CHAPTER 4: PREVENTION
Prevention and control is necessary for any effective
response to the threat from infectious disease. It can be made
more effective by repairing the deficit in trained personnel and
by improving education and training. Public awareness of infection
should be raised. Lines of responsibility for outbreak control
should be clarified. Vaccines could be used more, but public anxiety
and issues about R&D need to be addressed. The Government
should also ensure that there is secure access to vaccines in
case of national outbreaks.
4.1 Prevention of infectious disease is one of the
most effective courses of action that can be taken by public health
services, both in terms of human suffering and live and economically.
It relies principally on early detection and intervention, on
vaccination and on changing social conditions and human behaviour.
4.2 Since Edward Jenner demonstrated in 1796 that
vaccination prevented smallpox, development and use of vaccines
has considerably reduced illness and death from many common infections.
Smallpox was eventually eradicated through a global vaccine initiative
and, similarly, many countries, including the United Kingdom,
are now free of polio as a result of vaccination.
4.3 We heard that there are more vaccines that could
be routinely used, yet even if they were available (see chapter
8) this might prove difficult because of public anxiety about
safety [UK Vaccine Industry Gp, II p234-6].
4.4 Vaccines have powerful stimulatory effects on
the immune system and there may be unwanted side-effects in some
individuals. However, the majority of side-effects are minor and
short-lived. Improved understanding about the interaction between
vaccines and immune response should lead to more sophisticated
and safer vaccines. Nevertheless, adverse side effects are a public
concern and this should be a factor in considering whether to
expand the childhood schedule [Ghosh, Q333-4]. Whilst the public
seems to have accepted the recent inclusion of the meningitis
C vaccine, it is not clear that they would be willing to accept
yet more vaccines into the childhood schedule, particularly given
recent public and media anxiety about the mumps, measles and rubella
vaccine [CAMR, I p42, Soc Gen Microb, I p158].
4.5 Introducing more vaccines into the childhood
schedule could improve public health, but the Government needs
to assess whether increasing the number of vaccines is possible
or desirable. Surveillance of the effect of implementing vaccines
and of incidence of vaccine-preventable disease can inform this
decision as well as helping to reveal whether there are any side-effects
of vaccination [CAMR, I p42; Crowcroft, I p45-9].
4.6 In addition, we heard that there is need to communicate
more with the public about the benefits and risks of vaccines,
and we discuss this in chapter seven.
4.7 In the face of epidemics or global pandemics
there could be urgent need to vaccinate a significant proportion
of the population. Thus it would be important to have a secure
supply of vaccines. The Centre for Applied Microbiology and Research
(CAMR) (now HPA Porton) was responsible for developing and manufacturing
influenza vaccines following the Hong Kong avian flu epidemic
in 1997 but their capacity was stretched in order to do this [CAMR,
4.8 Very few vaccines are made in England and most
vaccines used here are purchased from manufacturers in France
and Belgium. England holds stocks of vaccine to meet anticipated
needs. Needs are based on recent trends in infection as well as
information about numbers of people likely to need vaccinating.
So far, demand for supply has usually been met, although there
was a recent shortage of BCG (an anti-TB vaccine).
4.9 One question that has been raised recently is
whether the Government should establish a centre to urgently develop
and manufacture vaccines [CAMR, II p382, Stewart, Troop, Q807-9].
In the event of a major global epidemic it is likely that overseas
suppliers of vaccines would be under pressure to give priority
to their own country's requirements. With this in mind, the National
Institutes of Health in the USA opened a vaccine institute three
years ago. This institute integrates basic immunology research
with clinical trials and vaccine manufacture and is now attempting
to develop and manufacture a vaccine for SARS. The Government
recently turned down an application by CAMR to develop a similar
facility on the basis of concerns over its cost [Blears, Q877;
Stewart & Troop Q809].
4.10 We note that it may not always be possible to
prevent an epidemic through mass vaccination [Kingston, Q575].
Some epidemics spread too quickly to allow effective prevention
by quick production and administration of vaccines, e.g. with
a new strain of influenza [US, II p386]. There are also other
issues that should be considered, such as the need for adequate
supply of materials required to produce vaccines [see box 5].
Indeed, the question of whether there would be enough health personnel
to administer a vaccine would also need to be considered.
4.11 It is important to consider the difficulties
of ensuring a secure supply of vaccines and how those difficulties
could be overcome. We note the need for effective global surveillance
networks which can provide information as early as possible and
thus instigate development and production of vaccines.
4.12 We note that the Government is currently addressing
how, in the face of a serious epidemic, they would secure vaccines
for the population [House of Lords Hansard, Col WA38]. We were
also pleased to hear from the Minister for Public Health and the
Chief Executive of the HPA, that the Department of Health is likely
to consider a further application from HPA Porton (previously
CAMR) to develop such a centre as discussed earlier (4.9) [Q809,
877]. We hope that this signifies that the Government will soon
publish their strategy relating to vaccine supply.
4.13 We recommend that, given that there is little
vaccine production capability in the United Kingdom, the Government
should, by April 2004, develop and publish a strategy to ensure
that there is secure access to supplies of vaccines in the face
of national outbreaks of infectious disease.
conditions and behaviour
4.14 Prevention of infection requires improvements
in social conditions [Assoc Brit Pharma Ind, I p10; Emery, I p111;
Finch, II p55; Hawker, I p117]. Poor housing, poor sanitation
and overcrowding can encourage infections to flourish and to be
transmitted between people. Pertinent examples of such conditions
are prisons and temporary housing for asylum seekers and the homeless
[Birmingham, II p395].
