Memorandum by Dr Maria C Zambon Head of
Respiratory Virus Unit, Deputy Director, ERNVL, PHLS Central Public
Health Laboratory, Dr David W G Brown Laboratory Director, ERNVL,
PHLS Central Public Laboratory, Dr Elizabeth Miller, Head of Immunisation
Division, PHLS Communicatable Disease Surveillance Centre
Surveillance systems in the United Kingdom cover
a wide span of organisms and microbiological problems from a variety
of perspectives. It is our view that the most effective surveillance
systems are those that are focused directly to specific public
health questions and from which data feeds directly into policy
decisions. Excellent examples of this would include the Measles,
Mumps and Rubella surveillance systems which hinge around the
verification of disease notification and the surveillance of influenza
which is based around the capture of influenza virus isolates.
Both of these examples are integral parts of national and international
vaccine programmes. Another excellent example is the surveillance
of meningococcal disease burden, disease notification and characterisation
of meningococcal isolates, the data outputs of which have verified
that the introduction of Meningococcal C vaccine, a significant
public health intervention, has indeed been a notable scientific
and public health success. All of these are examples of surveillance
programmes which have strong academic science inputs, with the
introduction and application of novel surveillance strategies
and implementation of cutting edge technologies.
However within the United Kingdom many disease
verification and microbiology surveillance systems suffer from
a historical approach, which is that of passive data collection,
without analysis or outcome measurements. It is our view that
this is not a particularly useful approach to public health microbiology.
Examples of this include our current salmonella surveillance programme
which has been successful over the years in identifying a range
of outbreaks, but is unable to do more than passively document
the rise and fall of particular salmonella strains with time,
providing little scientific insights into disease mechanisms or
ecological biology which may lead to useful interventions. In
our view, surveillance needs to be linked to more basic work on
pathogenesis in order to contribute to improvement in disease
management and public health interventions. This in turn argues
for a strong R&D element in national surveillance programmes.
Moreover, successful surveillance systems depend on the liaison
of different arms of medical, microbiological, scientific, clinical
and public health practice. Close integration takes a number of
years to achieve and useful outputs are dependent on good working
of a number of different disciplines with agreed objectives. Clear
leadership is important.
Effective national surveillance programmes are
also based upon the application of consistent and compatible methodologies,
both microbiological and epidemiological within regions, with
seamless interfacing of information management systems to allow
national consolidation of data. We are unconvinced that this will
happen without a strong central lead, clear indication of overall
objectives and farsighted IT investment. It is notable that countries
which already have devolved regional surveillance programmes of
disease are moving away from this model to more strongly co-ordinated
national programmes eg Spain and Germany. It is unclear in "Getting
Ahead of the Curve" how the powers devolved to RDPHs for
commissioning local reference services are to be integrated nationally
or how prioritisation may take place where there may be local
versus national conflict. Indeed it remains unclear as to how
national surveillance programmes required to underpin vaccination
programmes eg MMR/Polio/Influenza/Pertussis are to be co-ordinated
through the new Health Protection Agency. It is our view that
the proposed changes in structure afford some real risk to existing
high quality surveillance arrangements which are essential to
reduction in disease burden and good public health policy.
The strongest link between effective surveillance
and treatment of infectious disease occur where there are clear
interventions. This includes vaccines, anti-microbials, anti-virals,
risk management or environmental actions required to reduce communicable
disease burden. There are a number of surveillance programmes
where the information collected is of limited relevance because
it is not linked to public health interventions or does not contribute
to academic knowledge of the biology of the microorganism eg surveillance
programmes for campylobacter infections which until recently have
paid insufficient attention to the development of appropriate
tools for dissecting bacterial genomes, an academic question requiring
investment, rather than the more traditional approaches of collecting
and counting isolates. It is our view that surveillance should
be question driven, with a strong basic science input rather than
involving passive aggregation of data, which may often be uninterpretable.
Unfortunately, effective links between surveillance
and strategies preventing infectious disease are limited, but
work particularly well for vaccination programmes (see above).
However, the main strategies employed by the Food Standards Agency
(FSA) and attempts to limit sexually transmitted diseases (STIs)
include behaviour modification. Many of our current surveillance
programmes do not take this into account and do not monitor the
effectiveness of behavioural approaches to disease control. Thus,
substantial amounts of public health money may be spent on behavioural
programmes without any evidence of their usefulness.
A weakness in the current existing arrangement
for improving surveillance, vaccine and diagnostic technologies
is a lack of clear mechanism for the prioritisation of research
and developmental work. This is often lost in a hierarchy of bureaucratic
committee structures where individuals making decisions are technically
ignorant or where appropriate prioritisation cannot be achieved.
Unfortunately the proposed arrangements of the new HPA do not
show any improvements in the mechanism of the decision making,
nor how development monies are to be prioritised or made available
for public health. World class surveillance programmes require
continued investment and the application of cutting edge technology.
