Select Committee on Science and Technology Written Evidence

Memorandum by Sheffield City Council, the Health Protection Services


  1.  This evidence concerns itself mostly with the Chief Medical Officer's report "Getting Ahead of the Curve—a Strategy for Combating Infectious Diseases", and the subsequent decisions and development work of the Department of Health, aimed at bringing into fruition the new Health Protection Agency (HPA), proposed by the report.

  1.2  Environmental Health Departments in every local authority in the country are involved as a front-line service in the fight against infectious diseases. In practice, Environmental Health Officers act as the "foot soldiers" of local Consultants in Communicable Disease Control (CCDC), with regard to the control of many diseases. The exact working relationships between CCDC's and Environmental Health Departments varies across the country, with no prescribed model of partnership. In some areas, notification of infectious diseases is made direct to the CCDC's department, in others (as in Sheffield), notifications are received by the Environmental Health Department. Whatever the differing working relationships, Environmental Health Departments are involved in the investigation and control of many infectious diseases, gathering information from individual cases, identifying common factors, taking samples and specimens, and ultimately if possible, carrying out enforcement measures (eg closure of a premise or operation that has caused food poisoning, or legionnaires disease etc) to control the spread of the disease.

  1.3  Unfortunately, the major input of Environmental Health Departments in combating infectious disease is generally not recognised by the medical community and the tendency is for the Environmental Health Departments to be excluded or marginalized in any discussion or debate about infectious disease, other than at a very local level. This non-recognition has been demonstrated in the development work towards the birth of the Health Protection Agency. There are no representatives of the environmental health profession on either the Steering Group or Project Team, set up to oversee the development work.


  2.1  "Getting ahead of the curve" is a forward thinking document in so far as it accurately describes the challenges facing the country with regard to infectious diseases, the weaknesses within our present system of surveillance and control, and convincingly makes a case for change and improvement (Chapters 1-5).

  However, we believe that the strategy and proposed actions as laid down in Chapter 6 will not be sufficient or appropriate to fully meet the challenges facing the country.

  We agree in principle with the formation of the HPA. We fully agree that there is a need for a new national agency to act as a source of national expertise, take overall responsibility for the surveillance of infectious diseases and provide a service for their prevention and control. There is a need for a clear line of sight from national to regional to local level in these matters to speedily convert policy into action. However, we do not believe that the HPA as it is envisaged and appears to be developing, will have the optimal capability to meet the future challenges.

  In some respects we are concerned that the proposals will actually weaken our ability to fight infectious diseases.

  2.2  A major and illogical weakness in the strategy is the proposal to bring the HPA into being as a cost-neutral exercise. "Getting Ahead of the Curve" rightly describes the future increasing risk to the country from infectious diseases and accurately describes the weaknesses in the present arrangements, stating that we need to achieve higher levels of reporting infectious diseases, and closing serious gaps in the surveillance systems. No attempt has been made to carry out a base audit of the personnel and skills presently available in the various agencies working in this field. Therefore, how can we have any confidence that merely a re-jigging of present resources will be adequate to improve the situation as it stands, and also be in a fit position to adequately cope with any future increased demands?

  As an example of this, as described earlier, Environmental Health Department personnel carry out many of the front-line tasks in this field of work. Environmental Health Departments are charged with carrying out a multitude of functions, most of which are not directly concerned with infection control (food hygiene inspections, pollution control etc) and most of the personnel in Environmental Health Departments involved in infection surveillance/control work will also be expected to be carrying out a host of other unrelated tasks: their post will not be dedicated to infection surveillance/control work. Environmental Health Departments, in recent years, have come under tremendous pressure from central government to greatly improve their performance in many of their other areas of work, especially the number of food hygiene inspections they carry out, with no increase in resources. This has commonly lead to a diminution in the time staff have available to devote to infection control/surveillance. This pressure from competing functions is likely to increase in the future. The experiences of the Meat Hygiene Service (MHS), a relatively new, non-departmental government body brought into existence to improve hygiene standards in the meat production industry are of relevance in this matter. Most of the workforce employed by the MHS were previously employed by local authorities to do the same functions, but when the MHS came into being, they swiftly realised that they would need (and did employ) many more staff to successfully carry out their remit than local authorities had been able, with their limited budgets, to employ.

  2.3  We are concerned that the HPA as it seems to be evolving will not be a body that has any effective management control over many of the inter-relating strands of work that need to fit together to produce a coherent, co-ordinated and uniform national infection surveillance/control service.

  In our opinion, if the HPA wants to have "a clear line of sight from national to regional to local level" (quote—Getting Ahead of the Curve), then it requires (if not direct, then) executive management control over more strands of the national infection surveillance/control community than is being proposed. We are particularly concerned about the proposals for the transfer of many of the Public Health Laboratories to the National Health Service, (see below).

  We would suggest that the Committee looks at the Food Standards Agency as an example of a relatively new body which has impressively met its remit. The Food Standards Agency is a transparent organisation with a clear national focus. They are able to set national priorities based on the best science available, setting demanding operational standards and targets, and with an auditing/monitoring role with powers to enforce quality and uniformity across all inter-relating agencies.

  2.4  We are greatly concerned about the proposed transfer of many of the existing Public Health Laboratories to NHS control. We believe this strategy to be wrong-headed and much more likely to result in a reduction in capability to fight infectious diseases. Environmental Health Departments work very closely on a day-to-day basis with the Public Health Laboratories. It is a partnership that has served this country well for many years and we are sure that most Environmental Health Departments will look at these proposals with great apprehension. To be frank, the NHS managed laboratories we have dealings with have a poor understanding of their wider public health responsibilities, and are inherently inwardly focussed.

