Select Committee on Science and Technology Minutes of Evidence

Memorandum by the Association of Medical Microbiologists

  1.  The Association of Medical Microbiologists is a professional body concerned with all aspects of medical microbiology and infection in the United Kingdom. It provides a UK network involving over 500 senior members of the profession from university departments of medical microbiology, the Public Health Laboratory Service, National Health Service departments and the Armed Forces.

  1.1.  The first object of surveillance must be to provide a health benefit and we would see its role as:

  1.1.1.  the detection of outbreaks;

  1.1.2.  the detection of new, emerging and re emerging conditions which will include those due to bio terrorism and bio crime;

  1.1.3.  health-care planning, to include the formation of policies, guidelines and codes of practice; and

  1.1.4.  providing measures of performance and assessment of outcome.


2.1.   Importance of accurate microbiological confirmation

  2.1.1.  It should be noted that laboratory confirmed microbiological evidence is the only accurate representation of the true status of contagious disease. Although clinical diagnosis does provide an immediacy it is only in a small number of diseases that sensitivity and specificity of diagnosis would be reliable. The network of microbiology laboratories feeding significant isolates to specialist centres for typing and data for collation and epidemiology, would provide the most appropriate and durable system of epidemiological intelligence. It is also true that certain diseases for which a microbial aetiology is suspected but not yet proven, such as Kawasaki's disease can only be diagnosed clinically. A truly catholic surveillance programme would need to include such diseases.

  2.1.2.  There are areas where insufficient care is made in the accuracy of diagnosis, measles is now a clinically difficult disease to diagnose and is not always confirmed by the laboratory. In some areas where clinical diagnosis is difficult there are insufficiently sensitive laboratory techniques available, pertussis is an example. It may be justified to have "spotter" primary care practices, who are tasked with providing additional and more intensive microbial surveillance as opposed to just clinical diagnosis.

  2.1.3.  There is a need for standardisation both in the range of pathogens detected and in the methods employed. It is probably a requirement that the methodology employed in diagnostic laboratories should not only conform to accepted standards for the United Kingdom but also internationally. The area of antimicrobial sensitivity testing is an area where international standards should be applied.

  2.1.4.  Once, when there was a sense of community and there existed District General Hospitals, the local Microbiologist felt a responsibility for the welfare of the local population. The purchaser-provider split has tended to divorce hospitals from their population. Creating a team (microbiologists, family practitioners and public health professionals) that can recognise a local need would add meaning and contribute to the accuracy of surveillance.


  3.1.  A wide range of health-care personnel are involved in providing surveillance (clinicians, public health doctors, general practitioners, sexual health clinics). One of the tasks will be to extend the role of clinicians working in areas not traditionally involved in gathering data for microbial diseases, the accident and emergency and intensive care departments may be important for sentinel detection of bio terrorism.

  3.2.  The existing United Kingdom network of microbiology laboratories, which includes the NHS and PHLS networks has been feeding information centrally for several decades but with only patchy engagement. The current task is to make the collection of epidemiologically important information more inclusive and to ensure that the information held within the data set is used appropriately and distributed widely. This must be achieved within the manpower shortages that exist within the pathology services. It would be advisable to look at the skill mix of personnel currently involved in the collection of this information. For example, infection control is largely provided by medical and nursing staff, however the first call on these personnel is often the control of outbreaks and the care of the individual patient. Biomedical scientists and information technology staff should have an increased part to play in the infection team, their roles being more dedicated to the processing of epidemiologically important information.

  3.3.  The single major message must be that surveillance should be an integral part in the function of many health-care professionals and that methods must be found to integrate this task into the work pattern and to ensure that it causes no additional burden. The answer almost certainly lies within improved information technology.