It is far from clear how investment is to be determined and with
what priority. It is a real concern that technical understanding
is seriously lacking in the higher echelons of public health in
the UK, and when this is coupled with lack of far sighted investment,
it is a significant impediment to the deployment of new technologies.
Historically, surveillance, treatment and prevention
of infectious disease with an international perspective has been
rather ad hoc and dependent on leading individual academics, without
government funding or input into national strategies for responding
to emerging infections. There has hitherto not been an outward
looking approach to infectious disease burdens in the global context
or within the context of imported disease into the United Kingdom.
Recognition of the problem and improvement in identification of
imported cases of infectious disease requires a strategic investment
in microbiology and clinical expertise for a wide range of specific
organisms eg Malaria, Dengue, West Nile and Pox virus infections,
some of which currently cause an extremely limited disease burden
in the UK.
Much more work is needed to communicate risk
analysis to the general population. This is a long term objective
and may need to involve much more consideration with respect to
education at all levels of the population, including the way that
science is taught in schools. Furthermore, successful interactions
with the media are critical to the overall communication of scientific
issues to the general public. In our view, it is essential to
uncouple objective scientific/public health advice from the politicisation
of public health objectives, so that advice from organisations
such as the PHLS can be seen to be independent, rather than as
a party political line.
Government responses to recent public and animal
health threats, eg nvCJD, foot and mouth disease have seriously
undermined media confidence in the role of scientists, or scientific
advisers and considerable work is needed to repair public confidence
in the objectivity of high calibre scientific advice/work and
ensure that it is seen as independent of government policy.
Lack of clear leadership and failure
to agree common goals with all participating parties.
Lack of over arching umbrella with
Failure to join up existing human
Lack of integration with veterinary
medicine or primary care.
We recognise the need for change and applaud
the aspirational nature of the published documents. However, the
structure or mechanism for the implementation of proposed changes
is not detailed. The mechanism for ensuring consistency and quality
in surveillance systems is not apparent in the proposals, nor
how existing excellent systems are to be maintained, let alone
the development of new "better" structures. We wish
to reiterate our concern regarding the continued delivery of comprehensive
national surveillance programmes, on which our vaccination policy
is critically dependent, following the creation of the HPA.
Mechanisms for prioritisation and
Lack of clear structure for research
and development decisions.
Lack of adequate informed technical
and clinical input into decision making process.
Lack of integration where appropriate
between vet and human programmes.
We believe that there should be greater
population benefits achievable through an enhanced or expanded
vaccination programme. Licensing new vaccines has a huge cost,
for which cost recovery can only be driven through private enterprise.
Nevertheless successful vaccination programmes require sustained
public-private collaboration and liaison. Improved national and
political recognition of this important generic collaboration
is required and efficient mechanism found for protecting intellectual
property interests of the public sector. Currently public-private
interactions are governed by exceptionally cumbersome beaurocracy
despite enabling policy (TreasuryBaker Report), and full
potential of work in the public sector is not achieved.
The anti-vaccine lobby in the UK
is sufficiently strong to discourage industrial investment and
limit reasonable debate on significant expansion of vaccination
policy. This could be addressed, particularly through improved
media strategies, education and targeted research.
Currently prioritised important infections
Infections linked to chronic disease
or cancer eg Helicobacter pylori, Chlamydia, Hepatitis B &
C, Papilloma viruses and Cervical Cancer.
Newly Emerging infections eg CJD,
West Nile disease.
Education policies for science education
(hygiene and cross contamination).
Effective promotion of education
particularly relating to deployment of new vaccines eg Men C.
Extension of the public-private collaborations
which have assisted the implementation of Men C vaccines, to other
vaccines on the horizon eg pneumococcal and respiratory virus
We include a series of questions we believe
should be posed in the consideration of the implementation of
Getting Ahead of the Curve.
Q.1. How will proposals in Getting Ahead
of the Curve ensure current regional consistency and quality in
collection of national data required to underpin national public
health interventions eg vaccine strategy?
Q.2. What is the level of delegated
authority to the HPA to ensure the collection of adequate quality
data to underpin UK surveillance programmes?
Q.3. Was there a formal risk assessment
undertaken with regard to the dissolution of the PHLS and the
potential loss of microbiological data?
Q.4. Is the model for the HPA one of
a body of full independent status such as FSA, or a different
model such as the relationship between the VLA and DEFRA?
Q.5. How will the management of national
(microbiology) pathology networks be accomplished, within the
designated structures of the HPA?
Q.6. How will the integrity of national
surveillance programmes which underpin vaccine policy be guaranteed
after the 1 of April 2003?
Dr Maria C Zambon, BM BCh MA PhD, Head
of Respiratory Virus Unit, Deputy Director, ERNVL, PHLS Central
Public Health Laboratory.
Dr David W G Brown, MBBS MSc FRCPath,
Laboratory Director, ERNVL, PHLS Central Public Health Laboratory.
Dr Elizabeth Miller, Head of Immunisation
Division, PHLS Communicable Disease Surveillance Centre.