Memorandum by Dr Nick Beeching, Senior
Lecturer and Clinical Lead in Infectious Disease, Royal Liverpool
University Hospital and Liverpool School of Tropical Medicine
This evidence is provided from the viewpoint
of a clinician whose practice involves both imported and locally
acquired infections, with experience and interest in the interface
between public heath interventions and clinical activity, and
a strong interest in training in the infections specialists. I
believe that there are both strengths and weaknesses in the current
systems to manage infections and in the recommendations made in
"Getting Ahead of the Curve". Many improvements could
be made by provision of sufficient resources to define and provide
what is currently recognised as best practice, as well as by reorganisation
and the introduction of new technology. This evidence is submitted
as an individual, although I have listed relevant positions that
I hold at the end of the submission.
2. PROBLEM AREA
Failure of statutory notification
systems for specific diagnosis and co-ordination of these with
other sources of data, except for a small number of illnesses
eg tuberculosis. Notification is rarely complete the list is very
old and case definitions are vague eg "hepatitis", "dysentery".
Notification should be linked to specified outcomes eg contact
tracing or general surveillance.
Hospital impatient systems only report
on final diagnosis, coding of which is often poor. There is a
need for systematic coding of referral syndromes/problems as well
as final diagnosis, and for outpatient coding of referral problem
Current information technology in
British hospitals is inadequate to gather the above data from
clinicians in real time (and hence to improve accuracy).
Laboratory notification or reporting
is not universally applied or accepted (but is recommended in
Getting Ahead of the Curve).
Different systems are in use eg statutory
notification by clinician, laboratory reports etc and co-ordination
of these is unclear.
There is little feedback from central
systems to the reporting clinician, hence little motivation for
them to devote precious time to such activities. Lack of clarity
over who will provide aggregated data eg CDSC (or HPA) centrally,
Regional Public Health Observatory or other.
Lack of agreed policy/protocols for
routine surveillance of specific risks in disadvantaged groups
eg refugees/asylum seekers, prisoners.
Imported disease is largely neglected
apart from malaria and viral haemorrhagic fevers.
Specific schemes part "owned"
by clinicians eg HIV notification scheme, British Paediatric Surveillance
Schemes, Sentinel general practice surveillance schemes.
External international programmes
such as Geisentinel (from CDC Atlanta) or Trop Net Europe (co-ordinated
via Munich), or official interagency programmes such as Salmnet.
Notification of specified laboratory
isolates by a network of PHL laboratories who are engaged in routine
diagnostic work in district general hospitals across the country,
using standardised laboratory and notification procedures. This
is a big strength of the British PHL system compared to eg CDC
model in the USA which could be threatened by current plans.
Interventions are not universally
applied even for high profile conditions where early intervention
is recognised to be effective. eg pre hospital treatment of suspected
meningococcal meningitis and antibiotics, and immediate chemoprophylaxis
(and/or vaccination of appropriate) of contracts of a case. Continued
postgraduate medical education is essential to overcome this.
lack of basic audit tools and standards
for quality of management of most infectious problems eg chickenpox,
malaria, meningitis etc.
Inadequate recognition by organ-based
specialists of the public health implications of infectious problems
eg tracing/immunisation of contracts of hepatitis B patients seen
by specialists other than infectious disease physicians.
Some evidence base for success of
joint microbiology/infectious disease consultations in improving
clinical outcome of serious infection in hospitals and better
microbial use generally.
Co-ordinated approach achieved by
centres of infection in both teaching hospitals and district general
hospitals as recommended by British Infection Society, involving
Fragmented vaccine policies eg multiple
risk groups to be targeted for hepatitis B vaccination instead
of universal vaccination. Impossible for primary care or speciality
groups to track all these "risk groups".
Failure to fund new universal screening/vaccination
policies eg maternal HIV hepatitis B screening, so that implementation
is patchy and onward referral of cases (for treatment) and contacts
(for prevention) is poor.
Failure of resource-linked central
policies on screening, treatment and prevention for common problems
eg HIV, hepatitis, TB in high risk groups who have difficulty
accessing health care or are frequently moved:
asylum seekers/refugees; and
Failure to use media convincingly
to inform and empower the public to consider and accept health
education messages. Need to adopt a consumer friendly attitude
(eg Private Eye special issue on MMR) rather than indignant
central dictat. The campaign to educate the public about chlamydia
infection was far more effective educationally, targeting women's
magazines and other consumer orientated publications.
