Memorandum submitted by Professor S P
1. What are the main problems facing surveillance
treatment and prevention of human infectious disease?
1.1 The main problems in preventing infections
are not new and include the following:
Human behaviour (non-sexual)Best
practice has been identified for eg, food production and handling/preparation,
and hospital infection control. This is all too often not implemented
or followed eg, hand-washing. More work needs to be done on identifying
how to influence human behaviour.
Human behaviour (sexual)Casual
sex and rejection of barrier contraception contribute to the increases
in sexually transmitted infections (STIs), as does human trafficking
and enforced prostitution. For the former, more work is needed
on use of professional communicators (eg advertisers) to ensure
effective messaging to target groups.
Population perception of riskRisk
communication is poor. This compromises introductions of new vaccine
programmes and continuation of existing ones. A more pro-active
approach of risk communication may reduce the impact of publicity
perceived adverse events. Risk communication is also essential
to influence sexual behaviour and reduce STIs.
1.2 The main problems facing surveillance
Capture of diagnosis/test result
as testing becomes increasingly "near patient" and community
The increasing primacy of individual
privacy and confidentiality.
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
Only partly. There is a strong case for the
HPA to have a separate Vaccine Division.
3. Is the UK benefiting from advances in
surveillance and diagnostic technologies?
No. Overall, analysis of data provided to surveillance
centres is rudimentary and lacks the application of sophisticated
analytical techniques for trend analysis, pattern recognition
and cause-effect linkage that is routinely applied in other disciplines
eg, financial analysis, meteorological analysis.
The huge potential of new diagnostic technologies
is poorly realised in the UK due to conservatism as a nation characteristic,
under investment in adoption of current new technology, insufficient
evidence based guidance to advise on investment, delays in modernisation/rationalisation
4. Should the UK make a greater use of vaccines?
Yes. However, problems do exist in development
and utilisation of new, more effective/safer vaccines. The drive
is towards better characterised and standardised vaccines ie,
away from whole cell attenuated (with risk of adverse reactions
or reversion to wild type) and towards sub-unit vaccines. Problems
exist primarily in lack of GMP facilities causing bottlenecks
in early safety trials, absence of good animal models for early
safety and efficacy studies, the huge costs of clinical trials,
and risks of litigation.
The underlying science of basic immunology related
to induced protective immunity needs to be further developed,
as does our understanding of adjuvents and other methods of immunomodulation.
Studies on the genetic basis of adverse reactions
need to be encouraged, with the prospect of pre-screening to prevent
exposure of such individuals to particular vaccines or vaccination
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
Most predictions are based on what is currently
a problem and expected to increase, and as such are well-known
eg, TB, HIV-AIDS. The key point is that HIV was not predicted,
and its next equivalent is unknown. The next flu pandemic is predicted
only in so far as that there will be one. The purposeful or inadvertent
release of a genetically engineered microorganism has also enjoyed
much debate and publicity.
Key areas that have not received adequate consideration
and which may contribute to emergence of a significant future
Increasing exposure to new environments.
Most consideration has been given to encroachment by people. However,
unregulated/illegal export of wildlife and derived products poses
a real risk of bringing a new pathogen into an environment (the
UK) where population density and practices favour transmission.
In other words, the "jump" is made easier. An example
of risk here is the illegal importation and sale of bush meat
with questionable provenance.
Development of engineered vaccines
for veterinary use, or engineered microbes to control plant pests
could lead to an unforeseen and unpredictable change to host range
(to include man) or creation of virulence for man where none previously
6. What policy interventions would have the
greatest impact on preventing outbreaks and damage?
Most of the practices needed to attend to this
issue are already well known (see response to point 1 above).
The main problem is one of ensuring maintenance of best practice
and introduction and adoption of policy. The policy interventions
that will have the biggest impact are those that help guarantee
safe food and clean water.
There also needs to be greater understanding
of where and how outbreaks are detected to facilitate earlier
intervention, so minimising damage caused. There has been an over
emphasis on surveillance in the belief that surveillance detects
outbreaks. In the vast majority of cases, the situation is that
outbreaks are reported to those who are given responsibility for
surveillance eg, the two most recent ones in the UK being legionella
(Barrow-in-Furness; Sandwell, W Midlands) and Salmonella (National).
Good epidemological investigation helps to identify the source,
which then enables key interventions. It follows therefore that
supporting early detection of outbreaks (improved diagnostics,
improved training and awareness of frontline staff) and improved
and earlier reporting of outbreaks with good epidemiological response
We had the pre-surveillance era, and are now
at the end of the first quarter century of the structured national
surveillance era. There is need to move into the "post-surveillance"
era, where more resource is shifted to targeted specific question
led surveillance and to interventions.
Professor SP Borriello