Memorandum by Dr Derrick Crook
1. What are the main problems facing the
surveillance, treatment and prevention of human infectious disease
in the United Kingdom?
Surveillance as emphasised in "Getting
Ahead of the Curve" is heavily dependent on passive reporting.
This has served well in the past for detecting outbreaks; but,
as there is no reliable population base, record of disease manifestation
or outcome data, this design of surveillance is limited in its
capacity to measure the following important aspects of endemic
(a) Measure accurately the burden (morbidity
and mortality) of infectious diseases.
(b) Determine the transmission properties
of organisms (both hospital and community).
This information is crucial to forming policy
on disease priorities and the cost benefit of prevention strategies.
It also benefits understanding the variation in prevalence and
patterns of disease.
Comprehensive and enhanced passive surveillance
with clear aims will, however, provide a sound basis for detecting
outbreaks, be they naturally occurring or from a deliberate (bio-terrorist)
release. As emphasised in "Getting Ahead of the Curve",
this form of surveillance will need to be underpinned by good
clinical reporting and specialist laboratory facilities. Well
publicised examples of outbreaks in the USA further emphasise
Treatment of infectious diseases in the UK varies
in standard, improving on this will need long-term strategies.
The evidence base for treatment could be greatly improved, but
will need substantial clinical investigation. The clinical competence
of specialists in the field could be enhanced, but this will take
years to achieve.
Prevention is dependent on a complex interplay
between recruiting high quality people, remaining abreast of improvements
in knowledge and technology, and having a sound organisational
and physical infrastructure for delivering prevention. Much of
this rests on attracting high quality people into the field, which
is increasingly not the case, as is well illustrated by the Academy
of Medical Sciences report into Academic Bacteriology.
2. Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
The document addresses these problems and many
of the recommendations will part remedy the problems. However,
the document does not provide clear recommendations on the following:
(a) Building a cadre of highly motivated,
skilled and able specialists for the future. The CDC, Atlanta,
USA has promoted a training scheme for Epidemic Intelligence Service
(EIS) Officer that has attracted many of the most talented infectious
diseases clinicians in the USA. These people have gone on to successfully
seed the pool of people available to lead many aspects of "fighting
infection" in the USA and even in other countries.
(b) Emphasise the need for co-ordination
among specialists in the field and reduce fragmentation. This
is well illustrated by the small subspecialties of Clinical Virology
and to some extent applies to Infectious Diseases which work largely
independently of Clinical Microbiologists. A model for greater
co-ordination between these specialists in a joined up "practice"
will foster improvements in the delivery of infection services.
The report on Academic Bacteriology by the Academy of Medical
Sciences deals with this point and it deserves wider support in
the hope of overcoming artificial and inhibitory barriers.
(c) Improving the clinical microbiology laboratory
infrastructure. The recent deliberate anthrax releases in the
USA illustrated the inadequacy of Hospital and State Laboratories
in that country in meeting effectively the demands arising from
such an extreme and serious outbreak. A major programme of upgrading
laboratories there has been embarked on. UK labs are in need of
such upgrading to be adequately equipped for handling major outbreaks
and maintaining high standards of microbiology that underpin surveillance,
treatment and prevention of communicable disease.
3. Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles to its doing so?
(a) Improvement in surveillance depends not
only on training and recruiting high quality people, but also
on improving the rigor of surveillance by insisting on achieving
academic rigor in the work (as reflected by publication or grant
raising record). This fosters an attitude receptive to new ideas
which is an essential first step to benefiting from advances in
knowledge and technology. This is the case, for example, at the
CDC, Atlanta or The National Public Health Institute KTL, Finland.
A specific point to be considered is establishing defined population
based sampling frames (eg through sentinel PCTs, hospitals and
laboratories for measuring communicable disease).
(b) Similarly, improvement in advances in
diagnostic technologies depends on imposing similar academic rigor
in reference laboratories to create a permissive environment for
new developments. This could alternatively, in the future, be
lead through centres of excellence as proposed by the report on
Academic Bacteriology produced by the Academy of Medical Sciences.
4. Should the United Kingdom make greater
use of vaccines to combat infection and what problems exist for
developing new, more effective or safer vaccines?
(a) As in the past, a continuing programme
for introducing vaccines should be followed. The main obstacle
is determining the efficacy of vaccines. In part, this is possible
through challenge studies, but ultimately it will depend on large
scale efficacy trials. The scale of these studies may involve
a large part of the country and will inevitably be complex. Consequently,
an infrastructure suitable for conducting such large scale studies
is needed and may in part be provided by the MRC Clinical Trials
Unit and/or through collaboration with University Departments.
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
(a) "Getting Ahead of the Curve"
lists them well. Which new or re-emergent infections may arise
and pose major threat is stochastic and, therefore, difficult
to predict. An approach of being able to respond to outbreaks
in general is the best approach for this type of threat.
(b) An obvious and ongoing threat of infection
arises from adaptation of organisms to antibiotic exposure or
immune selection following vaccination. This could be quantified
through rigorous surveillance with state-of-the-art molecular
epidemiology and better predictions could be formulated about
future emergence and spread of such antibiotic resistant organisms
or variants that escape host immunity.
6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the United Kingdom?
The greatest impact would come from the following:
(a) Develop early and focused leadership
through the HPA that re-invigorates the field of Communicable
Disease Control at a national level and thereby promotes improvement
(b) Build a cadre of talented specialists
by creating a training fellowship scheme akin to the CDC EIS Officer
(c) Develop high-class epidemiology, surveillance
and reference microbiology with the achievement of high standards
through the early imposition of rigorous academic standards.
(d) Introduce state of the art information
technology necessary for both the clinical microbiology laboratories
and capturing surveillance data, this will only be achievable
in the medium term.
(e) Renewing the clinical microbiology laboratory
infrastructure as an early aim.
(f) Promote the coalescence of the fragmented
specialisations in Infection (eg Clinical Microbiology, Clinical
Virology, Infectious Diseases, etc) as an early aim.
(g) Build centres of academic excellence
as suggested in the report into Academic Bacteriology by the Academy
of Medical Sciences. These could work in concert with the HPA
in raising standards. This will take time to develop.
Further practical considerations:
(a) Recognise different, but complementary
requirements for conventional Clinical Microbiology versus preparing
for the threat of Bio-terrorism.
(b) Some changes are urgent and need early
implementation (eg organisational restructuring, immediate review
and imposition of higher standards in reference work) and others
need long term planning and execution (eg recruitment of highly
trained and talented people for the future).
(c) A major effort needs to be placed on
Information Technology, however this will need major investment.
(d) Establish guidelines for implementing
closer joint working between NHS laboratories, the HPA, University
Departments, related government departments (eg DEFRA) and even
(e) Undertake a thorough costing exercise
to determine the price of making major changes envisioned to improve
standards in the detection, surveillance, treatment and prevention
of human infectious disease.