Select Committee on Science and Technology Minutes of Evidence

Memorandum by Dr Stephen Wright, Infectious Disease Physician, London School of Hygiene and Tropical Medicine

  The first step in infectious disease surveillance is diagnosis. This diagnosis will initially be clinical, made at the bedside in hospital practice by the doctors attending the patient. Subsequently the initial diagnosis may or may not be substantiated by identification of a causative organism in cultured specimens, by use of the growing numbers of DNA based techniques (most often the polymerase chain reaction) or by identifying antibodies to the infecting organism in the patient's blood. In some instances the diagnosis is inferential related to the satisfactory response to treatment given.

  While the Chief Medical Officer's report, Getting Ahead of the Curve, stresses the importance of surveillance there is little mention of clinical services in infection. The one section that I could find relating to clinical practice of Infectious Diseases was section 5.85 on page 117. There are separate comments on paediatric infectious diseases provision. While I recognise that the main thrust of this report was to introduce concepts related to reorganising and integrating infectious disease surveillance and not service provision. I believe that this aspect needs to be considered because of my comments above. I have long believed that there needs to be an increased presence of Infectious Disease trained physicians in general hospitals. Paragraph 5.85 indicates that there are 80 consultants in infectious diseases in NHS hospitals and implies by that this is adequate (by saying nothing more about provision). I should like to see clinical infection specialists in district general hospitals as a matter of course rather than as the exception to the usual range of medical sub-specialties represented. The tendency has been to use the Consultant Microbiologist as the source of clinical consults for problems in infection. The new joint training for Specialist Registrars in Infectious Diseases and Microbiology is to be welcomed as going some way to redress matters but to have clinical infectious disease consultants in the mainstream of Departments of Internal Medicine in General Hospitals will serve to heighten awareness related to infections and increase training and teaching opportunities.

  Paragraph 5.84 places the burden of diagnosis and care of patients with infections on all doctors, nurses and other heath professional staff but opportunities for Specialist Registrars training in general medicine and their chosen sub-specialty to learn about infections apart from those directly affecting "their sub-specialty organ system" are limited. There does not appear to be a requirement for a continuing strand of non-specialist teaching related to General Internal Medicine.

  The Spirit of Infectious Diseases notification, when first introduced, was to alert public health authorities to settings in which disease outbreaks might be anticipated. Notification was required at the clinical suspicion of a notifiable infection. With time the practice has changed to notification on microbiology diagnosis. This leads to under notification of infections and inadequate recognition of the burden of infection in populations and potentially inadequate provision at all levels. The CMO's report highlights the ways in which the present means of notification and surveillance are rather disparate. The potential for use of electronic reporting systems should be developed to allow reporting from clinical suspicion through to laboratory confirmed isolate with anti-microbial sensitivities might be possible. Selection of what is to be reported is critical.

  The report draws attention to the importation of malaria into the United Kingdom by travellers and visitors, exemplifying the problems created by non-endemic infections brought into the UK. With time numbers of these cases have progressively risen and the parasite involved is predominately Plasmodium falciparum, the species capable of causing life threatening disease. Indeed in the last two years there has been an increase in deaths in patients with malaria treated in this country. This is a preventable disease. There is a wide range of sources of advice for the traveller but the tendency for their protection to be viewed solely in terms of vaccination needs to be countered. It takes a short time to give a series of vaccines but can take a relatively long time to present information on malaria prevention but for the person taking a holiday in the Gambia, the time spent doing that may be critical in keeping them healthy. The National Travel Health Advisory Centre & Network will provide authoritative, evidence based on information for practitioners and ideally the travelling public on all aspects of preparedness for overseas travel. This information should be web based.


  1.  Clinical diagnosis is the first step in management of patients with infections as well as the first step in surveillance. Provision of clinical infection services should be a part of the sub-specialist medical provision within district general hospitals to enhance clinical services, teaching and training.

  2.  Surveillance is an essential part of monitoring infections in communities and the importance of and responsibility for contributing to it is incumbent on all doctors. Getting Ahead of the Curve sets out a new framework for this and it is welcome.

  3.  The field of imported diseases is one in which there is the opportunity for effective interventions and the availability of a National Centre and Network for dissemination of relevant, evidence based information will be an important asset in preventing infections.

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