Select Committee on Science and Technology Fourth Report


Chapter summary

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.

Training of infection specialists

Microbiologists, 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 performed urgently.

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 posts available.

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.

Environmental health officers

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; Q235].

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.

Education 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, Q412].

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.

Communication, 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].

Confidence 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, I p175].

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.

The media

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 [Bryant Q327].

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 disease.

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