Memorandum by Sheffield City Council,
the Health Protection Services
1. This evidence concerns itself mostly
with the Chief Medical Officer's report "Getting Ahead of
the Curvea Strategy for Combating Infectious Diseases",
and the subsequent decisions and development work of the Department
of Health, aimed at bringing into fruition the new Health Protection
Agency (HPA), proposed by the report.
1.2 Environmental Health Departments in
every local authority in the country are involved as a front-line
service in the fight against infectious diseases. In practice,
Environmental Health Officers act as the "foot soldiers"
of local Consultants in Communicable Disease Control (CCDC), with
regard to the control of many diseases. The exact working relationships
between CCDC's and Environmental Health Departments varies across
the country, with no prescribed model of partnership. In some
areas, notification of infectious diseases is made direct to the
CCDC's department, in others (as in Sheffield), notifications
are received by the Environmental Health Department. Whatever
the differing working relationships, Environmental Health Departments
are involved in the investigation and control of many infectious
diseases, gathering information from individual cases, identifying
common factors, taking samples and specimens, and ultimately if
possible, carrying out enforcement measures (eg closure of a premise
or operation that has caused food poisoning, or legionnaires disease
etc) to control the spread of the disease.
1.3 Unfortunately, the major input of Environmental
Health Departments in combating infectious disease is generally
not recognised by the medical community and the tendency is for
the Environmental Health Departments to be excluded or marginalized
in any discussion or debate about infectious disease, other than
at a very local level. This non-recognition has been demonstrated
in the development work towards the birth of the Health Protection
Agency. There are no representatives of the environmental health
profession on either the Steering Group or Project Team, set up
to oversee the development work.
2.1 "Getting ahead of the curve"
is a forward thinking document in so far as it accurately describes
the challenges facing the country with regard to infectious diseases,
the weaknesses within our present system of surveillance and control,
and convincingly makes a case for change and improvement (Chapters
However, we believe that the strategy and proposed
actions as laid down in Chapter 6 will not be sufficient or appropriate
to fully meet the challenges facing the country.
We agree in principle with the formation of
the HPA. We fully agree that there is a need for a new national
agency to act as a source of national expertise, take overall
responsibility for the surveillance of infectious diseases and
provide a service for their prevention and control. There is a
need for a clear line of sight from national to regional to local
level in these matters to speedily convert policy into action.
However, we do not believe that the HPA as it is envisaged and
appears to be developing, will have the optimal capability to
meet the future challenges.
In some respects we are concerned that the proposals
will actually weaken our ability to fight infectious diseases.
2.2 A major and illogical weakness in the
strategy is the proposal to bring the HPA into being as a cost-neutral
exercise. "Getting Ahead of the Curve" rightly describes
the future increasing risk to the country from infectious diseases
and accurately describes the weaknesses in the present arrangements,
stating that we need to achieve higher levels of reporting infectious
diseases, and closing serious gaps in the surveillance systems.
No attempt has been made to carry out a base audit of the personnel
and skills presently available in the various agencies working
in this field. Therefore, how can we have any confidence that
merely a re-jigging of present resources will be adequate to improve
the situation as it stands, and also be in a fit position to adequately
cope with any future increased demands?
As an example of this, as described earlier,
Environmental Health Department personnel carry out many of the
front-line tasks in this field of work. Environmental Health Departments
are charged with carrying out a multitude of functions, most of
which are not directly concerned with infection control (food
hygiene inspections, pollution control etc) and most of the personnel
in Environmental Health Departments involved in infection surveillance/control
work will also be expected to be carrying out a host of other
unrelated tasks: their post will not be dedicated to infection
surveillance/control work. Environmental Health Departments, in
recent years, have come under tremendous pressure from central
government to greatly improve their performance in many of their
other areas of work, especially the number of food hygiene inspections
they carry out, with no increase in resources. This has commonly
lead to a diminution in the time staff have available to devote
to infection control/surveillance. This pressure from competing
functions is likely to increase in the future. The experiences
of the Meat Hygiene Service (MHS), a relatively new, non-departmental
government body brought into existence to improve hygiene standards
in the meat production industry are of relevance in this matter.
Most of the workforce employed by the MHS were previously employed
by local authorities to do the same functions, but when the MHS
came into being, they swiftly realised that they would need (and
did employ) many more staff to successfully carry out their remit
than local authorities had been able, with their limited budgets,
2.3 We are concerned that the HPA as it
seems to be evolving will not be a body that has any effective
management control over many of the inter-relating strands of
work that need to fit together to produce a coherent, co-ordinated
and uniform national infection surveillance/control service.
In our opinion, if the HPA wants to have "a
clear line of sight from national to regional to local level"
(quoteGetting Ahead of the Curve), then it requires (if
not direct, then) executive management control over more strands
of the national infection surveillance/control community than
is being proposed. We are particularly concerned about the proposals
for the transfer of many of the Public Health Laboratories to
the National Health Service, (see below).
We would suggest that the Committee looks at
the Food Standards Agency as an example of a relatively new body
which has impressively met its remit. The Food Standards Agency
is a transparent organisation with a clear national focus. They
are able to set national priorities based on the best science
available, setting demanding operational standards and targets,
and with an auditing/monitoring role with powers to enforce quality
and uniformity across all inter-relating agencies.
2.4 We are greatly concerned about the proposed
transfer of many of the existing Public Health Laboratories to
NHS control. We believe this strategy to be wrong-headed and much
more likely to result in a reduction in capability to fight infectious
diseases. Environmental Health Departments work very closely on
a day-to-day basis with the Public Health Laboratories. It is
a partnership that has served this country well for many years
and we are sure that most Environmental Health Departments will
look at these proposals with great apprehension. To be frank,
the NHS managed laboratories we have dealings with have a poor
understanding of their wider public health responsibilities, and
are inherently inwardly focussed.
