OUTBREAK DETECTION

  Surveillance is the foundation of any infectious disease control system. It enables the tracking of disease trends, the identification of new infectious disease threats, vaccine evaluation, the detection of outbreaks and the monitoring of control measures.

  In the UK the system functions acceptably well, however much disease goes unreported or is severely under-notified so that routine surveillance information gives an incomplete picture of the nature and size of the threat. The level of under-reporting varies according to the disease concerned.

  Over recent years the surveillance function of the notification system has been supplemented by other methods of reporting, notably the reporting of laboratory isolations of significant pathogenic micro-organisms through the Public Health Laboratory Service (PHLS) network. These and other microbiology laboratories, are however under no statutory requirement to report infections for public health purposes. More recently there have been some interesting experiments in the surveillance of the frequency of particular symptoms presenting in telephone consultations to NHS Direct[109].

POINTERS FOR REFORM

  The current notification system, with all its imperfections, is based on notification by doctors following a clinical diagnosis. This system should be retained, however, it should be supplemented with statutory notification by laboratories of specified micro-organisms. Because labs identify micro-organisms rather than diseases, the list of notifiable diseases may need slight amendment on this basis. The current notification system also has a major gap in that it is impossible to track antimicrobial resistance. This should be made notifiable by labs.











  Presumably in future notifications will now need to be directed to the field officers of the new Agency. The notification procedure should be set out in regulations instead of primary legislation, to allow flexibility for change in the future—particularly with a view to more sophisticated electronic forms of communication.

LEGAL PROVISIONS FOR INVESTIGATION OF OUTBREAKS

  For the most part, compulsory measures to investigate an outbreak of infectious disease will not be necessary. If legal powers are needed, the 1984 Act and 1988 Regulations give a wide range of powers and duties to local authorities to facilitate enquiries in an outbreak investigation. These fall under the following headings:

  1.  Identification of cases via:

    —  Notification (already discussed).

    —  Mandatory medical examination to assist identification.

  2.  Measures to assist epidemiological survey:

    —  Powers for compulsory provision of information.

    —  Powers of entry and investigation.

POINTERS FOR REFORM

  At first sight some of these powers seem draconian and out of keeping with modern notions of civil rights—a theme which will be discussed later.

  However, it probably is necessary to retain a power to require medical examination in the public interest. A number of safeguards are built in—that a medical examination is required in someone's interests and with the consent of the person's doctor (if they have one)—though the ex-parte decision-making is controversial.

  Current Powers of mandatory medical examination extend only to suspected "carriers", rather than suspected cases. This needs to be remedied.

  There are few powers to require individuals to provide information that may be required to properly investigate an infectious disease incident or outbreak. Provisions might be made requiring information from others who may be able to help an epidemiological survey including employers and owners or occupiers of buildings and managers of places used by people; eg schools, colleges, hospital and prisons. Apparently the Health and Safety Executive have such powers in relation to industrial accident investigations.

  Statutory rights of access to premises (including residential homes and businesses) could be given to specified officers to help control the spread of notifiable diseases in order to enable access to people for questioning.

  Powers of investigation need also to allow for examination and inspection of buildings sampling of water, food, cooling towers etc during outbreaks and enforcement of orders[110].

LEGAL PROVISIONS FOR OUTBREAK CONTROL

  Generally, compulsory measures to control an outbreak of infectious disease will not be needed. They may, however, provide an incentive for voluntary co-operation and occasionally will be required.

  The legal provisions directed to control outbreaks of infectious disease under the 1984 Act and 1988 Regulations can be grouped into two categories:

    —  Provisions to control person to person spread.

    —  Provisions to control environmental spread.

POINTERS FOR REFORM

  The existing law for the control of infectious disease is based on the Public Health (Control of Disease) Act 1984. However, this Act simply consolidated a number of earlier statutes. Many of its control provisions have remained essentially unchanged since the Sanitary Laws of the 1870s which were themselves piecemeal responses to crises or impending threats such as from cholera or smallpox. Many also appear inappropriate in light of contemporary living standards and social norms and current medical knowledge about disease transmission.

