Select Committee on Science and Technology Minutes of Evidence

Memorandum by Professor Roger Finch, Infectious Disease Physician, Nottingham City Hospital


  1.1  The burden of infection in the UK is substantial and poorly defined. This is particularly relevant to many community infections. Few diseases are statutorily noticeable and among those which are, there is considerable under-reporting. Information on the burden of infectious disease managed in hospital can be gleaned from ICD10 coding of admissions but this remains imperfect, especially where the diagnosis is not supported by microbiological information. Data on antibiotic usage, as a measure of infectious disease management, is only readily available in primary care, but here, much antibiotic prescribing is empirical and often given for minor self limiting viral upper respiratory infections and therefore remains an inaccurate measure of the true burden of infection. Diagnosis related prescribing is largely absent. Information from medical certification is likewise unreliable in defining the burden of infectious disease.

  1.2  In hospital practice, microbiologically defined infection is more common, but here the nature of sampling is highly selective and rarely denominator controlled. Lack of diagnostic precision applies particularly to infections of the respiratory and gastrointestinal tracts which are the leading causes of infectious morbidity and use of health care resources.


  2.1  Infectious disease surveillance serves many purposes. Not only should it provide a more accurate picture of the incidence, prevalence, geographic distribution and trends in disease, but should also inform the epidemiology, the consumption of health care resources and the wider economic impact. It also permits strategic planning including control measures and, in turn, is the yardstick whereby the effectiveness of any intervention can be determined.

  2.2  While surveillance is fundamental to the management of infectious disease, it should be based around a clear strategy and should not be an end in itself. The strategy should be shaped by a number of questions, such as: Why is surveillance required? How can this information be obtained most effectively? How much information do we need? How will the information be used? How will it support evolving approaches to the control of a particular target disease? How should it link with other measures of health and disease? How will success/failure be judged?

  2.3  There is thus a strong case for reviewing the current strengths, weaknesses and arrangements for infectious disease surveillance not only to ensure that it more accurately reflects the current infectious disease challenges, but also to inform specialists, general practitioners, the public and government more effectively. There are some examples of good practice, such as the surveillance of tuberculosis and HIV infection where well developed systems record the prevalence and epidemiology of these diseases and also inform management.


  3.1  Strategic planning for the management of infectious disease is largely frustrated by a lack of clarity concerning its true economic impact on the population as a whole in relation to the use of health care resources and on individual citizens. Parameters such as medical consultations, hospital admissions, use of laboratory investigations and therapeutic interventions are poor yardsticks. Health economic analyses are applied to relatively few infectious diseases and the cost effectiveness of disease management and prevention is largely lacking.

  3.2  Many infectious agents spread within the home, workplace, nurseries, schools and through the use of public transport, leisure and retail facilities. However, little effort is made to measure the importance of these mechanisms of spread and whether effective solutions might be developed.

  3.3  Many chronic disorders have an infectious basis and result in a substantial, but ill defined burden to the individual and society. Examples include hepatitis B & C (cirrhosis/tumour) and HIV (AIDS), papillomavirus (cervical carcinoma), helicobacter (peptic ulcer/gastric cancer) and chlamydia (infertility and possibly coronary artery disease).

  3.4  Specific populations in whom the burden of infection is inadequately defined, managed and funded includes asylum seekers and prisoners. Asylum seekers from resource poor countries in regions such as Eastern Europe and Africa are currently stressing local health and social services with complex problems including those linked to HIV infection. Likewise, the prison population (currently 0.1 per cent UK population) is at particular risk from the spread of blood borne virus infections (notably hepatitis C and HIV) but to an extent that is ill defined. Prisons are acting as an amplification system for infectious diseases which, on release from detention, become a high cost responsibility of health services which have little influence on how this problem might be more effectively managed.

  3.5  Intravenous drug misuse is a major challenge and carries the risk of blood borne virus infection, notably hepatitis C and HIV. Many affected are on the margins of society and outside the reach of existing health and social services. The health and economic impact of this population is substantial, largely undefined, increasing and requires more effective management.


  4.1  The respiratory tract provides the leading infectious cause for consultation in primary care. This includes endemic and epidemic infections, which are largely viral in nature. Epidemic and possibly pandemic influenza is an ever present additional threat. Strategies are needed to ameliorate this burden which currently suffers from a somewhat laissez faire approach.

  4.2  Gastrointestinal infections have been estimated to affect some eight million of the population annually but are largely medically unidentified and only a fraction are documented microbiologically. Among bacterial causes, Campylobacter, Salmonellosis and Shigellosis predominate, together with other food-associated infections, such as Ecoli 0157. Antibiotic resistance is also impacting on disease management. Protective mechanisms within the food chain needs to be strengthened and the population better educated concerning food hygiene.

  4.3  STD and hospital acquired infections are a major health care burden and are identified for completeness although subject to a separate inquiry by the House of Lords.