Targeted vaccination campaign eg
meningococcus C, Hib vaccines, despite resources being stretched
on the ground.
HIV in iv drug usersmultisectoral
policies leading to sustained lowest prevalence rates in Europe.
3. GETTING AHEAD
The overall concept of the document
is excellent, but it is important not to lose the strengths of
the current system (eg many PHL laboratories performing day to
day diagnostic and surveillance work) during implementation.
Must recognise the need for new resources
to enable clinicians and laboratory personnel to participate in
Need to involve clinicians, especially
adult and paediatric infectious disease (ID) specialists in planning,
especially in cross-speciality infections such as HIV, hepatitis
B and C, tuberculosis, where they provide a significant proportion
of total care. Central planning should recognise this role and
provide appropriate resources.
Need to recognise that models of
care provision in London are not necessarily appropriate for many
complex infectious problems (HIV, hepatitis, TB) outside London.
ID physicians are often at the centre of the "hub" in
"hub and spoke" care networks, but this role has been
insufficiently catered for in some central planning and commissioning
for such infections.
The current reorganisation of funding
responsibilities at PCT level has caused a hiatus in regional
planning and funding for infection related issues. These need
to be resolved, and the lines of responsibility and interaction
need to be clarified. Thus many HPA roles will be centrally driven,
but interaction at regional level with leads in PCTs, STAs and
Directorate of Public Heath need to be transparent, both to allow
involvement of local practitioners and to avoid duplication and
waste of effort and limited resources.
Information technology is not co-ordinated
and does not allow for syndromic surveillance (see 2.1).
Unusual new problems eg new variant
CJD may not be detected by current systemsthe Infectious
Disease Society of America has a voluntary programme for reporting
unusual infection syndromes that may detect new acute problems,
but is unlikely to detect illnesses with a more remote actiological
link with infection.
Imported disease is poorly registered
in current systems. This is being explicitly addressed by the
new DH funded National Travel Health Network and Centre (NaTHNaC),
one aim of which is to improve the surveillance of imported disease.
Absence of adequate surveillance
means that the potential effectiveness of intervention cannot
be modelled, and this particularly applies to prevention of travel
Resources need to be provided to
encourage "academics" to take more interest in operational
research on both community and hospital based surveillance, coupled
with intervention measures.
Currently recommended strategies
for adult immunisation are applied in a very patchy fashion eg
pneumococcal vaccine, influenza, hepatitis B.
Flexibility needs to remain to allow
visible public choice eg individual vaccines as well as MMR when
there is public concern (however appropriate).
Research on new vaccines that have
greater potency and less complicated regimens is desirable, but
should be linked to cost-effectiveness and programme implementation
Regional or sub-regional vaccination
centres should be established to cater for the many groups who
fail to be covered by the current systems eg children of hepatitis
B carrier mothers, contacts of hepatitis cases, groups such as
iv drug users, asylum seekers etc. Such centres should be closely
linked with regional surveillance centres and appropriate record
keeping systems devised.
Prison health systems provide an
under-utilised (and under-resourced) focus for health prevention
and vaccination of high risk groups.
The current major threats are common
conditions ie respiratory viruses and bacteria and gastrointestinal
infections, and sexually transmitted and blood borne infections.
Increasing resistance of pathogens
to commonly prescribed antibiotics is spreading from hospitals
to the community, particularly via community-based care of the
elderly. A co-ordinated approach to both surveillance and antibiotic
control policies is needed that can be readily adapted to changing
local (Regional or sub Regional) needs, with realistic identifiable
targets for success.
There is no extra capacity nationally
to cope with an outbreak of infectious disease, particularly one
that is highly contagious. Redundancy of personnel (clinical,
laboratory and public health) needs to be built into the system
to allow for outbreak management.
Some have already been suggested in preceding
paragraphs. In addition
A clearer system needs to be established
to review the "lessons learnt" from individual outbreaks
of both veterinary and human infections, and to share these lessons
and use them to amend system failures.
Surveillance at grass roots level
needs adequate resourcing, together with appropriate involvement
and regular feedback of individual and aggregated data to the
health care providers who generate the data.
There is a need for more hospital
specialists with expertise in clinical ID in both adult and paediatric
practice. Adult ID has grown by 5 per cent per year over the past
15 years, and the Royal College of Physicians together with the
specialist societies (British Infection Society, Royal Society
of Tropical Medicine and Hygiene) have recommended the need for
one adult ID physician per 250,000 population, a target of approximately
200 for England (RCP Working for Patients II). The currently agreed
growth targets are for just over half this number by the year
2010. Much of the growth has been in "academic specialists",
emphasising the importance of infection-related research, but
more hands are required to provide clinical bedside and consulting
expertise and to assist with outbreak control and planning input
at regional and national level (eg response to bioterrorism).
