Select Committee on Science and Technology Written Evidence

Memorandum by Profesor T H Pennington, Professor of Bacteriology, University of Aberdeen


  1.  Surveillance of human infectious disease is done better in the UK than in most other countries. However, it falls far short of what is achievable with current methods. There are two main deficiencies.

  2.  An excessive reliance on reactive surveillance. This is well illustrated in the Department of Health document Action to strengthen the microbiology function in the prevention and control of infectious diseases, which restricts itself exclusively to this topic. The deficiencies of reactive surveillance are well known. Hospital laboratories produce nearly all the data. But their primary function is to provide information for clinicians for patient management. Surveillance is a by-product; there is very little dedicated funding for it. Reactive surveillance grossly underestimates the level of infection in the community. The best recent demonstration of this was provided by Infectious Intestinal Disease Study (Report of the Study of Infectious Intestinal Disease in England, TSO, 2000).

  3.  The fragmented and ad-hoc nature of the surveillance network in the UK. This is apparent at all levels. (a) Unco-ordination is fed by the rivalries that inevitably exist between agencies (eg between different government departments, and between the NHS and universities). Surveillance of zoonoses is a good example, (eg reference laboratories for E.coli O157 are funded on the basis of the host species rather than the microbe); human and veterinary laboratory surveillance is not "joined up". (b) The level of commitment to surveillance work in hospital laboratories, which do most of it, varies. The major determining factors are variations in the degree of personal interest by staff, and the need to give higher priority to other work (eg routine diagnostic services) (c) At specific pathogen level, funding for surveillance is often driven by political pressure rather than by health needs (eg there is no comprehensive reference laboratory back up for UK laboratory surveillance of Campylobacter (about 50k infections reported annually) but there are two E.coli O157 reference laboratories (about 1.5k infections reported annually)).


  4.  This strategy proposes the abolition of the PHLS as a body concerned exclusively with infection. The transfer of PHLS laboratories to the NHS is being done at breakneck speed. The reasons for this, or its urgency, are unclear. The impact on surveillance will be negative. The transfer will destroy a network of laboratories with the public health function at their core. It is improbable in the extreme that NHS hospital managers will give this function the priority that it received from the PHLS. Inevitably, they will focus on diagnostic work for patient management rather than surveillance or outbreak control. The training function of the PHLS will disappear. This will be a major loss to UK medical microbiology: doctors and scientists with expertise, experience, and an interest in public health microbiology will in future emerge only capriciously and randomly through factors like personal interest. The training of medical microbiologists with broader interests than the diagnosis of infection and the provision of advice on therapy is already in very serious difficulties in the UK because of the collapse of academic bacteriology (described in the recent report by the Academy of Medical Sciences).

  5.  The transfer of R & D funds from the PHLS to the NHS will also have a negative impact on surveillance. Reference laboratories offer more than a routine specialist service. Essential parts of their function are to improve scientific services and track evolutionary change. They cannot do these things without core R & D funding.


  6.  There is no doubt that state-of-the-art, fit-for-purpose diagnostic and surveillance techniques are being quite widely used in the UK. But their full deployment in all appropriate circumstances is hindered by lack of money and a lack of understanding of their cost-effective benefits.

  7.  Laboratories are an easy target for budget cuts. The PHLS has had them year-on-year for a long time. In the NHS their impact on waiting lists and other performance indicators familiar to politicians and the public is too indirect to be noticed.

  8.  In my view gaps in the training of medical microbiologists and public health specialists means that many have a poor understanding of these aspects of molecular biology and population genetics that are essential for the deployment of molecular epidemiology methods and interpretation of their results. The demise of the PHLS—particularly its training function—and the terminal state of academic bacteriology will enhance these deficiencies.


  9.  One answer to the question "which infectious diseases pose the biggest threats in the foreseeable future" is that because of evolution—which is essentially unpredictable—nobody knows. The prospect of new or much changed pathogens appearing is always very real. Such threats can only be countered by having a surveillance system with a broader remit than just coping with existing pathogens using existing tests. It must have more flexibility and built-in capacity for innovation so that it can respond rapidly to new problems.


  10.  Britain has an excellent track record in basic research on pathogens. For example, our fundamental work over the years on TSEs and animal pathogens like FMD has been, and continues to be, of international quality. But our ability to link this work to policy has been dismal, as shown by BSE/vCJD and the 2001 FMD outbreak. For example, I was shocked, but after very brief reflection not surprised, to learn from the "Lessons Learned" Inquiry that Pirbright had not been consulted during the preparation of MAFF's FMD Contingency Plan. It is vital that lessons must be learned from these events. Policy makers must learn how to make the best use of scientific information. After all, our Nobel Prize track record shows that for basic science we are second to none. But it will not be enough for scientific advisory committees to follow the Nolan rules, have a few more members representing consumer interests, and to have their formal meetings in public. Their scientific membership should be more inclusive and less exclusive. The BSE Inquiry showed the importance of policy makers getting advice from scientists with detailed knowledge of the problems being addressed—and the bad consequences of not doing this. This is not being done as well as it should or could.

  11.  BSE and FMD also showed the importance of linking policy making with accurate field knowledge. The PHLS played a very important role over the years in the generation, assessment, and promulgation of scientific knowledge and, through its network of laboratories, the collection and interpretation of local data, events and issues. The best way forward would be to strengthen its central, and its local, functions. Like British Rail, the PHLS was not perfect. But replacing it with public health services whose levels and costs "will be the subject of service level agreements . . . normally . . . sustain(ing) existing service commitments" sounds just like Railtrack and its complex contractual relationships with Train Operating Companies, Rolling Stock Operating Companies and so on. I fear that the effects of this fragmentation (discussed, for example, in Lord Cullen's Ladbroke Grove Rail Inquiry Report) will be repeated for infection control. They included the loss of common objectives and a common culture, a lack of leadership, deskilling and training problems, bad effects from complex interfaces, and the loss of an R&D capability.

  12.  The public has a deep interest in infection. The handling of BSE and the emergence of vCJD caused a massive loss of trust in Government institutions and in science in general. The adoption by the Food Standards Agency of frankness and openness in transmitting uncertainty about risk is setting new standards. If other agencies and departments of Government followed this lead with enthusiasm the regaining of trust would go faster.

October 2002

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