Letter from Dr Jon S Friedland, Imperial
College School of Medicine
This letter is in response to the call for evidence
by House of Lords Sub-Committee on "Fighting Infection"
and is written on behalf of the clinical members of one of the
largest Academic Departments of Infectious Diseases and Microbiology
in the UK. We are based at the Hammersmith Hospitals NHS Trust
and Imperial College London and include nine Honorary Clinical
Consultants in Infectious Diseases and Microbiology (Senior Lecturers,
Readers and Professors) in addition to a strong non-clinical constituency.
Our department is pioneering in many ways including in the development
of surveillance with the appointment of the UK's only hospital
epidemiologist/infection control doctor who is a trained Infectious
Diseases physician (cited in the National Audit Office report).
We have made a limited number of comments directed towards specific
aspects of infection management in hospital.
1. Providing the service
There is a major shortage of specialists in
infection in the UK to deal with community- and hospital-acquired
infections. This also means that there are few people to educate
the next generation of doctors. The demands placed on infectious
diseases are increasing for many reasons ranging from the increased
global mobility of populations (we see about 100 new cases of
tuberculosis at this hospital each year) to the ever more complex
problems arising in the face of sophisticated immuno-suppression
protocols for treatment of malignancy, in organ transplantation
etc. Despite this, there remain Teaching Hospitals in the UK without
any infectious diseases physicians and few district hospitals
have been bold enough to appoint one. The fact is that there are
only about 100 ID physicians in the UK (many of whom are academics)
and nearer 3,000 in the USA although their population is not 30-fold
greater (The British Infection Society should have more exact
figures). The need for more trained physicians to guide treatment
and patient management can be highlighted by considering any response
to bio-terrorism when there are likely to be relatively few people
available to respond to a large scale attack. In addition, there
needs to be encouragement to Universities to appoint academic
clinical microbiologists who can lead translational research for
new methodologies for rapid diagnosis of infection, typing of
outbreak organisms, and detection of antibiotic resistance.
2. Training issues
In our department, there is close liaison between
infectious diseases physicians and clinical microbiologists which
we believe is essential in the modern era. We developed the first
UK training scheme designed to generate future consultants in
infectious diseases and microbiology who will straddle the disciplines.
The competition for these posts is fierce yet there are less than
10 such schemes in the UK. This needs overt encouragement for
the working pattern found in many hospitals of infection services
provided by single-handed microbiologists with inadequate time
to visit the wards is no longer tenable. The future is the development
of large joint departments of infection including ID, microbiology
and infectious disease epidemiology with category three isolation
facilities to deal with dangerous pathogens/potential terrorist
biohazards in all large centres of population and certainly in
3. Surveillance of infection
The Hammersmith Hospitals epidemiology service
is led by Dr. Holmes and is involved in pioneering many schemes
(eg antibiotic prescribing, neonatal bacteraemia, dialysis-related
bacteraemia and orthopaedic surgical site infections etc). Some
projects are based in West London, the orthopaedic study is funded
by the Department of Health and the dialysis study involves international
collaboration with The CDC in Atlanta. However, country-wide the
situation is that little is known about the local epidemiology
of infection or even the patterns of bacterial drug resistance
(with the decreasing GP surveillance cultures). Better surveillance
will lead to improved antibiotic usage and may slow the emergence
of antibiotic resistant organisms although ultimately this is
often an international problem.
There are two key problems in surveillance and
prevention activities in the UK. The first is the lack of direct
involvement of clinicians and clinical ownership of the process.
This needs to be embedded in integrated care pathways and within
the clinical governance systems in hospitals. There is a need
for concurrent fully trained infection control teams and real-time
bed management so that isolation rooms can be used to the full.
The second major issue is the woefully inadequate investment in
the necessary information technology and including personnel.
4. "Getting ahead of the curve"
A consequence of the proposed changes is that
many PHLS laboratories will transfer to NHS Trusts. A robust system
needs to be put in place that ensures the opportunities for co-operation
in the gathering of surveillance data is not compromised by this
change. Having uniform computer networks that facilitate rapid
collection and collation of data is essential.
5. Co-ordination of health targets
There is often disjointed thinking between and
within government departments. For example, there is great pressure
to clear A&E and then admitting wards of patients which may
result in considerable patient movement within hospitals and transmission
of infectious and possibly antibiotic-resistant organisms.
6. Educating the public
The Government needs to educate the public about
the real risk and hazards of infection so that the level of alarm
in response to each outbreak is more controllable. At present,
many patients in hospital believe MRSA bugs will kill them when
the truth is that they are often not pathogenic. The UK has a
culture of secrecy and we have a lot to learn from the Centres
for Disease Control, Atlanta, USA and others about communication
with patients, potential patients and their relatives. The information
provided about plans for responses to bioterrorism in the USA
is a good example of pre-informing the public.
7. Making the future happen
A critical issue is that new vaccines and treatments
are needed. This requires a far greater development of understanding
of disease processes; something which is just beginning in the
modern era of genomics and immunology. Whereas there are specific
charities directed to raising funds for cancer and heart disease
who support large amounts of research, this is not true in infection.
A large injection of cash is required in a ring-fenced environment.
Although some of this funding may be best directed at focused,
near-development large programmes of research, this may be a more
appropriate time to encourage involvement with pharmaceutical
companies. There is a critical need to allow new ideas about pathogenesis
and treatment of infections to develop in smaller groups working
on basic science where the clinical output is not explicit. It
is known that goal-directed university science does not necessarily
produce the best new ideasa famous example relates to monoclonal
antibodies now used world-wide for many different therapeutic
and diagnostic purposes which were not developed in Cambridge
as part of a clinical project. The important thing is to have
the infra-structure to allow promising and unexpected developments
that emerge in science to be harnessed, something that did not
happen with monoclonal antibodies. It is also necessary for the
Government to realise that science is an international not a parochial
enterprise and cannot exclude partner countries.
We hope that these general comments from our
department will be of some use to the Sub-Committee.