4.15 A significant amount of infection is food-borne
and is caused by poor hygiene relating to food production, storage
and preparation. Environmental Health Officers (EHOs) work with
food producers to ensure that levels of hygiene are sufficient
and that people who work there are trained. In addition, EHOs
also educate children in schools, although we heard that in Sandwell
EHOs have had to stop doing this as a result of resource shortages
[Bradford MDC, I p34-6; Birmingham, II p394].
4.16 Prevention is neither just an activity for health
professionals nor something that can be achieved solely by adequate
housing. Prevention relies on all individuals practising good
hygiene, particularly in relation to food preparation and sex.
High-risk behaviour such as intravenous drug users sharing needles
also has a role in transmitting infection. It is clear that public
understanding of the importance of behaviour in preventing infection
is insufficient [Bryant, Q360]. We make recommendations about
the interaction between social behaviour and infection in chapters
seven and eight.
4.17 When prevention fails it is necessary to introduce
control measures to avert further spread of infection [Sheffield,
I p152]. Control measures are required in both community and hospital
settings. Many health professionals are involved in control, with
the HPA playing a supporting and coordinating role [see boxes
6 and 7].
4.18 Control of infection requires finding out where
and how infection has arisen, how it is being transmitted and
who might have been exposed to it. It is then necessary to put
in place some measures to stop infection from spreading and to
ensure that those who have become infected are treated as soon
as possible [see Box 7].
4.19 There are some good examples of plans about
how to respond to infection outbreaks, such as the UK pandemic
influenza plan. This describes the national response in the event
of a new influenza virus appearing which has the potential to
cause a world wide pandemic [http://www.doh.gov.uk/panflu.htm].
The plan was prepared to facilitate a prompt, effective national
response. It describes a phased response and defines the roles
of the organisations which would be involved. At the time of the
appearance of H5N1 influenza in Hong Kong in 1997 the UK was one
of the few countries to have such a plan in place and it was widely
seen as a model to follow [USA, II p386].
4.20 Nevertheless, we heard that there are enormous
disparities in community based infection prevention services across
the country. A survey for the NHS Executive in 1997 found that
there was significant underresourcing of those responsible for
infection control and thus underperformance in many districts;
charges which, we heard, districts have not adequately responded
to [Hawker, II p118]. As we outlined in chapter three, there is
also wide variation in numbers of infection control nurses [Infection
Control Nurses Assoc, II p176 ].
4.21 We heard that there is a shortage of EHO posts
in local authorities and a shortage of people training in environmental
health at university [Emery, II, p111]. The local authority is
isolated from other health protection services, and we heard that
this can prevent EHOS from forming effective collaborative relationships
with other professionals [Emery, II Q229, 244; Bradford MDC, I
p34, Wiltshire Food Liaison Grp, I p171]. In particular, when
attempting to trace the source of an outbreak and to implement
control measures, EHOs can have difficulty accessing information
from doctors concerned about patient confidentiality [Bradford
MDC, I p34].
4.22 The lack of coordination and communication between
different areas of community infection control is an issue that
concerns a significant number of people [Emery, II Q231, Hawker
II, Q231 p 118; Faculty Public Health Med, I p52-3]. Lines of
responsibility for investigating outbreaks and implementing control
measures are often unclear. Recent changes to health services
organisation, including the creation of the HPA, are believed
to have made lines of responsibility less clear and have led to
the loss of informal support and collaborative networks [see chapter
4.23 Infection control is a fundamental component
of hospital activity, with health care acquired infectionscosting
approximately £1 billion every year and leading to 5,000
deaths [Stewart II, 316, Bard Ltd, I p19; NAO, II p375; Brogan,
Q680]. Outbreaks of infection such as the Norwalk virus (causing
diarrhoea and vomiting, recently associated with outbreaks on
cruise ships) can lead to wards being shut down. This significantly
increases pressure on beds and can lead to a reduction in the
numbers of available staff, with some becoming sick themselves
and others being confined to working on wards where the outbreak
4.24 Clinical microbiologists and infection control
nurses play an important role in implementing control measures
in hospitals. However, we heard that control cannot be the responsibility
only of specialists, with all health care professionals needing
to take measures, such as washing hands when moving between patients
[NAO, II p375, Birmingham, II p393,5; see box 14]. We note that
clinical microbiologists and infection control nurses are accountable
to different people within the hospital, which may be a potential
cause for confusion.
4.25 We found that in many hospitals there is inadequate
provision of single rooms suitable for the isolation of patients
[NAO, II p376]. Demand for single rooms for other purposes can
be considerable and it is often difficult to keep these rooms
available for infected patients [Naylor, Q679]. There was also
concern that the availability of specialised facilities, such
as negative pressure isolation rooms, essential when caring for
patients with certain infectious conditions such as resistant
tuberculosis, was inadequate [Birmingham, II p393]. For example
St George's Hospital in London with a specialised infection unit
has only four, significantly fewer than a comparable hospital
in the US [USA, II p385].
4.26 The only formal recommendation that we make
in this chapter is found in paragraph 4.13 and relates to security
of vaccine supply. However there are a number of other ways in
which prevention and control of infection can be improved and
we make recommendations in further chapters relating to the following:
development of new vaccines [see chapter 8];
and improving education and training of specialist and non-specialist
health professionals from undergraduate degree level upwards [see
surveillance [see chapter 5]
levels of public awareness about the importance of hygiene and
improve understanding of risk [see chapter 7 and 8]
lines of responsibility to encourage better co-ordination between
different groups of health professionals [see chapter 9].
12 The Management and Control of Hospital Acquired
Infection in Acute NHS Trusts in England, HC 306, Session