  Some provisions are unnecessarily strict for example the offences around using public transport. Many potentially useful provisions are simply absent. The law clearly needs modernisation and simplification. It is also too rigid and a degree of flexibility to circumstances is required.

Reform of Provisions to Control Person to Person Spread

  In the past, with lesser technology, the main objective was to isolate infected persons to prevent person-to-person spread. Today, however, there would be a much greater accent upon limiting infectivity via early administration of effective treatment and immunisation.

  Nevertheless, isolation still has a place today. Previous provisions identified particular places from which a person might be excluded from going. This is still appropriate for children vis-a"-vis schools, cre"ches and nurseries but not in most other situations. Rather, it would be better infrequently to have recourse to powers to restrict movement and contact with others by a time-limited order[111] in the individual outbreak[112]. This could include preventing a sufferer, contact, or carrier from working, limitations on travel, restrictions on gatherings, closure of schools and public places, and more rarely quarantine of cases, contacts or to asymptomatic carriers. Legal sanctions would apply for breach of an order.

  The power to remove to and detain in hospital where necessary for the purpose of quarantine should remain. It is important from the point of view of effectiveness and of civil rights (see later) that the criteria for making these orders are sufficiently precise and that they give the right weight to the interests of the infected person. The present law is probably inadequate on these scores. The current provisions also only apply to cases suffering from disease. Consideration should be given to whether the powers should be expanded to cover carriers of a disease.

  The current law provides for a person suffering from a notifiable disease to undergo mandatory medical examination and to be removed to hospital involuntarily, and once there, to be and detained against their will—principally for the purposes of isolation or quarantine. There is, however, no provision for compulsory treatment under the Act. Though this issue is obviously also very sensitive in civil liberties terms, it might be more logical in the modern era of effective immunisation and treatment than some of the other provisions. This is evidenced by the emergence of multi-drug resistant TB (which is untreatable and therefore fatal in 50 per cent of cases) as a result of failure of patients to complete full courses of treatment. The public interest favours compulsion or incentivisation of directly observed therapy (DOTS), an avenue pursued in the United States.

  Also in the United States, compulsory routine vaccination has been found to be consistent with constitutional rights and school entry is dependent upon prior vaccination. Compulsory vaccination was tried in the UK in the Nineteenth Century but aroused widespread public opposition and was withdrawn. It is therefore unlikely that compulsory vaccination (routine or emergency) would be acceptable in the UK where the law rarely provides for coercive health measures.

Reform of Provisions to Control Environmental Spread

  Most of the legislative provisions for the control of the environmental are not contained in the public health acts but in environmental and food law. Those environmental provisions which are within the public health acts including the sending of infected articles to a laundry, disinfecting library books, restricting traders in rags and clothes, wakes, and the detailed delousing and disinfection powers, now seem anachronistic and irrelevant. The measures need updating.

  For instance, during epidemics of cholera, plague, anthrax, or viral haemorrhagic fever the corpses of victims may be a source of infection and require special precautions. However, assuming a legal power is still required relating to disposal of human bodies, it could be limited solely to victims of these diseases rather than applying more widely to a long list of notifable diseases.

An Infectious Disease Control Order?

  In order to address the perceived rigidity of the current legal framework, the 1989 Department of Health consultation paper on communicable disease control law proposed replacing the current range of specific control powers with a single flexible "Infectious (Communicable) Disease Control Order"[113]. However, nothing was ever implemented.

  The single order, served on individuals or groups of person, or on employers and owners of buildings, would be simpler than requiring each power to be exercised individually.

  However, if such orders are to be enforced by criminal sanctions for disobedience it will be necessary for the order-making power to be clearly defined. If not, there would in effect be an open-ended criminal offence, the character of which would be completely and arbitrarily altered, and this would be unacceptable.[114]

  The order would therefore need to be served upon the recipient and this would give him notice of what was required or prohibited. This would be an improvement on the current position where the person is uncertain of the range of offences that are against the law.

