Memorandum by Profesor T H Pennington,
Professor of Bacteriology, University of Aberdeen
1. Surveillance of human infectious disease
is done better in the UK than in most other countries. However,
it falls far short of what is achievable with current methods.
There are two main deficiencies.
2. An excessive reliance on reactive surveillance.
This is well illustrated in the Department of Health document
Action to strengthen the microbiology function in the prevention
and control of infectious diseases, which restricts itself
exclusively to this topic. The deficiencies of reactive surveillance
are well known. Hospital laboratories produce nearly all the data.
But their primary function is to provide information for clinicians
for patient management. Surveillance is a by-product; there is
very little dedicated funding for it. Reactive surveillance grossly
underestimates the level of infection in the community. The best
recent demonstration of this was provided by Infectious Intestinal
Disease Study (Report of the Study of Infectious Intestinal
Disease in England, TSO, 2000).
3. The fragmented and ad-hoc nature of the
surveillance network in the UK. This is apparent at all levels.
(a) Unco-ordination is fed by the rivalries that inevitably exist
between agencies (eg between different government departments,
and between the NHS and universities). Surveillance of zoonoses
is a good example, (eg reference laboratories for E.coli O157
are funded on the basis of the host species rather than the microbe);
human and veterinary laboratory surveillance is not "joined
up". (b) The level of commitment to surveillance work in
hospital laboratories, which do most of it, varies. The major
determining factors are variations in the degree of personal interest
by staff, and the need to give higher priority to other work (eg
routine diagnostic services) (c) At specific pathogen level, funding
for surveillance is often driven by political pressure rather
than by health needs (eg there is no comprehensive reference laboratory
back up for UK laboratory surveillance of Campylobacter (about
50k infections reported annually) but there are two E.coli O157
reference laboratories (about 1.5k infections reported annually)).
4. This strategy proposes the abolition
of the PHLS as a body concerned exclusively with infection. The
transfer of PHLS laboratories to the NHS is being done at breakneck
speed. The reasons for this, or its urgency, are unclear. The
impact on surveillance will be negative. The transfer will destroy
a network of laboratories with the public health function at their
core. It is improbable in the extreme that NHS hospital managers
will give this function the priority that it received from the
PHLS. Inevitably, they will focus on diagnostic work for patient
management rather than surveillance or outbreak control. The training
function of the PHLS will disappear. This will be a major loss
to UK medical microbiology: doctors and scientists with expertise,
experience, and an interest in public health microbiology will
in future emerge only capriciously and randomly through factors
like personal interest. The training of medical microbiologists
with broader interests than the diagnosis of infection and the
provision of advice on therapy is already in very serious difficulties
in the UK because of the collapse of academic bacteriology (described
in the recent report by the Academy of Medical Sciences).
5. The transfer of R & D funds from
the PHLS to the NHS will also have a negative impact on surveillance.
Reference laboratories offer more than a routine specialist service.
Essential parts of their function are to improve scientific services
and track evolutionary change. They cannot do these things without
core R & D funding.
UK BENEFITING FROM
6. There is no doubt that state-of-the-art,
fit-for-purpose diagnostic and surveillance techniques are being
quite widely used in the UK. But their full deployment in all
appropriate circumstances is hindered by lack of money and a lack
of understanding of their cost-effective benefits.
7. Laboratories are an easy target for budget
cuts. The PHLS has had them year-on-year for a long time. In the
NHS their impact on waiting lists and other performance indicators
familiar to politicians and the public is too indirect to be noticed.
8. In my view gaps in the training of medical
microbiologists and public health specialists means that many
have a poor understanding of these aspects of molecular biology
and population genetics that are essential for the deployment
of molecular epidemiology methods and interpretation of their
results. The demise of the PHLSparticularly its training
functionand the terminal state of academic bacteriology
will enhance these deficiencies.
9. One answer to the question "which
infectious diseases pose the biggest threats in the foreseeable
future" is that because of evolutionwhich is essentially
unpredictablenobody knows. The prospect of new or much
changed pathogens appearing is always very real. Such threats
can only be countered by having a surveillance system with a broader
remit than just coping with existing pathogens using existing
tests. It must have more flexibility and built-in capacity for
innovation so that it can respond rapidly to new problems.
10. Britain has an excellent track record
in basic research on pathogens. For example, our fundamental work
over the years on TSEs and animal pathogens like FMD has been,
and continues to be, of international quality. But our ability
to link this work to policy has been dismal, as shown by BSE/vCJD
and the 2001 FMD outbreak. For example, I was shocked, but after
very brief reflection not surprised, to learn from the "Lessons
Learned" Inquiry that Pirbright had not been consulted during
the preparation of MAFF's FMD Contingency Plan. It is vital that
lessons must be learned from these events. Policy makers must
learn how to make the best use of scientific information. After
all, our Nobel Prize track record shows that for basic science
we are second to none. But it will not be enough for scientific
advisory committees to follow the Nolan rules, have a few more
members representing consumer interests, and to have their formal
meetings in public. Their scientific membership should be more
inclusive and less exclusive. The BSE Inquiry showed the importance
of policy makers getting advice from scientists with detailed
knowledge of the problems being addressedand the bad consequences
of not doing this. This is not being done as well as it should
11. BSE and FMD also showed the importance
of linking policy making with accurate field knowledge. The PHLS
played a very important role over the years in the generation,
assessment, and promulgation of scientific knowledge and, through
its network of laboratories, the collection and interpretation
of local data, events and issues. The best way forward would be
to strengthen its central, and its local, functions. Like British
Rail, the PHLS was not perfect. But replacing it with public health
services whose levels and costs "will be the subject of service
level agreements . . . normally . . . sustain(ing) existing service
commitments" sounds just like Railtrack and its complex contractual
relationships with Train Operating Companies, Rolling Stock Operating
Companies and so on. I fear that the effects of this fragmentation
(discussed, for example, in Lord Cullen's Ladbroke Grove Rail
Inquiry Report) will be repeated for infection control. They included
the loss of common objectives and a common culture, a lack of
leadership, deskilling and training problems, bad effects from
complex interfaces, and the loss of an R&D capability.
12. The public has a deep interest in infection.
The handling of BSE and the emergence of vCJD caused a massive
loss of trust in Government institutions and in science in general.
The adoption by the Food Standards Agency of frankness and openness
in transmitting uncertainty about risk is setting new standards.
If other agencies and departments of Government followed this
lead with enthusiasm the regaining of trust would go faster.