Memorandum by Dr R L Salmon, PHLS Communicable
Disease Surveillance Centre (Wales)
1. Given, the sub-committee's call for "evidence
on any area of infectious disease", the scope of the inquiry
is potentially limitless. I have substantially confined my submission
to the sub-committee's six particular questions. In so doing,
I have been mindful of the House of Lords functions as legislature
and court and given most prominence to areas where there is greatest
scope for these functions to aid "fighting infection".
The views expressed are personal and based on twelve years as
a regional epidemiologist in Wales. However, they have been seen
by colleagues in the Regional Services' Division of the Public
Health Laboratory Service Communicable Disease Surveillance Centre,
which covers England and Northern Ireland and which division,
I have headed for the last two years.
1. What are the main problems facing the
surveillance, treatment and prevention of human infectious disease
in the United Kingdom?
2. Many of the factors which change a society's
experiences of infectious disease may have their roots in decisions
some way removed from science or health or agriculture. By way
of a historical illustration, the Black Death, the plague, caused
by the bacillus Yersinia pestis killed 20-25 per cent of
Western Europe's 80 million population, between 1348 and 1352.
It is believed to have been introduced by the Mongols of the Golden
Horde who had swept westwards from Central Asia and laid siege
to Kaffa in the Crimea, a trading post established by the Genoese.
Plague broke out among the Mongols investing the city. It is believed
this was as a result of the Mongols' practice of killing marmots,
which carry the plague bacillus without getting disease, for their
furs. Contemporary accounts have them also throwing the corpses
of plague victims over the walls of the city. Plague subsequently
spread along the trade routes around Europe. This, apart from
illustrating that the emergence of infectious disease is not a
new phenomenon, also indicates a number of the categories of factors
that are repeatedly seen to contribute. It shows the critical
roles played by movements of peoples, in this case the
Mongols, and patterns of trade, particularly of fur and
silk. It shows the role of transportation whether medieval
ships or Tartar horsemen. It also indicates the ever present threat
of biological warfare. These four aspects, changed in their
detail, are recognisable as key general problem areas in the prevention
of infection today.
3. The comparatively monolithic nature of
health services' organisation in the UK when compared with other
developed countries means that human health surveillance
usually functions at least adequately. It does of course rely
on a cultural preparedness to share information, in the public
interest, between health professionals. This culture has received
certain setbacks, of late. The legal framework around the transmission
of information has become progressively more complex and restrictive.
The Health and Social Care Act 2001 has qualified the justifications
of "medical purposes" and "public interest"
which previously allowed patient identifiable information to be
shared, without necessarily obtaining the patient's consent, under
the Data Protection Acts and the common law.
4. Veterinary surveillance has also been
problematic but has been reviewed and is the subject of redevelopment
by DEFRA. A particular gap is the lack of surveillance for companion
animals, particularly with the relaxation of restrictions on their
movements brought about by the passports for pets scheme. A further
issue is the integration of surveillance data from human health,
animal health and food which in the UK, compared with a number
of countries, notably the Netherlands and Denmark, is very underdeveloped.
5. Problems arise when moving from surveillance
("information for action") to taking action whether
it be treatment or prevention or further investigation
in the field. This always requires a modicum of intelligence and
courage. Three things provide an additional handicap.
Much of the fieldwork capacity resided between
health authorities and local authorities (in their environmental
health department or equivalent). As a result of NHS reorganisation,
health authorities have disappeared in England and are due to
disappear in Wales. This has left Consultants in Communicable
Disease Control housed temporarily in various organisations and
loss, particularly of support staff. Similarly following the modernisation
of local government, local authority environmental health departments
have enjoyed mixed fortunes. Often they have lost status and resource
to areas of local government activity with a higher political
profile such as education, social services or housing.
The Research Paradigm
For a number of reasons public health investigations
have increasingly become viewed not as public health practice
(by analogy with clinical medical practice) but research. Reasons
for this, amongst others, are the fact that public health investigations
utilise similar (usually epidemiological) techniques such as questionnaires
and surveys and an increasing involvement of academic bodies in
research in the field of public health (in itself welcome). When
a public health investigation becomes viewed as research it comes
under the research ethics committees. This inevitably adds the
bureaucracy of an application process, may introduce delay and
sometimes effectively prevents the work from taking place at all.
The News Media
The proliferation of radio and TV channels as
well as the internationalisation of news means that the sheer
volume of media inquiries can pose a considerable obstacle to
the efficient pursuit of an investigation as well as diverting
substantial skilled resource from solving whatever is the problem.
There is a potential compensation in that this could result in
greater public understanding and awareness. Unfortunately, the
narrow economic requirements of the News Media as an industry
determine coverage and if anything, often distort public understanding.
Issues with a complex technical background and long gestation
period fare particularly badly. Some examples are HIV and AIDS
where some newspapers expended a lot of energy in denying that
HIV caused AIDS and the MMR controversy which is substantially
sustained by media coverage. These are sins of commission. As
a sin of omission, I might cite the early years of BSE where sustained
serious journalistic interest in the possible relationship with
CJD might have been beneficial but no such interest was forthcoming.
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, "Getting
Ahead of the Curve"?
6. This document contains quite a good synopsis
of many of the wider issues that can result in infectious disease
problems. The solutions proposed are, however, substantially of
an administrative nature, involving the reorganisation of existing
services. Much of the focus of the reorganisation is, also, not
infectious diseases but wider aspects of health protection (particularly
from chemicals and radiation). Much will depend on the resource
given to the new agency as well as the energy and independence
of its leadership. It will also be important to clarify the contribution
required from other bodies such as primary healthcare and hospital
trusts and re-develop effective means of teamworking.
3. Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles to its doing so?
7. Technological developments such as near
patient or, indeed, home testing produce data that the current
surveillance mechanisms do not have a ready means of capturing.
It will be important to develop further primary care based surveillance
to address this potential gap.
4. Should the United Kingdom make greater
use of vaccines to combat infection and what problems exist for
developing new, more effective, safer vaccines?
8. The Joint Committee on Vaccination and
Immunisation has a mechanism for addressing decisions on vaccination
that has substantially stood the test of time. Indeed the improvement
in the organisation of the vaccine programme and in uptake of
most vaccines since the early 1980s could be considered a considerable
success. Nevertheless although in "the Green Book" and
similar publications doctors and other health professionals have
an accessible source of advice, many only have a hazy notion of
the scientific and epidemiological basis of this official advice
and how it is arrived at. This may be a handicap in giving the
vaccination programme the support and professional commitment
all such programmes need to sustain success. More open government,
as reflected in documents such as the government's code of conduct
for scientific committees, may potentially bring unanticipated
benefits by remedying this and building trust.
5. Which infectious diseases pose the biggest
threat in the forseeable future?
9. There are a number of quite disparate
threats, even without considering biological warfare about which
much has been written, which must not be lost sight of.
HIV is proving difficult to contain and despite
success with treatment will remain a health burden until a vaccine
is successfully developed.
Verotoxin producing E.coli O157 remains
a relatively rare disease in the UK, with the exception of parts
of Scotland. Nevertheless infections result in a high burden of
illness, often in children and there is an ever present threat
of outbreaks. Containment requires action by a number of agencies
at a number of levels which may prove difficult to sustain.
Effective tuberculosis control similarly requires
effective team working between different healthcare organisations
and other agencies. This will need to be born in mind with moves
toward greater autonomy for healthcare providers which, although
they may be desirable for the efficient delivery of much clinical
care, can handicap public health efforts.
The scale of the variant CJD epidemic remains
unclear even though there are some grounds for cautious optimism.
Preventing potential human to human spread via surgery and blood
transfusion is proving a complex and sometimes costly exercise.
It seems inconceivable that there will not be
another influenza pandemic.
The development of a vaccine for group B meningococci
remains a priority. It will become an even more pressing issue
if any transfer of virulence genes from group C strains, a plausible
consequence of the welcome and successful vaccination campaign,
were to take place.
The burden of treatment of hepatitis C is beginning
to become apparent.
Finally experience with Foot and Mouth Disease
(FMD) and Classical Swine Fever (CSF), which are not zoonotic,
should alert us to the risk of the introduction of zoonotic animal
diseases. Had Nipah virus rather than CSF or FMD been introduced
from the Far East, the consequences for human health, particularly
in occupations dealing with pigs or pork would have been much
greater. The steady expansion of the Pets Travel Scheme, although
welcomed by the public, may well have disease introduction consequences
which are difficult to predict.
6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the United Kingdom?
10. As well as addressing the provision
of structures that directly address infectious disease there is
also a need to consider more widely those policies which may,
as a by product, either make infectious disease problems more
or less likely. With national and international policies a formalised
approach to assessing the infectious diseases impact, such as
microbiological risk assessment, may be helpful. Internationally,
a policy framework might be an overall review of the International
Health Regulation to take into account the more diffuse nature
of human contacts through globalisation of markets. They were
last subject to major revision in 1969 and cover only plague,
cholera and yellow fever. They do not reflect the modern day nature
of a number of markets with an impact on health such as food,
tourism and health care. They are being revised and modernised
by WHO and will move away from reporting of three specific diseases
towards reporting of syndromes of international public health
significance. Although WHO will consult WTO in this process there
is a case for considering the development of a wider role for
WTO in a broader regulation, on health grounds, of the movement
of people, animals and goods. The latter body is influential on
national governments in a way WHO is not. Further, as a recent
joint WHO/WTO report, "WTO Agreements and Public Health"
acknowledged (BMJ 31 August 2002, page 460), "governments
may put aside WTO commitments in order to protect human life".
Thus any new regulations may be a legitimate restriction of trade.
11. Where people and goods move quickly,
information to contain infectious diseases must move quickly as
well. Electronic communication has facilitated this but the legal
framework around the transmission of information, as has been
noted, has become progressively more complex and restrictive.
Although the Health Service (Control of Patient Information) Regulations
2002 do now provide a mechanism for the Secretary of State to
give permission for patient identifiable information to be shared
without consent, that mechanism is cumbersome and bureaucratic
and the permission has to be renewed at least annually. Simplification
of these regulations or how they are administered would be welcome.
Quite apart from the energies that such processes use up, they
foster a culture inimical to the sharing of information of all
kinds, on which surveillance and disease control are ultimately
based. An alternative legislative approach might be a new public
health act actively requiring modern systems of disease reporting
as well as laying a general duty of sharing information
that may be required for communicable disease control.
12. Finally the News Media represent a well
organised and well capitalised industry whose actions have a demonstrable
impact on health, sometimes for the worse. Arguably they have,
just as any other industry, a duty of care which may be enforceable
under the Health and Safety at Work Act 1974. This, or other mechanisms
which might promote the reporting of health topics in such a way
as not to diminish the health of the population, should be explored.
Dr R L Salmon
Director, PHLS Communicable Disease Surveillance
Head, Regional Services Division, PHLS Communicable
Disease Surveillance Centre
11 October 2002