There is a need for more integrated
training of specialists in infection, without diluting the current
training experience. The new joint training programme at specialist
registrar level in infectious diseases and clinical microbiology
is gaining in popularity and will produce pluripotential specialists.
More such posts should be established, and there is a need to
allow joint training of public health specialists with microbiology
or ID to maintain a cadre of public health specialist with more
in-depth knowledge and current practice in infection.
Undergraduate teaching in all aspects
of infections needs to be maintained. At least one new British
medical school does not appear to have plans to appoint any senior
academics in infection-related specialitiesthis does not
bode well for training of undergraduates. Previous surveys (eg
British Society of Antimicrobal Chemotherapy) have emphasised
The interface between all infections
related specialities should involve all parties on a daily basis,
as recommended by the British Infection Society. Teaching hospital
centres with clinical specialists in ID should be part of a large
infection team. In district general hospital settings, single-handed
microbiologists (20 per cent of all UK) cannot be expected to
cope with providing all the necessary input to policies and clinical
care, but should be supplemented by a second appointment either
a clinician, clinician/microbiology joint specialist or further
Job plans for infections specialists
should recognise that much of their working week is spent on improving
quality not quantity of patient care eg telephone of bedside consultation,
committee work in formulary, antibiotic or infection control,
and running local, regional and national networks, as well as
input to postgraduate training of all hospital and community-based
specialities. Job plans based on patient or specimen turnover
do not currently reflect this type of work adequately, and further
resources are required.
A co-ordinated multi-sectoral approach
is needed to provide for surveillance, management and prevention
of infection in mobile, disadvantaged groups such as centres of
aggregated data relating to zoonotic infections.
The current international excellence
of British Tropical Medicine research and training, supported
largely by the Wellcome Trust and MRC, should be encouraged and
nurtured. This allows more specialists to gain experience of exotic
disease and to apply this experience within the UK. Probably each
ID Unit (there are about 25) should have a specialist with substantive
overseas experience during training.
While NaTHNaC will address the need for national
standards of advice and best practice in surveillance and prevention
of travel related disease, there is a need for defining and auditing
standards of training and practice in community and hospital based
There are many strengths of the changes proposed
in "Getting Ahead of the Curve". Achieving improvements
in surveillance requires a number of inputs, including resources,
to enable and encourage involvement of health care providers at
grass roots level. If not, they will neither identify nor produce
surveillance data that are essential to an enhanced national system.
In turn, management and prevention need to be encouraged by the
provision of meaningful aggregated surveillance data at local
level and in real time.
NaTHNaC stands for the National Travel Health
Network and Centre. This is a network for England, and the founder
participants are the Department of Health, Communicable Disease
Surveillance Centre of the Public Health Laboratory Service, London
School of Hygiene and Tropical Medicine, Hospital for Tropical
Diseases, and Liverpool School of Tropical Medicine. They will
network with other key players in travel health throughout Britain.
Currently staff have been appointed to be based in 3 of the participating
centres, and the director's post will be advertised shortly. The
administrative offices are based at HTD. NaTHNaC has not been
publicly "launched" yet but will be early in the New
Revised Core Functions of NaTHNaC21
May 2002 (adapted from 16 January, revised
"To protect the health of British travellers."
1. To develop consistent and authoritative
national guidance on general health matters for health professionals
and for institutional customers advising the public travelling
2. To disseminate the above guidance widely.
3. To develop and provide guidance on special
situations relating to health of travellers, including provision
of real-time access to a national expert for health care professionals
in need of further specific advice.
4. To carry out surveillance of infectious
and non-infectious hazards abroad (concentrating on types of traveller,
types of destination and types of hazard) and producing accessible
regular outputs of such surveillance.
5. The provision and dissemination of expert
advice and guidance on international travel health risks to bodies
concerned with the public health.
6. To administer the yellow fever vaccination
7. To engage the major stakeholders concerned
with travel health especially the travel industry, insurance industry
and other government bodies, to assist both in sentinel surveillance
and to engage in constructive dialogue towards a unified prevention
8. To facilitate and provide resources for
the training of health care and other personnel in the provision
of best quality travel health advice, based on such evidence as
9. To define short-term and long-term research
priorities in relation to the above.