  4.4  HIV and hepatitis C virus are major challenges which continue to spread and present complex medical and social challenges. Effective management is costly and will continue to increase until vaccine prevention of HIV becomes a reality.

  4.5  Tuberculosis is a growing challenge in response to factors such as travel to endemic countries, infected asylum seekers, the increase in immune deficient citizens and as a response to socio-economic factors. Furthermore, multi-drug resistant tuberculosis is steadily increasing and is a particular threat from the Baltic States and the former Soviet Union. Latency in disease expression characterises tuberculosis infection and inevitably means that in future, an increasing number of persons will present with drug resistant disease with its inherent problems of early diagnosis and appropriate drug therapy.

  4.6  Among community acquired infections, pneumococcal disease, particularly that caused by penicillin-resistant organisms, will increase and create major difficulties for antibiotic management in the community where treatment largely relies on oral agents. The effectiveness of recently licensed conjugate pneumococcal vaccines in controlling drug resistant disease is unproven.

  4.7  MRSA infections, currently rampant in hospitals, are now spreading into the community and affecting persons who have no clear epidemiological links to hospitals or nursing homes. This is extremely worrying, since many minor staphylococcal infections will no longer be responsive to conventional oral agents available to general practitioners. This will likely result in increasing referrals for hospital management.

  4.8  Climate change is likely to see an increase in the distribution of various insect vectors. For example, this could result in mosquito-associated diseases such as malaria, dengue and possibly West Nile virus.


  5.1  Education and hygiene

  5.1.1  Prevention is better than cure. Priority should be given to education and to emphasising the role of public health measures and hygiene for disease control. Public awareness remains poor and requires a strategic effort to remedy and sustain across generations and ethnic groups. This should focus on factors within the home, school, workplace, food outlets as well as hospitals.

  5.1.2  The explosion of information has also meant that most of those who are dealing with infectious disease problems cannot keep up to date with the key clinical literature, let alone the underlying scientific literature. Here it is appropriate to highlight a recent initiative under the umbrella of the National electronic Library for Health (NeLH).

  The National electronic Library for Communicable Disease (NeLCD), one of the virtual branch libraries of the NeLH, aims to provide rapid access to the best available evidence on the surveillance, investigation, control and treatment of infection. The organisation of the NeLCD, is such that it has support and representation from across the entire range of those involved in Communicable Disease, including Infection Control Nurses and Environmental Health Officers as well as Microbiologists, CCDCs and Infectious Disease Physicians.

  The NeLCD is developing an Internet infectious disease portal with access to material provided by the various expert groups engaged in infectious disease. It is developing systems so that there will be rapid access to reviewers assessments of the key evidence, as well as direct access to the published evidence where available. The NeLCD is also intending to develop forums for exchange of information and training materials.

  If the practice of infectious disease is to improve it will require effective use of information technology to disseminate best practice. The NeLCD should be a key element of any future strategy. To date, the NeLCD has been developed on intermittent funding from the NeLH core budget and from the PHLS. It is vital that there is a clear commitment to adequate long term funding for the NeLCD so that the staff can be secured and that the plans for developing the NeLCD can be implemented.

  5.2  Immunisation

  5.2.1.  Vaccines rank among the most successful of public health measures. However, the supply of vaccines should be made more secure in order to prevent interruptions of childhood immunisation. The manufacturing base for vaccines in the UK has diminished and is a cause for concern. It clearly weakens the UK base for promoting new initiatives for the vaccine control of disease, as well as increasing our reliance on overseas manufacturers.

  Childhood immunisation schedules lack international standardisation and harmonisation which often delays licensing and limits the amount of information on performance according to UK schedules. International efforts to remedy this state of affairs should be given a higher priority. New vaccines will continue to be developed and are to be encouraged. However, this presents new challenges in defining the safety and efficacy of exposure to multiple antigens. A strong research led strategy is essential.

  5.2.2  Adult immunisation is currently erratic, selective, non-strategic and largely driven by travel or occupational needs. Likewise, medical records relevant to past immunisations are variable in quality. The effectiveness of vaccine control should be made part of the schools' curriculum in order to improve knowledge of the nature of immunisation and promote understanding of the risk/benefit issues. Hopefully, this will lead to greater acceptance of the vaccine control of disease. At present, vaccine programmes are vulnerable to sensational reporting often based on the release of premature information. This has had a devastating effect on such diseases as pertussis and measles which can have serious long term consequences in those affected.


At present, the effectiveness of surveillance, links between surveillance and treatment and the links between surveillance and strategies for preventing infectious disease is weak. The solution should be based on strengthening the foundation base around an agreed strategy and the establishment of robust systems for communication, implementation and audit. Links with international agencies is essential because of the nature of infectious disease challenges. The UK is well positioned to provide leadership in this important area of public health

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