Select Committee on Science and Technology Minutes of Evidence

Memorandum by the Infection Control Nurses Association

  This evidence is submitted on behalf of the Infection Control Nurses Association of the UK and Eire. The Association has 1,600 members, mainly nurses. The membership is representative of many areas in which health and social care is delivered in primary and secondary care settings as well as private healthcare providers. The evidence has been prepared from written comments as well as from a debate on the subject of surveillance that took place at our recent annual conference.

1.   What are the main problems facing the surveillance, treatment and prevention of human infectious disease in the United Kingdom?

1.1  Current surveillance systems are not all standardised and therefore there is a variety of surveillance data that is collected. Collection of accurate data can be difficult and time consuming, which may lead to information being incomplete. Feedback of surveillance data in a timely manner is vital in order for actions to be agreed and taken but turn around of information is often slow indicating a need to improve feed back systems.

  1.2  Mechanisms do not always exist to ensure that data collected in primary care informs policies and strategies in secondary care and vice-versa. For example data on tuberculosis infection in the community should inform decisions made within acute hospitals as to how many isolation rooms are needed including those that are negative pressure for multi-drug resistant disease. Although systems exist for surveillance in acute hospitals and the notification of infectious diseases system operates in the community these do not necessarily embrace other areas where care is delivered such as nursing and residential homes or special schools. The existing notification of infectious disease does not at present give the in depth information that is needed to develop health promotion and infection prevention strategies. In addition this system identifies only those who have attended a health care professional for treatment and therefore not all cases will be identified and the true incidence of disease is not always known.

  1.3  In order to address the difficulties of accurate data collection across care settings lateral and innovative ways of collecting the data need to be developed, for example, using the expertise of organisations that work with high risk groups such as substance misuse teams and homeless workers. It will be necessary to develop partnerships for data collection, whether this is through surgeons in the acute setting or School Nurses in community areas. Without the engagement of these clinicians and care workers there is a danger that the data and the actions taken in response to the data will not have local ownership and changes will not take place. However, where data is collected locally there is a need for validation to improve accuracy. Whilst it is acknowledged that collecting a minimum amount of data could give accurate and valuable information, more in-depth data, for example on risk factors may be needed to inform future prevention and treatment strategies.

  1.4  There are enormous disparities in infection and infectious disease prevention services across the country. The Public Health Laboratory Service study into Infection Control in the Community (published June 2002) found that the ratio of Community Infection Control Nurses (CICNs) to population ranged from 0-4.5 whole time equivalent (wte) CICNs per 500,000 population with a median range of 1.7 wte. This report also identified serious gaps in tuberculosis contact tracing with many CICNs fulfilling multiple roles that involve contact tracing and infection prevention strategies.

  1.5  Public perception of risk impacts on the ability of CICNs to perform their role within the limited resources available to them. CICNs report that much of their time is spent on addressing and mitigating against risks that have low likelihood of causing a problem, which spreads their resources inappropriately and does not allow them to focus on in depth work with real risks. There is a need for the public to receive a cohesive message that there will always be risks with infectious disease, together with a realistic approach to what "science" can offer in terms of infectious diseases.

  1.6  With regards to education on infection prevention there is a need to address this across all healthcare providers, particularly in the community setting. The PHLS study into Infection Control in the Community found that 58 per cent of districts had no training programme for dental practices. Although National Vocational Qualification programmes of learning are in progress in relation to infection control there are specific issues in community settings where frequently there is poor access to CICNs for mentorship and where assessors have little or no background understanding of specific infectious diseases and infection prevention issues.

  1.7  Treatments for infectious diseases can have undesirable side effects and may need to be taken for prolonged periods of time (for example treatments for HIV and tuberculosis), which can lead to lack of compliance and risk of drug resistance developing.

2.   Will these problems be adequately addressed by the Government's recent infectious disease strategy, Getting Ahead of the Curve?

  2.1  Getting Ahead of the Curve offers immense potential to make a difference. Implementing the strategies for Hepatitis C, Tuberculosis and sexual health will require good, targeted surveillance data and interventions based on principles of collaborative working. Implementing these strategies will require expert and organised leadership.

  2.2  Getting Ahead of the Curve will only impact on the prevention and treatment of infectious disease if new ways of working are embraced. There is a need to challenge assumptions and to ensure that everyone recognises their role and responsibilities in infection prevention. The involvement of all stakeholders, including patients, relatives, domestic staff etc, in the development of infection prevention strategies is vital in order to promote ownership and to focus on what is achievable.

  2.3  There is a need to consider how the primary and secondary care settings will interact in implanting the targeted action plans and actions required within Getting Ahead of the Curve. Strategic Health Authorities may play a role in supporting the development of collaborative strategies and programmes for infectious disease prevention.

3.   Is the United Kingdom benefiting from advances in surveillance and diagnostic technologies; if not, what are the obstacles to its doing so?

