Memorandum by the Public Health Medicine
We welcome the opportunity to contribute to the evidence
to be considered by the Science and Technology Sub-Committee I.
The Public Health Medicine Environmental Group is
a professional organisation concerned with the public health aspects
of communicable disease and non-communicable environmental hazards.
Currently there are over 200 members most of whom are consultants
in communicable disease control or consultant epidemiologists.
Q 1.a Surveillance of infectious disease
The main problems are:
1.1 The piecemeal nature of our current surveillance
programmes which have been developed in an ad hoc manner over
many years. We need a properly resourced national surveillance
strategy where the cost of the individual programmes balances
the benefit they bring.
1.2 Many surveillance programmes are inadequately
resourced. They are often dependent on the good will of clinical
staff whose primary role is care of individual patients. Provision
of surveillance data must be integrated into clinical care so
that it is neither a burden nor an optional extra.
1.3 Many surveillance programmes are not based on
modern technology, but are reliant on paper based data flows and
multiple data entry.
1.4 There is a growing tension between the individual's
right to privacy and the need to collect and analyse individual
surveillance data for the purpose of protecting the public health.
1.5 We do not make adequate use of case definitions
for clinical case reporting and notification. This undermines
the validity of our data sets for disease such as measles.
1.6 As well as disease specific surveillance, we
need to develop syndromic surveillance to pick up new and emerging
1.7 We need to make better use of our surveillance
data particularly to model future trends to inform national, regional
and local strategies.
1.8 Consultants in communicable disease control and
their teams need to be resourced to ensure that there is adequate
surveillance of all infections at local level, including HIV and
other sexually transmitted infections.
Q 1.b Treatment of Infectious Disease
1.9 The growing problem of antibiotic resistance
is an important issue although not the focus of the current enquiry.
1.10 The incidence and prevalence of infections such
as hepatitis C and tuberculosis in marginalised and hard to reach
groups present special challenges.
1.11 GUM department do not currently have sufficient
capacity to diagnose and manage sexually transmitted infections.
Q 1.c Prevention of Infectious Diseases
1.12 We need to strengthen our research capacity
to develop more effective population prevention programmes, especially
for sexual transmitted infections (STIs).
1.13 There is a need for dialogue with the public
to help maintain confidence in universal immunisation programmes.
1.14 It can be difficult at local level of secure
adequate resources to fight infection in the face of competing
priorities such as cancer or coronary heart disease.
The disease burden from individual infections such
as syphilis or TB may be relatively small, so it is important
that there is a strong focus locally to provide leadership and
expertise for all the aspects of prevention, investigation, treatment
and control of all infections irrespective of their causative
organism or of which branch of the health service has responsibility
for treatment and care.
Q 2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
2.1 The 12 action points in GAC have the potential
to tackle the major challenges associated with fighting infection
in the UK.
However, we are concerned that progress in some areas
may be very slow and that the potential in others will not be
achieved unless control of infectious diseases achieves a higher
priority and increased investment both within local government
and the NHS.
2.2 The Health Protection Agency is potentially an
important means of raising the profile of communicable disease
control and of bringing together those with specialist expertise
in this field.
There is, however, a risk that this may weaken the
local function and, that the NHS may see the HPA as doing"
all health protection. Finally, the increased emphasise on control
of non-communicable environmental hazards must not be at the expense
of control of communicable disease. Both elements need adequate
Q 3. Is the UK benefiting from advances in surveillance
and diagnostic technologies?
3.1 Molecular typing is an important development
in this field. Within the field of meningococcal disease there
is no doubt that the UK has a world class service. However, in
other areas it is lagging behind. An obvious example is that of
tuberculosis. A national strategy is however being developed.
It is unlikely that this strategy will involve the typing of every
isolate. In Holland, for example, every isolate is characterised
using molecular techniques. The main limitations are the perception
that such technology has limited value in the public health management
of tuberculosis (not true) and the inherent complexities in the
interpretation of the typing data, together with uncertainties
as to the best methodologies. The main obstacles to this are:
lack of consensus as to the methodologies;
lack of consensus as to the usefulness;
lack of resources to carry out the tests;
lack of training for microbiologists, clinicians
and public health doctors in these techniques and therefore a
lack of confidence in their interpretation.
3.2 Another major problem is the lack of investment
in information technology to facilitate the collection and transmission
of surveillance data.
3.3 A third challenge will be to ensure that public
health needs are taken into consideration when new technologies
such as near patient testing are introduced into clinical practice.
Q 4. Should the United Kingdom make greater use
of vaccines to combat infection and what problems exist for developing
new, more effective or safer vaccines?
4.1 Safe, effective and acceptable vaccines are the
cornerstone of prevention of communicable disease. As the perceived
risks of an infection decrease, the public will require robust
evidence of the benefits of new vaccines. Before these are introduced,
careful thought should be given to the acceptability of any proposed
new universal vaccine programme and to the likely effect on current
Q 5. Which infectious disease pose the biggest
threats in the foreseeable future?
Those caused by microrganisms which develop
resistance to antimicrobials.
Tuberculosis, particularly MDRTB.
Sexually transmitted infections particularly
HIV and Hepatitis B.
Travel associated and imported infections.
Infections resulting from bio-terrorist attacks.
Q 6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the United Kingdom?
6.1 One of the main policy interventions that would
support the management of change is modernisation of the public
health legislation. This is long overdue and the current lack
of clarity causes difficulties in ensuring proper resourcing and
accountability for the control of communicable disease.
6.2 Consideration should be given to policy initiatives
that will enable infection to be on the agenda of health service
managers and to performance targets that are related to infection
control and provision of health care services for people with
infectious diseases. Locally, this could be facilitated by the
development of stakeholder groups similar to those in the management
6.3 One of the key determinants of successful outbreak
management is joined up working of all relevant agencies. An important
policy initiative is to examine ways of promoting joined up working
between the Health Protection Agency, the Food Standards Agency,
DEFRA and the Veterinary Investigation Agency as well as NHS and