Question 1What are the main problems
facing the surveillance, treatment and prevention of human infectious
disease in the United Kingdom?
Memorandum by Professor Paul D Griffiths, Chief
Executive of the Clinical Virology Network
The UK Clinical Virology Network was established
last year to co-ordinate the activities of the nation's Virologists.
Full details of our activities are available on the website, www.clinical-virology.org
but, in summary, we have agreed to interact as a series of specialist
laboratories aiming to provide best practice to all parts of the
UK. We aim to do this by sharing laboratory protocols and epidemiological
information and plan to use the Network to ensure that information
on current epidemiology of virus infections is provided electronically
to the Communicable Disease Surveillance Centre. Please note that
our work is complementary to that of Medical Microbiologists (who
deal with the laboratory aspects of bacterial/parasitic/fungal
and some common virus infections) and Infectious Disease Physicians
(who provide clinical care to patients with illnesses caused by
all types of infectious agents). Virologists provide specialist
laboratory diagnostic services for virus infections and are at
the forefront of applying molecular biological techniques to achieve
rapid and sensitive diagnosis. Our members include all of the
specialist Virologists practising within the UK and our activities
to date have been funded entirely from our own resources.
This response deals with all viruses of medical
importance. As requested, we will focus on natural infections
rather than bioterrorism although better surveillance and control
of the former will obviously facilitate prompt recognition of
ANew viruses have been discovered (approximately
one per annum over the last two decades), new antiviral drugs
have been discovered (approximately two per annum over the past
two decades) and better diagnostic methods have been developed
through the application of molecular biological techniques. Yet,
there has been no official co-ordination
of the activity of the nation's Virologists;
work is not conducted according to
a common standard operating procedure;
there is no guarantee from local
NHS Trusts/Universities/PHLS that the needs of accreditation will
we have a small number of trained
medical Virologists, many working in single handed clinical practice;
there is an insufficient number of
training posts to provide the next generation of medical Virologists;
surveillance of viral infections
through the PHLS has never provided comprehensive cover of London.
Question 2Will these problems be adequately
addressed by the Government's recent infectious disease strategy,
"Getting Ahead of the Curve?"
As a professional group we support the recommendations
for change in "Getting Ahead of the Curve" but have
no confidence that the changes to bureaucracy will help achieve
the defined objectives. We have taken the initiative to contact
distinct branches of the Department of Health on several occasions
but, apart from polite holding letters, our views have not been
acknowledged. (See attached letters of 28 June 2002 to the Chief
Medical Officer, 13 September 2002 to Dr Mary O'Mahony and 13
September 2002 to Sir William Stewart).
Our response to the consultation exercise on
a national specialised services definition set for pathology had
a particularly disappointing outcome. It appears that those commissioned
to produce the report did not realise that the diagnosis of virus
infections relies upon specialist services. Our colleagues in
Medical Microbiology identified this omission and I was asked
as CEO of the Clinical Virology Network to provide information
on Specialist Virology Services. This information answered the
concerns of the people who responded to the national consultation
process, 100 per cent of whom had stated that the original version
was inappropriate for Virology. For some reason, the additional
text I provided was subsequently edited out at the final stage.
There was no response to either my initial email (shown below)
or a follow up letter of 17 September 2002 (attached). We feel
that a response addressing these issues of concern raised by experts
in the field would have been appropriate for a body which should
have a commitment both to quality and to the need to learn from
its own mistakes.
In summary, our experience to date leads us
to question whether the final goal is the delivery of a better
service rather than the creation of more bureaucracy.
Question 3Is the United Kingdom benefiting
from advances in surveillance and diagnostic technologies; if
not, what are the obstacles to its doing so?
The shortage of trained laboratory staff within
the UK should be addressed by co-ordinating activities and rolling
out best practice throughout the nation, for example, by developing
networks of specialists as we have proposed for Virology.
Question 4Should the UK make greater use
of vaccines to combat infection and what problems exist for developing
new, more effective or safer vaccines?
The UK is one of a dwindling number of countries
worldwide who have not yet introduced hepatitis B vaccine. Chronic
hepatitis B infection causes chronic liver disease and hepatoma
so that this is the first vaccine against human cancer.
Likewise, other virus infections cause other
chronic diseases and so vaccines should also be prepared for these.
However, there is no real "market"
for vaccines which are priced according to their cost not their
value to individuals or to society. In particular, the policy
of discounting future benefits is inappropriate for investments
in health, yet is applied uncritically in health economic analyses.
Question 5Which infectious diseases pose
the biggest threats in the foreseeable future?
1. Those which are preventable by routine
immunisation but where a substantial minority of the public have
lost confidence in vaccine safety, so risking herd immunity for
the whole country.
2. Human Immunodeficiency VirusWhile
great strides have been made in controlling the mortality attributable
to AIDS, the incidence of HIV continues unchecked so that prevalence
is rising at a great rate. Resistance to antiviral drugs is widespread,
including patients who present with primary infection having acquired
resistant strains from the donor of the virus.
3. Hepatitis C Virus cause chronic
liver disease and has now become the major indication for liver
transplantation in the UK.
4. Herpes Simplex Virus is important
in its own right and also because it facilitates spread of HIV
by causing genital ulcers and by driving the replication of HIV.
5. CytomegalovirusA recent
report from the Institute of Medicine identifies CMV vaccine as
a number one priority for the United States due to the damage
caused to the unborn child, presenting as mental retardation and
hearing loss after birth. The report estimates that a modest vaccine
programme could yield savings of $50,000 for every quality adjusted
life year that is saved.
6. Influenza causes an excess of
deaths every winter. Yet vaccines and new treatments are still
targeted at those at highest risk of disease, whereas they could
be used to interrupt transmission in the community.
7. Viruses which cause diarrhoea and
vomiting such as Norwalk, produce outbreaks in the community
or in hospitals. Most are not formally diagnosed despite the potential
of new molecular assays to do so.
8. Emerging viruses such as West
Nile. Epidemiological data are needed to determine if this virus
has reached the UK. Network members have responded enthusiastically
to this challenge and testing of a substantial number of cerebrospinal
fluid samples is underway.
Question 6What policy interventions would
have the greatest impact on preventing outbreaks of and damage
caused by infectious disease in the United Kingdom?
ARestoration of public confidence in
vaccines; aggressive deployment of new vaccines and antiviral
treatments; Co-ordination of activity by specialists as described
above so that best practice can be rolled-out across the country.
Please let me know if you would like any further
information on these or any other items. As requested, this letter
is being sent by email but I will also send you by surface mail
a copy of our booklet, "A National Strategy for Clinical
Virology in the UK".
Professor Paul D Griffiths
Chief Executive Officer
Clinical Virology Network
10 October 2002