Memorandum by Mark Kealy, Consultant for
Communicable Disease Control, North and East Devon
1. Problems affecting surveillance, treatment
and prevention of human infectious disease in the UK
Surveillancegood data is available
from microbiology laboratories on infections where specimens have
been submitted, which implies good coverage of the more severe,
or more chronic diseases. However, the great bulk of acute infectious
disease is either managed by patients and their families, or managed
by general practitioners, and treated on an empirical basis with
antibiotics. This means that there is little reliable data available
on the circulating micro-organisms, particularly viruses. The
only data there is comes from clinical diagnoses from sentinel
practices in the RCGP scheme. The notification scheme is grossly
under-used and has poor coverage of diseases/diagnoses anyway.
The recent large community study of gastro-intestinal
disease yielded much useful information about the incidence and
prevalence of infectious gastro-intestinal disease. Similar and
ongoing studies in respiratory disease would be most valuable.
One other useful thing would be to link the
surveillance databases for both human and animal diseases. There
is quite a lot of animal testing done yielding information on
diseases relevant to humans(such as Salmonella), but there is
little published which allows trends to be seen between disease
in animals and disease in humans.
Treatmentthere is some link with
surveillance in that accurate, timely diagnosis is probably the
biggest problem with treatment. Although antibiotic resistance
is a factor at present. The difficulty is that even if appropriate
specimens are taken, a bacteriological result may well take 3
days, and a virology result may take 2 weeks! Often not soon enough
to be helpful in treatment.
Preventionthere are broadly two
aspects to prevention, one is immunisation, which is progressing
well in many ways, but in others is a victim of its own success.
The other is public, and professional education, which seems to
have mixed success.
The UK pursues a prudent policy in respect of
immunisation, which means that the population benefit from vaccines
with proven benefit at an early stage in development. A good example
of the early use of a new vaccine was the meningococcal C campaign.
On the other hand I think the UK has been wise to resist pressure
for the routine use of Hepatitis B vaccine where the benefits
outside the risk groups are less clear. The need for caution in
the introduction of vaccines is clearly seen in the current MMR
controversy, trying to introduce a new vaccine (such as Hep B
or chickenpox) into the childhood schedule where people do not
perceive a need would be likely to fail. Perversely, it is also
the success of vaccines in virtually eliminating some diseases
which causes some people to question the need for them, preferring
to rely on herd immunity or alternative therapies.
In terms of public education, there continue
to be problems in getting people to practise good hand hygiene,
let alone effective food safety and kitchen hygiene. It is probable
that more needs to be done at primary school level, and this may
include improving some school facilities.
The current Public Health Law means that where
compliance with public health requirements cannot be ensured voluntarily,
compulsion is extremely difficult to achieve.
2. Getting Ahead of the Curvewill
it be effective?
In my opinion GAC will improve systems for the
laboratory surveillance of disease, it may also sponsor large
community studies, it certainly has that potential. However, this
is unlikely to be achieved without significant cost.
However, in terms of the secondary prevention
of disease, which is the focus of much of my work, I am concerned
that the lack of clarity about the split of responsibilities proposed
in GAC. At the local level this could lead to confusion about
roles between the HPA and the Primary Care Trusts and gaps in
coverage. Similarly the large number of PCTs needing to communicate
with the new HPA and vice versa mean that there is a risk of breakdowns
in communication. I would have preferred to have seen a stand-alone
organisation dealing with communicable disease control and environmental
hazards, but accountable to the PCT via a service level agreement.
The inclusion of emergency planning within the new HPA seems a
little incongruous, unless it is limited to providing advice on
the response to chemical, radiological and biological hazards.
3. Benefit from new diagnostic tests
It will be seen from my earlier responses that
I believe accurate and timely diagnosis a major prerequisite to
the surveillance and treatment of infectious disease. I believe
that more use should be made of near patient testing, which is
adequately quality controlled. Tests already exist for streptococci,
and I am sure more demand would increase the range of tests available.
I think one of the obstacles is the resistance of laboratories
to the use of this type of test.
I think it will be clear from the foregoing
that I believe that the UK has a very good record in terms of
its immunisation policies, and that a good balance is achieved
between the early introduction of vaccines for which there is
a clear need and resistance to those where the need is less clear.
5. Threats for the future
Another major pandemic of a new strain of influenza
must be a major threat, as is the re-introduction of Smallpox.
Patterns of migration, sexual behaviour and drug use mean that
HIV still remains a major threat. Tuberculosis is not effectively
controlled particularly through Port Health arrangements, and
the incidence rate will continue to rise. Sexually transmitted
infections such as chlamydia, gonorrhoea and syphilis are dangerously
out of control. Global warming means that Malaria might make a
reappearance in the UK.
One policy initiative which is unlikely to win
wide support, but would reduce the incidence of food poisoning,
would be the greater use of radiation treatment in food processing.
The other major policy initiative would be a
major reform of public health law, particularly port health, and
the ability to restrain potentially infectious persons.