Further memorandum from Department of
Health Re: Getting Ahead of the Curve and further action against
bioterrorism (7 May 2002)
ENHANCED SURVEILLANCE
AND TRAINING
OF KEY
PERSONNEL TO
IDENTIFY NEW
DISEASES OR
UNUSUAL PATTERNS
National surveillance has been strengthened.
On-going mechanisms are being developed by the Communicable Disease
Surveillance Centre (CDSC) to alert relevant clinicians to achieve
the earliest possible detection of the first cases of illness
due to deliberate release of biological agents. Guidelines on
the approach to the care of patients with rare diseases, developed
with multi-agency groups, have been published on the PHLS web-site.
CDSC is also piloting a new system that captures early patient
reports of symptoms that could be associated with the release
of certain organisms. NHS Direct is a national nurse help line
which aims to provide the public with rapid access to professional
health advice and information about health, illness and the NHS.
The data that NHS Direct provides can be collated for use as an
early warning system and complements the existing national schemes
run by CDSC, of clinician, routine and specialist laboratory reporting
systems that capture illness at a slightly later stage. However,
this system is likely to be at its most effective once an attack
is suspected of confirmed as it would provide an early assessment
of the potential extent of an attack. The response element to
an outbreak or a change in pattern of a particular disease is
outlined below in the section on identifying newly emergent pathogens.
In addition, there is increasing alignment of surveillance of
organisms in animal, food and humans that will assist in identification
and monitoring of control measures of infectious disease incidents.
Training has been undertaken and is being developed
further. Clinical awareness is the foundation stone for the early
detection of a covert attack, as clinicians inform public health
response teams and organisations at local, regional and national
levels. This integrated approach ensures that the relevant diagnostic
tests and public health investigations are carried out to determine
the precise cause of the infection as well as ensure the appropriate
treatment and control measures. Information on key diseases is
readily accessible on the Public Health Laboratory Service (PHLS)
web-site. Infectious Disease Physicians, Medical Microbiologists
and Public Health Physicians have worked to produce training materials
that are available for use and the topic has been discussed at
professional training events. DH has hosted scenario-planning
exercises for anthrax and smallpox with stakeholders. At present,
additional training is being developed, under the auspices of
DH that will be tailored to the needs of different professional
groups with the aim of ensuring continuing awareness as well as
rapid response and appropriate response that is continually up-to-date.
This additional training is scheduled to begin in the Autumn.
A mult-country smallpox scenario exercise is
being planned for 2003 and follows the G7 ministerial conference
in March 2002. As part of this activity, DH is liasing with the
World Health Organisation and the Centres for Disease Control
and Prevention (CDC) in the US on training initiatives.
DEVELOPING RAPID
DIAGNOSTIC TECHNIQUES
DH is taking this work forward with the aim
of having tests that are rapid, accurate, sensitive, valid and
as easy as possible to undertake. DH is supporting programmes
at the PHLS Central Public Health Laboratory (CPHL) and at the
Centre for Applied Microbiology and Research (CAMR). Staff at
each of these Centres are developing rapid tests based on modern
technologies that include DNA microchips and laser based detection
systems. The application of these methods in the detection of
potential terrorist attacks is being co-ordinated by a project
team comprising CAMR, CPHL and the National Institute for Biological
Standards and Control (NIBSC). In addition, CAMR has a close working
relationship with its neighbour, the Defence Science and Technology
Laboratory.
IDENTIFYING NEWLY
EMERGENT PATHOGENS
Surveillance will be a cornerstone in the recognition
and identification of emergent pathogens. This will build on the
raised clinical, microbiological and public health awareness,
as outlined above, with the ability to identify organisms and
have the appropriate clinical and public health response.
DH is sponsoring a programme of work at CAMR
to establish a detection capability for the newly discovered viruses,
Hendra and Nipah. In doing this, CAMR is collaborating with CDC.
Assessing antibiotic resistance in potential
bio-terrorist agents is an integral component of the functions
of the Reference Laboratories.