  In Sheffield, the unhindered partnership between the Sheffield Public Health Laboratory and the Environmental Health Department has over the past 20 years resulted in a number of major advancements in the wider understanding of a number of infectious diseases. Examples of these are given below.

  2.4.1  In 1984 and 1985 there was a substantial increase in the number of human infections caused by Salmonella typhimurium phage type 141 in the UK. Investigative work by Sheffield Environmental Health Officers lead them to believe that a substantial proportion of these infections were being caused by contaminated hens eggs. When contacted, both the Communicable Disease Surveillance Centre (CDSC) and the Ministry of Agriculture, Fisheries and Food (MAFF) were reluctant to believe this hypothesis and MAFF refused to cooperate in any work to investigate the hypothesis further. Sheffield Public Health Laboratory, on the other hand, had no hesitation in diverting resources to enter into a major piece of research work, in partnership with the South Yorkshire Environmental Health Departments. This research proved that hen eggs from a number of farms in Lincolnshire were responsible for human Salmonellosis in South Yorkshire caused by S. typhimurium PT 141. It should be noted that before this work, it was generally considered that hens eggs were sterile and could not possibly be a cause of salmonella food poisoning.

  2.4.2  During the late 1980's it was recognised that there was an upsurge in the number of cases of cryptosporidiosis occurring during the spring months in Sheffield. It was also discovered that this increase was related to the differing areas of the city, which received their water supplies from one of the 10 different sources in Sheffield. Previous to this, it was considered that cryptosporidiosis was a disease caused by contact with infected animals or humans; contamination of water supplies was not a recognised route of transmission. Again, Sheffield PHLS involved themselves, in partnership with Sheffield Environmental Health Department in research work which proved that contaminated water supplies can be a common source of cryptosporidiosis and also that some types of water treatment plant, in common use throughout the country at that time, were incapable of filtering out cryptosporidia oocysts.

  2.4.3  Unpasteurised milk was first recognised as a possible source of E. coli 0157 infection as a result of work carried out by Sheffield's Environmental Health Department and Public Health Laboratory. Since then, Dr Peter Chapman, at the laboratory, has carried out pioneering research into the epidemiology of E. coli 0157 which has greatly expanded our knowledge of this serious newly-emergent pathogen and which has resulted in him being recognised as a world expert in this field.

  We seriously doubt if any of these pieces of work, which required substantial diversion of resources in the laboratory to achieve, would have come about if the laboratory had been under local NHS management at the time. It must be understood that much pioneering work has been carried out in the local Public Health Laboratories across the country, and not just in the central or major regional Public Health Laboratories. We believe the national network of Public Health Laboratories to be the "jewel in the crown" of this country's good record of success in the fight against infectious diseases since the Second World War.

  The proposals for the HPA seem to be following a strategy of divesting all clinical microbiology (including in those Public Health Laboratories to transfer to the HPA) out of its management, as if clinical microbiology has no core Public Health function. We would argue to the contrary, that clinical microbiology is fundamental to Public Health surveillance and that it would make more sense to transfer the NHS laboratories to the management of the PHLS. This would also make it easier to improve standards in NHS managed laboratories and also facilitate their much needed, greater understanding of their public health role. The proposals do not seem to recognise that much of the clinical diagnostic work undertaken by both NHS laboratories and Public Health Laboratories is done on behalf of GPs, and not just hospitals. It is surely a valid argument that it is just as logical, if not more so, for this work to be done in laboratories managed by the PHLS.


  3.1  The call for evidence asks the question, "should the UK make greater use of vaccines to combat infection?"

  Vaccination has a critical role to play in infection control, and vaccination policy must be set nationally with adequate resources to ensure that any strategy is implemented effectively.

  Vaccines however should not be seen as a universal panacea. Very often the root causes of an outbreak of infection are contained within the wider environmental and public health conditions at large at the time. For example, the incidence of TB was greatly reduced between 1850 and 1940 (Source: McKeown 1979) due to improvements in food hygiene and working and living conditions, which was well before the introduction of vaccines. The "tail end" of TB was dealt with by vaccines.

  3.2.  The following example also reinforces the points made earlier, that the HPA needs to be a robust organisation, with seem-less ability to convert policy and guidance into timely action.

  In September 2001, the PHLS Advisory Committee on Vaccination and Immunisation published "Guidelines for the Control of Hepatitis A Virus Infection". Amongst other measures the guidelines recommended that "injecting drug users, should be offered HAV vaccination as a preventative measure" and "in order to achieve high coverage in this group, concerted action is required from all agencies, including outreach services and prisons".

  There is presently a substantial outbreak of Hepatitis A infection, affecting injecting drug users and their contacts, across South Yorkshire and also affecting the population of Doncaster Prison. Only now is the vaccination of injecting drug users against Hepatitis A starting to happen in this region, and only because the outbreak has occurred. If the PHLS guidance had been acted upon sooner, we believe the outbreak may not have affected as many as it has. We also suspect that in other areas of the country, very little will have been done as yet to initiate the preventative measures outlined in this guidance.

  We have a good history in the UK of recognising what needs to be done but a less than perfect record in pushing through those measures.

October 2002

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