CHAPTER 7: TRAINING
A successful infection service requires infection
specialists to be well trained and to have knowledge and understanding
about other areas of the service. However, infectious disease
cannot be the responsibility of infection specialists alone. Other
doctors and nurses should also be involved and thus require sufficient
training to confidently treat infection, as well as, increasingly,
managing and implementing infectious disease control measures.
We are concerned that the general public has a
poor understanding of risk relating to infectious disease and
to vaccines. We call on the infectious disease community to provide
the public with clear information about issues relating to risk
and infectious disease: the HPA should take the lead in this.
of infection specialists
Infectious Disease Physicians and epidemiologists
7.1 We heard that there is a lack of specific expertise
in identifying and treating difficult or rare infection [Griffiths,
II p90]. This means that patients can receive sub-optimal clinical
care. In addition, there is a risk that potentially significant
events, indicative of an outbreak, could be overlooked until a
major epidemic has taken hold [Assoc Med Microb, II p71; Beeching,
Q119; Cohen, Q44; Wright, Q115]. We note that the early detection
of the anthrax outbreak in the US was due to general clinicians
who became suspicious that something untoward was occurring and
who then ensured that basic confirmatory laboratory tests were
7.2 There are also concerns that there is a shortage
of individuals with skills needed to direct laboratories and to
care for patients, as we have already discussed (see chapter 3).
Posts in medical microbiology are difficult to fill and recent
increases in academic microbiology fellowships have not had significant
effect [Cohen, Q48; Pennington Q46;Wellcome Trust Q736]. In contrast,
physicians in training are attracted to careers as Infectious
Disease (ID) physicians, but there is a limited number of substantive
7.3 We heard that epidemiological skills (those of
tracing incidence and predicting likely further outbreaks of disease)
are also in short supply [AcMedSci, II p35] both at regional level
and at national level within the HPA. These skills are essential
to CCDCs, who play a key role in prevention and control. We heard
that CCDCs have difficulty in providing the best possible service
as they are often overworked and cover large population areas
[Hawker, II p118]. ID physicians and medical microbiologists can
provide little aid in this area as they receive only a small amount
of epidemiological training [Crook, II p88].
7.4 One recent development which capitalises on physicians'
interest in clinical infectious disease, and which may help to
reverse the shortage of those with both clinical and laboratory
skills, is the provision of joint training in microbiology and
infectious disease [Friedland, I p67]. This could be expanded
further to include training in epidemiology [Beeching, II p50;
Cohen, Q48; Crook, II p89; Wright, II p56].
7.5 We recommend that the Government, in conjunction
with relevant Royal Colleges and the Joint Committee on Infection
and Tropical Medicine, address the shortage of expertise in clinical
infectious disease, clinical microbiology and communicable disease
epidemiology by increasing numbers of fully funded consultant
posts and ensuring that there are available training posts.
7.6 There is a growing national shortage of graduates
in environmental health with an eighty percent reduction in applications
to environmental health degree courses since 1995 [Emery, II p111].
In the last three years, three environmental health degree courses
have closed and we heard that the remaining courses are struggling
to remain viable. Furthermore, only 4,500 of the 9,500 environmental
health officers who are registered with the Chartered Institute
of Environmental Health work in local authorities [Emery; II p111;
7.7 In addition we heard that some local authorities
are replacing Chief Environmental Health Officers with Directors
of Technical Services: these Directors may not have any understanding
of environmental health issues [Emery; II p111].
7.8 We are concerned about the shortage of trained
officers required to carry out food inspections and to investigate
infectious disease as this could adversely affect any national
or local infection prevention activity.
7.9 We recommend that the Government investigate
the decline in numbers of trained Environmental Health Officers
in local authorities and take steps to reverse this trend.
of health professionals other than infection specialists
7.10 Given that the health care system relies on
a variety of practitioners being well-informed about infection
we were concerned to hear that training in infectious disease
for non-specialist doctors, nurses and other health professionals
was inadequate [Coates, I p45; Emery, II p133; Little, p195, Q408;
Perry, Q412; Birmingham, p395].
7.11 Whilst all medical students see infection in
the course of their training, we heard that there is wide variation
in terms of undergraduate teaching. On some courses clinical infection
and public health training is patchy and isolated from other components
of medical training [Beeching, II p52, Finch, Q123]. Clinical
training is often delivered by non-specialists. The low numbers
of microbiologists and infectious disease specialists may mean
that this situation will continue.
7.12 We heard there is insufficient post-graduate
training in infection for GPs considering that infection is a
large component of their work [Little, Q408]. Pre- and post- registration
nursing training is also viewed as "very poor" in terms
of information on basic microbiology and immunology which leads
to a lack of thorough underpinning knowledge about infectious
disease [Howard, Q412].
7.13 We believe that levels of infectious disease
training of all clinicians and nurses must be increased in order
to enhance the likelihood that significant events indicative of
unusual infection are detected. We believe that basic knowledge
and understanding of infection is essential for communicating
with the public. For example, nurses working in vaccination clinics
with inadequate understanding could find it difficult to respond
to authoritatively to patients' questions about vaccination [Howard,
7.14 One way of tackling concerns about lack of expertise
is to ensure that there are specialists in infection in all regions
and that other professionals know how to access them. We discuss
this further in chapter 9. However we also call on bodies responsible
for education of health professionals to improve education and
training in infection.
