Select Committee on Science and Technology Minutes of Evidence

Memorandum by Dr Nick Beeching, Senior Lecturer and Clinical Lead in Infectious Disease, Royal Liverpool University Hospital and Liverpool School of Tropical Medicine


  This evidence is provided from the viewpoint of a clinician whose practice involves both imported and locally acquired infections, with experience and interest in the interface between public heath interventions and clinical activity, and a strong interest in training in the infections specialists. I believe that there are both strengths and weaknesses in the current systems to manage infections and in the recommendations made in "Getting Ahead of the Curve". Many improvements could be made by provision of sufficient resources to define and provide what is currently recognised as best practice, as well as by reorganisation and the introduction of new technology. This evidence is submitted as an individual, although I have listed relevant positions that I hold at the end of the submission.


  2.1  Surveillance—problems

    —  Failure of statutory notification systems for specific diagnosis and co-ordination of these with other sources of data, except for a small number of illnesses eg tuberculosis. Notification is rarely complete the list is very old and case definitions are vague eg "hepatitis", "dysentery". Notification should be linked to specified outcomes eg contact tracing or general surveillance.

    —  Hospital impatient systems only report on final diagnosis, coding of which is often poor. There is a need for systematic coding of referral syndromes/problems as well as final diagnosis, and for outpatient coding of referral problem and diagnosis.

    —  Current information technology in British hospitals is inadequate to gather the above data from clinicians in real time (and hence to improve accuracy).

    —  Laboratory notification or reporting is not universally applied or accepted (but is recommended in Getting Ahead of the Curve).

    —  Different systems are in use eg statutory notification by clinician, laboratory reports etc and co-ordination of these is unclear.

    —  There is little feedback from central systems to the reporting clinician, hence little motivation for them to devote precious time to such activities. Lack of clarity over who will provide aggregated data eg CDSC (or HPA) centrally, Regional Public Health Observatory or other.

    —  Lack of agreed policy/protocols for routine surveillance of specific risks in disadvantaged groups eg refugees/asylum seekers, prisoners.

    —  Imported disease is largely neglected apart from malaria and viral haemorrhagic fevers.

  2.2  Surveillance—strengths

    —  Specific schemes part "owned" by clinicians eg HIV notification scheme, British Paediatric Surveillance Schemes, Sentinel general practice surveillance schemes.

    —  External international programmes such as Geisentinel (from CDC Atlanta) or Trop Net Europe (co-ordinated via Munich), or official interagency programmes such as Salmnet.

    —  Notification of specified laboratory isolates by a network of PHL laboratories who are engaged in routine diagnostic work in district general hospitals across the country, using standardised laboratory and notification procedures. This is a big strength of the British PHL system compared to eg CDC model in the USA which could be threatened by current plans.

  2.3  Treatment/management—problems

    —  Interventions are not universally applied even for high profile conditions where early intervention is recognised to be effective. eg pre hospital treatment of suspected meningococcal meningitis and antibiotics, and immediate chemoprophylaxis (and/or vaccination of appropriate) of contracts of a case. Continued postgraduate medical education is essential to overcome this.

    —  lack of basic audit tools and standards for quality of management of most infectious problems eg chickenpox, malaria, meningitis etc.

    —  Inadequate recognition by organ-based specialists of the public health implications of infectious problems eg tracing/immunisation of contracts of hepatitis B patients seen by specialists other than infectious disease physicians.

  2.4  Treatment/management—success

    —  Some evidence base for success of joint microbiology/infectious disease consultations in improving clinical outcome of serious infection in hospitals and better microbial use generally.

    —  Co-ordinated approach achieved by centres of infection in both teaching hospitals and district general hospitals as recommended by British Infection Society, involving multidisciplinary groups.

  2.5  Prevention—problems

    —  Fragmented vaccine policies eg multiple risk groups to be targeted for hepatitis B vaccination instead of universal vaccination. Impossible for primary care or speciality groups to track all these "risk groups".

    —  Failure to fund new universal screening/vaccination policies eg maternal HIV hepatitis B screening, so that implementation is patchy and onward referral of cases (for treatment) and contacts (for prevention) is poor.

    —  Failure of resource-linked central policies on screening, treatment and prevention for common problems eg HIV, hepatitis, TB in high risk groups who have difficulty accessing health care or are frequently moved:

    —  prisoners;

    —  drug misusers;

    —  asylum seekers/refugees; and

    —  homeless/very poor.