  4.1.  Probably the single most important task in enabling the flow of data centrally to the Communicable Disease Surveillance Centre would be changes to the information technology agenda. Where previous attempts at inclusiveness have fallen short, was the requirement to add information manually to the data set. Many laboratories found that they had insufficient resource to enhance the data. Given the shortages of staff and insufficient funding provided to diagnostic microbiology laboratories, the task of transmission of epidemiology data centrally must be both simple and automatic. Only information collected by laboratory information systems can be reliably forwarded. There is no standardisation for these systems with regard to a minimal data set for epidemiological and surveillance purposes. The sending of electronic pathology messages has not, in the field of infection, been crowned with success. Schemes such as the Reed coding system have not been a success in this area, we are aware of initiatives being undertaken within the NHS and priority must be given to the successful coding of epidemiologically important data. All previous attempts seem to have concentrated on the coding of numerical data ie haematology and clinical chemistry, probably because this problem was most easily solved.

  4.2.  For information technology to benefit surveillance the following points are absolute requirements:

  4.2.1.  there must be standardisation of data captured during the requesting of the clinical microbiology investigation and this should include epidemiological information where appropriate;

  4.2.2.  the NHS messaging systems need to be improved to allow a standardised infection/epidemiology message to be sent;

  4.2.3.  only data captured automatically in the above systems should be part of the surveillance output; and

  4.2.4.  data storage systems must be more highly developed to include information necessary for different surveillance systems. Information required for surveillance of hospital-acquired infections will require more complex coding of untoward events and complications. Epidemiological information on community infections will require linking to immunisation and general practice records. The surveillance of antimicrobial resistance will need linking to primary care and hospital prescribing information. The combining of all these data systems into the health record would provide an immensely powerful tool for surveillance.


  5.1.  All health-care systems require surveillance, both for predicting the needs of the population and to monitor outcomes of treatment. In an ideal system of surveillance data capture would be embedded within the process and function of clinical care. We currently face the problem of inadequate engagement of clinical staff within the process. There are certainly areas where we believe that targeted surveillance would improve outcomes. An example of this would be orthopaedic hip and knee surgery. Reliable diagnosis of the infective complications is not necessarily an easy task and requires significant clinical input. It is not yet clear what is the appropriate skill mix for performing surveillance of surgical site infection. It is likely that the clinical team will need augmentation, probably from the infection control team, to provide logistic support and an element of quality assurance. Clinical microbiology has so far driven this process but lacks the appropriate manpower resource and possibly training to complete this cycle. Expansion of targeted surveillance, even if microbiology was to take only a supervisory and educational role, rather than the current executive function, would not be possible within the available manpower structures.


  6.1.  There are other areas of communicable disease where we believe that surveillance requires enhancement. The aetiological diagnosis of respiratory tract infection is inadequate, the newer anti-viral treatments require the positive identification of the pathogen before treatment is started, this is well indicated with the recent introduction of newer agents active against influenza virus. Greater investment in molecular diagnostic methods must be made before such advances in the treatment of the population can be reliably and efficiently introduced. Similarly there has been a failure to adequately research the area of prevention by immunisation. Outstanding examples are the lack of vaccines for the sexually transmitted diseases and the poor performance of those that exist for the prevention of tuberculosis.


  7.1.  One of the transparent omissions within "Getting Ahead of the Curve" is the failure to address the issue of surveillance of community acquired infections post the establishment of the Health Protection Agency. There is a lack of reassurance that resources currently expended on surveillance of communicable disease by PHLS laboratories will be transferred to NHS laboratories, and that all microbiology laboratories will receive additional funding to improve the surveillance of disease. There are also concerns that the pace of change envisaged by "Getting Ahead of the Curve" will lead to the removal of one network before new NHS networks are in place. It is also not clear whether the different models envisaged in the current pathology modernisation schemes are appropriate for microbiology. Whilst it is highly desirable that microbiology should be part of an integrated pathology unit at trust level, the most appropriate network for microbiology laboratories could require a degree of separation.

previous page contents next page

House of Lords home page Parliament home page House of Commons home page search page enquiries index

© Parliamentary copyright 2003