7.15 We recommend that the General Medical Council,
the Nursing and Midwifery Council, the General Dental Council
and the Health Professions Council ensure that universities strengthen
existing content relating to clinical and public health aspects
of infection in undergraduate education.
7.16 We recommend that, with respect to postgraduate
education, the medical Royal Colleges and the Nursing and Midwifery
Council should ensure that infection prevention and control is
a key component.
education and the public
7.17 In our report on antibiotic resistance we noted
that it was important to improve public understanding about antibiotics.
We heard in this inquiry of the need for public education about
infectious disease. Without public understanding of infection
it will be difficult to reduce infection, particularly in the
community [Friedland, I p67].
7.18 Both the public understanding of science, and
scientists' understanding of the public is deemed to be inadequate
[Bryant, Q354]. For example we heard that "it would be wonderful
if people knew that viruses and bacteria were different"
[Bryant Q360]. However, many of the issues relating to infectious
disease and vaccination are complex. In particular, understanding
risk in relation to infection is difficult [Calman, Q341; Crowcroft,
I p46; Ghosh, Q342; PowderJect, I p125].
7.19 Educating children at school is an important
way of increasing public understanding of infectious diseases
[Bradford MDC, I p46]. We are pleased to note that there are components
of infection control highlighted in the National Curriculum at
all Key Stages. EHOs have traditionally provided some education
of children about food hygiene but, in some areas, have recently
had to stop attending schools owing to insufficient resources
[Birmingham, II p394].
in Government and Scientists
"The handling of BSE and the emergence of vCJD
caused a massive loss of trust in Government institutions and
in science in general" [Pennington, I p122]
7.20 Witnesses were concerned that the public had
lost confidence in official pronouncements about infectious disease
issues [Ghosh, Q342; Pennington, I p122]. This was probably a
consequence of the BSE/vCJD outbreak and subsequently Foot and
Mouth [Griffiths, II p91; UK Vaccine Industry Gp, II p235; Wyeth,
7.21 We were warned that a public lack of confidence
could be exacerbated by Government or officials suggesting that
there was no risk attached to something. This tactic was used
in attempt to stem anxiety about the MMR vaccine and had failed
[Ghosh, Q329, 334]. Nearly all human activity has an element of
risk and the public understand this [Calman, Q345; Ghosh, Q342].
7.22 Witnesses suggest that scientists and other
professionals rather than Government should communicate with the
public about infectious disease [Calman, Ghosh, Q367]. Those people
responsible for communicating should both be, and be viewed as,
independent. It could also be useful to have a single authoritative
source for information about infectious disease. The HPA may be
the most suitable body to have responsibility for communicating
with the public [Stewart P316; Troop, Q821].
7.23 We agree that the HPA should take the lead in
public communication and we would agree with witnesses that the
Food Standards Agency provides a useful example of how to communicate
clearly without appearing to be controlled by Government or industry
(but note The Guardian 23rd May) [Pennington, I p122; Sheffield
City Council, I p151]. We recognise that the HPA is independent
but expect it to develop and maintain its independence and we
look forward to seeing it proactively communicating with the public
and providing clear assessments of risk.
7.24 We recommend that the HPA, like the Food
Standards Agency, should act, and should be seen to be acting,
independently of Government.
7.25 One of the most important aspects of public
education and communication is improving communication between
scientists and the media, an issue which we heard about in this
inquiry but also explored in our report, Science and Society
[Bryant, Q327; Ghosh Q357]. The role of the media in promoting
health messages is considerable.
7.26 We heard that the media can do well at communicating
concepts of risk and raising awareness about infectious disease:
chlamydia was widely reported in women's magazines and it is thought
that this led to significantly raised awareness. We note however
that increased awareness has not yet resulted in a drop in infection
rates [Beeching Q88]. A further suggestion was to use storylines
in soap operas to promote particular issues [USA, II p385]. A
more negative example of media power is their role in perpetuating
wide-spread anxiety about the MMR vaccine.
7.27 It is increasingly being recognised by doctors
that they should prepare for routine media communication and establish
media contacts in order to quickly convey information when needed.
However, we heard that a culture change is still required and
the importance of communication needs to be further recognised
7.28 Mr Pallab Ghosh, Science Correspondent for the
BBC, praised the placing of clear accurate information on websites.
However he warned that this is insufficient, as journalists want
to put questions to people and to explore different angles of
an event. Journalists need to be able to obtain information at
all times, ideally from a spokesperson [Q368]. He suggested establishing
more phone "hot-lines" in relevant press offices when
there are episodes of intense media interest. Ideally the infectious
disease community should provide a media-friendly, articulate
and clear spokesperson, available at all times.
7.29 The mode of communication cannot only be one-way
and we were interested to hear about the journalist fellowships
run by the Centers for Disease Control and Prevention in Atlanta
where journalists learn about issues related to infectious disease
[USA, II p397].
7.30 We recommend that the HPA creates a post
for a well-resourced infectious disease specialist to act as spokesperson
and to lead on all aspects of communicating with the public including
developing innovative methods of increasing awareness of infectious