  An appeal mechanism (which would need to operate rapidly) would be needed to balance the flexibility afforded to the public health officer in the public interest against the rights of the individual.

CONCLUSIONS

  The current legal framework, which was drafted in the 19th century, with no reasoned reform since 1945 is, neither based on a modern understanding of infectious disease control, nor does it adequately address the main infectious disease problems of today.

  Because the provisions have changed so little over so many years they have also largely been bypassed by modern ideas on civil rights in complete contrast to the position regarding Mental Health Law with its myriad safeguards to protect against abuse.

  The legislation that applies today is fragmented mainly as a result of crisis measures that were taken to respond to a particular event rather than a comprehensive body of legislation. Devolution is adding to this. English Law is admired for being pragmatic but its peculiarity whereby the law is built up piecemeal over many years is not suited to devolution.

  The complexity of the legal base laid down in multiple layers also serves to obscure the true legal position in relation to powers. This is especially difficult for non-lawyers—including those who are charged with protecting the people's health. Worse, at times the complexity has resulted in a loss of clarity of powers, even when interpreted by lawyers. As already indicated, this includes matters as fundamental as which body is responsible for controlling infectious disease at the local level and the precise nature of its specific powers.

  Thus, at best the relevant law can be described as untidy, not comprehensive, and in need of updating and streamlining. At the very least a tidying up of the existing statutory framework most directly relevant to public health is required. At worst:

    —  The United Kingdom Government may be in breach of its obligations under the European Convention on Human Rights in failing to provide adequate safeguards against the possible abuse of public health powers.

    —  There is genuine ambiguity about where leadership and responsibility to control infectious disease lie—at the various levels.

  Given that it is often unclear where the organisation accountabilities lie—often "no one is in charge".

  The problems highlighted by the Phillips Report in the wake of the BSE and CJD crisis demonstrated how government departments show a lack of clarity about who is responsible for specific cross-sectoral issues. The BSE incident raised questions about the role of government departments and their advisory committees, as well as the public's access to information. The BSE incident also demonstrated the public's lack of confidence in the Government's ability in providing scientific advice independent from political and commercial interests.

  Even after the latest reorganisations in England and Wales the structures responsible for monitoring, protecting or improving different aspects of the public health remain confused and lack co-ordination—particularly at the local level. The latest restructurings also introduce further diversity and complexity across the UK, which may also make the enforcement of regulations and the provision of public health information and advice difficult.

  There is an unquestionable need for co-ordination, rationalisation and simplification. Given the advent of devolution, with the legislation, policies and structures applying across the UK becoming different, these problems are now likely to become more acute unless a fundamental legal rationalisation is considered. With continuing devolution, this situation will increase and totally different systems and legislation could apply in the various entities of the UK.

  It would therefore clearly be desirable that there should be a UK-wide co-ordinating mechanism, operating in a clear and transparent fashion, both to ensure uniformity of approach across the United Kingdom, and to reassure the public that there is an effective, UK-wide response to the threats posed by infectious disease.

EPILOGUE: A TIME FOR ACTION ON PUBLIC HEALTH LAW REFORM

  In his article "When a Bioweapon Strikes, Who Will Be in Charge", Cole has said of the United States:

    Laws are so antiquated and unclear that no-one even knows what our powers and duties are. For example it isn't clear whether any legal authority has the power to force people to be vaccinated, treated, quarantined, or isolated. These powers will almost certainly be needed in the event of a bioterrorist attack[115]

  I have demonstrated that the position appears worryingly similar in the UK.

  The state of public health law needs urgent review if we are to effectively control the spread of a serious infectious disease outbreak within the population while at the same time not contravening the Human Rights Act.