  3.1  Although infection prevention and control staff have access to computer hardware there is still a need to improve this and to work towards using portable methods of data collection more effectively. Resources for this remain an issue with many infection prevention and control teams in both primary and secondary care settings having no or limited access to funds to enable upgrading of equipment on a regular basis.

  3.2  Compatibility between different computer systems used within laboratories and primary and secondary care settings makes timely linking and use of data difficult. There may be a need to develop standard systems that uses automatic data capture and interfaces with patient administration data systems within Trusts. The opportunity to integrate surveillance information into the electronic patient record must not be missed.

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?

  4.1  The UK could make more use of vaccination, particularly for illnesses that result in economic and social disruption such as the flu. Within the Wessex area GPs are not being encouraged to vaccinate `at risk' groups under 65 years, because they will not be paid for it. Wide coverage of the population could result in fewer emergency admissions, outbreaks in hospitals and care homes, time off work and school.

  4.2  The immunisation programme needs to be considered in view of recent public concerns over safety of vaccines. It is important that the public receive the message that no vaccine is 100 per cent safe or 100 per cent effective. Current scepticism over vaccine safety will impact on the introduction of new vaccine programmes and cautious promotion of new programmes will be required otherwise there is a danger that there will be a decrease in the numbers of children protected.

  4.3  The impact of higher levels of immigrants may need to be taken in to consideration when determining vaccination strategies. Whereas the resident UK population will have been exposed to infectious diseases such as chickenpox as children, thus giving immunity, as these diseases are not common in other countries there is the potential for the proportion of adults that are susceptible to these infections to be increased. This can in turn lead to outbreaks of these infections and the risk of long term complications, for example, damage to the foetus during pregnancy leading to ongoing health problems when the child is born.

5.   Which infectious diseases pose the biggest threats in the foreseeable future?

  5.1  The impact of multi-resistant organisms is not confined to acute care settings. As increasing numbers of patients, who would traditionally have been cared for in hospital settings, are being cared for in the community there is the risk that these organisms will become more prevalent in the wider community. An increasingly elderly population as well as health care developments improving survival of serious and chronic disease leads to a rise in the susceptibility of the general population to infection with these organisms. Poor standards of infection control in some community settings can contribute to the spread of these organisms and there is a need to address this within the standards set by the National Care Standards Commission, which are at present very basic and limited in terms of infection control.

  5.2  Tuberculosis continues to pose a threat due to a number of reasons. As previously noted compliance with treatment may be poor. Increasing levels of immigrants from areas with high levels of drug resistant disease may increase drug resistant levels in the UK. As rates of tuberculosis have declined in the 20th century health care professionals may not have a high index of suspicion for the disease when patients present with symptoms, therefore diagnosis can often be made late.

  5.3  Sexually transmitted infections including Hepatitis B and C and HIV. Despite education campaigns there is evidence that sexually transmitted infections are not declining. Although the national strategies for combating these infections have much to offer there is a need for good quality targeted surveillance to ensure effective use of resources and effective targeting of prevention in the community.

  5.4  Food related illness continues to be a large problem in terms of both individual notified cases and outbreaks. The impact of these economically in terms of loss of earnings and working/school days lost is immense. There is a need for much more lateral and collaborative thinking for strategies to prevent these infections. The role of school nurses and health visitors in the promotion of hygiene should be explored, with nationally supported campaigns linking to the national curriculum. Opportunities to promote food hygiene on the back of other campaigns, for example the `five a day fruit/vegetable' campaign should be explored.

  5.5  Changing patterns of existing diseases cannot necessarily be predicted but must be considered. This is demonstrated well by the numerous and ongoing outbreaks of gastro-enteritis due to Norwalk-like viruses that have occurred throughout 2002. These outbreaks have not been restricted to healthcare settings but have been present in schools and hotels and have had considerable impact economically due to outbreak control requirements.

6.   What policy interventions would have the greatest impact on preventing outbreaks of and damage caused by infectious disease in the United Kingdom?

  6.1  Policy interventions need to focus firstly on prevention of infection and infectious disease. There is a need to ensure infection prevention education is given priority, which suggests this should be a mandatory requirement in all areas where care is delivered.

  6.2  There is a need to ensure that infection prevention and control is an integral part of all new health initiatives and National Service Frameworks. Controls Assurance Standards for infection control have led to infection prevention becoming part of the organisational structure in Primary Care and Acute Trusts. This approach is needed in the wider community.

  6.3  The development of standards for infection control in all care settings should be encouraged. This should be followed by monitoring and possibly by an accreditation scheme. Monitoring should include not only the existence of policies, but also the implementation of them.

  6.4  There is a need for Local Authorities and District Councils to work more closely with the Health Protection Agency and in turn for these to work with secondary care providers to incorporate infection prevention and control into all initiatives.

  6.5  Outbreak management must include the development of teams that work across boundaries of health and social care provision.

24 November 2002

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