Memorandum by Leeds City Council, West
Yorkshire Environmental Health and CCDC Audit Group and Communicable
Diseases Section of the Department of Housing and Environmental
1. What are the main problems faxing the
surveillance, treatment and prevention of human infectious disease
in the United Kingdom?
There are important differences in emphasis
between local and national surveillance systems. Local action
requires timeliness and detail such as patient name, general practitioner
and address all essential for prompt control measures. National
surveillance is often seeking to identify trends and patterns
that lead to longer term control measures.
It is often difficult to access and interpret
national data for relevant areas. In order to improve surveillance
systems there is a need to ensure proper feedback to those who
report into the surveillance system. Those who report need to
know that something is done with the information they share and
that it is not simply filed away. Greater awareness of the purpose
of surveillance among those who diagnose infections would be helpful.
Under-reporting of cases is a fundamental flaw in existing arrangements.
The lack of uniform case definitions of infectious
diseases that are widely accepted is a serious problem. Flexibility
to respond to particular incidents in a timely manner requires
the ability to develop suitable case definitions for the incident
group to work with. We need to be very clear that all areas of
the country and reporting bodies are clear and consistent in what
they report. For example, food poisoning is one of the notifiable
infectious diseases along with Infectious Hepatitis in the Public
Health (Control of Disease) Act 1984 whose definition needs to
be revised. Locally, to ensure consistency of reporting, Leeds
City Council in co-ordination with the West Yorkshire CCDC/EHO
Audit Group have developed a flow-chart to address the inconsistencies
that were identified in interpretation of Food Poisoning as a
reportable illness. A copy of this is appended and we would hope
could be incorporated into national guidance which is conspicuous
by its absence. The inconsistency in the reporting of food poisoning
locally will naturally be replicated nationally and does not currently
produce quality surveillance data.
There is also a need to be able to split imported
from UK acquired infections in reporting and recording systems
to enable workers to develop suitable controls for each category.
IT developments are required to assist reports
from laboratories as well as clinicians. A real time national
IT system accessed by clinicians, laboratories, local authorities
and HPA could provide accurate local and national surveillancegiving
useful data to aid both investigation and national research alike.
Confidentiality issues to be clarified, certainly
as data is sent away from the local level.
The development of national surveillance systems
that bypass Consultants in Communicable Disease Control are counter
productive and lead to duplicated work and misunderstandings.
Primary Care Trusts are disease focused rather
than prevention focused, so it is not clear where resources for
prevention will come from.
Calculations presented to the West Yorkshire
CCDC/EHO Audit Group suggest that every single week of the year
the equivalent of seven weeks worth of work is devoted to the
completion of NOIDS reports for England and Wales by local authorities.
It is not clear how that information is being used for the control
of communicable disease. Ambiguity in what is to be reported is
rife, the accuracy and value of this national "data"
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, "Getting
Ahead of the Curve"
It is not yet clear how the proposed strategy
will be implemented or what can be delivered. The strategy set
out in "Getting Ahead of the Curve" is as yet
undefined so it is impossible to give an informed response.
3. Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles in doing so?
Help with defining outbreaks requires better
organism identification, but much still needs to be done to get
the information promptly to those who need to see it.
There is a desperate need to establish a meaningful
typing system for Campylobacter, if we can establish "environmental
contamination" routes for this organism significant reduction
in cases could be achieved, the Government's food poisoning target
reduction would be met overnight.
If you do not look you do not find, so users
of new identification and reporting systems may be criticised
for identifying more problems. (Leeds, which has an active interest
in the notification system, frequently reports more Food Poisoning
Greater recognition should be placed on the
surveillance system capturing information determined on investigation
by local authorities on the likely source of illness. Home acquired
infections deserve more attention eg food poisoning, to enable
resources to be directed where they will do most good and alternative
types of intervention developed.
There are cost implications. Which body will
pay for the new technologies, particularly if they are used for
public health surveillance? Without resources available the only
sampling will be that taken for clinical purposes which will not
provide all the information required. Sampling for surveillance
and investigative purposes undertaken by local authorities must
be similarly resourcedprevention is always better than
Continuing problems exist in defining denominator
populations with population movements in and out for work, leisure
and study. The new HPA/PHLS proposal to base sampling resources
on residential population is flawed.
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?
Vaccines can be used to greater effect. Some
existing, proven effective, vaccines such as hepatitis A and hepatitis
B should be used for the universal childhood programme.
New vaccines for meningococcal B infections,
tuberculosis and some of the gastro-enteric viruses would be welcome.
The currently used live polio vaccine should
be phased out and replaced with the safer inactive vaccine until
polio eradication is achieved.
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
We suggest that antibiotic resistant organisms,
tuberculosis, HIV and vCJD present the greatest challenge for
the future. There will also be serious problems with influenza
and similar airborne viruses including those causing gastroenteritis
eg Norwalk virus.
6. What policy interventions would have the
greatest impact on preventing outbreaks, of and damage caused
by, infectious diseases in the United Kingdom?
Establishing clear roles for the agencies involved
and providing adequate resources for them to operatein
both the investigative and health educationpreventative
Most action to prevent outbreaks and to manage
them at an early stage is undertaken at local level. The effectiveness
of that local action has to be supported and developed. There
is a real risk that heavy handed supervision from higher levels
will reduce the capacity of local teams.
Local teams need to be resourced and supported
by policies that empower them. Flexibility to deal with local
problems needs to be encouraged and when the review of the law
on communicable disease is finally moved forward the value of
accountable flexibility needs to be recognised and the role of
the local authority must be acknowledged as the current model
has been appropriate and timely for the local populations at risk.