January 2003








88   The State of Communicable Disease Law. The Nuffield Trust, London 2002. Back

89   An unhealthy defence for the public. The Times, London Tuesday 14 May 2002. Back

90   The Case for a New Health of the People Act. (In Press) The Nuffield Trust, London 2003. Back

91   Betrayal of Trust: The Collapse of Global Public Health. Hyperion Books. New York 2002. Back

92   Garrett L. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. Farrar, Strauss and Giroux. New York 1994. Back

93   Including HIV/AIDS, BSE/nvCJD, Ebola Fever, Marburg Fever, Hong Kong (Bird) Flu, E. Coli 0157. Back

94   Department of Health Getting Ahead Of The Curve. A strategy for combating infectious diseases (including other aspects of health protection). The Stationery Office. London 2002. Back

95   Betrayal of Trust: The Collapse of Global Public Health. Hyperion Books. New York 2000. Back

96   Circular HRC(73)34. Back

97   Public Health (Control of Disease) Act 1984 (c 22), s.1. Back

98   Most notably the salmonella food poisoning outbreak at the Stanley Royd Hospital in Wakefield in 1984 and the legionnaires disease outbreak in Stafford in 1985. Back

99   Chapters 4 and 7. Back

100   "Public Health in England" stated that responsibility for the surveillance prevention and control of most infectious disease lay with health authorities, though it also acknowledged the local authority's continuing role in prevention and control of diseases that were food and water borne. Circular HC(88)64 reminded health authorities of their duties in this area. Back

101   The exceptions being the food related issues related to the Lanarkshire E. Coli outbreak (as summarised in the Pennington Report) and central government policy in the Bovine Spongiform Encephalitis (BSE) and New Variant Creutzfeldt Jacob Disease (nvCJD) affair (as summarised by the Phillips Enquiry) which have led to the setting up of the Food Standards Agency. Back

102   Department of Health. Getting Ahead Of The Curve. A strategy for combating infectious diseases (including other aspects of health protection). The Stationery Officer. London. 2002. Back

103   The Agency will subsume the existing Public Health Laboratory Service (an England and Wales-wide network of microbiology laboratories originally set up in World War II) and its Communicable Disease Surveillance Centre (CDSC) which currently provides expert support in informing policy, in co-ordinating surveillance activities and in the investigation of outbreaks and epidemics. It will also subsume the Centre for Applied Microbiology and Research (the biological warfare facility at Porton Down), the National Radiological Protection Board and the National Focus for Chemical Incidents, to provide public health protection nationally and locally right across biological, chemical and radiological hazards. Back

104   To deliver specified functions relating to the prevention, investigation and control of infectious diseases as well as chemical and radiological hazards. Back

105   Hodgkin P, Perrett K. The role of primary care in bio-terrorism, epidemics and other major emergencies: failing too plan is planning to fail. BJGP, 2003, 53, 5-6. Back

106   Section 10 of the Public Health (Control of Disease) Act 1984 designates five diseases (subject to the International Health Regulations) as being "notifiable" diseases': cholera, plague, relapsing fever, smallpox, typhus. In addition food poisoning is made notifiable in section 11 of the 1984 Act. Unfortunately there are several different definitions of "food poisoning" in the 1984 Act and 1988 regulations. Ideally a common definition should be adopted. Back

107   Department of Health. Review of Law on Infectious Disease Control (Consultation Document). HMSO. London 1989. Back

108   Department of Health. Review of Law on Infectious Disease Control (Consultation Document). HMSO. London 1989. Back

109   Hodgkin P, Perrett K. The role of primary care in bioterrorism, epidemics and other major emergencies: failing to plan is planning to fail. BJGP, 2003, 53, 5-6. Back

110   Department of Health. Review of Law on Infectious Disease Control (Consultation Document). HMSO. London 1989. Back

111   The time period would be specified in advance would depend upon the incubation period and period of infectiousness. Back

112   Department of Health. Review of Law on Infectious Disease Control (Consultation Document) HMSO. London 1989. Back

113   Department of Health. Review of Law on Infectious Disease Control (Consultation Document) HMSO. London 1989. Back

114   Department of Health. Review of Law on Infectious Disease Control (Consultation Document). HMSO. London 1989. Back

115   Cole T B. When a Bioweapon Strikes, Who Will Be in Charge. JAMA 284, 8, 946-948 2000. Back


 
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