Memorandum by the Royal College of Pathologists
The College oversees the education and training
of specialists in all pathology disciplines, which includes medical
microbiologists and virologists. It sets standards and organises
assessment, monitors appointments to consultant posts and publishes
reports and guidelines. It also has an important role in promoting
public understanding of laboratory medicine and advising Government
bodies. With regard to "Fighting Infection" all consultant
medical microbiologists and virologists and heads of NHS microbiology
and PHLS laboratories are members or fellows of the Royal College
of Pathologists. There are also several CsCDC and REs and academic
staff who are members of the College. The Vice President, Professor
D Jeffries, is the current chair of the joint RC Physicians/Pathologists
Committee on Infection and Tropical Medicine. This group has established
joint training posts in infectious diseases/microbiology and with
the Speciality Advisory Committee of the RC Pathologists is involved
in discussions covering manpower and training with the Workforce
Confederation. Both these initiatives should help to strengthen
infection services in the future. The current shortage of specialists
and laboratory staff in general is a constraint to improving the
surveillance, prevention and control of human infectious diseases.
The College has been pivotal to discussions
with the Department of Health on "Modernisation of Pathology"
and is committed to working in networks of laboratories where
expertise, staff and equipment may be shared to improve the service
to patients. This process has progressed in some areas and the
College favours the proposals in the DH paper on Microbiological
Services (www.doh.gov.uk/cmo/laboratories) that there should be
regional microbiology networks. However there are problems about
the speed of the process and the ability of networks to deliver
the surveillance requirements of the Health Protection Agency
by April 2003.
The first step in counting the number and causes
of deaths in the UK was taken with the publication of Risks
of Mortality in 1532 as a response to the threat of a plague
epidemic in London. This lead in 1662 to John Graunt publishing
the first scientific work on disease surveillance. These modest
beginnings produced the Registrar General's returns, the Office
of National Statistics and the legislation most recently revised
as the Public Health Act 1984 and the Infectious Diseases Regulations
1988. All these efforts depend on doctors seeing ill patients
and making a clinical diagnosis which is then notified to the
Proper Officer of the local government authority. The legislation
and practice associated with the notification of infectious diseases
is far behind the science of laboratory medicine. We believe the
time is well overdue for a re-examination of public health law,
in particular the Infectious Diseases Regulations which are the
basis for statutory notification. We consider this should be augmented
by laboratory reporting of significant microbial diagnoses. There
should be a duty on all medical microbiology and virology departments
to completely report in a timely fashion to public health officials.
This will require appropriate information technology and resourcing.
The flow of data from laboratories in England and Wales to the
Communicable Disease Surveillance Centre (CDSC) and in Scotland
to the Scottish Centre for Infection and Environmental Health
(SCIEH) has been voluntary and in some regions and countries nearly
complete. The Public Health Laboratory Service (PHLS) staff have
generally performed better than NHS Trusts, but not always (the
College published an audit of this in 1994 by Dr Mark Farrington
and others). Returns from smaller and private laboratories have
been poorer. Complete reporting is essential for the surveillance
of infectious diseases.
Studies comparing clinical notifications and
laboratory reporting often show wide variation. For example, statutory
notifications of the childhood diseasesmeasles, mumps and
rubellacompared with salivary antibody confirmation have
shown hundredfold differences in incidence. The notification of
"suspected food poisoning" may yield dozens of different
causes without microbiological and chemical examination of specimens.
Surveillance of infectious diseases without laboratories is like
pathology without a microscope, chemistry without a balance or
surgery without an anaesthetic.
Similarly, physicians have little hope in making
an accurate diagnosis, prescribing correct treatment and preventing
the spread of an infection without laboratory backup. Lack of
a confirmed diagnosis may lead to wrong decisions in choice of
antibiotic, advice to the patient and control of infection. Needless
to say the laboratory methods used must be standardised with good
quality assurance. We believe this requires nationally agreed
procedures in accredited laboratories. In the UK this is best
achieved by the CPA, which is strongly supported by the RC Path.
There is a concern that some new diagnostic kits are designed
for near-patient testing without adequate control.
For surveillance purposes, the denominator population
and sampling methods need to be addressed. There is some concern
that Primary Care Trusts may not wish to sample, for public health
reasons, where the result of a faecal sample, for example, may
be of value for epidemiological purposes but not of benefit to
the management of the individual patient.
Many Members and Fellows of the College are
engaged in the research for new diagnostic methods and vaccine
development. The task of validating and bringing new discoveries
into clinical practice is an important part of the work of microbiologists
and virologists and we would be interested in providing further
evidence if the Committee were interested. Star gazing about future
threats may be less productive but the College has always been
interested in addressing the risks of newly emerging infections
and informing our members and the public in a balanced way.
The new strategy contains much valuable information
and highlights the need for action plans in some specific topics.
However, the proposal to join chemical and radiation agencies
with the PHLS/CDSC and the significance put on dealing with emergencies
might take the Government's "eye off the ball" of the
burden of infection. The College welcomes the stress on good laboratory
methods working to common standards and would wish to take this
forward with the other professional bodies.