National plans for outbreak response are being
updated by DH and CDSC. These will deal with outbreaks that:
— occur naturally and frequently eg
E.coli;
— occur naturally and infrequently
eg international flu epidemics;
— are "expected" eg West
Nile Fever;
— are due to bio-terrorist activity
that may be due to any of the above and/or due to unusual organisms;
— DH is preparing a specific plan for
smallpox with input from across the NHS, PHLS including CDSC,
and CAMR;
— Advice from DH expert advisory committees
will be fed into these plans. These include the Joint Committee
on Immunisation and Vaccination, the Advisory Committee on Dangerous
Pathogens and the Specialist Advisory Committee on Antimicrobial
Resistance.
ENSURING ADEQUATE
DIAGNOSTIC AND
MANAGEMENT SUPPORT
Appropriate diagnosis and management relies
on good procedures and standards.
Standard laboratory and surveillance operating
procedures have been updated and complement the existing work
of the PHLS laboratory and surveillance/response activity of CDSC
on protocols for infectious diseases.
As part of the new strategy for infectious diseases,
all NHS microbiology laboratories will undertake the four basic
public health functions of reporting to public health departments
and CDSC, sending appropriate specimens to specialist/reference
laboratories, supporting outbreak investigations and development
of local policy. All clinical laboratories will be required to
operate to common reference standards and standard operating procedures.
The new Health Protection Agency will provide
the specialist microbiology and surveillance/response expertise
to local teams. This will build on the current PHLS, CAMR and
NIBSC systems that support local NHS teams and contributes to
European and international infectious disease surveillance and
response activities.
A new Inspector of Microbiology post will be
established to ensure a rigorous approach to laboratory standards
and safeguards.
DH strengthened supporting arrangements in August
2001 through the establishment of an Emergency Response Capability
at CAMR which includes the provision of the diagnosis of anthrax,
plague and other bio-terrorist agents. An increased capacity is
now in place and was in operation in 2001.
In addition, CDSC is a member of the EU wide
surveillance network. It is a leading centre for a number of disease
surveillance networks that use common protocols and contribute
to the investigation of multi-country outbreaks. The reference
laboratories in CAMR and the PHLS have joined the USA Laboratory
Response Network that facilitates international co-operation in
information, methods and re-agents.
CONTINUOUS HORIZON
SCANNING, SCENARIO
PLANNING, RISK
ASSESSMENT AND
RESEARCH
Plans are being developed for a new National
Panel for Emerging Infectious Diseases which will regularly review
any new of emerging infectious diseases reported in this country
or from elsewhere in the world. This is one of the recommendations
in the new strategy for infectious diseases. The Panel will advise
on the potential threat to the population and of any protection
or control measures that should be initiated to reduce the potential
threat to the population's health. The Panel will subsume the
work of the National Zoonoses Committee which has cross working
with other government departments especially DEFRA. Risk assessment,
scenario planning and the need for appropriate research will be
an integral follow through component to this system.
PROMOTING RESEARCH
INTO ANTIVIRAL
DRUGS AND
VACCINES
The development of new anti-viral drugs is an
activity of high cost and risk. Industry figures indicate that
R&D costs of £800 million for each successful new drug.
This is not an area that the UK will pursue alone, but will be
the subject of wider international co-operation.
The Ministry Of Defence, through its corporate
research programme, is supporting research at DSTL into new vaccines
for anthrax, plague, tularaemia and smallpox. DH is working with
MOD to ensure that the products of this research will be applicable
to public health. As part of this, DH has commissioned CAMR to
consider the design and costing of an emergency vaccine manufacturing
capacity facility.
CREATING INNOVATIONS
IN COUNTERMEASURES
Innovations in countermeasures will come from
obtaining advice from independent experts as well as working within
and between relevant departments and countries.
At present DH is working with other government
departments and countries in certain areas in countermeasures.
DH wishes to capitalise on this joint working and with the establishment
of the new HPA, wishes to promote a more systematic approach to:
— prioritise areas of work across departments;
— develop multi-disciplinary/agency
teams for key areas of work;
— build on particular areas of expertise;
— tap into networks already in existence
or planned;
— joint audit performance manage the
outputs/outcomes.
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