    —  Failure to use media convincingly to inform and empower the public to consider and accept health education messages. Need to adopt a consumer friendly attitude (eg Private Eye special issue on MMR) rather than indignant central dictat. The campaign to educate the public about chlamydia infection was far more effective educationally, targeting women's magazines and other consumer orientated publications.

  2.6  Prevention—success

    —  Targeted vaccination campaign eg meningococcus C, Hib vaccines, despite resources being stretched on the ground.

    —  HIV in iv drug users—multisectoral policies leading to sustained lowest prevalence rates in Europe.


    —  The overall concept of the document is excellent, but it is important not to lose the strengths of the current system (eg many PHL laboratories performing day to day diagnostic and surveillance work) during implementation.

    —  Must recognise the need for new resources to enable clinicians and laboratory personnel to participate in surveillance reporting.

    —  Need to involve clinicians, especially adult and paediatric infectious disease (ID) specialists in planning, especially in cross-speciality infections such as HIV, hepatitis B and C, tuberculosis, where they provide a significant proportion of total care. Central planning should recognise this role and provide appropriate resources.

    —  Need to recognise that models of care provision in London are not necessarily appropriate for many complex infectious problems (HIV, hepatitis, TB) outside London. ID physicians are often at the centre of the "hub" in "hub and spoke" care networks, but this role has been insufficiently catered for in some central planning and commissioning for such infections.

    —  The current reorganisation of funding responsibilities at PCT level has caused a hiatus in regional planning and funding for infection related issues. These need to be resolved, and the lines of responsibility and interaction need to be clarified. Thus many HPA roles will be centrally driven, but interaction at regional level with leads in PCTs, STAs and Directorate of Public Heath need to be transparent, both to allow involvement of local practitioners and to avoid duplication and waste of effort and limited resources.


    —  Information technology is not co-ordinated and does not allow for syndromic surveillance (see 2.1).

    —  Unusual new problems eg new variant CJD may not be detected by current systems—the Infectious Disease Society of America has a voluntary programme for reporting unusual infection syndromes that may detect new acute problems, but is unlikely to detect illnesses with a more remote actiological link with infection.

    —  Imported disease is poorly registered in current systems. This is being explicitly addressed by the new DH funded National Travel Health Network and Centre (NaTHNaC), one aim of which is to improve the surveillance of imported disease.

    —  Absence of adequate surveillance means that the potential effectiveness of intervention cannot be modelled, and this particularly applies to prevention of travel related infection.

    —  Resources need to be provided to encourage "academics" to take more interest in operational research on both community and hospital based surveillance, coupled with intervention measures.


    —  Currently recommended strategies for adult immunisation are applied in a very patchy fashion eg pneumococcal vaccine, influenza, hepatitis B.

    —  Flexibility needs to remain to allow visible public choice eg individual vaccines as well as MMR when there is public concern (however appropriate).

    —  Research on new vaccines that have greater potency and less complicated regimens is desirable, but should be linked to cost-effectiveness and programme implementation research.

    —  Regional or sub-regional vaccination centres should be established to cater for the many groups who fail to be covered by the current systems eg children of hepatitis B carrier mothers, contacts of hepatitis cases, groups such as iv drug users, asylum seekers etc. Such centres should be closely linked with regional surveillance centres and appropriate record keeping systems devised.

    —  Prison health systems provide an under-utilised (and under-resourced) focus for health prevention and vaccination of high risk groups.


    —  The current major threats are common conditions ie respiratory viruses and bacteria and gastrointestinal infections, and sexually transmitted and blood borne infections.

    —  Increasing resistance of pathogens to commonly prescribed antibiotics is spreading from hospitals to the community, particularly via community-based care of the elderly. A co-ordinated approach to both surveillance and antibiotic control policies is needed that can be readily adapted to changing local (Regional or sub Regional) needs, with realistic identifiable targets for success.

    —  There is no extra capacity nationally to cope with an outbreak of infectious disease, particularly one that is highly contagious. Redundancy of personnel (clinical, laboratory and public health) needs to be built into the system to allow for outbreak management.


  Some have already been suggested in preceding paragraphs. In addition

    —  A clearer system needs to be established to review the "lessons learnt" from individual outbreaks of both veterinary and human infections, and to share these lessons and use them to amend system failures.

    —  Surveillance at grass roots level needs adequate resourcing, together with appropriate involvement and regular feedback of individual and aggregated data to the health care providers who generate the data.