In Sheffield, the unhindered partnership between
the Sheffield Public Health Laboratory and the Environmental Health
Department has over the past 20 years resulted in a number of
major advancements in the wider understanding of a number of infectious
diseases. Examples of these are given below.
2.4.1 In 1984 and 1985 there was a substantial
increase in the number of human infections caused by Salmonella
typhimurium phage type 141 in the UK. Investigative work by
Sheffield Environmental Health Officers lead them to believe that
a substantial proportion of these infections were being caused
by contaminated hens eggs. When contacted, both the Communicable
Disease Surveillance Centre (CDSC) and the Ministry of Agriculture,
Fisheries and Food (MAFF) were reluctant to believe this hypothesis
and MAFF refused to cooperate in any work to investigate the hypothesis
further. Sheffield Public Health Laboratory, on the other hand,
had no hesitation in diverting resources to enter into a major
piece of research work, in partnership with the South Yorkshire
Environmental Health Departments. This research proved that hen
eggs from a number of farms in Lincolnshire were responsible for
human Salmonellosis in South Yorkshire caused by S. typhimurium
PT 141. It should be noted that before this work, it was generally
considered that hens eggs were sterile and could not possibly
be a cause of salmonella food poisoning.
2.4.2 During the late 1980's it was recognised
that there was an upsurge in the number of cases of cryptosporidiosis
occurring during the spring months in Sheffield. It was also discovered
that this increase was related to the differing areas of the city,
which received their water supplies from one of the 10 different
sources in Sheffield. Previous to this, it was considered that
cryptosporidiosis was a disease caused by contact with infected
animals or humans; contamination of water supplies was not a recognised
route of transmission. Again, Sheffield PHLS involved themselves,
in partnership with Sheffield Environmental Health Department
in research work which proved that contaminated water supplies
can be a common source of cryptosporidiosis and also that some
types of water treatment plant, in common use throughout the country
at that time, were incapable of filtering out cryptosporidia oocysts.
2.4.3 Unpasteurised milk was first recognised
as a possible source of E. coli 0157 infection as a result
of work carried out by Sheffield's Environmental Health Department
and Public Health Laboratory. Since then, Dr Peter Chapman, at
the laboratory, has carried out pioneering research into the epidemiology
of E. coli 0157 which has greatly expanded our knowledge
of this serious newly-emergent pathogen and which has resulted
in him being recognised as a world expert in this field.
We seriously doubt if any of these pieces of
work, which required substantial diversion of resources in the
laboratory to achieve, would have come about if the laboratory
had been under local NHS management at the time. It must be understood
that much pioneering work has been carried out in the local Public
Health Laboratories across the country, and not just in the central
or major regional Public Health Laboratories. We believe the national
network of Public Health Laboratories to be the "jewel in
the crown" of this country's good record of success in the
fight against infectious diseases since the Second World War.
The proposals for the HPA seem to be following
a strategy of divesting all clinical microbiology (including in
those Public Health Laboratories to transfer to the HPA) out of
its management, as if clinical microbiology has no core Public
Health function. We would argue to the contrary, that clinical
microbiology is fundamental to Public Health surveillance and
that it would make more sense to transfer the NHS laboratories
to the management of the PHLS. This would also make it easier
to improve standards in NHS managed laboratories and also facilitate
their much needed, greater understanding of their public health
role. The proposals do not seem to recognise that much of the
clinical diagnostic work undertaken by both NHS laboratories and
Public Health Laboratories is done on behalf of GPs, and not just
hospitals. It is surely a valid argument that it is just as logical,
if not more so, for this work to be done in laboratories managed
by the PHLS.
3.1 The call for evidence asks the question,
"should the UK make greater use of vaccines to combat infection?"
Vaccination has a critical role to play in infection
control, and vaccination policy must be set nationally with adequate
resources to ensure that any strategy is implemented effectively.
Vaccines however should not be seen as a universal
panacea. Very often the root causes of an outbreak of infection
are contained within the wider environmental and public health
conditions at large at the time. For example, the incidence of
TB was greatly reduced between 1850 and 1940 (Source: McKeown
1979) due to improvements in food hygiene and working and living
conditions, which was well before the introduction of vaccines.
The "tail end" of TB was dealt with by vaccines.
3.2. The following example also reinforces
the points made earlier, that the HPA needs to be a robust organisation,
with seem-less ability to convert policy and guidance into timely
In September 2001, the PHLS Advisory Committee
on Vaccination and Immunisation published "Guidelines for
the Control of Hepatitis A Virus Infection". Amongst other
measures the guidelines recommended that "injecting drug
users, should be offered HAV vaccination as a preventative measure"
and "in order to achieve high coverage in this group, concerted
action is required from all agencies, including outreach services
There is presently a substantial outbreak of
Hepatitis A infection, affecting injecting drug users and their
contacts, across South Yorkshire and also affecting the population
of Doncaster Prison. Only now is the vaccination of injecting
drug users against Hepatitis A starting to happen in this region,
and only because the outbreak has occurred. If the PHLS guidance
had been acted upon sooner, we believe the outbreak may not have
affected as many as it has. We also suspect that in other areas
of the country, very little will have been done as yet to initiate
the preventative measures outlined in this guidance.
We have a good history in the UK of recognising
what needs to be done but a less than perfect record in pushing
through those measures.