    —  There is a need for more hospital specialists with expertise in clinical ID in both adult and paediatric practice. Adult ID has grown by 5 per cent per year over the past 15 years, and the Royal College of Physicians together with the specialist societies (British Infection Society, Royal Society of Tropical Medicine and Hygiene) have recommended the need for one adult ID physician per 250,000 population, a target of approximately 200 for England (RCP Working for Patients II). The currently agreed growth targets are for just over half this number by the year 2010. Much of the growth has been in "academic specialists", emphasising the importance of infection-related research, but more hands are required to provide clinical bedside and consulting expertise and to assist with outbreak control and planning input at regional and national level (eg response to bioterrorism).

    —  There is a need for more integrated training of specialists in infection, without diluting the current training experience. The new joint training programme at specialist registrar level in infectious diseases and clinical microbiology is gaining in popularity and will produce pluripotential specialists. More such posts should be established, and there is a need to allow joint training of public health specialists with microbiology or ID to maintain a cadre of public health specialist with more in-depth knowledge and current practice in infection.

    —  Undergraduate teaching in all aspects of infections needs to be maintained. At least one new British medical school does not appear to have plans to appoint any senior academics in infection-related specialities—this does not bode well for training of undergraduates. Previous surveys (eg British Society of Antimicrobal Chemotherapy) have emphasised this need.

    —  The interface between all infections related specialities should involve all parties on a daily basis, as recommended by the British Infection Society. Teaching hospital centres with clinical specialists in ID should be part of a large infection team. In district general hospital settings, single-handed microbiologists (20 per cent of all UK) cannot be expected to cope with providing all the necessary input to policies and clinical care, but should be supplemented by a second appointment either a clinician, clinician/microbiology joint specialist or further microbiologist.

    —  Job plans for infections specialists should recognise that much of their working week is spent on improving quality not quantity of patient care eg telephone of bedside consultation, committee work in formulary, antibiotic or infection control, and running local, regional and national networks, as well as input to postgraduate training of all hospital and community-based specialities. Job plans based on patient or specimen turnover do not currently reflect this type of work adequately, and further resources are required.

    —  A co-ordinated multi-sectoral approach is needed to provide for surveillance, management and prevention of infection in mobile, disadvantaged groups such as centres of aggregated data relating to zoonotic infections.

    —  The current international excellence of British Tropical Medicine research and training, supported largely by the Wellcome Trust and MRC, should be encouraged and nurtured. This allows more specialists to gain experience of exotic disease and to apply this experience within the UK. Probably each ID Unit (there are about 25) should have a specialist with substantive overseas experience during training.

  While NaTHNaC will address the need for national standards of advice and best practice in surveillance and prevention of travel related disease, there is a need for defining and auditing standards of training and practice in community and hospital based travel clinics.


  There are many strengths of the changes proposed in "Getting Ahead of the Curve". Achieving improvements in surveillance requires a number of inputs, including resources, to enable and encourage involvement of health care providers at grass roots level. If not, they will neither identify nor produce surveillance data that are essential to an enhanced national system. In turn, management and prevention need to be encouraged by the provision of meaningful aggregated surveillance data at local level and in real time.


  NaTHNaC stands for the National Travel Health Network and Centre. This is a network for England, and the founder participants are the Department of Health, Communicable Disease Surveillance Centre of the Public Health Laboratory Service, London School of Hygiene and Tropical Medicine, Hospital for Tropical Diseases, and Liverpool School of Tropical Medicine. They will network with other key players in travel health throughout Britain. Currently staff have been appointed to be based in 3 of the participating centres, and the director's post will be advertised shortly. The administrative offices are based at HTD. NaTHNaC has not been publicly "launched" yet but will be early in the New Year.

Revised Core Functions of NaTHNaC—21 May 2002 (adapted from 16 January, revised in February)


  "To protect the health of British travellers."


  1.  To develop consistent and authoritative national guidance on general health matters for health professionals and for institutional customers advising the public travelling abroad.

  2.  To disseminate the above guidance widely.

  3.  To develop and provide guidance on special situations relating to health of travellers, including provision of real-time access to a national expert for health care professionals in need of further specific advice.

  4.  To carry out surveillance of infectious and non-infectious hazards abroad (concentrating on types of traveller, types of destination and types of hazard) and producing accessible regular outputs of such surveillance.

  5.  The provision and dissemination of expert advice and guidance on international travel health risks to bodies concerned with the public health.

  6.  To administer the yellow fever vaccination centres.

  7.  To engage the major stakeholders concerned with travel health especially the travel industry, insurance industry and other government bodies, to assist both in sentinel surveillance and to engage in constructive dialogue towards a unified prevention approach.

  8.  To facilitate and provide resources for the training of health care and other personnel in the provision of best quality travel health advice, based on such evidence as is available.

  9.  To define short-term and long-term research priorities in relation to the above.

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